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Cataract

Cataract

Dfinition
Thecataractisaneyediseasecharacterisedbyacloudinessofthenormallytransparentcrystalline lens.Itmayaffecttheentirecrystallinelensoronlyaspecificpart,suchastheanteriorcapsule,the posteriorcapsule,thecrystallinecortex,orthecrystallinecore.Asthediseaseprogresses,the cataractmayleadtoareductionofvisualacuity Note: Thecrystallinelensiscomposedofatransparentgelandsurroundedbyacapsule.Itliesbehindthe posteriorfaceoftheirisandinfrontofthevitreousbody.Thecrystallinelensplaysanimportantrole intheprocessofaccommodation,whichallowsustoseeclearlybothcloseupandatadistance. Furthermore,thecrystallinelensfocuseslightraysontotheretinainthebackoftheeye.There,they areconvertedtoelectricalsignalswhicharetheytransferredtothebrainviatheopticnerve.In patientssufferingfromacataract,thecloudinessofthecrystallinelensmaycompromisethese functions. Incertaincases,theposteriorcrystallinecapsulebecomescloudyagainseveralmonthsoryearsafter extracapsularcataractextraction,theinitialcataractsurgery.Thisnewopacificationiscalleda secondarycataract.Itdevelopsgraduallyandprogressivelywithtimeandgenerallyoccurrsbetween 3monthsand4yearsaftertheinitialsurgicalintervention.1Symptomsaresimilartotheprimary cataractsymptomsdescribedinthischapter.Sessionsoflasertreatmentarethefoundationof secondarycataracttreatment.

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Epidemiology
Cataracts are very common in the elderly. In the United Kingdom, 2.4 million English and Welsh subjects suffer from cataracts.2 In France, around 20% of people older than 65 years of age, 35% of those older than 75, and more than 60% of those older than 85 are affected3 . In Canada, 12% of people aged 6569 years and 28% of people older than 80 years suffer from cataracts.4 Among Belgians aged 65 years or older, 6.2% of men and 12.2% of women present this condition.5 Due to theincreaseinlifeexpectancy,frequencyratesofcataractsareontherise. __________________________

Riskfactors
Age is certainly the most significant risk factor,6 with those older than 65 being particularly at risk2 . Whenthecrystallinelenscloudswithage,thecataractisconsideredsenile.

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Besides age, there are other risk factors. For instance, a traumatic cataract may result from an eye trauma7. The delay between the initial trauma and the onset of symptoms may vary from a few days toseveralyears. Certain medical interventions can cause lens cloudiness, in this case called an iatrogenic cataract. Longterm treatment with corticosteroids may lead to a cataract8. Certain surgical interventions on the eye, for example intraocular implants or vitrectomies, may also cause lens cloudiness8 . Finally, cataractscanalsobeduetoXrayexposure,forinstanceinthecaseofcancerradiotherapy8. In some cases, the cataract is secondary to other medical diseases, such as diabetes9 , or other eye diseaseslikeseveremyopia,uveitis,orglaucoma8. Smokingand alcoholconsumptionare alsocataract riskfactors7. Notethatcataractsmayalreadybe present at birth when the mother contracted measles during pregnancy. This congenital cataract is veryrare,andconcernsfewerthaneightbirthsper100,000.10 __________________________

Symptoms
The cloudiness of the crystalline lens usually develops slowly and progressively. It very often affects botheyes,butatvaryingdegrees11.Dependingonwhichregionofthecrystallinelensisaffected,the cataractcanbeassociatedwithothersymptoms. As the cloudiness of the crystalline lens progresses, light rays are less able to penetrate the lens and reach the retina, and vision becomes obscured. Patients perceive a kind of a fog before their eyes and headlights may appear too bright. Also, halos may appear around lights. All this may be particularly disturbing during the night, due to the headlights of other cars, or on very sunny days7. Colour vision may be altered, with colours appearing faded.7 Another, less common symptom is double vision, called monocular diplopia. Eventually, this condition causes a progressive and painless decreaseinvisualacuity7.Furthermore,infarsightedpatients,myopiamaydeveloptosuchadegree thattheirclosevisionactuallyimproves7. If notice these symptoms, you should consult your ophthalmologist quickly, as a thorough examinationofyoureyesisrequired. __________________________

Diagnosis
The first step is a detailed discussion with your ophthalmologist, who will ask you precise questions aboutyoursymptoms.Hewillthenmeasureyourvisualacuityforcloseanddistancevisionbyasking youtoreadlettersofdifferentsizeonanilluminateddisplay.

