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Cataract (Lecture)

Patient presents as → a 78-year-old man who complains of slowly progressive vision loss over the last several years. He describes his vision as if he is looking through "dirty glass" and reports seeing a white halo around lights. On physical exam, there is clouding of the lens and no red reflex.

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Cataracts are an opacity of the lens that affects the vision and are the leading cause of blindness worldwide

  • Risk factors for cataracts include age (usually > 60), smoking, ETOH, sunlight exposure, diabetes, metabolic syndrome, prolonged drug use (esp. glucocorticoids), radiation
  • Seen with prolonged systemic or inhaled steroid use and statins

Cataract appears dark against the red reflex on exam

  • Slit lamp to magnify, difficult to see the fundus

In the early stages, lifestyle modifications like using glasses, brighter lighting, anti-glare sunglasses, and pupillary dilation (with phenylephrine 2.5% every 4 to 8 hours) can be effective

  • Definitive treatment is with cataract removal - Surgery is generally reserved for more severe cases where vision impairment significantly affects daily activities

Picmonic
Cataracts

IM_NUR_Cataract_v1.2_

Cataracts are opacities of the lens that develop gradually over time. These are age-related and are typically painless. When examining patients we see a cloudy, opaque lens, which leads to decreased visual acuity. The definitive treatment for cataracts is surgery.

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Question 1
Which of the following is NOT a known risk factor for developing cataracts?
A
Advanced age
Hint:
This is the most significant risk factor for cataracts. The risk of cataract formation increases with each decade of life after the age of 40.
B
Smoking
Hint:
Smoking is a well-established risk factor for cataracts. The toxins in cigarette smoke can alter the lens cells and lead to cataract formation.
C
Prolonged corticosteroid use
Hint:
Long-term use of corticosteroids is associated with an increased risk of developing cataracts.
D
Frequent ultraviolet light exposure
Hint:
UV light exposure, particularly UVB, has been linked to an increased risk of cataract development.
E
High dietary intake of vitamin C
Question 1 Explanation: 
High dietary intake of vitamin C is not a known risk factor for developing cataracts. In fact, some studies suggest that a diet rich in antioxidants, including vitamin C, might have a protective effect against the formation of cataracts. Antioxidants help to neutralize free radicals, which can damage proteins within the lens, leading to cataract formation.
Question 2
Which of the following is a primary pathophysiological mechanism in the development of age-related cataracts?
A
Chronic intraocular inflammation
Hint:
Chronic intraocular inflammation can contribute to cataract formation, but it is not the primary mechanism in age-related cataract
B
Oxidative stress and lens protein denaturation
C
Increased intraocular pressure causing lens opacity
Hint:
Increased intraocular pressure is associated with glaucoma, not directly with cataract formation.
D
Autoimmune destruction of lens fibers
Hint:
Autoimmune destruction of lens fibers is not a recognized mechanism in the development of age-related cataracts.
E
Vitreous humor degeneration
Hint:
Vitreous humor degeneration can lead to other eye problems but is not a direct cause of cataract formation.
Question 2 Explanation: 
Age-related cataracts primarily develop due to oxidative stress, which leads to the denaturation and aggregation of lens proteins. This process results in the gradual clouding of the lens, impairing vision. Factors contributing to oxidative stress include UV light exposure, metabolic changes, and the accumulation of reactive oxygen species over time.
Question 3
Which clinical finding is most characteristic of a nuclear sclerotic cataract?
A
A painless, gradual decrease in vision
B
Sudden vision loss with eye pain and redness
Hint:
Sudden vision loss with pain and redness is more indicative of acute glaucoma or other ocular emergencies, not cataracts.
C
Fluctuating vision that improves in brighter light
Hint:
Fluctuating vision that improves in brighter light is not typical of nuclear sclerotic cataracts.
D
Peripheral vision loss progressing to central vision loss
Hint:
Peripheral vision loss progressing to central vision loss is characteristic of glaucoma, not cataracts.
E
Halos around lights and difficulty with night driving
Hint:
Halos around lights and difficulty with night driving are more characteristic of posterior subcapsular cataracts.
Question 3 Explanation: 
Nuclear sclerotic cataracts, the most common type of age-related cataracts, typically present with a painless, gradual decrease in vision. The lens becomes harder and more yellow, leading to progressive visual impairment.
Question 4
A 70-year-old patient with bilateral cataracts reports difficulty reading and driving, especially at night. What is the most appropriate management for this patient?
A
Observation and regular follow-up
Hint:
Observation and regular follow-up may be appropriate for early cataracts not significantly affecting vision, but this patient's activities are being impacted, indicating the need for surgical intervention.
B
Prescription of new corrective glasses
Hint:
While new corrective glasses can help in the early stages of cataracts, they are not sufficient for advanced cataracts causing significant visual impairment
C
Topical corticosteroid therapy
Hint:
Topical corticosteroids are not effective in treating cataracts and are used for inflammatory eye conditions.
D
Cataract extraction with intraocular lens implantation
E
Laser therapy
Hint:
Laser therapy is not a standard treatment for cataracts. The primary treatment is surgical removal of the cataract.
Question 4 Explanation: 
Cataract extraction with intraocular lens implantation is the definitive treatment for cataracts causing significant visual impairment, such as difficulty reading and driving. This surgical procedure involves removing the cloudy lens and replacing it with a clear artificial lens, which can significantly improve vision.
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References: Merck Manual · UpToDate

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