What is Complicated Cataract?

A cataract is a condition that clouds the eye’s natural lens, blocking light from reaching the retina and causing vision loss. This can dramatically impact a person’s day-to-day life. A complicated cataract is a specific type where the lens becomes clouded due to other eye diseases, particularly types of inflammation affecting different layers of the eye, known as uveitis. However, other eye conditions can also lead to complicated cataracts. This issue is particularly disabling in younger people because it not only affects their vision but also necessitates cataract surgery, which carries its own risks.

Cataracts associated with uveitis form because of ongoing inflammation and the use of steroids. Managing a complicated cataract can be a difficult task for an eye doctor, as it involves not only addressing the cataract but also carefully controlling the inflammation and treating the underlying eye disease. Therefore, a team-based approach, involving various medical specialists, is often necessary.

What Causes Complicated Cataract?

Complicated cataracts can be caused by multiple conditions within the eye:

1. Inflammatory conditions like iridocyclitis, pars planitis, posterior uveitis, hypopyon corneal ulcers, and endophthalmitis. These often start as an alteration in the back part of the lens of the eye.

2. Degenerative conditions such as essential iris atrophy, Retinitis Pigmentosa, myopic chorioretinal degenerations, and other pigmentary retinal dystrophies. Cataract is a common complication of retinitis pigmentosa, which affects the front segment of the eye. The cataract usually begins at the back of the lens but can also affect the front face or the interior of the lens.

3. Prolonged retinal detachment – this can also result in complicated cataracts.

Conditions like glaucoma, either primary or secondary, can lead to cataracts. If glaucoma causes a high rise in eye pressure, it can result in grey-white cloudy spots on the front part of the eye’s lens. Intraocular tumors, such as retinoblastoma, melanoma, and metastatic tumors, can also cause complicated cataracts.

In many cases, complicated cataracts occur as a result of long-term eye inflammation caused by the conditions mentioned above or the use of corticosteroids to treat inflammation. Therefore, it’s crucial to understand the primary eye condition to effectively manage the complicated cataract.

Risk Factors and Frequency for Complicated Cataract

Cataracts are a leading cause of vision loss and blindness. It’s estimated that around 20 million people are blind due to cataracts. Complicated cataracts, which develop due to persistent or recurrent uveitis (inflammation of the middle layer of the eye), are common. They can be caused by inflammation inside the eye and steroid therapy, causing about 40% of vision problems in patients with uveitis.

  • Complicated cataracts are responsible for about 1.2% of all cataract surgeries.
  • The likelihood of developing cataracts increases as people get older.
  • In 2013, over 22 million people in the United States had cataracts, with the figure rising to 30.1 million by 2020.
  • About 70% of people aged 80 or over have cataracts.
  • Cataracts are more common in females.

Signs and Symptoms of Complicated Cataract

To diagnose an eye condition, doctors need to do thorough eye and body examinations. They must identify and address the main cause inside the eye.

When investigating a patient’s history, they typically ask about the following:

  • Vision changes, including when it started, how it developed, if it has changed, the characteristics of the change, how it varies throughout the day, and any related symptoms such as eye pain, redness, or watering.
  • Associated visual disturbances such as flashes, floaters, coloured rings around lights, glare, or double vision.
  • Previous episodes of eye pain or redness.
  • Treatment history, including the use of steroids, drugs that suppress the immune system, any surgical procedures, or chemotherapy for eye tumors.
  • Past incidents of trauma.
  • Existing health conditions like diabetes, high blood pressure, autoimmune diseases, tuberculosis, or sarcoidosis.

A general physical examination is done, which typically involves checking the patient’s pulse, breathing rate, and blood pressure. A systemic examination is carried out to look for any body-wide illness.

