A client with a cataract would most likely complain of which symptom?
Practice EssentialsSenile cataract is an age-related, vision-impairing disease characterized by gradual progressive clouding and thickening of the lens of the eye. It is the world’s leading cause of treatable blindness. Show
Signs and symptomsA patient with senile cataract often presents with a history of gradual progressive visual deterioration and disturbance in night and near vision. Characteristic symptoms of senile cataract include the following:
DiagnosisA complete ocular examination must be performed, beginning with visual acuity for near and far distances. When the patient complains of glare, visual acuity should be tested in a brightly lit room. Contrast sensitivity may also be checked, especially if the history points to a possible problem. Diagnosis can also include the following:
Ocular imaging studies such as ultrasonography, computed tomography (CT) scanning, or magnetic resonance imaging (MRI) are requested when a significant posterior pole pathology is suspected and an adequate view of the back of the eye is obscured by a dense cataract. Staging Clinical staging of senile cataract is traditionally based on the appearance of the lens on slit-lamp examination, as follows:
Clinical staging of senile cataract can also be based on the visual acuity of the patient, as follows:
ManagementLens extraction is the definitive treatment for senile cataract. It can be accomplished via the following procedures:
Intraocular lens (IOL) implantation is customarily used in combination with each of these techniques, although ECCE and phacoemulsification allow for more advantageous anatomical placement of the IOL than does ICCE.  BackgroundSenile cataract is a vision-impairing disease characterized by gradual, progressive thickening of the lens. It is the leading cause of blindness in the world today. This is unfortunate, considering that the visual morbidity brought about by age-related cataract is reversible. As such, early detection, close monitoring, and timely surgical intervention must be observed in the management of senile cataracts. Even greater challenges abound in economically disadvantaged and geographically isolated regions where limited healthcare access precludes early intervention. The subsequent section is a general overview of senile cataract and its management. PathophysiologyThe pathophysiology behind senile cataracts is complex and yet to be fully understood. In all probability, its pathogenesis is multifactorial involving complex interactions between various physiologic processes modulated by environmental, genetic, nutritional, and systemic factors. As the lens ages, its weight and thickness increases while its accommodative power decreases. As the new cortical layers are added in a concentric pattern, the central nucleus is compressed and hardened in a process called nuclear sclerosis. Multiple mechanisms contribute to the progressive loss of transparency of the lens. The lens epithelium is believed to undergo age-related changes, particularly a decrease in lens epithelial cell density and an aberrant differentiation of lens fiber cells. Although the epithelium of cataractous lenses experiences a low rate of apoptotic death, which is unlikely to cause a significant decrease in cell density, the accumulation of small scale epithelial losses may consequently result in an alteration of lens fiber formation and homeostasis, ultimately leading to loss of lens transparency. Furthermore, as the lens ages, a reduction in the rate at which water and, perhaps, water-soluble low-molecular weight metabolites can enter the cells of the lens nucleus via the epithelium and cortex occurs with a subsequent decrease in the rate of transport of water, nutrients, and antioxidants. Consequently, progressive oxidative damage to the lens with aging takes place, leading to senile cataract development. Various studies showing an increase in products of oxidation (eg, oxidized glutathione) and a decrease in antioxidant vitamins and the enzyme superoxide dismutase underscore the important role of oxidative processes in cataractogenesis. Another mechanism involved is the conversion of soluble low-molecular weight cytoplasmic lens proteins to soluble high molecular weight aggregates, insoluble phases, and insoluble membrane-protein matrices. The resulting protein changes cause abrupt fluctuations in the refractive index of the lens, scatter light rays, and reduce transparency. Other areas being investigated include the role of nutrition in cataract development, particularly the involvement of glucose and trace minerals and vitamins. Senile cataract can be classified into 3 main types: nuclear cataract, cortical cataract, and posterior subcapsular cataract. Nuclear cataracts result from excessive nuclear sclerosis and yellowing, with consequent formation of a central lenticular opacity. In some instances, the