Cataracts

Background

Eye anatomy.

• Opacification of the lens of one or both eyes, which can lead to decreased visual acuity and visual distortions
• Most commonly due to normal age related changes, however they can also be caused by eye trauma, exposure to sunlight or radiation, malnutrition, corticosteroid use, and other pathologic processes
• By age 80, approximately 50% of Americans have been diagnosed with one or more cataracts
• Additional risk factors for cataract include diabetes, smoking, prolonged exposure to sunlight, and alcohol use
• Typically a non-emergent pathology and can be managed with outpatient ophthalmologic surgery on a routine basis.
  • With the exception of traumatic cataract, vision loss from cataract is typically not acute; rather, develops over the course of months to years.

Clinical Features

The appearance of a dense, white cataract in a 60 year-old male.

• Vision loss typically not acute but develops over months to years (unless traumatic cataract)

History

• Cloudy or blurry vision
• Difficulty with night time vision
• Colors appear faded
• Appearance of a halo around bright lights
• +/- Recent trauma to the eye

Exam Findings

• Lens opacity
• Darkening of red reflex
• Decreased visual acuity

Differential Diagnosis

Acute Vision Loss (Noninflamed)

• Painful
  • Arteritic anterior ischemic optic neuropathy
  • Optic neuritis
  • Temporal arteritis^†
• Painless
  • Amaurosis fugax
  • Central retinal artery occlusion (CRAO)^†
  • Central retinal vein occlusion (CRVO)^†
  • High altitude retinopathy
  • Open-angle glaucoma
  • Posterior reversible encephalopathy syndrome (PRES)
  • Retinal detachment^†
  • Stroke^†
  • Vitreous hemorrhage
  • Traumatic optic neuropathy (although may have pain from the trauma)

^†Emergent Diagnosis

Subacute Vision Loss (Noninflamed)

• Cataracts
• Congenital blindness
• Diabetic retinopathy

Orbital trauma

Acute

• Caustic keratoconjunctivitis^^
• Conjunctival hemorrhage
• Conjunctival laceration
• Corneal abrasion, Corneal laceration
• Globe rupture^
• Iridodialysis
• Lens dislocation
• Ocular foreign body
• Orbital fracture
  • Frontal sinus fracture
  • Naso-ethmoid fracture
  • Inferior orbial wall fracture
  • Medial orbital wall fracture
• Posterior vitreous detachment
• Retinal detachment
• Retrobulbar hemorrhage/hematoma
  • Ocular compartment syndrome
• Subconjunctival hemorrhage
• Traumatic hyphema
• Traumatic iritis
• Traumatic mydriasis
• Traumatic optic neuropathy
• Vitreous detachment
• Vitreous hemorrhage
• Ultraviolet keratitis

Subacute/Delayed

• Corneal ulcer^
• Endophthalmitis^

Unilateral red eye

• Nontraumatic
  • Acute angle-closure glaucoma^
  • Anterior uveitis
  • Conjunctivitis
  • Corneal erosion
  • Corneal ulcer^
  • Endophthalmitis^
  • Episcleritis
  • Herpes zoster ophthalmicus
  • Inflamed pinguecula
  • Inflamed pterygium
  • Keratoconjunctivitis
  • Keratoconus
  • Nontraumatic iritis
  • Scleritis^
  • Subconjunctival hemorrhage
• Orbital trauma
  • Caustic keratoconjunctivitis^^
  • Corneal abrasion, Corneal laceration
  • Conjunctival hemorrhage
  • Conjunctival laceration
  • Globe rupture^
  • Hemorrhagic chemosis
  • Lens dislocation
  • Ocular foreign body
  • Posterior vitreous detachment
  • Retinal detachment
  • Retrobulbar hemorrhage
    • Ocular compartment syndrome
  • Traumatic hyphema
  • Traumatic iritis
  • Traumatic mydriasis
  • Traumatic optic neuropathy
  • Vitreous detachment
  • Vitreous hemorrhage
  • Ultraviolet keratitis

^Emergent diagnoses ^^Critical diagnoses

Evaluation

• Typically diagnosed clinically by the finding of lens opacity on direct ophthalmic exam
  • Precise classification (nuclear, cortical, posterior sub-capsular) may be done by ophthalmologist
• If the patient has risk factors for diabetes or HIV/AIDS, consider appropriate diagnostic tests

Management

• Definitive treatment is (typically outpatient, non-emergent) surgery, wherein clouded lens is removed and replaced with clear, artificial lens
• Other supportive care modalities that help with visual symptoms include:
• Using brighter lights while at work or at home
• A trial of anti-glare sunglasses for outdoor activities
• Using magnifying lens glasses for reading and other daily

Disposition

• Discharge with optho follow up

See Also

• Acute Vision Loss (Noninflamed)
• Orbital trauma
• Unilateral red eye

External Links

• https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/cataracts
• https://www.aao.org/young-ophthalmologists/yo-info/article/how-to-conduct-eight-point-ophthalmology-exam