The comprehensive eye examination consists of assessing:

  • Visual acuity without correction, after considering correcting factors, and near vision.
  • Intraocular pressure to rule out eye conditions like glaucoma and hypotony.
  • The lacrimal (tear) system to ensure there’s no obstruction.
  • Pupil reactions to evaluate the optic nerve.
  • Different sections of the eye, such as the cornea, anterior chamber, iris, and lens; and looking for any abnormalities there.
  • Crystaline lens for an underlying cataract condition. The cataract often starts as a specific type and shape, showing up as “breadcrumb” on the slit lamp (an eye examination tool). Gradually becomes a full cataract.
  • Vitreous (gel-like substance in the eye) to reveal any opacities or cells in the eye cavity.
  • The macula (area at the back of the eye) for signs of damage. Also, the optic disc is assessed for damage due to glaucoma.
  • The back of the eye after dilation for any retinal detachments or tumors.

The doctors may also look for degenerative retinal conditions, such as retinitis pigmentosa (a genetic disorder that causes loss of vision), which commonly associates with cataract development. The typical signs in retinitis pigmentosa include certain patterns in the mid-periphery of the eye, a pale optic disc, and thinned retinal blood vessels.

Testing for Complicated Cataract

If vision loss is primarily due to the formation of a cataract, a surgery to remove the cataract is usually the most beneficial treatment. The success of this operation depends on many factors, including the diagnosis, the patient’s care before, during, and after surgery, and how meticulous the surgery itself is. Conditions that affect only the front section of the eye tend to have better outcomes than those impacting the back section of the eye. It’s vital to evaluate the eye’s potential for visual improvement before planning cataract surgery because it significantly influences the visual outcome. Additional tests can identify other eye conditions that could affect surgery or require additional or multiple-step procedures.

Lab Tests:

Broad tests could include a complete blood count, tests for inflammation markers such as erythrocyte sedimentation rate and C-reactive protein, and a blood sugar check. If the patient’s medical history or physical examination suggests other conditions, more specific tests could be required. These tests could check for tuberculosis, sarcoidosis, syphilis, infections during pregnancy (TORCH), rheumatoid arthritis, and other autoimmune diseases.

Eye Tests:

Several eye-specific tests might be done:

1. Gonioscopy – Examines the drainage angle of the eye.
2. Laser Flare Meter – Measures inflammation in the front section of the eye and can guide treatment.
3. Ultrasound B Scan – Checks the retina status when the lens is completely cloudy, rules out excessive fluid or tumors in the eye.
4. Ultrasound Biomicroscopy – Done in eyes with low pressure to check the status of the ciliary body (a ring of tissue behind the peripheral iris), its processes, the ring of fibers (zonules) around the lens, the status of the back of the lens, and any inflammation in the eye.
5. OCT of the Macula – Evaluates the thickness of the macula and the presence of abnormal blood vessels or a thin layer of scar tissue on the retina.
6. Fundus Fluorescein Angiography – Checks for lack of oxygen, swelling, or fluid leakage in the retina.
7. Perimetry – Done if any optic nerve disease is suspected.

Ultrasound Biometry is useful for calculating optical parameters such as the length of the eye, the depth of the front section of the eye, and the thickness of the lens. These measurements are necessary for determining the required power of the intraocular lens that replaces the natural lens after cataract surgery. Other devices can be used to evaluate the potential for vision improvement.

Treatment Options for Complicated Cataract

In managing patients with complex cataracts, it’s crucial to properly diagnose the cause of the cataract. This allows doctors to choose the patients who’ll benefit most from cataract surgery. Since most complex cataracts occur following inflammation of the uvea (the middle layer of the eye), special attention must be paid to managing this type of cataract.

One aspect of cataract management is controlling inflammation both before and after surgery. Steroids can be used to reduce the risk of complications after surgery. These can be given as eye drops, orally, or around the eye. The goal is to control any inflammation inside the eye to prevent complications during and after surgery. For patients with a high risk of complications, such as those with sarcoidosis or previous episodes of swelling at the back of the eye (known as cystoid macular edema), steroid treatment should be started early. Additional steroid treatment can also be given during surgery for good control.

