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Learning Log

Part A
Presentation
Decreased vision in both eyes for 6 months; Watery discharge from both eyes for 5
months
Main diagnosis
Age related cataract

History taken Yes

Patient examined Yes

Where seen (OPD/ER/ Specialty Ward): OPD


When seen (insert date): 28th June, 2015
Age: 72 years

Gender: Female

History of Presenting Complaints and associated features


Patient was apparently well six months ago. She then started to have decreased vision
in both her eyes. Decrease in vision was gradual in onset, painless and progressive in
nature. She has diminished vision in both far and near distance. She also has history
of intermittent watery discharge from same eye which was gradual in onset, painless
and was progressive; aggravated in bright light during day and relieved at night in low
light. She denied history of coloured halos, flashes and floaters. She also denied
history of double vision, redness, itching. She doesnt use glasses.
Past medical and surgical History
She had visited eye hospital two years to cut her eye lashes that were disturbing her
vision. Otherwise, she doesnt have diabetes mellitus, hypertension and other chronic
systemic disease and ophthalmic problems.
Drug and allergy history
She hasnt been under any medication; no allergies known yet.
Family History
No history of similar illness in the family.
Personal history
She is non-smoker and non-alcoholic.
Summary of history
72 years female, non-smoker and non-alcoholic, presented with chief complaint of
painless, gradual loss of vision of both eyes for six months associated with
intermittent watery discharge.

Summary of examination
On examination, she had symmetrical forehead crease. Eyebrows were normal and no
swelling, redness in eyelids. Torch light examination of both the eyes showed no
congestion in conjunctiva and no opacity and deposits in cornea. Iris was dark brown
in colour with normal pattern. Pupils were round, regular and reactive to light.
Anterior chamber depth was normal.
Opacity was seen in the lens of right eye which was more pronounced than in left eye.
Ocular motility test was normal. Her vision on right eye was 5/6 while left eye was
6/60 unaided. IOP was 13 and 14 on right and left eyes respectively. Her BP was
130/80 mmHg.
Provisional diagnosis
Age related cataract
Summary of investigations
She was sent for Biometry.
Management including medications
No any medication was given.
Management
She was advised for surgery for treatment of cataract- Phacoemulsification with
Intraocular lens.
Part B
What causes this condition (summarize the pathophysiology)?
Cataract is development of opacity in lens or its capsule. It can be congenital or
acquired. Senile cataract is the commonest type of acquired cataract and usually
occurs after 50 years of age. It is usually bilateral and affects both sexes. Senile
cataract is aging process so age is the most important risk factors. Other factors like
heredity, UV radiation exposure, diet deficient in certain proteins, amino acids,
vitamins and essential elements, previous dehydration crises due to diarrhoea and
cholera have role in incidence, age of onset and maturation of the disease. Besides,
smoking is associated with increased frequency of disease.
Morphologically, senile cataract is of two types-cortical where hydration and decrease
synthesis of protein followed by denaturation of proteins occurs primarily in cortex
and nuclear cataract where slow sclerosis occurs in nucleus of lens.
As the cataract is a gradually progressing disease, maturation of cataract takes place in
following stages:
Maturation of cortical type of senile cataract:
Stage of lamellar separation
Stage of incipient cataract
Immature senile cataract
Mature senile cataract
Hyper-mature senile cataract

Maturation of nuclear senile cataract:


Nuclear sclerosis begins centrally and spreads slowly peripherally almost upto the
capsule when it becomes mature. It typically blurs distant vision more than near
vision.
How may it be prevented?
Cataract cannot be prevented as it is a natural age-related process. But, following
measures can reduce the risk of disease and slow down the progression:
Avoiding radiation exposure
Wearing dark goggles
Smoking cessation
Having nutritious diet
Controlling diabetes
Commonly presenting features
Symptoms
Intolerance of bright light (glare)
Uniocular polyopia
Coloured halos
Black spots in front of eyes
Blurring and distorting of image
Loss of vision
Signs
Visual acuity: decreased
Oblique illumination: colour of lens in pupillary area
Iris shadow: crescentric shadow of papillary margin of iris present in
immature cataract
Direct ophthalmoscope: black shadow against red glow or absence of red glow
(if complete opacity)
Slit lamp examination: complete morphology of opacity
Natural history/prognosis
When not treated in time, decrease in vision can ultimately result in complete loss of
vision. Besides, it can cause following complications
Phacoanaphylactic uveitis
Phacolytic glaucoma
o due to leakage of proteins into anterior chamber from hypermature
cataract
Subluxation or dislocation of lens due to degeneration of zonules in
hypermature cataract

Most useful investigations


Diagnosis of senile cataract is basically based on thorough history and physical
examinations. Some of the investigations are:
Visual acuity testing
Tonometry
Ocular imaging studies (USG, CT, MRI) if posterior pole pathology is
suspected
Preoperative screening for coexisting disease (DM, HTN, cardiac anomalies)
Evidence for treatment
The only treatment for cataract is to surgically remove the opacified lens from
the eye to restore transparency of the visual axis. Treatment of senile cataract
consists of the following measures:

Surgical management
Intracapsular cataract extraction
Extracapsular cataract extraction
Conventional extracapsular cataract extraction
Manual small incision cataract surgery
Phaecoemulsification
Laser phaecoemulsification

Student reflection on patient/presentation


From this case, I learned that senile cataract is one of the most common types of
acquired cataract. It is one of the most important differential diagnoses of gradually
progressive painless loss of vision. It is essentially an age related process and occurs
usually after 50 years. I learned about its risk factors, pathogenesis, types, clinical
features and its management options.
The knowledge which I have learned following this case will help me in future when I
come across similar problems. Cataract has been an important cause of decreased
vision and thus proper history followed by a proper examination is crucial to
diagnosis of cataract. After making the diagnosis of the condition, I would counsel the
patient and refer him/her to the higher centre.