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. \Lens and Calarad
 Lens and
Cataract

Section 11
2011-2012
(Last major revision 2008- 2009)

t::lD. AMERICAN ACADEMY LHHON"

\V OF OPHTHALMOLOGY [Dl)(:ATlON _ _

Th" Eye M .D. AUoc;ati(ln 0 ' H T HAlMOI 0(; 1 sT'

 The Basic an d Cli nical Science Course is one component of the Lifelong
Education fo r the Ophthal mologist (LEO) framework, which assists mem-
bers in planning their continuing medical education. LEO includes an array
of clinical education products that members may select to form individu -
alized, self-directed learning plans for updating their cli nical knowledge.
Active members or fellows who use LEO components may accumulate sufficient CME
credits to earn the LEO Award. Contact the Academy's Clinical Education Division for
further information on LEO.

The American Academy of Ophthalmology is accredited by the Accreditation Coun-

cil for Continuing Medical Education to provide continuing medical education for
physicians.

Th e American Academy of Ophthalmology designates this enduring material for a

maximum of10 AMA PRA Category 1 Credits™ . Physicians should claim only cred it
commensurate with the extent of their participation in the activity.

The Academy provides this material for educational purposes only. It is not intended
to represent the only or best method or procedure in every case, nor to replace a physi-
cian's own judgment or give specific advice for case management. Including all indica-
tions, contraindications, side effects, and alternative agents for each drug or treatment
is beyond the scope of this material. All information and recommendations should be
verified, prior to use, with current information included in the manufacturers' package
inserts or other independent sources, and considered in light of the patient's con dition
and history. Reference to certain drugs, instruments, and other products in this course
is made fo r illustrative purposes only and is not intended to constitute an endorsement
of such. Some material may include information on applications that are not considered
community standard, that reflect indications not included in approved FDA labeling, or
that are approved for use only in restricted research settings. The FDA has stated that
it is the responsibility of the physician to determine the FDA status of each drug or
device he or she wishes to use, and to use them with appropriate, informed patient
consent in compliance with applicable law. The Academy specifically disclaims any
and all liability for injury or other damages of any kind, from negligence or otherwise,
for any and all claims that may arise from the use of any recommendations or other
information contained herein.

Cover image cou rtesy of Karla J. Joh ns, MD.

Copyright © 2011
American Academy of Ophthalmology
All rights reserved
Printed in Singapore
Basic and Clinical Science Course

Gregory L. Skuta, MD, Oklahoma City, Oklahoma, Senior Secretary for

Clinical Education
Louis B. Cantor, MD, Indianapolis, Indiana, Secretary for Ophthalmic
Knowledge
Jayne S. Weiss, MD, Detroit, Michigan, BCSC Course Chair

Section 11

Faculty Responsible for This Edition

James C. Bobrow, MD, Chair, Clayton, Missouri
Mark H. Blecher, MD, Philadelphia, Pennsylvania
David B. Glasser, MD, Columbia, Maryland
Kenneth B. Mitchell, MD, Columbia, South Carolina
Lisa F. Rosenberg, MD, Chicago, Illinois
Joseph Reich, MD, Consultant, Toorak, Australia
Edward K. Isbey III, MD, Asheville, North Carolina
Practicing Ophthalmologists Advisory Committee for Education

Financial Disclosures
The authors state the following financial relationships:
Dr Blecher: Advanced Medical Optics, grant recipient
The other authors state that they have no significant financial interest or other relationship
with the manufacturer of any commercial product discussed in the chapters that they con-
tributed to this course or with the manufacturer of any competing commercial product.

Recent Past Faculty

Cynthia A. Bradford, MD
Steven I. Rosenfeld, MD
In addition, the Academy gratefully acknowledges the contributions of numerous past
faculty and adVisory committee members who have played an important role in the devel-
opment of previous editions of the Basic and Clinical Science Course.
American Academy of Ophthalmology Staff
Richard A. Zorab, Vice President, Ophthalmic Knowledge
Hal Straus, Director, Publications Department
Chr istine Arturo, Acquisitions Manager
Stephanie Tanaka, Publications Manager
D. Jea n Ray, Production Manager
Bri an Veen, Medical Editor
Steven Huebner, Administrative Coordinator

'][~, AMERICAN ACADEMY

~ OF OPHTHALMOLOGY
Tbt £yt M.D. Auociatio ..