In some cases, like certain inflammatory diseases or if a patient has infectious inflammation of the eye, oral anti-viral medications should be given before surgery to prevent recurrence of inflammation.

As for the surgical management of uveitic cataracts, surgery becomes necessary under several conditions. For instance, when lens proteins leak and cause inflammation, when the cataract significantly impairs vision and thus needs to be removed, or when the cataract blocks the doctor’s ability to see the back of the eye. Surgery should only be performed when the eye has been inflammation-free for at least three months to reduce the risk of complications after the operation.

Cataract surgery usually involves a small cut in the eye and removal of the cataract. The surgeon then replaces it with an artificial lens. The exact technique varies based on the firmness of the cataract and any additional eye conditions the patient might have. A specific type of lens made of acrylic is preferred, as it lowers the chance of complications compared to other types of lenses.

However, cataract surgery can be challenging, especially if the patient has a small pupil, scar tissue between the iris and cornea, or a cloudy cornea. Introducing adrenaline into the eye or using special devices can help manage these issues. Other possible complications during surgery can include tears in the posterior capsular (the thin layer around the back part of the lens), weak zonular fibers which hold the lens in place, or hemorrhage in the anterior chamber (the front part of the eye). A surgeon must be prepared to manage these potential complications to ensure successful cataract surgery.

When considering a complex cataract, which is a secondary condition, doctors look at the possibility of other health problems including:

  • Uveitis (inflammation of the middle layer of the eye)
  • Glaucoma (an eye condition that damages the optic nerve)
  • Retinal Detachment (when the retina at the back of the eye pulls away from its normal position)
  • Retinitis Pigmentosa (a group of rare, genetic disorders that involve a breakdown and loss of cells in the retina)
  • Optic Atrophy (damage to the optic nerve that can affect vision)
  • Intraocular Tumors (tumors inside the eye)
  • Refractive Errors (vision issues caused by the shape of the eye preventing light from focusing directly on the retina)
  • Macular Degenerations (an age-related disease that gradually destroys sharp, central vision)

Physicians must consider these potential conditions and conduct proper tests before they can confirm a diagnosis of a complex cataract.

What to expect with Complicated Cataract

Cataract removal surgery typically leads to improved vision. However, the final outcome also depends on the original cause of the vision loss.

In cases where the vision issues are caused by inflammatory conditions, like uveitis, the final result can vary. It depends on the specific type of uveitis and how well inflammation is controlled before and after surgery. Fuchs’ heterochromic iridocyclitis patients generally see good results with minimal inflammation after surgery. On the other hand, vision results for juvenile arthritis-associated uveitis patients are uncertain due to the high chances of inflammation post-surgery. However, carefully managing inflammation can lead to satisfactory vision results. People with Behcet’s disease may face complications due to severe inflammation and other issues such as optic atrophy and an epiretinal membrane. In addition to these autoimmune conditions, for infectious uveitis patients, it’s imperative to receive proper antimicrobial treatment as there’s a high risk of recurrence, which could complicate post-surgery results.

In degenerative conditions, where vision loss is primarily due to severe cataracts rather than another medical condition, removing the cataract and placing an intraocular lens (IOL) usually improves vision. However, patients with significant damage to the macula (the central part of the retina) may not see much improvement. Also, patients who have had a detached retina, glaucoma, or intraocular tumors may not see improved vision post-surgery if the original condition caused extensive damage to the eye’s interior.

Possible Complications When Diagnosed with Complicated Cataract

During eye surgery, there can be certain issues that may arise. These are known as intraoperative complications, which include conditions such as Zonulolysis, which can happen if the patient has chronic uveitis. In such cases, a capsular tension ring (CTR) is usually required. This helps to avoid improper placement of intraocular lenses (IOL) because of major zonular weakness. Another intraoperative complication is phototoxic retinal damage. Sometimes, due to poor visibility during surgery, small pieces of the lens or nucleus may get left behind in the eye. This can later lead to severe inflammation so, careful extraction is crucial.

