CASE REPORT MATURE CATARACT

Craeted by: Mega Heksana Devi I11106028 Oponent: Dian. A Gerry Juwita Kwan C Mutia A.P

SMF MATA RSUD DR. SOEDARSO FACULTY OF MEDICINE PONTIANAK 2010

Lembar Persetujuan

Telah disetujui Presentasi Kasus dengan Judul: KATARAK MATUR

Telah disetujui, Pontianak, 29 April 2010 Konsulen Disusun oleh :

dr. Moh. Iqbal, Sp.M.M.kes

Mega Heksana Devi I11106028

CHAPTER I INTRODUCTION A cataract is a clouding of the eye's natural lens, which lies behind the iris and the pupil. The lens works much like a camera lens, focusing light onto the retina at the back of the eye. The lens also adjusts the eye's focus, letting us see things clearly both up close and far away.(1) Aging is the most common cause of cataract (esp. persons over 65-70 years) but many other factors can be involved, including trauma, toxins, systemic disease, and heredity. Age related cataract is a common cause of visual impairment. Cataract usually happens in both eyes, but traumatic cataract may happen in only one eye. Congenital cataract remains stationary. When cataract have progressed enough to seriously impair patient's vision and affects patient's daily life, it will be treated by day surgery operation. The lens is mostly made of water and protein. The protein is arranged in a precise way that keeps the lens clear and lets light pass through it. But as we age, some of the protein may clump together and start to cloud a small area of the lens. This is a cataract, and over time, it may grow larger and cloud more of the lens, making it harder to see. Researchers are gaining additional insights about what causes these specific types of proteins (crystallins) to cluster in abnormal ways to cause lens cloudiness and cataracts. One recent finding suggests that fragmented versions of these proteins bind with normal proteins, disrupting normal function.

CHAPTER II LITERATURE REVIEW A. Definition The term cataract is derived from the Greek word cataractos, which describes rapidly running water. When water is turbulent, it is transformed from a clear medium to white and cloudy. Keen Greek observers noticed similar-appearing changes in the eye and attributed visual loss from "cataracts" as an accumulation of this turbulent fluid, having no knowledge of the anatomy of the eye or the status or importance of the lens.(1) A cataract is a clouding of the eye's natural lens, which lies behind the iris and the pupil. The lens works much like a camera lens, focusing light onto the retina at the back of the eye. The lens also adjusts the eye's focus, letting us see things clearly both up close and far away. Cataract development is usually a very gradual process of normal aging but can occasionally occur rapidly. Many people are in fact unaware that they have cataracts because the changes in their vision have been so gradual. Cataracts commonly affect both eyes, but it is not uncommon for cataracts in one eye to advance more rapidly. Cataracts are very common, affecting roughly 60% of people over the age of 60, and over 1.5 million cataract surgeries are performed in the United States each year.

B. Anatomy of the Lens

Lens is avascular structure that facilitates image focus, made of 3 components: a) Lens capsule: the basement membrane of the epithelial cells that is an homogenous

translucent CT matrix rich in glycoprotein. Zonule fibers attach to this around the periphery of the lens b) c) Subcapsular epithelium: single layer of cuboidal cells Lens fibers: elongated cells derived from the subcapsular epithelia near the equator of the