655 Beach Street

Box 7424
San Francisco, CA 94 120-7424
Contents

General Int roduction xiii

Objectives .1
Introduction . .3

1 Anatomy . .5
Normal Crystalline Lens. .5
Capsule. .7
Zonular Fibers .8
Lens Epitheli um. .8
Nucleus and Cortex . .9

2 Biochemistry. 11
Molecular Biology 11
Crystallin Proteins 11
Memb ra ne Structural Proteins and Cytoskeletal Proteins . 12
Increase of Water-Insoluble Proteins With Age 13
Carbohydrate Metabolism . 13
Oxidative Damage and Protective Mechanisms . 16

3 Physiology . 19
Maintenance of Lens Water and Cation Balance . 19
Lens Epitheli um: Site of Active Transport. 19
Pum p-Leak Theory 20
Accommodation 22
Presbyopia . 23

4 Embryology 25
Normal Development. 25
Lens Placode . 25
Lens Pit . 25
Lens Vesicle 25
Primary Lens Fibers and the Embr yoniC Nucleus 25
Secondary Lens Fibers. 27
Lens Sutures and the Fetal Nucleus 28
Tunica Vasculosa Lentis . 29
Zonules of Zinn. 29
Congenital Anomalies and Abnor malities 30
Congenital Aphakia. 30
Lenticonus and Lentiglobus. 30
Lens Coloboma. 31
Mittendorf Dot. 31

v
vi • Contents

Epicapsular Star. 31
Peters Anomaly. 32
Microspherophakia 32
An iridia 33
Congenital and Infantile Cataract 34
Developmental Defects 39
Ectopia Lentis . . 39
Marfan Syndrome. 40
Homocystinuria . 41
Hyperlysinem ia. 41
Sulfite Oxidase Deficiency 41
Ectopia Lentis et Pupillae. 42
Persistent Fetal Vascu lature. 42

5 Pathology. . . . . 43
Aging Changes. 43
Nuclear Cataracts . 43
Cortical Cataracts . 45
Posterior Subcapsular Cataracts. 46
Genetic Contributions to Age- Related Cataracts. 50
Drug-Induced Lens Chan ges . 52
Corticosteroids . 52
Phenothiazines . 52
Miotics 53
Amioda rone 53
Statins. 53
Trauma 53
Contusion 53
Perforating and Penetrat ing Inju ry. 55
Radiation ..... . 55
Chemical Injuries . 57
Intralenticular Foreign Bodies 57
Metallosis 57
Electrical Injury. 58
Metabolic Cataract 59
Diabetes Mellitus 59
Galactosemia. 60
Hypocalcemia . 61
Wilson Disease. 61
Myotonic Dystrophy. 61
Effects of Nutrition and Smoking. 62
Cataract Associated With Uveitis 63
Cataracts Associated With Ocular Therapies 64
Pseudo exfoliation Syndrome. 65
Cataract and Skin Diseases . 66
Atopic Dermatitis. 66
Phacoantigenic Uveitis· 66
 Contents • vii

Lens-Induced Glaucoma . . 67
Phaco lytic Glaucoma 67
Lens Particle Glauco ma 67
Phacomorphic Glaucoma 67
Glaukomflecken . . . . 68
Ischemia. . .... 68
Cataracts Associated With Degenerat ive Ocular Disorders . 68

