Week 1- Disorders of the Crystalline Lens
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1.
Is the lens
Transparent
opaque or transparent?
2.
Use a word to de- Bioconvex
scribe the shape
of the lens?
3.
What constituents make
up the lens?
4.
How is the lens? Avascular and non-innervated
5.
What is the lens Supported by zonular fibres and attached to the ciliary process of the ciliary body
supported by and
attached to?
6.
What happens in Zonular fibres relax and lens bulges causing accommodation
terms of the lens
when the ciliary
body contracts?
7.
What are the 3
Capsule, cortex and nucleus
anatomical parts
of the lens?
8.
How does lens
metabolism occur?
Water, proteins and salt
Via anaerobic glycolysis in epithelium
9.
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What happens to Bulges as the amount of protein inside increases with age, lens capsule thins and
the lens as it
allows fluid uptake
grows?
10. What is cataract? Loss of lens transparency
11. What symptoms - Gradual loss of vision
do all cataracts - Glare
produce?
- Blur
- Reduced CD
- Poorer colour vision
12. What signs do
Refractive error shifts, altered colour perception
all cataracts produce?
13. What are the dif- - Retinoscopy
ferent methods - Slit lamp examination via direct (diffuse for general view and narrow slit beam
for cataract iden- for position/depth info) and indirect illumination
tification?
14. What are the 3
Age-related, acquired and congenital
broad classes of
cataract types?
15. What are the
different types
of age-related
cataracts, in order of prevalence?
Nuclear, Cortical, Posterior Sub-capsular
16.
Secondary, induced, traumatic/radiation
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What are the
different types
of acquired
cataracts?
17. What are the
signs of nuclear sclerotic
cataract?
- Appears as haze in the nucleus
- Colour change from white -yellow - brown
18. Describe the ae- - Yellowing and hardening of central portion of lens slowly over the yr
tiology of nuclear - Hardening lens causes refractive power to increase causing myopia (px who
sclerosis?
relied on read glasses may not need)
- Cause colours to be less vibrant
19. What are the
- Glare
symptoms asso- - Light loss due to yellowing of vision
ciated with nu- Myopic shift
clear sclerotic
scatter?
20. What are signs of - Wedges or spokes in cortex
cortical cataract? - Seen as black against red background in retro illumination
- Starts peripherally but progresses by expansion and joining together of spokes
21.
- Glare
- Can effect vision depending on how close opacities are to the visual axis
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What are the
- Increase in astigmatiosm
symptoms of cor- - Mainly affects vision at night/ when dilated (due to glare)
tical cataract?
22. Describe the ae- - Occurs when portion of lens surrounding nucleus becomes opacified
tiology of cortical - Variable progression
cataract?
23. Describe the ae- - Located in posterior cortical layer, directly under the lens capsule
tiology of poste- - Occurs in younger px than other cataract
rior sub-capsular - Progression is variable but more rapid than nuclear sclerosis
(PSC) cataract?
- Can reduce VA (quicker than nuclear or cortical)
24. What are the
- Cloudiness in central posterior lens
signs of posteri- - Difficulty with fundus examination as it impedes view into eye
or sub capsular
cataract?
25. What symptoms Glare and reduced vision (even with mild cataracts), progresses very quickly
occur with posterior sub capsular
cataract?
26. Describe Christ- Polychromatic deposits in the cortex and nucleus (not common)
mas tree cataract
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27. What might
all cataracts
progress to become?
Mature cataract
28. Describe mature Whole lens becomes opaque and no light can enter/leave, meaning there is no
cataract
vision
(surgery becomes more difficult)
29. What is
morgagnian
cataract?
A form of hypermature cataract (not treated) where the cortex becomes liquid and
nucleus sinks inferiorly
30. What test do
all babies need
checked before
discharge for
their eyes?
Red reflex check
31. What problems Can be sight threatening and lead to deprivation amblyopia
might congenital
cataracts cause?
32. What are the
different caus-
Idiopathic, hereditary, maternal infection, drug abuse, malnutrition, metabolic
errors, chromosomal abnormalities, prematurity
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es/ risk factors for congenital cataracts?
33. Do all congenital - Not all reduce vision
cataracts reduce - If normal vision development then no active intervention
vision? What can
be done with?
34. What are some
different types
of congenital
cataracts?
Blue dot cataracts, sutural cataracts
35. Describe
axial/sutural
cataract
Chalky white clusters on/near the sutures (doesn't affect VA, slow/ non-progressive, doesn't require surgical intervention)
36. Describe blue dot Small blue dots in the outer nucleus/cortex, mainly in the periphery of the lens
cataracts
37. What are sec- Forms as a result of another disease e.g anterior uveitis
ondary cataracts? - No pattern as it depends on what is secondary to
- Pupil margins are affected in most secondary cataracts, glauckomflecken (primary
angle closure glaucoma)
38. What are
Many substances are cataractogenic (induced cataract) e.g corticosteroids for PSC,
induced/toxic
antipsychotics
cataracts caused
by?