lens. As the cells grow and are pushed to the optical axis of the lens, they loose their nuclei. At the optical axis, the cells are hexagonal and pack in a highly organized fashion with little intercellular space. Cells contain few organelles but are high in protein (60 -70%). Major protein in lens is crystallins that have function to increase refractive index of cytosol. C. Classification of Cataract 1. Congenital Cataract : Some babies are born with cataracts or develop them in childhood, often in both eyes. These cataracts may be so small that they do not affect vision. If they do, the lenses may need to be removed. 2. Traumatic Cataracts : Cataracts can develop after an eye injury, sometimes years later.
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3. Secondary Cataracts :Cataracts can form after surgery for other eye problems, such as glaucoma. Cataracts also can develop in people who have other health problems, such as diabetes. Cataracts are sometimes linked to steroid use 4. Senile Cataract SENILE CATARACT Senile cataract is a vision-impairing disease characterized by gradual, progressive thickening of the lens. It is one of the leading causes of blindness in the world today. This is unfortunate, considering that the visual morbidity brought about by age-related cataract is reversible. As such, early detection, close monitoring, and timely surgical intervention must be observed in the management of senile cataracts. The succeeding section is a general overview of senile cataract and its management. 1,2 Causes Numerous studies have been conducted to identify risk factors for development of senile cataracts. Various culprits have been implicated, including environmental conditions, systemic diseases, diet, and age. West and Valmadrid stated that age-related cataract is a multifactorial disease with different risk factors associated to the different cataract types. In addition, they stated that cortical and posterior subcapsular cataracts were related closely to environmental stresses, such as ultraviolet (UV) exposure, diabetes, and drug ingestion. However, nuclear cataracts seem to have a correlation with smoking. Alcohol has been associated with all cataract types. A similar analysis was completed by Miglior et al. They found that cortical cataracts were associated with the presence of diabetes for more than 5 years and increased serum potassium and sodium levels. A history of surgery under general anesthesia and the use of sedative drugs were associated with reduced risks of senile cortical cataracts. Posterior subcapsular cataracts were associated with steroid use and diabetes, while nuclear cataracts had significant correlations with calcitonin and milk intake. Mixed cataracts were linked with a history of surgery under general anesthesia.
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Systemic diseases and senile cataract Senile cataracts have been associated with a lot of systemic illnesses, to include the following: cholelithiasis, allergy, pneumonia, coronary disease and heart insufficiency, hypotension, hypertension, mental retardation, and diabetes. Systemic hypertension was found to significantly increase the risk for posterior subcapsular cataracts. In a related study by Jahn et al, hypertriglyceridemia, hyperglycemia, and obesity was found to favor the formation of posterior subcapsular cataracts at an early age. A possible pathway for the role of hypertension and glaucoma in senile cataract formation was proposed with induced changes in the protein conformational structures in the lens capsules, subsequently causing alterations in membrane transport and permeability of ions, and, finally, increasing intraocular pressure resulting in the exacerbation of cataract formation.

UV light and senile cataract The association of UV light and development of senile cataract has generated much interest. One hypothesis implies that senile cataracts, particularly cortical opacities, may be the result of thermal damage to the lens. An animal model by Al-Ghadyan and Cotlier documented an increase in the temperature of the posterior chamber and lens of rabbits after exposure to sunlight due to an ambient temperature effect through the cornea and to increased body temperature. In related studies, people living in areas with greater UV exposure were more likely to develop senile cataracts and to develop them earlier than people residing in places with less UV exposure.1,2

Other risk factors Significant associations with senile cataract were noted with increasing age, female sex, social class, and myopia. Consistent evidence from the study of West and Valmadrid suggested that the prevalence of all cataract types was lower among those with higher education. Workers exposed to infrared radiation also were found to have a higher incidence of senile cataract development. Although myopia has been implicated as a risk factor, it was shown that persons with myopia who had worn eyeglasses for at least 20 years underwent cataract extraction at a significantly older age than emmetropes, implying a protective effect of the eyeglasses to solar UV radiation. The role of nutritional deficiencies in senile cataract has not been proven or established. However, a high intake of the 18-carbon polyunsaturated fatty acids linoleic acid and linolenic acid reportedly may result in an increased risk of developing age-related nuclear opacity.