6 Epidemiology of Cataracts. . . 71

7 Evaluation and Management of Cataracts in Adults 75

Clinical History: Signs and Symptoms . 75
Decreased Visual Acuity. 75
Glare . . . ...... 76
Altered Contrast Sensitivity. 76
Myopic Shift . . 77
Monocular Diplopia or Polyop ia 77
Medical Management. 77
Low Vision Aids for Cataract. 78
Indications for Surgery 78
Preoperative Evaluation 79
General Health of the Patient. 79
Pertinent Ocular History . 80
Social History . 81
Measurements of Visual Function. 81
Visual Acuity Testing 81
Refraction . . 81
Brightness Acuity . 81
Contrast Sensitivity 82
Visual Field Testing 82
External Examination. 82
Motili ty 82
Pupils. . . . 82
Slit-Lamp Examination 83
Conjunctiva . . 83
Cornea . . . . 83
Anterio r Chamber. 84
Iris . . . . . 84
Crystalline Lens. 84
Limitations of Slit-Lamp Exa mination 85
Fundus Evaluation . 85
Ophthalmoscopy 85
Optic Ne rve . 85
Fundus Evaluation With Opaque Media
.' 86
Special Tests. . . . 86
Potential Acuity Estimation. 86
Tests of Macular Function . 87
viii • Contents

Preoperative Measurements 88
Biometry . . . . 88
Corneal Topography . 88
Corneal Pachymetry. 88
Specular Microscopy 88
Patient Preparation and Informed Consent. 88

8 Surgery for Cataract . . . . . 91

The Remote Past . . . . . . . 91
Ancient and Medieval Techn iques. 91
Early Ext racapsular Cataract Extraction 92
Early Intracapsular Cataract Extraction 94
The Recent Past . . . . . . 94
Modern Advances in Intracapsular Surgery. 94
The Renaissance of Extracapsular Extracti on 96
The Modern ECCE Procedure 97
Ophthalmic Viscosurgical Devices 98
Physical Properties . . . . 99
Characteristics of OVDs . . 99
Anesthesia fo r Cataract Surgery. 100
Phacoem ulsification. . . . . 104
Ult rasonics Te rminology. · 104
Vacuu m Terminology . · 106
Phaco Instrumentation. · 106
Phaco Power Delivery . · 108
Irrigation . · 110
Aspiration · 110
Making the Transition . · III
A Basic Phaco Procedure Outline. · 113
Exposure of the Globe . 113
Paracentesis . 11 3
Scleral Tunnel Incisions 11 3
Clear Corneal Incision. 11 6
Continuous Cur vilin ear Capsulorrhexis · 119
Hydrodissection . · 120
Hydrodelineation. . . . . . . . . . · 121
Nuclear Rotation ....... . · 121
Instrument Settings for Phacoemulsification · 121
Strategies for Irrigation and Aspiration. 122
Location of Emulsification . . . . . . . . 123
One-Handed Technique of Nucleus Disassembly 125
Two- Handed Techniques of Nucle us Disassembly. 126
Advances in Energy Delivery. . 130
Alcon Infiniti. ..... . · 130
AMO Sovereign With WhiteStar 130
Bausch & Lomb Millennium . 131
STAA R Surgical Sonic WAVE. 131
 Contents. ix

Alternate Technologies for Nucleus Removal . 131

Sutureless Nonphaco Cataract Surgery. 131
Laser Photolysis. 132
Fluid-Based Phacolysis. 132
Antimicrobial Prophylaxis. 132
Before Surgery 132
In Surgery. 133
After Surgery. 134
Modificati on of Preexisting Astigmatism. 134
Incision Size and Location 135
Astigmatic Keratotomy. 135
Limbal Relaxing Incisions 135
Toric 10Ls . 136
Special Circumstances . 136
Cataract Surgery in the Patient Taking Anticoagulants 136
Cataract Surgery in the Patient Taking Tamsulosin . 137
Use of Capsule Staining 137
Use of Pupillary Expansion. 137
Capsulorrhexis Issues 138
Loose Zonules 138
Mature Cataracts 139
Posterior Capsule Rupture 140
Pars Plana Lensectomy 142
Indications. 142
Contraindications . 142
Intraocular Lens Implantation 142
Historical Perspectives. . 142
Posterior Chamber 10Ls . 144
Multifocal Lenses. . 146
Other Designs 148
10L Power Determination 149
Phakic 10Ls . 153
Techniques of Lens Implantation 154
Procedure . . 154
Secondary 10L Implantation . . 155
Relative Contra indications to Lens Implantation. 156
Outcomes of Cataract Surgery . . 156
Appendix. 157
The Modern Intracapsular Cataract Surgical Procedure. 157
The Modern Extracapsular Cataract Surgical Procedure 160

