Senile Cataract (Age-Related Cataract) Workup

Updated: Mar 02, 2021
  • Author: Vicente Victor Dizon Ocampo, Jr, MD; Chief Editor: Andrew A Dahl, MD, FACS  more...
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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, especially if synechiolysis, a retrobulbar block, or an adjunctive procedure such as microincisional glaucoma surgery (MIGS) or pars plana vitrectomy is anticipated. Additional risk factors for accentuated perioperative bleeding should also be assessed, including the use of oral NSAIDs, anticoagulant prescription medications, or omega-3 supplements containing vitamin E (eg, fish oil).

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Imaging Studies

Ocular imaging studies (eg, ultrasonography, CT scanning, MRI) can be requested when a posterior pole pathology is suspected and an adequate view of the back of the eye is obscured by an extremely dense or hypermature 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.

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Other Tests

Additional patient-specific tests can be performed when coexisting ocular diseases are suspected, especially in identifying the etiology of preoperative visual loss. Aside from 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). Above all, macular optical coherence tomography (OCT) should prove to be the most informative regarding structure.

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. A simple color vision test with a large Ishihara chart or muscle light illuminated color-coded glaucoma medication caps can also qualitatively predict intact macular function.

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 selecting the IOL style, power, optics (spheric or aspheric), and premium features best suited to the individual eye. 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), while also anticipating future surgeries. Ocular dominance is also important since many patients tolerate a small degree of monovision with a small add or additional IOL plus power in the nondominant eye, often called mini-monovision.

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 via pachymetry, slit lamp 40x high-magnification endothelial specular illumination, 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. A preoperative discussion of endothelial transplantation, however brief, is wise in the context of even minimal detected endothelial pathology.

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Histologic Findings

Nuclear cataracts are characterized by homogeneity of the lens nucleus with loss of cellular laminations. Cortical cataracts typically manifest with hydropic swelling of the lens fibers with globules of eosinophilic material (morgagnian globules) seen in slit-like 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. [22] 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 cytoplasm 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.

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Staging

Clinical staging of senile cataract is traditionally based on the appearance of the lens on slit-lamp examination, as follows:

  • Hypermature cataract: This is a dense white opacity that obscures the red reflex and contains milky fluid within the capsule, a result of degenerated lens cortex. The capsule if often tense or wrinkled. A morgagnian cataract is a type of hypermature cataract in which the nucleus sinks within the fluid cortex.
  • Mature cataract: This is a cataract that is opaque, totally obscuring the red reflex. It is either white or brunescent.
  • Immature cataract: This is a cataract characterized by a variable amount of opacification, present in certain areas of the lens. These may include both high- and low-density areas, with some clear lens fibers.
  • Incipient cataract: This is a cataract that is seen on slit-lamp examination but is of little clinical significance.

Clinical staging of senile cataract can also be based on the visual acuity of the patient, as follows: 

  • Hypermature cataract: The patient generally sees worse than count fingers (CF) or hand motion (HM).
  • Mature cataract: The patient cannot read better than 20/200 on the visual acuity chart. 
  • Immature cataract: The patient can distinguish letters at lines better than 20/200.
  • Incipient cataract or dysfunctional lens syndrome: The patient reports visual complaints but can still read at 20/20 despite lens opacity confirmed via slit lamp-examination.

Numerous methods have been formulated to assess the severity of cataracts. Among them are the Lens Opacities Classification (LOCS), the Oxford Clinical Cataract Classification and Grading System, and the Johns Hopkins system.  The LOCS is the most commonly used system in the clinics. It allows a qualitative staging of cataracts based on a series of images for grading nuclear color (NC), nuclear opalescence (NO), cortical cataract (C), and posterior subcapsular cataract (P). Three versions have been developed (LOCS I, II, III).

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