Pathophysiology The pathophysiology behind senile cataracts is complex and yet to be fully understood. In all probability, its pathogenesis is multifactorial involving complex interactions between various physiologic processes. As the lens ages, its weight and thickness increases while its accommodative power decreases. As the new cortical layers are added in a concentric pattern, the central nucleus is compressed and hardened in a process called nuclear sclerosis.2 Multiple mechanisms contribute to the progressive loss of transparency of the lens. The lens epithelium is believed to undergo age-related changes, particularly a decrease in lens epithelial cell density and an aberrant differentiation of lens fiber cells. Although the epithelium of cataractous lenses experiences a low rate of apoptotic death, which is unlikely to cause a significant decrease in cell density, the accumulation of small scale epithelial losses may consequently result in an alteration of lens fiber formation and homeostasis, ultimately leading to loss of lens transparency. Furthermore, as the lens ages, a reduction in the rate at which water and, perhaps, water-soluble low-molecular weight metabolites can enter the cells of the lens
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nucleus via the epithelium and cortex occurs with a subsequent decrease in the rate of transport of water, nutrients, and antioxidants. 2 Consequently, progressive oxidative damage to the lens with aging takes place, leading to senile cataract development. Various studies showing an increase in products of oxidation (eg, oxidized glutathione) and a decrease in antioxidant vitamins and the enzyme superoxide dismutase underscore the important role of oxidative processes in cataractogenesis. Another mechanism involved is the conversion of soluble low-molecular weight cytoplasmic lens proteins to soluble high molecular weight aggregates, insoluble phases, and insoluble membrane-protein matrices. The resulting protein changes cause abrupt fluctuations in the refractive index of the lens, scatter light rays, and reduce transparency. Other areas being investigated include the role of nutrition in cataract development, particularly the involvement of glucose and trace minerals and vitamins. Senile cataract can be classified into 3 main types: nuclear cataract, cortical cataract, and posterior subcapsular cataract. Nuclear cataracts result from excessive nuclear sclerosis and yellowing, with consequent formation of a central lenticular opacity. In some instances, the nucleus can become very opaque and brown, termed a brunescent nuclear cataract. Changes in the ionic composition of the lens cortex and the eventual change in hydration of the lens fibers produce a cortical cataract. Formation of granular and plaquelike opacities in the posterior subcapsular cortex often heralds the formation of posterior subcapsular cataracts.

In clinical,senile cataract devided to 4 stadium (4): 1) Insipient Cataracts In this stadium opacity start from marginal equator to anterior and posterior cortex. This opacity can arised poliopia because refraction index is not same in the all of lens. 2) Immature Cataracts Opacity at a part of lens. In this stadium lens volume will increase and make osmotic pressure increase too. Subsequently, lens more convex and occure block pupil,finally can arise secunder glaucoma. 3) Mature Catarcts Opacity can found in all of lens. This opacity can occure because there is calcium depotitions in the lens. Fluid in the lens will remove out so that lens will back at normal size, anterior chambers back at normal depth and there isnt iris image at the opaque lens so shadow test is negative.

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4) Hipermature Cataracts Mass lens move out from the lens capsule so lens becomes small,yellow colored and dry. In the examination seen anterior chamber is deep and there is lens capsule fold. If cataractc process continued accompanied with thicken capsule so cortex degeneration can not move out and can seen like a milk pack accompanied nucleus that concentrate in basal lens cortex. This condition called Morgagni Cataract. Difference of Cataract Stadium (4) insipen Mild Lense fluid Iris Anterior chamber Angle Shadow test Complicated cataract Normal negative Narrow positive glaucoma Normal negative open pseudopos Uveitis+galucoma Normal Normal Normal immature moderate increase Pushed Pushed Mature All of the lense normal Normal Normal Decrease Tremulans Deep Hypermature massive

Clinical Manifestation 1. History

Careful history taking is essential in determining the progression and functional impairment in vision resulting from the cataract and in identifying other possible causes for the lens opacity. A patient with senile cataract often presents with a history of gradual progressive deterioration and disturbance in vision. Such visual aberrations are varied depending on the type of cataract present in the patient. (2,3) a. Decreased visual acuity Decreased visual acuity is the most common complaint of patients with senile cataract. The cataract is considered clinically relevant if visual acuity is affected significantly. Furthermore, different types of cataracts produce different effects on visual acuity. For example, a mild degree of posterior subcapsular cataract can produce a severe reduction in visual acuity with near acuity affected more than distance vision, presumably as a result of accommodative miosis. However, nuclear sclerotic cataracts often are associated with decreased distance acuity and good near vision. A cortical cataract generally is not clinically relevant until late in its progression when cortical spokes compromise the visual axis. However, instances exist when a solitary cortical spoke occasionally results in significant involvement of the visual axis. b. Glare Increased glare is another common complaint of patients with senile cataracts. This complaint may include an entire spectrum from a decrease in contrast sensitivity in brightly lit environments or disabling glare during the day to glare with oncoming headlights at night. Such visual disturbances are prominent particularly with posterior subcapsular cataracts and, to a lesser degree, with cortical cataracts. It is associated less frequently with nuclear sclerosis. Many patients may tolerate moderate levels of glare without much difficulty, and, as such, glare by itself does not require surgical management. c. Myopic shift