9 Complications of Cataract Surgery. 163

Corneal Edema. 163
Brown-McLean Syndrome . . . . . . . 165
Vitreocorneal Adherence and Persistent Corneal Edema 165
Corneal Complications of Ultrasound . 166
Detachment of Descemet's Membrane. . . 166
x • Contents

Induced Astigmatism 167

Corneal Melting 167
Incision Leak or Inadvertent Filtering Bleb. 168
Epithelial Downgrowth 168
Toxic Solutions. 169
Conjunctival Ballooning. 170
Shallow or Flat Anterior Chamber 170
Intraoperative 170
Postoperative. 17 1
Elevated Intraocular Pressu re . 172
Intraoperative Floppy Iris Syndrome 173
Iridodialysis 174
Cyclodialysis. 174
Ciliary Block Glaucoma . 174
Chronic Uveitis. 175
Retained Lens Material 175
Capsular Rupture. 176
Vitreous Prolapse. 178
Complications ofIOL Implantation 178
Decentration and Dislocation. 178
Pupillary Capture. 180
Capsular Block Syndrome 180
Uveitis-Glaucoma-Hyphema Syndrome 181
Pseudophakic Bullous Keratopathy 181
Incorrect IOL Power. 181
IOL Design, Glare, and Opacification 182
Capsular Opacification and Contraction. 182
Posterior Capsule Opacification. 182
Anterior Capsule Fibrosis and Phimosis 184
Nd:YAG Capsulotomy . 184
Indications . 184
Contraindications . 184
Procedure 185
Complications 187
Hemorrhage . 187
Retrobulbar Hemorrhage. 188
Suprachoroidal Effusion or Hemorrhage 188
Expulsive Suprachoroidal Hemorrhage . 189
Delayed Suprachoroidal Hemorrhage 190
Hyphema 190
Endophthalmitis 190
Diagnosis 191
Treatment 191
Cystoid Macular Edema . 193
Retinal Light Toxicity 195
Macular Infarction . 195
Retinal Detachment. " 196
 Contents. xi

10 Cataract Surgery in Special Situations 199

Cataract in Children . · 199
Surgical Plan ning. · 199
Surgical Technique .200
Postoperative Care . 202
Complications . .202
Prognosis . . .202
Correction of Aphakia . .203
Psychosocial Considerations . .204
Claustrophobia . · 204
Dementia or Other Mental Disabilities . · 205
Inability to Communicate With the Patient. · 205
Systemic Conditions .......... . .205
Anticoagulation Therapy or Bleeding Disorders. .205
Art hritis. . . . . . . . . . .206
Chronic Obstructive Pulmonary Disease . · 207
Diabetes Mellitus · 208
Obesity .209
Ocular Conditions · 210
External Eye Disease. .210
Corn eal Conditions . .211
Mature Cataract/ Poor Red Reflex · 214
Cataract Following Refractive Surgery. · 215
Developmental Abnormalities · 216
Increased Risk of Exp ulsive Hemorrhage. · 219
Glaucoma · 221
High Refract ive Error .224
Hypotony . . . .226
Uveitis . . . . .226
Retinal D isease. · 227
Trauma. · 228
Visualization. . .228
Inflammation. . 228
Retained Foreign Matter . .229
Damage to Other Ocular Tissues .229
Zonular Dehiscence With Lens Subluxation or Dislocation .230
Lens Implantation. · 231

Basic Texts . .233

Related Academy Materials .234
Credit Reporting Form · 237
Study Questions · 241
Answers. · 249
Index. · 255
General Introduction

The Basic and Clinical Science Course (BCSC) is designed to meet the needs of residents
and practitioners for a comprehensive yet concise curriculum of the field of ophthalmol-
ogy. The BCSC has developed fro m its original brief outline format, which relied heavily
on outside readings, to a more convenient and educationally useful self-contained text.
The Academy updates and revises the course annually, with the goals of integrating the
basic science and clinical practice of ophthalmology and of keeping ophthalmologists cur-
re nt with new developments in the various subspecialties.
The BCSC incorporates the effort and expertise of more than 80 ophthalmologists,
organized into 13 Section faculties, working with Academy editorial staff. In addition, the
course continues to benefit from many lasting contributions made by the faculties of pre-
vious editions. Members of the Academy's Practicing Ophthalmologists Advisory Com-
mittee for Education serve on each faculty and, as a group, review every volume before
and after major revisions.