nucleus can become very opaque and brown, termed a brunescent nuclear cataract. Changes in the ionic composition of the lens cortex and the eventual change in hydration of the lens fibers produce a cortical cataract. Formation of granular and plaquelike opacities in the posterior subcapsular cortex often heralds the formation of posterior subcapsular cataracts. FrequencyUnited StatesIn the Framingham Eye Study from 1973-1975, senile cataract was seen in 15.5% of the 2477 patients examined. The overall rates of senile cataract in general, and of its 3 main types (ie, nuclear, cortical, posterior subcapsular), rapidly increased with age; for the oldest age group (≥75 y), nuclear, cortical, and posterior subcapsular cataracts were found in 65.5%, 27.7%, and 19.7% of the study population, respectively. Nuclear opacities were the most commonly seen lens change. An updated study by the Wilmer Eye Institute in 2004 noted that approximately 20.5 million (17.2%) Americans older than 40 years had a cataract in either eye and 6.1 million (5.1%) were pseudophakic/aphakic. [1] These numbers are expected to rise to 30.1 million cataracts and 9.5 million cases with pseudophakia/aphakia by 2020. Prevent Blindness America currently estimates that more than 22 million Americans aged 40 years and older have a cataract. An average of 3 million Americans undergo cataract surgery every year, with a 95% success rate of obtaining a best corrected vision of 20/20-20/40. InternationalSenile cataract continues to be the main cause of visual impairment and blindness in the world. In recent studies performed in China, [2, 3] Canada, [4] Japan, [5] Denmark, [6] Argentina, [7] and India, [8] cataract was identified as the leading cause of visual impairment and blindness, with statistics ranging from 33.3% (Denmark) to as high as 82.6% (India). Published data estimate that 1.2% of the entire population of Africa is blind, with cataract causing 36% of this blindness. In a survey conducted in 3 districts in the Punjab plains, the overall rates of occurrence of senile cataract was 15.3% among 1269 persons examined who were aged 30 years and older and 4.3% for all ages. This increased markedly to 67% for ages 70 years and older. An analysis of blind registration forms in the west of Scotland showed senile cataract as 1 of the 4 leading causes of blindness. Mortality/MorbidityMost morbidity associated with senile cataracts occurs postoperatively and is discussed in further detail later. Failure to treat a developing cataract surgically may lead to devastating consequences, such as lens swelling and intumescence, secondary glaucoma, and, eventually, blindness. Although the risk of dying as a result of cataract extraction is almost negligible, studies have shown an increased risk of mortality in patients who underwent surgery. In a comparison of 167 patients aged 50 years or older who underwent cataract extraction at the New England Medical Center in a period of 1 year to 824 patients who elected 1 of 6 other surgical procedures, it was found that the former had almost twice the mortality of the latter. Further analysis showed no significant correlation between diabetes and increased mortality. In a similar 5-year mortality analysis, patients with cataracts who were younger than 75 years had significantly higher age-specific rates of mortality than would be expected from US life tables. These data imply an association between senile cataracts and increased mortality. Meddings et al suggest that senile cataract may be a marker of generalized tissue aging, which may be independent of cumulative ultraviolet exposure. [9] Hirsch and Schwartz who proposed the concept that senile cataracts reflect systemic phenomena rather than only a localized ocular disease share this view. [10] RaceAlthough race has been suggested as a possible risk factor for senile cataract, scarce literature exists to prove this theory. However, it has been observed that unoperated cataracts account for a higher percentage of blindness among blacks compared to whites. Instead, various other correlates may explain racial disparities, including medical comorbidities such as diabetes mellitus or lifetime ultraviolet (UV) exposure due to occupation, altitude, or latitude. SexStudies on the prevalence of senile cataract between males and females have yielded contrasting results. In the Framingham Eye Study from 1973-75, females had a higher prevalence than males in both lens changes (63% vs 54.1%) and senile cataract (17.1% vs 13.2%). Sperduto and Hiller noted that each of the 3 types of senile lens opacities was found more often in women than in men. [11] In a separate investigation by Nishikori and Yamomoto, the male-to-female ratio was 1:8 with a female predominance in patients older than 65 years who were operated on for senile cataract. [12] In a hospital-based, case-control study of senile cataract conducted in Japan, it was observed that an