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39. Define glaukom- A cataract that forms secondary to primary angle closure glaucoma
flecken
40. What are the
different causes of traumatic
cataracts?
Penetrating injury, blunt injury, radiation cataracts
41. Why is
Often associated zonular damage (zonular dialysis) so less stable
surgery generally
more complicated for traumatic
cataracts?
42. Describe the typ- Not round
ical shape of the
pupil for an eye
that has a traumatic cataract
43. What are some
lens opacities
that are not
cataracts?
- Pseudo-exfoliation
- Epicapsular
- Mittendorf dot
44. What is pseudo-exfoliation?
Deposits of protein-based material at the pupil margin and the anterior lens
capsule;
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45. What are 2 important risks to
consider with a
px with pseudo
exfoliation?
- Cause secondary pseudo exfoliative glaucoma
- Increases the risk of intraoperative complications in cataract surgery (especially
posterior capsule rupture)
46. What are signs
of epicapsular
stars?
Iris pigment on the anterior lens capsule
47. What are symp- - Not sight threatening
toms of epicapsu- - Glare, more refractive anterior on anterior lens
lar stars?
- generally asymptomatic
48. What is mittendorf dot?
Remnant of hyaloid artery around on the posterior lens capsule
49. What slit lamp
Optic section
technique would
you use to see a
mittendorf dot?
50. What is the cause Congenital caused by incomplete closure of embryonic fissure
for iris coloboma?
51. What are signs of - Inferior
iris coloboma?
- Keyhole shape to iris
- Associated with colobomas of other structures in the eye (choroid, retina, optic
nerve)
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52. What are symp- - Normal good VA
toms associated - Can develop amblyopia bc fovea hasn't developed due to improper closing of iris
with iris coloboma?
53. What is lenticonus?
-Anterior/ posterior coning of lens surface (Slow progressing)
-Irregular lenticular astigmatism which reduces VA
54. What are signs of Subluxation or dislocation of the lens due to zonular rupture
ectopic lentils?
55. What ocular con- Glaucoma, uveitis
ditions might ectopic lentils lead
to?
56. What are the
Due to dislocated lens (secondary to other pathology)
causes of ectopic Marfan's syndrome, anterior uveal tumours, homocystinuria familial
lentis?
57. How would you
treat ectopia
lentis?
Removal of the lens
58.
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What are the 3
types of glaucoma when induced by the
lens?
- Phakmorphic
- Phakolytic
- Lens displacement
59. What does it
Glaucoma caused by an increased lens shape/size
mean if glaucoma is phakomorphic?
60. What does it
Glaucoma caused by capsular leakage
mean if glaucoma is phakolytic?
61. What are the 2
-Phakoanaphylactic
types of uveitis - Phakotoxic
if induced by the
lens?
62. What does it
Caused by auto immune sensitivity to lens protein
mean if uveitis
is phakoanaphylactic?
63. What does it
Involves toxic reaction to lens protein
mean if uveitis is
phakotoxic?
64. What should you Do NOT refer them
do if your
px doesn't want
cataract surgery?
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65. What things
- Symptoms and reason for referral
needs to includ- - Social history= driving, carer, working
ed in a referral
- Ocular history= amblyopia, co-morbidity
letter for cataract - General health= diabetes, HT, shortness of breath
surgery?
- Medication= anticoagulants, alpha-blockers
66. What investigations must be
performed before referring a
px for cataract?
- Visions and refraction
- Pupil responses - RAPD
- Dilated fundus assessment
- Slit lamp examination of anterior segment
67. What should you Eyelid position and blepharitis, cornea, anterior chamber depth, cataract type and
look at during
severity
a slit lamp examination of the
anterior segment
before referring
for cataract?
68. When would you - When cataract is causing significant symptoms
consider surgery —>Vision is reduced, local threshold guidelines set by individual CCG tells what
for cataract?
vision a px need to qualify for surgery
e.g unable to meet driving standards, if risk at falls, unable to undertake required
tasks for work, unable to under take leisure activities
- When cataract is causing other pathological complications e.g narrowing of AC
angle causing angle closure glaucoma
69. What must be
discussed when
managing px
with cataract?
- Before referring px to HES for consideration of surgery. Undertake a shared
decision making process with px
-Ensure px knows
—>what happens if they don't proceed with surgery e.g vision loss without
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treatment may need other aids, loss of independence if unable to drive, other
complications e.g falls
—>potential intra and post- operative complications
70. Describe how
you would
explain to the px
on cataract
surgery?
(Phcoemulsification + IOL)
Day surgery- under local anaesthesia (eye drops and intracameral injection)
- Corneal incision —> Surgeon will make incision/cut on the cornea (px is under
anaesthesia so wont feel it or pain)
- Capsulorhexis —> Open the capsule lens
- Phacoemulsification —> Use ultrasound (instrument) to break down the lens
- Suction to remove the lens fragment (leaving capsule intact)
- Insertion of intraocular lens (IOL) (which will allow the px to see will and return
vision)
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