Mansukhani, Sujata To Marcial, Karmi Margarette. This 30 year old male sought consult because of...

Mansukhani, Sujata To Marcial, Karmi Margarette

This 30 year old male sought consult because of blurring of vision of the left eye. Visual acuity was light perception on the involved eye. This condition has been present since childhood.

OutlineWhat is your diagnosis?What diagnostic test would you do to help

you decide on your management?What is your treatment plan?What will be the visual outcome of this

patient after your surgical management?

Question # 1

SALIENT FEATURESPatient presented with:

LEUKOCORIAUNILATERAL, PAINLESS BLURRING OF

VISIONCondition is congenital or “present since birth”

Patient Retinopathy of

prematurity

Retinal Detachment

Coloboma Cataract

UnilateralGradual, Painless Blurring of Vision present since birthLight perception on affected eyeLeukocoria

occurs in premature, low-birth-weight infants maintained on oxygen therapy

risk factors: trauma and surgery, vitreous detachment, high myopia, retinal breaks or tears, retinal vascular disease, and history of detachment in the other eyeflashes of light, floaters, curtain-like decrease in vision

Congenitalcaused by incomplete closure of the fetal fissureDegree of visual loss related to area affected (iris, retina, choroid, or optic nerve head)

May be: age-related childhood cataract (congenital or acquired) traumatic drug-inducedUnilateral or bilateralPainlessleukocoriaGlare or star bursts

Question # 2

History and PEthorough history careful physical examination must be

performedentire body habitus is checked for

abnormalities that may point out systemic illnesses

Ocular ExaminationVisual acuity for both

near and far distances (Snellen’s Chart)

Glare- brightly lit room

Swinging Flashlight Testdetects for a Marcus Gunn

pupil or a relative afferent pupillary defect (RAPD)

indicative of optic nerve lesions or diffuse macular involvement.

RAPD + Cataract= very guarded visual prognosis after cataract extraction

Ocular Motilitylong-standing ptosis since

childhood may have occlusion amblyopia decreased visual acuity

rather than the cataract Checking all directions- to

rule out any other causes for the patient's visual symptoms

Slit Lamp Examinationshould not only

concentrate on evaluating the lens opacity but the other ocular structures as well (eg, conjunctiva, cornea, iris, anterior chamber)

Corneal thickness and the presence of corneal opacities

lens noted meticulously before and after pupillary dilation

Nuclear size and Brunescence as indicators of cataract density can be determined prior to phacoemulsification surgery.

lens position and integrity of the zonular fibers also should be checked lens subluxation may indicate previous eye

trauma, metabolic disorders, or hypermature cataracts.

Dilated fundus examination is recommended as part of the ocular examination for both unilateral cataract cases and bilateral cataract cases.

Question # 3

Early cataracts may be managed with the following measures:Stronger eyeglasses or contact lensesUse of a magnifying glass during readingStrong lightingMedication that dilates the pupil. (This may

help some people with capsular cataracts, although glare can be a problem with this treatment.)

Indications for SurgeryThe Snellen eye test reports 20/40 or worse,

with a cataract being responsible for vision loss that cannot be corrected by glasses.

Performing everyday activities has become difficult to perform to the point that independence is threatened, or the patient is at risk for accident or injury.

Three basic types of surgeryExtracapsular cataract extractionIntracapsular cataract extractionPhacoemulsification

Surgery to remove cataracts is generally an outpatient procedure. A local anesthetic is used and the procedure lasts about an hour.

Question # 4

A comprehensive study reported in Archives of Ophthalmology (1994)95.5 percent of healthy eyes achieved 20/40

uncorrected vision or better outcomes following cataract surgery

Of the more than 17,000 eyes evaluated, fewer than 2 percent had sight-threatening complications.

Sight-threatening complications

• associated with individuals who are much older or who already have poor underlying health affecting how their eyes heal.

• cataracts are far more advanced or "hardened" at the time of surgery, making them difficult to remove

• Glaucoma• Retinal detachment• Endophthalmitis• Secondary cataract

A Swedish study published in the British Journal of Ophthalmology (1999)Younger people undergoing cataract surgery

reported the highest satisfaction levels.

Less satisfactory outcome when other eye problems were present

British Journal of Ophthalmology (2000)people in their 6Os undergoing cataract

surgery were 4.6 percent more likely to achieve 20/40 uncorrected vision or better than people in their 80s