Organization of the Course

The Basic and Clinical Science Course comprises 13 volumes, incorporating fundamental
ophthalmic knowledge, subspecialty areas, and special topics:
I Update on Gene ral Medicine
2 Fundamentals and Principles of Ophthalmology
3 Clinical Optics
4 Ophthalmic Pathology and Intraoc ular Tumors
5 Neuro-Ophthalmology
6 Pediatric Ophthalmology and Strabismus
7 Orbit, Eyelids, and Lacrimal System
8 External Disease and Cornea
9 Intraocular Inflammation and Uveitis
10 Glaucoma
II Lens and Cataract
12 Retina and Vitreous
13 Refractive Surgery
In addition, a comprehensive Master Index allows the reader to easily locate subjects
throughout the entire series.

References
Readers who wish to explore specific topics in greater detail may consult the references
cited within each chapter and listed in the Basic Texts section at the back of the book.
These references are intended to be selective rather than exhaustive, chosen by the BCSC
faculty as being important, cur rent, and read ily available to residents and practitioners.

xii i
xiv. Genera l IntroduGt ion

Related Academy educational materials are also listed in the appropriate sections.
They include books, online and audiovisual materials, self-assessment programs, clinical
modules. and interactive programs.

Study Questions and CME Credit

Each volume of the BCSC is designed as an independent study activity for ophthalmology
residents and practitioners. The learn ing objectives for this volume are given on page 1.
The text, illustrations, and references provide the in for mat ion necessary to achieve the ob-
jectives; the study questions allow readers to test their understanding of the material and
their mastery of the objectives. Physicians who wish to claim CME credit for this educa-
tional activity may do so by mail, by fax. or online. The necessary forms and instructions
are given at the end of the book.

Conclusion
The Basic and Clinical Science Course has expanded greatly over the years, with the ad-
dition of much new text and numerous illustrations. Recent editions have sought to place
a greater em phasis on clinical applicability while maintaini ng a solid foundation in basic
science. As with any educational program, it reflects the experience of its authors. As
its faculti es change and as medicine progresses, new viewpoints are always emerging on
controversial subjects and techniques. Not all alternate app roaches can be included in
this series; as with any educational endeavor, the learner should seek additional sou rces,
including such carefully balanced opinions as the Academy's Preferred Practice Patterns.
The BCSC faculty and staff are continuously striving to improve the educational use-
fulness of the course; YOll, the reader, can contribute to this ongoing process. If you have
any suggestions or questions about the series, please do not hesitate to contact the faculty
or the editors.
The authors, editors, and reviewers hope that you r study of the BCSC will be oflasting
value and that each Section will serve as a practical resource for quality patient care.
Introduction

The ancient Greeks and Romans believed that the lens was the part of the eye respon -
sible for the faculty of seeing. They theorized that the optic nerves were hollow channels
through which "visual spirits" traveled from the brain to meet visual rays from the outside
world at the lens, which they thought was located in the center of the globe. The visual
information would then flow back to the brain. This concept was known as the emanation
theory of vision. Celsus (25 Be- AD 50) drew the lens in the center of the globe, with an
empty space called the locus vacuus anterior to it, in AD 30 (Fig I- I ).
These erroneous ideas about lens position and function persisted through the Middle
Ages and into the Renaissance, as shown by the drawings of the Belgian anatomist An-
dreas Vesalius in 1543 (Fig 1-2). However, the true position of the crystalline lens was
illustrated by the Italian anatomist Fabricius ab Aquapendente in 1600 (Fig 1-3); and the
Swiss physician Felix Plater (1536-1614) first postulated that the retina, and not the lens,
was the part of the eye responsible for sight.
Today, many areas of lens physiology and biochemistry are still subjects of active re-
search. No medical treatment, for example, can yet prevent the formation or progres-
sion of cataract in the lens of the otherwise healthy adult eye, and theories about cataract
fo rmation and innovative forms of management continue to be controversial. Although
various risk factors for cataract development (UV-B radiation, diabetes mellitus, drug use,
smoking, alcohol use, severe malnutritio n, and oxidative damage) have been identified,
data to develop guidelines for reducing the risk of cataract remain inconclusive.