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However, the most important examination is performed with an instrument called a slit lamp. It allows your doctor to see with great precision whether your lens is clouded and if you suffer from a cataract. If this is the case, the slit lamp examination allows him to determine the exact location, characteristics,anddimensionsofthecloudiness. In order to exclude all other eye disorders, your ophthalmologist may also perform complementary examinations. A measurement of intraocular pressure allows him to exclude glaucoma, and an examination of the back of your eye permits him to rule out any affliction of the retina or optical nerve. __________________________

Examinations
Inordertodeterminewhetheryousufferfromacataract,theophthalmologistperformsaslitlamp examinationofyoureye. Composedofamobilelightsourceandadoublemicroscope,thisinstrumentallowsthe ophthalmologisttomagnifytheanteriorpartoftheeye,whichconsistsoftheanteriorchamber,the cornea,theiris,thepupil,thevitreousbody,andthecrystallinelens. Thisexamdoesnottakealongtimeandispainless.Sometimes,inordertodilateyourpupilsand facilitatetheexamination,yourophthalmologistmayapplyeyedropsbeforetheexamination.You willsitinfrontoftheapparatuswithyourchinrestingonachinrestandyourforeheadpressedto thedevice.Ontheothersideoftheapparatus,yourophthalmologistwillexamineoneeyeafterthe otherwithabrightlight. __________________________

Progressionandcomplications
Thecataractalwayscausesanincreasingcloudinessofthecrystallinelens,thoughthespeedatwhich thecloudinessdevelopsisvariable.Intheabsenceoftreatment,visualacuitydeterioratesin60%to 70%ofpatientswithin2years.2Thisdeteriorationseemstobemorerapidinpatientssufferingfrom cloudinesslocatedontheposteriorlenscapsuleandinpatientsaffectedbyjuvenilediabetes2.With time,cataractsmaycloudthecrystallinelenscompletelyandcauseblindness6.Othercomplications maybeobservedifthecataractisnotappropriatelytreated.Inrarecases,asharpincreaseinthe crystallinelensvolumemayprovokeanincreaseinintraocularpressureand,byextension,acute glaucoma7.Pleasenotethatinindustrializednations,cataractsarewelltreatedwithsurgery, permittingustoavoidthesecomplications.InFrance,cataractsurgeryisthemostfrequentformof surgicalintervention,andisperformed500,000timeseachyear.12 __________________________
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Treatment
Today,theonlycurativetreatmentissurgery.Itconsistsofreplacingthecrystallinelenswithan intraocularimplantinordertocompensateforitsdecreasingrefractorypower. Indications Ingeneral,cataracttreatmentisnotanemergencyoperation.Thedecisiontooperatewilldependon theseriousnessofyourcomplaintsandtheextentofyourvisionloss.Yourophthalmologistwillalso takeintoaccountyoursocioprofessionalbackgroundandthepresenceofotherconcomitantfactors whichaffectyourvisualacuity.Thereisnovisualacuitythresholdwhichclearlyindicatessurgery,but generallyasurgicalinterventionisproposedwhenyourvisualacuityislessthan4to5/10ths.13 Techniques Threedifferenttechniquesmaybeemployedtoextractthecataract: Intracapsularextractioninvolvesthecreationofawideopeninginthecorneainordertoremovethe entirecrystallinelenswithaninstrumentcalledacryode.Thereafter,anintraocularimplantisput intoplace.Today,thistechniqueisnolongerused. Extracapsularextractioninvolvesalongerincisiononthesideofthecornea,andremovesthe crystallinecoreandcortexwithaspatulashapedtool,whileleavingthecapsuleinplace.Following this,thesurgeonintroducestheintraocularimplantintothecapsule.Thistechniqueisnowusedless andlessfrequently,asithasbeenreplacedbythefollowingprocedure,butitisstillemployedwhen thecloudinessisverydense. Phacoemulsificationisthetechniqueofchoiceinindustrializedcountriesforseveralreasons:itis effective,successisrelativelypositive,and,asitinvolvesonlyaverysmallincision,recoveryofvision isveryquick12.Duringphacoemulsification,asmallincisionismadeonthesideofthecornea,anda tinyprobeisinsertedintoyoureye.ThisdeviceemitsUltrasoundwavesthatsoftenandbreakup yourlens,allowingittoberemovedbysuctionwithoutdisplacingthelenscapsule.Anintraocular implantisthenputintoplace. Results Asthesurgicalinterventionismostoftenconductedunderlocalanaesthesia12,itcanbeperformed asanoutpatientprocedure.Note,however,thatyouwillnotbeallowedtodriveonthedayofthe procedure,soyoushouldmakeappropriateprovisions. Thedayafterthesurgery,youwillhavetoreturntoseeyoursurgeon,whowillexaminethestateof youreye.Regularvisitsonascheduledeterminedbyyourophthalmologistwillbenecessary thereafteraspartofalongtermfollowup. Ingeneral,resultsareverypositive.Inthemajorityofcases,visionrecoverswithin4daysofthe operation12andmorethan90%ofpatientsachievevisualacuitygreaterthanorequalto5/10ths withoutcorrectivelenses.2 Potentialcomplications Cataractsurgeryisusuallyverywelltolerated.Note,however,thatanysurgicalinterventioncarriesa riskofcomplications.Ifyounoticeasuddendecreaseinyourvisualacuityorifyoureyebecomes painfulorred,youmustconsultyourophthalmologistimmediately.
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Potentialcomplicationsincludeaneyeinfectioncalledendophtalmia,glaucoma,retinaldetachment, implantdisplacement,ormacularoedema.However,thesecomplicationsareveryrare2. Another,morecommoncomplicationofcataractsurgeryisthedevelopmentofasecondarycataract, calledaposteriorcapsuleopacification.Inthiscase,thecrystallinecapsulewhichsurgeryleftinplace becomescloudyagainandsymptomsreappear.Thiscomplicationisobservedin18%ofpatients within1yearaftersurgeryandin38%within9years1.Secondarycataractsdevelopgraduallyand progressivelywithtime,usuallyoccurringbetween3monthsand4yearsfollowingsurgery1.Laser treatment,calledcapsulotomy,isthetreatmentofchoiceinthecaseofthiscomplication.1 __________________________