Another condition known as Posterior capsular rent can lead to significant postoperative inflammation and needs to be carefully managed. This usually involves the performance of an anterior vitrectomy and careful IOL implantation based on the capsular status. If the patient lacks significant support for the IOL, a scleral fixated IOL can be used or the patient may be left without a lens (aphakic).

After the operation, there may be a few complications. These can include excessive inflammation, abnormal intraocular pressure (IOP), recurrence of uveitis, and opacification of the posterior capsule. If inflammation is not controlled, oral steroids are usually needed. Abnormal IOP can be high or low. High IOP may be due to compromised trabecular meshwork or angles and managed with anti-glaucoma medications. Low IOP can result from choroidal detachment or phthisis bulbi and managed using oral steroids.

Another major issue associated with eye surgeries is Endophthalmitis Cystoid macular edema. This can occur as a complication prior and after the surgery. It is a significant contributor to blindness in uveitis patients. The condition arises due to the inflammation-induced breakdown of the inner or outer blood-retinal barrier. Steroids administered in various forms, such as topical, oral, periocular, or intravitreal, are the main treatment for this condition.

Recovery from Complicated Cataract

After surgery, patients are usually given eye drops containing prednisolone acetate 1%, flurbiprofen, moxifloxacin or tobramycin, as well as eye ointment containing atropine 1%. These are intended to help manage inflammation. It’s crucial to keep an eye on the pressure inside the eye, and medication may be provided if necessary.

If the patient was already taking oral corticosteroids or any preventative antibiotics, they should keep taking their usual dose. These medications should be decreased slowly as the inflammation lessens. In some cases, such as severe eye inflammation or conditions like Vogt-Koyanagi-Harada disease, Behcet disease, or for patients with one eye, oral corticosteroids are necessary.

In patients who have had a particular type of lens replacement surgery (pseudophakic patients), they will find that they can no longer naturally adjust or “accommodate” their close-up vision. Because of this, once the patient’s eye condition has stabilized after surgery, reading glasses should be prescribed to help improve their near vision.

Preventing Complicated Cataract

A complicated cataract can greatly affect a patient’s vision, adding to the consequences of the existing eye disease. This can significantly impact the patient not just physically, but psychologically as well. As a result, it’s essential for the patients to fully understand their condition, potential risks, benefits of timely treatment, and the importance of long-term tracking of their condition. Especially because these patients likely have been receiving treatment for an extended period already, it’s crucial to provide thoughtful advice and support throughout their health care journey.

Frequently asked questions

A complicated cataract is a specific type where the lens becomes clouded due to other eye diseases, particularly types of inflammation affecting different layers of the eye, known as uveitis.

Complicated cataracts are responsible for about 1.2% of all cataract surgeries.

Signs and symptoms of Complicated Cataract may include: - Vision changes, such as blurriness or cloudiness in the affected eye. - Difficulty seeing in low light or at night. - Sensitivity to glare or bright lights. - Double vision or multiple images in one eye. - Changes in color perception. - Frequent changes in eyeglass or contact lens prescription. - Halos around lights. - Poor night vision. - Decreased visual acuity. - Eye pain or discomfort. - Redness or inflammation in the eye. - Watery eyes. - Difficulty reading or performing close-up tasks. - Decreased depth perception. - Problems with contrast sensitivity. - Visual disturbances, such as flashes of light or floaters. - Gradual or sudden vision loss. - Difficulty driving, especially at night. - Impaired ability to perform daily activities that require clear vision. It is important to note that these signs and symptoms may vary depending on the severity and specific characteristics of the Complicated Cataract. It is always recommended to consult with a healthcare professional for a proper diagnosis and treatment.

Complicated cataracts can be caused by multiple conditions within the eye, including inflammatory conditions, degenerative conditions, prolonged retinal detachment, glaucoma, and intraocular tumors.

