MANAGEMENT OF CATARACT IN ADULTS

Treatment of cataract essentially consists of its
surgical removal. However, certain non-surgical
measures may be of help, in peculiar circumstances,
till surgery is taken up.
A. Non-surgical measures
1. Treatment of cause of cataract. In acquired
cataracts, thorough search should be made to find
out the cause of cataract. Treatment of the causative
disease, many a time, may stop progression and
sometimes in early stages may cause even regression
of cataractous changes and thus defer the surgical
treatment. Some common examples include:
Adequate control of diabetes mellitus, when
discovered.
Removal of cataractogenic drugs such as
corticosteroids, phenothiazenes and strong
miotics, may delay or prevent cataractogenesis.
Removal of irradiation (infrared or X-rays) may
also delay or prevent cataract formation.
Early and adequate treatment of ocular diseases
like uveitis may prevent occurrence of complicated
cataract.
2. Measures to delay progression. Many commercially
available preparations containing iodide salts of
calcium and potassium are being prescribed in
abundance in early stages of cataract (especially in
senile cataract) in a bid to delay its progression.
However, till date no conclusive results about their
role are available. Role of vitamin E and aspirin in
delaying the process of cataractogenesis is also
mentioned.
3. Measures to improve vision in the presence of
incipient and immature cataract may be of great
solace to the patient. These include:
Refraction, which often changes with considerable
rapidity, should be corrected at frequent intervals.
Arrangement of illumination. Patients with
peripheral opacities (pupillary area still free), may
be instructed to use brilliant illumination.
Conversely, in the presence of central opacities,
a dull light placed beside and slightly behind the
patient’s head will give the best result.
Use of dark goggles in patients with central
opacities is of great value and comfort when
worn outdoors.
Mydriatics. The patients with a small axial cataract,
frequently may benefit from pupillary dilatation.
This allows the clear paraxial lens to participate
in light transmission, image formation and
focussing. Mydriatics such as 5 percent
phenylephrine or 1 percent tropicamide; 1 drop
b.i.d. in the affected eye may clarify vision.
B. Surgical management
Indications
1. Visual improvement. This is by far the most
common indication. When surgery should be advised
for visual improvement varies from person to person
depending upon the individual visual needs. So, an
individual should be operated for cataract, when the
visual handicap becomes a significant deterrent to
the maintenance of his or her usual life-style.
2. Medical indications. Sometimes patients may be
comfortable from the visual point (due to useful vision
from the other eye or otherwise) but may be advised
cataract surgery due to medical grounds such as
Lens induced glaucoma,
Phacoanaphylactic endophthalmitis and
Retinal diseases like diabetic retinopathy or retinal
detachment, treatment of which is being hampered
by the presence of lens opacities.
3. Cosmetic indication. Sometimes patient with
mature cataract may insist for cataract extraction (even
with no hope of getting useful vision), in order to
obtain a black pupil.
Preoperative evaluation
Once it has been decided to operate for cataract, a
thorough preoperative evaluation should be carried
out before contemplating surgery. This should
include:
I. General medical examination of the patient to
exclude the presence of serious systemic diseases
especially: diabetes mellitus; hypertension and
cardiac problems; obstructive lung disorders and any
potential source of infection in the body such as
septic gums, urinary tract infection etc.
II. Ocular examination. A thorough examination of
eyes including slit-lamp biomicroscopy is desirable
in all cases. The following useful information is
essential before the patient is considered for surgery:

be explored since, if it is defective, operation will be
valueless, and patient must be warned of the
prognosis, to avoid unnecessary disappointment and
medicolegal problems. A few important retinal function
tests are considered here.
1. Light perception (PL). Many sophisticated retinal
function tests have been developed, but light
perception must be present, if there is to be any
potential for useful vision.
2. A test for Marcus-Gunn pupillary response
(indicative of afferent pathway defect) should be
made routinely. If present, it is a poor prognostic
sign.
3. Projection of rays (PR). It is a crude but an
important and easy test for function of the
peripheral retina. It is tested in a semi-dark room
with the opposite eye covered. A thin beam of
light is thrown in the patient's eye from four
directions (up, down, medial and lateral) and the
patient is asked to look straight ahead and point
out the direction from which the light seems to
come.
4. Two-light discrimination test. It gives information
about macular function. The patient is asked to
look through an opaque disc perforated with two
pin-holes behind which a light is held. The holes
are 2 inches apart and kept about 2 feet away
from the eye. If the patient can perceive two
lights, it indicates normal macular function.
5. Maddox rod test. The patient is asked to look at
a distant bright light through a Maddox rod. An
accurate perception of red line indicates normal
function.
6. Colour perception. It indicates that some macular
function is present and optic nerve is relatively
normal.
7. Entoptic visualisation. It is evaluated by rubbing
a point source of light (such as bare lighted bulb
of torch) against the closed eyelids. If the patient
perceives the retinal vascular pattern in black
outline, it is favourable indication of retinal
function. Being subjective in nature, the
importance of negative test can be considered if
the patient can perceive the pattern with the
opposite eye.
8. Laser interferometry. It is a very good test for
measuring the macular potential for visual acuity
in the presence of opaque media.
9. Objective tests for evaluating retina are required
if some retinal pathology is suspected. These
tests includes ultrasonic evaluation of posterior
segment of the eye; electrophysiological studies
such as ERG (electroretinogram), EOG
(electrooculogram) and VER (visually-evoked
response); and indirect ophthalmoscopy if
possible.
B. Search for local source of infection should be
made by ruling out conjunctival infections,
meibomitis, blepharitis and lacrimal sac infection.
Lacrimal sac should receive special attention. Lacrimal
syringing should be carried out in each patient with
history of watering from the eyes. In cases where
chronic dacryocystitis is discovered, either DCR
(dacryocystorhinostomy) or DCT (dacryocystectomy)
operation should be performed, before the
cataract surgery.
C. Anterior segment evaluation by slit-lamp
examination. It is of utmost importance. Presence of
keratic precipitates at the back of cornea, in a case of
complicated cataract, suggests management for subtle
uveitis before the cataract surgery. Similarly,
information about corneal endothelial condition is also
very important, especially if intraocular lens
implantation is planned.
D. Intraocular pressure (IOP) measurement.
Preoperative evaluation is incomplete without the
measurement of IOP. The presence of raised IOP
needs a priority management.
Preoperative medications and preparations
1. Topical antibiotics such as tobramycin or
gentamicin or ciprofloxacin QID for 3 days just
before surgery is advisable as prophylaxis against
endophthalmitis.
2. Preparation of the eye to be operated. Eyelashes
of upper lid should be trimmed at night and the
eye to be operated should be marked.
3. An informed and detailed consent should be
obtained.
4. Scrub bath and care of hair. Each patient should
be instructed to have a scrub bath including face
and hair wash with soap and water. Male patients
must get their beard cleaned and hair trimmed.
Female patients should comb their hair properly.

5. To lower IOP, acetazolamide 500 mg stat 2 hours
before surgery and glycerol 60 ml mixed with
equal amount of water or lemon juice, 1 hour
before surgery, or intravenous mannitol 1 gm/kg
body weight half an hour before surgery may be
used.
6. To sustain dilated pupil (especially in
extracapsular cataract extraction) the
antiprostaglandin eyedrops such as indomethacin
or flurbiprofen should be instilled three times one
day before surgery and half hourly for two hours
immediately before surgery. Adequate dilation of
pupil can be achieved by instillation of 1 percent
tropicamide and 5 percent or 10 percent
phenylephrine eyedrops every ten minutes, one
hour before surgery.
Anaesthesia
Cataract extraction can be performed under general
or local anaesthesia. Local anaesthesia is preferred
whenever possible (see page 571-573).
Types and choice of surgical techniques
I. Intracapsular cataract extraction (ICCE) . In this
technique, the entire cataractous lens along with the
intact capsule is removed. Therefore, weak and
degenerated zonules are a pre-requisite for this
method. Because of this reason, this technique
cannot be employed in younger patients where
zonules are strong. ICCE can be performed between
40-50 years of age by use of the enzyme alphachymotrypsin
(which will dissolve the zonules).
Beyond 50 years of age usually there is no need of
this enzyme.
Indications. ICCE has stood the test of time and has
been widely employed for about 50 years over the
world. Now (for the last 25 years) it has been almost
entirely replaced by planned extracapsular technique.
At present the only indications of ICCE is markedly
subluxated and dislocated lens.
II. Extracapsular cataract extraction (ECCE). In
this technique, major portion of anterior capsule with
epithelium, nucleus and cortex are removed; leaving
behind intact posterior capsule.
Indications. Presently, extracapsular cataract
extraction technique is the surgery of choice for
almost all types of adulthood as well as childhood
cataracts unless contraindicated.
Contraindications. The only absolute contraindication
for ECCE is markedly subluxated or
dislocated lens.

Types of extracapsular cataract extraction
The surgical techniques of ECCE presently in vogue
are:
Conventional extracapsular cataract extraction
(ECCE),
Manual small incision cataract surgery (SICS),
Phacoemulsification