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The progression of cataracts may frequently increase the diopteric power of the lens resulting in a mild-to-moderate degree of myopia or myopic shift. Consequently, presbyopic patients report an increase in their near vision and less need for reading glasses as they experience the so-called second sight. However, such occurrence is temporary, and, as the optical quality of the lens deteriorates, the second sight is eventually lost. Typically, myopic shift and second sight are not seen in cortical and posterior subcapsular cataracts. Furthermore, asymmetric development of the lens-induced myopia may result in significant symptomatic anisometropia that may require surgical management. d. Monocular diplopia At times, the nuclear changes are concentrated in the inner layers of the lens, resulting in a refractile area in the center of the lens, which often is seen best within the red reflex by retinoscopy or direct ophthalmoscopy. Such a phenomenon may lead to monocular diplopia that is not corrected with spectacles, prisms, or contact lenses. 2. Physical After a thorough history is taken, careful physical examination must be performed. The entire body habitus is checked for abnormalities that may point out systemic illnesses that affect the eye and cataract development. A complete ocular examination must be performed beginning with visual acuity for both near and far distances. When the patient complains of glare, visual acuity should be tested in a brightly lit room. Contrast sensitivity also must be checked, especially if the history points to a possible problem. Examination of the ocular adnexa and intraocular structures may provide clues to the patient's disease and eventual visual prognosis. A very important test is the swinging flashlight test which detects for a Marcus Gunn pupil or a relative afferent pupillary defect (RAPD) indicative of optic nerve lesions or diffuse
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macular involvement. A patient with RAPD and a cataract is expected to have a very guarded visual prognosis after cataract extraction. A patient with long-standing ptosis since childhood may have occlusion amblyopia, which may account more for the decreased visual acuity rather than the cataract. Similarly, checking for problems in ocular motility at all directions of gaze is important to rule out any other causes for the patient's visual symptoms. Slit lamp examination should not only concentrate on evaluating the lens opacity but the other ocular structures as well (eg, conjunctiva, cornea, iris, anterior chamber).
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Corneal thickness and the presence of corneal opacities, such as corneal guttata, must be checked carefully. Appearance of the lens must be noted meticulously before and after pupillary dilation. The visual significance of oil droplet nuclear cataracts and small posterior subcapsular cataracts is evaluated best with a normal-sized pupil to determine if the visual axis is obscured. However, exfoliation syndrome is appreciated with the pupil dilated, revealing exfoliative material on the anterior lens capsule.

o o

After dilation, nuclear size and brunescence as indicators of cataract density can be determined prior to phacoemulsification surgery. The lens position and integrity of the zonular fibers also should be checked because lens subluxation may indicate previous eye trauma, metabolic disorders, or hypermature cataracts.

The importance of direct and indirect ophthalmoscopy in evaluating the integrity of the

posterior pole must be underscored. Optic nerve and retinal problems may account for the visual disturbance experienced by the patient. Furthermore, the prognosis after lens extraction is affected significantly by detection of pathologies in the posterior pole preoperatively (eg, macular edema, age-related macular degeneration).

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Treatment The definitive management for senile cataract is lens extraction. Over the years, various surgical techniques have evolved from the ancient method of couching to the present-day technique of phacoemulsification. Almost parallel is the evolution of the IOLs being used, which vary in ocular location, material, and manner of implantation. Depending on the integrity of the posterior lens capsule, the 2 main types of lens surgery are the intracapsular cataract extraction (ICCE) and the extracapsular cataract extraction (ECCE). Below is a general description of the 3 commonly used surgical procedures in cataract extraction, namely ICCE, standard ECCE, and phacoemulsification. Reading books on cataract surgeries for a more in-depth discussion of the topic, particularly with regard to technique and procedure, is also recommended (5).
A.

Intracapsular cataract extraction

Prior to the onset of more modern microsurgical instruments and better IOLs, ICCE was the preferred method for cataract removal. It involves extraction of the entire lens, including the posterior capsule. In performing this technique, there is no need to worry about subsequent development and management of capsular opacity. The technique can be performed with less sophisticated equipment and in areas where operating microscopes and irrigating systems are not available.