The doctor needs to rule out the following conditions when diagnosing Complicated Cataract: - Uveitis (inflammation of the middle layer of the eye) - Glaucoma (an eye condition that damages the optic nerve) - Retinal Detachment (when the retina at the back of the eye pulls away from its normal position) - Retinitis Pigmentosa (a group of rare, genetic disorders that involve a breakdown and loss of cells in the retina) - Optic Atrophy (damage to the optic nerve that can affect vision) - Intraocular Tumors (tumors inside the eye) - Refractive Errors (vision issues caused by the shape of the eye preventing light from focusing directly on the retina) - Macular Degenerations (an age-related disease that gradually destroys sharp, central vision)

To properly diagnose complicated cataract, a doctor may order the following tests: Lab Tests: - Complete blood count - Tests for inflammation markers such as erythrocyte sedimentation rate and C-reactive protein - Blood sugar check - Specific tests for conditions such as tuberculosis, sarcoidosis, syphilis, infections during pregnancy (TORCH), rheumatoid arthritis, and other autoimmune diseases Eye Tests: - Gonioscopy to examine the drainage angle of the eye - Laser Flare Meter to measure inflammation in the front section of the eye - Ultrasound B Scan to check the retina status and rule out excessive fluid or tumors in the eye - Ultrasound Biomicroscopy to check the status of the ciliary body, processes, zonules, back of the lens, and any inflammation in the eye - OCT of the Macula to evaluate the thickness of the macula and presence of abnormal blood vessels or scar tissue on the retina - Fundus Fluorescein Angiography to check for lack of oxygen, swelling, or fluid leakage in the retina - Perimetry if optic nerve disease is suspected Ultrasound Biometry may also be used to calculate optical parameters for determining the required power of the intraocular lens after cataract surgery. Additionally, other devices can be used to evaluate the potential for vision improvement. Managing complicated cataracts involves properly diagnosing the cause of the cataract and controlling inflammation before and after surgery.

Complicated cataract is treated through a combination of managing inflammation, using steroids to control inflammation before and after surgery, and administering oral anti-viral medications in certain cases. Surgery is necessary when the cataract significantly impairs vision, causes inflammation, or blocks the doctor's ability to see the back of the eye. The eye must be inflammation-free for at least three months before surgery to reduce the risk of complications. During surgery, the cataract is removed and replaced with an artificial lens. Special techniques and devices may be used to manage challenges such as a small pupil, scar tissue, or a cloudy cornea. Surgeons must be prepared to handle potential complications to ensure successful cataract surgery.

When treating complicated cataracts, there can be side effects associated with the treatment. These side effects include: - Complications from inflammation, such as cystoid macular edema or swelling at the back of the eye. - Adverse effects from steroid treatment, which can be given as eye drops, orally, or around the eye. These side effects may include increased intraocular pressure, cataract formation, or delayed wound healing. - Potential complications during surgery, such as tears in the posterior capsular, weak zonular fibers, or hemorrhage in the anterior chamber. - Intraoperative complications, including zonulolysis and phototoxic retinal damage. - Postoperative complications, such as excessive inflammation, abnormal intraocular pressure, recurrence of uveitis, or opacification of the posterior capsule. - Endophthalmitis, which is a severe infection of the eye that can occur as a complication before or after surgery.

The prognosis for complicated cataract depends on the underlying cause of the vision loss. In cases where the vision issues are caused by inflammatory conditions like uveitis, the final result can vary. Patients with Fuchs' heterochromic iridocyclitis generally see good results with minimal inflammation after surgery, while patients with juvenile arthritis-associated uveitis may have uncertain vision results due to the high chances of inflammation post-surgery. Carefully managing inflammation can lead to satisfactory vision results. In degenerative conditions where vision loss is primarily due to severe cataracts, removing the cataract and placing an intraocular lens usually improves vision, unless there is significant damage to the macula or other extensive damage to the eye's interior.

An eye doctor or ophthalmologist.

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