Download What is your diagnosis?

Mansukhani, Sujata To Marcial, Karmi Margarette
 This 30 year old male
sought consult because
of blurring of vision of
the left eye. Visual
acuity was light
perception on the
involved eye. This
condition has been
present since
childhood.
Outline
 What is your diagnosis?
 What diagnostic test would you do to help you decide
on your management?
 What is your treatment plan?
 What will be the visual outcome of this patient after
your surgical management?
Question # 1
SALIENT FEATURES
 Patient presented with:
 LEUKOCORIA
 UNILATERAL, PAINLESS BLURRING OF VISION
 Condition is congenital or “present since birth”
Patient
Unilateral
Gradual,
Painless
Blurring of
Vision present
since birth
Light
perception on
affected eye
Leukocoria
Retinopathy of
prematurity
Retinal
Detachment
Coloboma
occurs in
premature, lowbirth-weight
infants
maintained on
oxygen therapy
risk factors:
trauma and
surgery, vitreous
detachment, high
myopia, retinal
breaks or tears,
retinal vascular
disease, and
history of
detachment in
the other eye
flashes of light,
floaters, curtainlike decrease in
vision
Congenital
caused by
incomplete
closure of the
fetal fissure
Degree of
visual loss
related to area
affected (iris,
retina, choroid,
or optic nerve
head)
Cataract
May be:
age-related
childhood
cataract
(congenital or
acquired)
traumatic
druginduced
Unilateral or
bilateral
Painless
leukocoria
Glare or star
bursts
Question # 2
History and PE
 thorough history
 careful physical examination must be performed
 entire body habitus is checked for abnormalities that
may point out systemic illnesses
Ocular Examination
 Visual acuity for both near
and far distances (Snellen’s
Chart)
 Glare- brightly lit room
Swinging Flashlight Test
 detects for a Marcus Gunn pupil
or a relative afferent pupillary
defect (RAPD)
 indicative of optic nerve lesions
or diffuse macular involvement.
 RAPD + Cataract= very guarded
visual prognosis after cataract
extraction
Ocular Motility
 long-standing ptosis since
childhood may have occlusion
amblyopia
 decreased visual acuity rather
than the cataract
 Checking all directions- 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)
 Corneal thickness and the presence of corneal
opacities
 lens noted meticulously before and after pupillary
dilation
 Nuclear size and Brunescence as indicators of cataract
density can be determined prior to
phacoemulsification surgery.
 lens position and integrity of the zonular fibers also
should be checked
 lens subluxation may indicate previous eye trauma,
metabolic disorders, or hypermature cataracts.
 Dilated fundus examination is recommended as part of
the ocular examination for both unilateral cataract cases
and bilateral cataract cases.
Question # 3
 Early cataracts may be managed with the following
measures:
 Stronger eyeglasses or contact lenses
 Use of a magnifying glass during reading
 Strong lighting
 Medication that dilates the pupil. (This may help some
people with capsular cataracts, although glare can be a
problem with this treatment.)
Indications for Surgery
 The Snellen eye test reports 20/40 or worse, with a
cataract being responsible for vision loss that cannot
be corrected by glasses.
 Performing everyday activities has become difficult to
perform to the point that independence is threatened,
or the patient is at risk for accident or injury.
Three basic types of surgery
 Extracapsular cataract extraction
 Intracapsular cataract extraction
 Phacoemulsification
 Surgery to remove cataracts is generally an outpatient
procedure. A local anesthetic is used and the
procedure lasts about an hour.
Question # 4
A comprehensive study reported in
Archives of Ophthalmology (1994)
 95.5 percent of healthy eyes achieved 20/40
uncorrected vision or better outcomes following
cataract surgery
 Of the more than 17,000 eyes evaluated, fewer than 2
percent had sight-threatening complications.
Sight-threatening complications
• associated with individuals
• Glaucoma
who are much older or who
already have poor
underlying health affecting
how their eyes heal.
• cataracts are far more
advanced or "hardened" at
the time of surgery,
making them difficult to
remove
• Retinal detachment
• Endophthalmitis
• Secondary cataract
A Swedish study published in the
British Journal of Ophthalmology
(1999)
 Younger people undergoing cataract surgery reported
the highest satisfaction levels.
 Less satisfactory outcome when other eye problems
were present
British Journal of Ophthalmology
(2000)
 people in their 6Os undergoing cataract surgery were
4.6 percent more likely to achieve 20/40 uncorrected
vision or better than people in their 80s