However, a number of disadvantages and postoperative complications accompany ICCE. The larger limbal incision, often 160-180, is associated with the following risks: delayed healing, delayed visual rehabilitation, significant against-the-rule astigmatism, iris incarceration, postoperative wound leaks, and vitreous incarceration. Corneal edema is a common intraoperative and immediate postoperative complication.

Furthermore, endothelial cell loss is greater in ICCE than in ECCE. The same is true about the incidence of postoperative cystoid macular edema (CME) and retinal detachment. The broken integrity of the vitreous can lead to postoperative complications even after a seemingly uneventful operation. Finally, because the posterior capsule is not intact, the IOL to be implanted must either be placed in the anterior chamber or sutured to the posterior chamber. Both techniques are more difficult to perform than simply placing

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an IOL in the capsular bag and are associated with postoperative complications, the most notorious of which is pseudophakic bullous keratopathy. (5)

Although the myriad of postoperative complications has led to the decline in popularity and use of ICCE, it still can be used in cases where zonular integrity is too severely impaired to allow successful lens removal and IOL implantation in ECCE. Furthermore, ICCE can be performed in remote areas where more sophisticated equipment is not available.

ICCE is contraindicated absolutely in children and young adults with cataracts and cases with traumatic capsular rupture. Relative contraindications include high myopia, Marfan syndrome, morgagnian cataracts, and vitreous presenting in the anterior chamber.

B.

Extracapsular cataract extraction In contrast to ICCE, ECCE involves the removal of the lens nucleus through an opening in the anterior capsule with retention of the integrity of the posterior capsule. ECCE possesses a number of advantages over ICCE, most of which are related to an intact posterior capsule, as follows:

A smaller incision is required in ECCE, and, as such, less trauma to the corneal endothelium is expected. Short- and long-term complications of vitreous adherence to the cornea, iris, and incision are minimized or eliminated.

A better anatomical placement of the IOL is achieved with an intact posterior capsule. An intact posterior capsule also (1) reduces the iris and vitreous mobility that occurs with saccadic movements (eg, endophthalmodonesis), (2) provides a barrier restricting the exchange of some molecules between the aqueous and the vitreous, and (3) reduces the incidence of CME, retinal detachment, and corneal edema.

Conversely, an intact capsule prevents bacteria and other microorganisms inadvertently introduced into the anterior chamber during surgery from gaining access to the posterior vitreous cavity and causing endophthalmitis.
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Secondary IOL implantation, filtration surgery, corneal transplantation, and wound repairs are performed more easily with a higher degree of safety with an intact posterior capsule. The main requirement for a successful ECCE and posterior capsule IOL implantation is

zonular integrity. As such, when zonular support is insufficient or appears suspect to allow a safe removal of the cataract via ECCE, ICCE or pars plana lensectomy should be considered.
C.

Standard ECCE and phacoemulsification Standard ECCE and phacoemulsification are similar in that extraction of the lens nucleus is performed through an opening in the anterior capsule or anterior capsulotomy. Both techniques also require mechanisms to irrigate and aspirate fluid and cortical material during surgery. Finally, both procedures place the IOL in the posterior capsular bag that is more anatomical than the anteriorly placed IOL. Needless to say, significant differences exist between the 2 techniques. Removal of the lens nucleus in ECCE can be performed manually in standard ECCE or with an ultrasonically driven needle to fragment the nucleus of the cataract and then to aspirate the lens substrate through a needle port in a process termed phacoemulsification. The more modern of the 2 techniques, phacoemulsification offers the advantage of using smaller incisions, minimizing complications arising from improper wound closure, and affording more rapid wound healing and faster visual rehabilitation. Furthermore, it uses a relatively closed system during both phacoemulsification and aspiration with better control of intraocular pressure during surgery, providing safeguards against positive vitreous pressure and choroidal hemorrhage. However, more sophisticated machines and instruments are required to perform phacoemulsification. Ultimately, the choice of which of the 2 procedures to use in cataract extraction depends on the patient, the type of cataract, the availability of the proper instruments, and the degree at which the surgeon is comfortable and proficient in performing standard ECCE or phacoemulsification
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CHAPTER III CASE A. ANAMNESIS Identity Name Sex Age Address Job Religion : Mr.S : male : 48 years old : Jl. Parit Haji Husin 2 : Swasta : Islam

