eMedicine Specialties > Ophthalmology > Lens

Cataract, Senile: Differential Diagnoses & Workup

Author: Vicente Victor D Ocampo, MD, Consulting Staff, Department of Ophthalmology, Asian Hospital and Medical Center, Philippines
Coauthor(s): C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution
Contributor Information and Disclosures

Updated: May 20, 2009

Differential Diagnoses

Cataract, Traumatic

Other Problems to Be Considered

Aside from being age related and due to trauma, cataract formation in adult patients also may be due to chronic uveitis, long-term steroid use, or posterior pole pathologies (eg, intraocular tumor, long-standing retinal detachment).

Workup

Laboratory Studies

  • Diagnosis of senile cataract is made basically after a thorough history and physical examination are performed. Laboratory tests are requested as part of the preoperative screening process to detect coexisting diseases (eg, diabetes mellitus, hypertension, cardiac anomalies). Studies have shown that thrombocytopenia may lead to increased perioperative bleeding and, as such, should be properly detected and managed before surgery.

Imaging Studies

  • Ocular imaging studies (eg, ultrasound, CT scan, MRI) are requested when a posterior pole pathology is suspected and an adequate view of the back of the eye is obscured by the dense cataract. This is helpful in planning out the surgical management and in providing a more guarded postoperative prognosis for the visual recovery of the patient.

Other Tests

  • Other special tests can be performed when coexisting ocular diseases are suspected, especially in identifying preoperative visual loss resulting from them. Aside from the routine visual acuity testing, testing for brightness acuity and contrast sensitivity and confrontation visual field testing can be performed to assess visual function. Patients with a history of glaucoma, optic nerve disease, or retinal abnormality should undergo an automated visual field test to document the degree of preoperative field loss.
  • In patients suspected of having a macular problem, the following tests may be performed to evaluate macular function: Maddox rod test, photostress recovery test, blue-light entoptoscopy, Purkinje entoptic phenomenon, and visual-evoked response and electroretinography (VER-ERG).  
    • In patients with dense cataracts that preclude adequate visualization of the fundus, a Maddox rod test can be used to grossly evaluate macular function with detection of a large scotoma, represented as a loss of the red line, a sign suggestive of a macular pathology.
    • While the photostress recovery test is a semiquantitative estimate of macular function, both blue-light entoptoscopy and Purkinje entoptic phenomenon are subjective means of evaluating macular integrity. The most objective method of measuring macular function is VER-ERG.
  • Several measurements should be taken preoperatively, particularly in an anticipated cataract extraction with intraocular lens (IOL) implantation.
    • Careful refraction must be performed on both eyes in planning the IOL to be implanted. The power of the IOL on the operated eye must be compatible with the refractive error of the fellow eye to avoid complications (eg, postoperative anisometropia).
    • An accurate biometry also should be performed to calculate for the IOL power to be used.
    • Corneal integrity, specifically the endothelial layer, must be assessed very well through pachymetry and specular microscopy to predict postoperative corneal morbidities (eg, corneal edema, corneal decompensation) and to weigh the risks versus the benefits of performing cataract extraction.

Histologic Findings

Nuclear cataracts are characterized by homogeneity of the lens nucleus with loss of cellular laminations, while cortical cataracts typically manifest with hydropic swelling of the lens fibers with globules of eosinophilic material (morgagnian globules) seen in slitlike spaces between lens fibers. Finally, a posterior subcapsular cataract is associated with posterior migration of the lens epithelial cells in the posterior subcapsular area, with aberrant enlargement of the epithelial cells (Wedl or bladder cells).

Costello et al examined senile cataracts using electron microscopy to highlight differences in the cellular architecture of the various forms of age-related lens changes.10 Comparisons were made between a typical nuclear cataract with a central opacity and a transparent rim, and a more advanced or mature, completely opaque nuclear cataract. The former was described as having no obvious cell disruption, cellular debris, or changes that could readily account for the central opacity. The fiber cells had intact uniformly stained cytoplasms with well-defined plasma membrane borders and gap junctions. The mature cataract exhibited various types of cell disruption in the perimeter but not in the core of the nucleus in the form of globules, vacuoles, multilamellar membranes, and clusters of highly undulating membranes.

Staging

Clinical staging of senile cataract is based largely on the visual acuity of the patient. A patient who cannot read better than 20/200 on the visual acuity chart is said to have a mature cataract. If the patient can distinguish letters at lines better than 20/200, then the cataract is described as being immature. An incipient cataract is found in a patient who can still read at 20/20 but possesses a lens opacity as confirmed by slit lamp examination.

More on Cataract, Senile

Overview: Cataract, Senile
Differential Diagnoses & Workup: Cataract, Senile
Treatment & Medication: Cataract, Senile
Follow-up: Cataract, Senile
References
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Further Reading

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Keywords

senile cataract, age-related cataract, vision loss, visual deficit, blindness

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Contributor Information and Disclosures

Author

Vicente Victor D Ocampo, MD, Consulting Staff, Department of Ophthalmology, Asian Hospital and Medical Center, Philippines
Vicente Victor D Ocampo, MD is a member of the following medical societies: American Academy of Ophthalmology, Philippine Academy of Ophthalmology, and Philippine Ocular Inflammation Society
Disclosure: Nothing to disclose.

Coauthor(s)

C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution
C Stephen Foster, MD, FACS, FACR, FAAO is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association of Immunologists, American College of Rheumatology, American College of Surgeons, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, American Uveitis Society, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, Royal Society of Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Richard W Allinson, MD, Associate Professor, Department of Surgery, Texas A&M University Health Science Center; Senior Staff Ophthalmologist, Scott and White Clinic
Richard W Allinson, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

J James Rowsey, MD, Former Director of Corneal Services, St Luke's Cataract and Laser Institute, Florida
J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Pan-American Association of Ophthalmology, Sigma Xi, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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