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References

1Affsaps,HauteAutoritdeSant.Miseaupointsurlesimplantsintraoculairesmonofocaux utilissdansletraitementchirurgicaldelacataracte.Avril2008.p.14. 2TheRoyalCollegeofOphthalmologists.Cataractsurgeryguidelines2004.p.6. 3ANAES.Evaluationdutraitementchirurgicaldelacataractedeladulte.Fvrier2000.p.4. 4 Millar WJ. Problmes de vision chez les personnes ges. Dans: Rapports sur la sant. Volume16n1.StatistiqueCanada.2004.p.4954. 5 Institut Scientifique de la Sant Publique. Enqute de sant par interview Belgique 2004. LivreIIChapitre2:Maladiesetaffectionschroniques.2006.p.667. 6OrganisationMondialedelaSant.Prventiondelaccitetdesdficiencesvisuelles Cataracte.http://www.who.int/blindness/causes/priority/fr/index1.html. 7BeersMH,PorterRS,JonesVTetal.Cataracte.Dans:LemanuelMerck.MerckResearch Laboratories2006,p.9112. 8BaudouinC,FlixD.Certainstraitementspeuventilsprovoquerunecataracte.Dans: CataracteGuidelusagedespatientsetdeleurentourage.Bash2008,p.51. 9MalecazeF.Lachirurgiedelacataractechezlediabtique.Journalfranais dophtalmologie2003;26:5257. 10Confrenceeuropennesurlesmaladiesrares.Luxembourg,2122juin2005.p.21. 11BaudouinC,FlixD.Lacataracteestellerversible?Atteintelletoujourslesdeuxyeux? Dans:CataracteGuidelusagedespatientsetdeleurentourage.Bash2008,p.43. 12AncelJM.Lesprogrsdelacataracteen2008.EmmoiresdelAcadmieNationalede Chirurgie2008;7:4344. 13BaudouinC,FlixD.Surquelscritreslophtalmologisteprendilladcisiondeproposer uneintervention?Dans:CataracteGuidelusagedespatientsetdeleurentourage.Bash 2008,p.6970.

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