Patient was examined on April 20th, 2010

Main complaint : Blurry vision in right eye

History of desease : Blurry vision is affected both eyes since 8 month ago, since 1 week ago patient complaint that her right eyes can not see anythings. Patient feels like there is some cloudy

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in her sight and often feel glared when see the light. Headache (-), pain in the eyes (-), discharge (-), redness(-), itching (-). Traumatic history (-)

Past clinical history : there is no history of hypertension, diabetes mellitus, eye disease and traumatic history

Family history :There is no one of his family occurs the same complaint

B. PHISICAL EXAMINATION Done on April 20th 2010 General condition : good, compos mentis

Ophthalmologycal status Visual acuity : OD : 1 /300 good proyection

 OS

Eye ball position : ortho Eye movement : OD OS

Inspection OD Movement(+), ptosis (-), lagoftalmos (-), oedem(-) redness (-), discharge (-), injection(-), ulcer (-), foreign body (-) Oedem (-), ulcer (-) Cornea OS Movemen (+), ptosis (-), lagoftalmos (-), oedem (-) redness (-), discharge (-), injection(-), ulcer (-), foreign body (-) Oedem (-), ulcer (-)

Palpebra conjungtiva

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clear, deep sense

Anterior chamber

Clear, deep sense

Iris colour : brown, sinekia (-) Sircular pupil, isochore, opaque sense Cannot be described Cannot be described Shadow test : negative to right eye Funduscopy : Cannot be described Ischihara test : cannot be done

Iris/pupil Lensa Vitreous Fundus

Iris colour : brown, sinekia (-) Sircular pupil, isochore, Cannot be described Cannot be described

Intra Ocular pressure (tonometry) : OD 14 mmHg, OS 11 mm Hg

Visual field test (confrontation): can not be done

C. RESUME A male , 48 years old, came to ophthalmologic clinic with the complain of blurry vision since 8 months ago, and since 1 week ago her right eye can not see anything. Photopobia (+) Visual acuity is 1/300 for OD with good proyection. No foreign body was found. From clinical assestment, there is opacity on the right lense, that cause funduscopy can not be done. Intra ocular pressure is 14 mmHg for OD, 11 mmHg for OS. Confrontation test cannot be done, shadow test (-) to right eye

D. DIAGNOSIS Working Diagnosis : OD : Mature catarac et causa degeneration process

E. PLAN OF EXAMINATION Slit lamp USG and Laboratorium: preparation to surgery

F. TREATMENT Surgery : SICS + IOL G. PROGNOSIS a. Ad vitam b. Ad functionam c. Ad sanationam : bonam : dubia ad bonam : dubia ad bonam

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CHAPTER IV CASED EXPLANATION By knowing the patient complaint of blurred vision and inspecting the lense, it can be conclude that there are cataract in right eyes. Opacity of the lense will make disrupting the refraction media so the light can not focused to retina,finally produce blurred vision. Vision slowly blurred because of the progression of opacity in the lense (thickness of opacity infulence the degree of vision lost). Increased glare is another common complaint of patients with senile cataracts. This complaint may include an entire spectrum from a decrease in contrast sensitivity in brightly lit environments. Visual Acuity is 1/300 for OD with good proyection for OD. Cephalgia (-), pain in the eye (-), normal intraocular pressure from tonometry, normal eye appearance (redness(-), no injection): it mean that there is no secondary glaucoma.

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LITERATURE

(1) Lee, J., Bailey, G., Journal of the American Medical Association,2002 (2) Ocampo, V.V.D., Senile Cataract,eMedicine Specialistis,2009 (3) Ilyas, S., Ilmu Penyakit Mata, edisi ketiga . Balai Penerbit FK UI: Jakarta,2009 (4) Amoaku, W.M., Cataract surgery guidelines. Royal College of Ophthalmologists, 2004. http://www.rcophth.ac.uk/

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