increased risk of cataract was found in males who were presently spending 7 hours or more outdoors and in females with 4 or fewer remaining teeth. However, in another analysis by Martinez et al, no sexual difference was noted in the prevalence of senile cataract. [13] AgeAge is an important risk factor for senile cataract. As a person ages, the chance of developing a senile cataract increases. In the Framingham Eye Study from 1973-1975, the number of total and new cases of senile cataract rose dramatically from 23.0 cases per 100,000 and 3.5 cases per 100,000, respectively, in persons aged 45-64 years to 492.2 cases per 100,000 and 40.8 cases per 100,000 in persons aged 85 years and older. PrognosisIn the absence of any other accompanying ocular disease prior to surgery that would affect significantly the visual outcome (eg macular degeneration or optic nerve atrophy), a successful uncomplicated standard ECCE or phacoemulsification carries a very promising visual prognosis of gaining at least 2 lines in the Snellen distance vision chart. The main cause of visual morbidity postoperatively is CME. A major risk factor affecting visual prognosis is the presence of diabetes mellitus and diabetic retinopathy. Patient EducationTo date, no established guidelines are available for the prevention of senile cataracts. Education programs are geared toward early detection and surgical intervention when vision is impaired functionally. With the advent of phacoemulsification, patients are advised against delaying lens extraction to the point when the cataract is hard and mature and the likelihood of postoperative complications increases. For patient education resources, see the Eye and Vision Center and Cataracts.
Author Vicente Victor Dizon Ocampo, Jr, MD Chair, Department of Ophthalmology, Head, Uveitis and Ocular Immunology Service, Ospital ng Makati, Philippines; Vice-Chair, Department of Ophthalmology, Asian Hospital and Medical Center, Philippines; President, Philippine Ocular Inflammation Society Vicente Victor Dizon Ocampo, Jr, MD is a member of the following medical societies: International Ocular Inflammation Society, Philippine Academy of Ophthalmology, Philippine Ocular Inflammation Society Disclosure: Nothing to disclose. Coauthor(s) C Stephen Foster, MD, FACS, FACR, FAAO, FARVO 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, FARVO 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, Sigma Xi, The Scientific Research Honor Society Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Aldeyra Therapeutics (Lexington, MA); Bausch & Lomb Surgical, Inc (Rancho Cucamonga, CA); Eyegate Pharma (Waltham, MA); Novartis (Cambridge, MA); pSivida (Watertown, MA); Xoma (Berkeley, CA); Allakos (Redwood City, CA) Specialty Editor Board Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape. J James Rowsey, MD Former Director of Corneal Services, St Luke's Cataract and Laser Institute 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, Sigma Xi, The Scientific Research Honor Society, Southern Medical Association, Pan-American Association of Ophthalmology Disclosure: Nothing to disclose. Chief Editor Andrew A Dahl, MD, FACS Assistant Professor of Surgery (Ophthalmology), New York College of Medicine (NYCOM); Director of Residency Ophthalmology Training, The Institute for Family Health and Mid-Hudson Family Practice Residency Program; Staff Ophthalmologist, Telluride Medical Center Andrew A Dahl, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Intraocular Lens Society, American Medical Association, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Medical Society of the State of New York, New York State Ophthalmological Society, Outpatient Ophthalmic Surgery Society Disclosure: Nothing to disclose. Additional Contributors Which of the following is a symptom of cataracts?Signs and symptoms of cataracts include: Clouded, blurred or dim vision. Increasing difficulty with vision at night. Sensitivity to light and glare.
What are 4 clinical manifestations of cataracts?Babies, young children and middle-aged adults can also have cataracts, either present at birth or sometimes related to other medical conditions. Common symptoms from cataracts include halos around lights, needing more light to read, reduced clarity of vision and reduction in the brightness of colors.
What is the most common complication of cataract?A long-term consequence of cataract surgery is posterior capsular opacification (PCO). PCO is the most common complication of cataract surgery. PCO can begin to form at any point following cataract surgery.
What are the symptoms of worsening cataracts?Blurry vision at any distance is the most common symptom of cataracts. Your view may look foggy, filmy, or cloudy. Over time, as the cataracts get worse, less light reaches the retina. People with cataracts may have an especially hard time seeing and driving at night.
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