Doctors Revision

Ophthalmology (Eye Conditions)

Cataract

Opacity or clouding of the eye's natural lens, leading to progressive, painless loss of vision. Most common cause of blindness globally, particularly age-related cataract.

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Referral and warning signs

When to refer

Refer to Ophthalmologist/Eye Centre (HC4/H/RR) when cataract causes visual impairment significant enough to interfere with patient's daily life and desired activities, for surgical assessment and management.

Red flags

  • Sudden loss of vision (unlikely to be cataract alone).
  • Eye pain associated with cataract (suggests complication like phacomorphic glaucoma).
  • Rapid progression of cataract.
  • Leukocoria (white pupil) in a child (suspect congenital cataract or retinoblastoma - urgent referral).

Signs and symptoms

  • Gradual, progressive blurring or dimming of vision.
  • Difficulty seeing at night or in dim light.
  • Glare sensitivity (e.g., from headlights).
  • Halos around lights.
  • Faded or yellowish appearance of colours.
  • Need for brighter light for reading.
  • Frequent changes in eyeglass prescription.
  • Monocular diplopia (double vision in one eye).
  • Visible white/grey/cloudy appearance of the pupil (mature cataract).

Risk factors

  • Increasing Age (most common - senile cataract).
  • Diabetes Mellitus.
  • Long-term Corticosteroid use (systemic or topical).
  • Excessive Ultraviolet (UV) light exposure.
  • Smoking.
  • Alcohol abuse.
  • Eye trauma.
  • Previous eye surgery.
  • Uveitis.
  • Certain medications (e.g., phenothiazines).
  • Congenital factors / Genetic predisposition.
  • Radiation exposure.

Diagnosis

Clinical assessment

History of gradual visual decline. Visual Acuity measurement (reduced). Ophthalmic examination:

Investigations

  • Visual Acuity test.
  • Ophthalmic examination (Slit lamp, Fundoscopy).
  • Refraction.
  • Biometry (measurement of eye length and corneal curvature for intraocular lens power calculation before surgery).

Diagnostic criteria

Clinical finding of lens opacity on ophthalmic examination, correlating with visual symptoms.

Differential diagnosis

  • - Distant Direct Ophthalmoscopy: Diminished or absent red reflex, visible lens opacities.
  • - Slit Lamp Examination: Detailed assessment of type (nuclear, cortical, posterior subcapsular), location, and density of lens opacity.
  • - Dilated Fundus Examination: To rule out other causes of vision loss (e.g., macular degeneration, glaucoma, diabetic retinopathy).

Management

Non-pharmacological management

  • Early Stages:
  • - Update eyeglass prescription.
  • - Improve lighting for reading.
  • - Use sunglasses to reduce glare.
  • - Magnifying aids.
  • Definitive Treatment:
  • - Cataract Surgery: Removal of the cloudy lens and replacement with an artificial Intraocular Lens (IOL). Highly effective procedure when vision significantly impaired.
  • - Decision for surgery based on visual acuity level AND impact on patient's daily activities/quality of life.
  • - Common techniques: Phacoemulsification (ultrasound), Manual Small Incision Cataract Surgery (MSICS), Extracapsular Cataract Extraction (ECCE).

Pharmacological treatment

  • No eye drops effectively treat or prevent age-related cataracts.
  • Post-operative eye drops required after surgery (antibiotics, steroids, NSAIDs).

Monitoring

Monitor vision changes. Post-operative follow-up after surgery.

Complications

  • Visual impairment / Blindness (if untreated).
  • Increased risk of falls.
  • Phacomorphic glaucoma (swollen cataract blocks fluid outflow).
  • Phacolytic glaucoma (leaking lens protein causes inflammation/glaucoma).
  • Complications of cataract surgery (infection, inflammation, retinal detachment, cystoid macular oedema, posterior capsule opacification - rare but possible).

Prevention

  • UV protection (sunglasses).
  • Smoking cessation.
  • Good control of diabetes.
  • Healthy diet rich in antioxidants (evidence less clear).
  • Avoidance of long-term unnecessary steroid use.

Patient education

  • Explanation of cataract as clouding of the lens.
  • Natural aging process (usually).
  • Progressive nature.
  • Management options (glasses initially, surgery definitive).
  • Cataract surgery procedure basics (lens replacement).
  • Risks and benefits of surgery.
  • Expected visual outcome after surgery.
  • Post-operative care instructions.

Uganda-specific notes

Age-related cataract is the leading cause of blindness. Surgical services (often MSICS) available at district/regional hospitals and through outreach camps. Backlog of untreated cataract is significant. Pediatric cataract requires specialized care (See OPH011).

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 20, Section 20.2.1

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