Metabolic and Complicated Cataract: DR - Ajai Agrawal Additional Professor Department of Ophthalmology AIIMS, Rishikesh

Metabolic and complicated cataract
Dr.Ajai Agrawal
Additional Professor
Department of Ophthalmology
AIIMS, Rishikesh
Learning Objectives
• At the end of this class students shall be able
to :
• Classify cataract according to aetiology.
• Understand pathophysiology of metabolic and
complicated cataract.
• Identify distinct morphological subtypes of
metabolic and complicated cataract.
2
‘CATARACTA’(LATIN)MEANING ‘WATERFALL’
3
Definition of cataract
• Any opacity in the lens or its capsule
4
Etiological classification of cataract
1. Age related cataract
2. Traumatic cataract
3. Metabolic cataract
4. Complicated cataract
5. Toxic cataract
6. Radiation induced cataract
5
METABOLIC CATARACTS
• Due to endocrine disorders and biochemical
abnormalities.
• Diabetic cataract
Hyperglycemia
Excess glucose metabolizes into

sorbitol
(Aldose reductase mediated)
Osmotic over hydration
6
1. Age related cataract in
diabetics
• Early onset
• Rapid progression
2. True diabetic cataract.
• Also called ‘snow flake
cataract’ or ‘snow-storm
cataract’
• Fluid vacuoles appear
underneath anterior
and posterior capsules
• Bilateral snowflake-like white
cortical opacities Snowflake cataract 7
Galactosemia
• Multisystem disorder
• Inborn error of galactose
metabolism
• Anterior and posterior

subcapsular lamellar
opacities- ‘oil droplet Oil droplet cataract
cataract’
8
Myotonic dystrophy
• Fine dust like opacities

with tiny iridescent spots
in cortex- ‘christmas tree
cataract’
• May progress to stellate
opacity at posterior pole
Christmas tree cataract
9
Hypocalcaemic cataract
• May be associated with parathyroid tetany.
• Multicoloured crystals
or
• Small discrete white flecks of cortical opacities
10
Wilson’s disease
• ‘Sunflower cataract’ is
rare in such patients.
• ‘Kayser-Fleischer ring’
(KF ring) in the cornea
Sunflower cataract
is more common.
(Photographs- Courtesy :
Kanski’s Clinical Ophthalmology)
11
Lowe's syndrome
• Lowe’s (Oculo-cerebral-renal) syndrome
• Rare inborn error of amino acid metabolism.
• Ocular features
congenital cataract and glaucoma
• Systemic features
mental retardation
dwarfism
osteomalacia
muscular hypotonia
frontal prominence.
12
13
COMPLICATED CATARACT
• Opacification of the lens secondary to

some other intraocular disease.
• Inflammatory conditions
• Uveal inflammations
(like iridocyclitis, pars planitis, choroiditis)
• Hypopyon corneal ulcer
• Endophthalmitis.
14
• Degenerative conditions
• Retinitis pigmentosa
• Myopic chorioretinal degeneration
• Retinal detachment
Long-standing cases
• Glaucoma (primary or secondary)
• Intraocular tumours
• Retinoblastoma
• Malignant melanoma
15
• Lens changes typically in front
of the posterior capsule.
• Irregular in outline
• Variable in density
• Appearance like ‘breadcrumb’.
• A very characteristic sign is
Iridescent coloured particles
‘polychromatic lustre’ of
reds, greens and blues.
16
• Chronic anterior uveitis

Most common cause
• Polychromatic lustre
at posterior pole
• If persists, anterior and
posterior opacities develop
17
Angle closure glaucoma
Focal infarcts of lens

epithelium
-small grey-white anterior

subcapsular or capsular
opacities
‘glaukomfecken’
18
•Pathological myopia
Posterior subcapsular opacities

Early onset nuclear sclerosis
•Hereditary fundus dystrophies
Lebers: total cataract

Stickler syndrome: cortical cataract
19
Toxic cataracts
1. Smoking
2. Alcohol
3. Drug induced cataract

Corticosteroids
Phenothiazines
Pilocarpine
Diuretics
Amiodarone
Allopurinol
Chloroquine
20
Other types:
• Infrared (heat) cataract:
‘Glass-blower’s or Glassworker’s cataract’
• Irradiation cataract
• Ultraviolet radiation cataract
• Electric cataract
21
MANAGEMENT OF CATARACT IN ADULTS
• A. Non-surgical measures
• B. Surgical management
22
Non-surgical measures
1. Treatment of cause of cataract
2. Measures to delay progression
3. Measures to improve vision in the presence of

incipient and immature cataract
23
Surgical management
• Indications
1. Visual improvement
2. Medical indications :
Lens induced glaucoma
Retinal diseases like
diabetic retinopathy or retinal detachment
(treatment of which is hampered by
presence of lens opacities)
3. Cosmetic indications
24
Preoperative evaluation
I. General medical examination of the patient
II. Ocular examination
A. Retinal function tests

B. Search for local source of infection
C. Anterior segment evaluation by slit-lamp
examination
D. Intraocular pressure (IOP) measurement
25
Retinal function tests
• Light perception (PL)
• Projection of rays (PR)
• Pupillary reaction to light
• Two-light discrimination test
• Maddox rod test
26
Retinal function tests
• Colour perception
• Entoptic visualisation
• Laser interferometry
• Objective tests for evaluating retina

like VEP, ERG, EOG, USG
27
Preoperative medications and preparations
• 1. Topical antibiotics
• 2. Preparation of the eye to be operated.
• 3. An informed and detailed consent
• 4. Scrub bath and care of hair.
• 5. To lower IOP
• 6. To sustain dilated pupil
• Anaesthesia
• LA/GA
28
Types and choice of surgical techniques
• Phacoemulsification (MICS)
• Small incision cataract surgery (SICS)
• Extracapsular cataract extraction (ECCE)
• Intracapsular cataract extraction (ICCE)
29
Conclusion
• Metabolic cataracts are due to endocrine
disorders and/or biochemical abnormalities.
• Complicated cataracts involve opacification

of the lens secondary to some other
intraocular disease.
• Many metabolic and complicated cataracts

have distinctive morphologies.
30
Thank you
31

Metabolic and Complicated Cataract: DR - Ajai Agrawal Additional Professor Department of Ophthalmology AIIMS, Rishikesh

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Metabolic and complicated cataract

Excess glucose metabolizes into

• Anterior and posterior

• Fine dust like opacities

• May be associated with parathyroid tetany.

• Opacification of the lens secondary to

• Glaucoma (primary or secondary)

• Chronic anterior uveitis

Focal infarcts of lens

-small grey-white anterior

Posterior subcapsular opacities

•Hereditary fundus dystrophies

Lebers: total cataract

3. Drug induced cataract

• Ultraviolet radiation cataract

1. Treatment of cause of cataract

2. Measures to delay progression

3. Measures to improve vision in the presence of

II. Ocular examination

A. Retinal function tests

• Projection of rays (PR)

• Pupillary reaction to light

• Two-light discrimination test

• Maddox rod test

• Objective tests for evaluating retina

• Small incision cataract surgery (SICS)

• Extracapsular cataract extraction (ECCE)

• Intracapsular cataract extraction (ICCE)

• Complicated cataracts involve opacification

• Many metabolic and complicated cataracts

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