locus Var:U!lS

Figure 1-1 The eye, after Celsus. (From Gorin G

History of Ophthal mology. Wilmington __ Publish or Perish,
TO vc).ollOic,
Inc; 1982.)

3
4 • Lens and Catara ct

Figure 1-2Schematic eye from De fabrica cor- Figure 1-3 Sketch from De ocufo of Fabricius
poris humamof A ndreas Vesa li us (1514- 15641. ab Aquapenden t e (1 537 - 16191. showi ng cor-
(Reproduced by permission from th e Ophthalmic Publish- rect position of the lens w ithi n the eyeba ll.
ing Company. Feigenbaum A. Early history of cataract (Reproduced by permission from the Ophthalmic Publish-
and the ancient operation for cataract. Am J Ophthalmol. ing Company. Feigenbaum A. Early history of cataract
1960;49:307.) and the ancient operation for cataract. Am J Ophthalmol.
1960;49:307.)

Cataract is the leading cause of preventable blindness in the world, whereas cataract ex-
traction with intraocular lens (IOL) implantation is perhaps the most effective surgical pro-
cedure in all of medicine. More than 1.8 million cataract procedures are performed on the
population older than age 65 in the United States each year, and the visual disability associated
with cataract formation accounts for more than 8 million physician office visits each year.
The prevalence of lens disorders and continuing developments in their management
make the basic and clinical science of the lens an important su bj ect in ophthalmology
training. The goal of Section 11 is to provide a curriculum for the study of all aspects of
the lens, including the structure and function of the normal lens, the features of diseases
involVing the lens, and the surgical management of lens abnormalities, such as recent
developments in phacoemulsification and laser capsulotomy. Because the specifics of sur-
gical tech niques and instrumentation are constantly changing, the authors of this volume
have chosen to provide a balanced presentation ofthe general principles of cataract man -
agement, emphasizing the major prevailing approaches.
In addition, to help put today's techniques into perspective, historical vignettes de-
scribing the evolution of cataract surgery and 10L implantation appear at the beginning
of Chapter 8 and in the discussion oflOLs later in that chapter.
CHAPTER 1
Anatomy

Normal Crystalline lens

The crystalline lens is a transparent, biconvex structure whose functions are
to maintain its own clarity
• to refract light
• to provide accommodation

The lens has no blood supply or innervation afte r feta l development, and it depends en-
tirely on the aqueous humor to meet its metaboli c requirements and to carry off its wastes.
It lies posterior to the iris and anterior to the vitreous body (Fig I-I ). The lens is suspended
in position by the zonules of Zinn, which consist of delicate yet strong fibers that support
and attach it to the Ciliary body. The lens is composed of the capsule, lens epithelium,
cortex, and nucleus (Fig 1-2).
The anterior and posterior poles of the lens are joined by an imaginary line called the
optic axis, which passes through th em. Lines on the surface passing from one pole to the
other are referred to as meridians. The equator of the lens is its greatest circumference.

Figure , ., Cross section of the human crystalline lens, showing the relationship of the lens
to surrounding ocular structures. (Illustration by Christine Gralapp.)

5
6 • Lens and Catara ct

Capsule

Nucleus

Anterior
pole

Optic axis

Zonule
Equator

Fiber

Fi gu re 1·2 Struct ure of th e norm?1human lens. (Illustration by Carol Donner. Reproduced with permission
from Koretz JF. Handelman GH. How th e human eye focuses. Scientific American . July 1988:94.)
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