(1) B: Anterior polar cataract is a form of developmental cataract in which there is opacification of the anterior pole of the lens.

It causes little effect on vision as it is away from the nodal point. (2) F: Sutural cataract is a form of developmental cataract that develops along one of the Y-shaped sutures & usually has no or little effect on vision. (3)A: There're wedge-shaped opacities with clear areas inbetween in front & behind the nucleus.The apex of the opacity is directed towards the centre. Red reflex appears as dark sectors against the red background. (4)C: The crystalline lens is opaque & anteriorly dislocated (i.e. in front of the iris).This leads to pupillary block & 2ry angle closure glaucoma. Acute IOP rise causes ciliary injection. Pupillary dilation lowers IOP by allowing aqueous to pass from the posterior to anterior chamber (glaucoma inversus means glaucoma that gets relieved by mydriatics rather than miotics as in any case with pupillary block) The definitive glaucoma treatment is of course lens extraction. (5)A: Zonular or lamellar cataract is the commonest form of developmental cataract.The opacity is a zone of fibres around the fetal nucleus.The opacity is disc-shaped with clear lens around. Radial extensions (riders like the steering wheel of a ship) extend from the main opacity.The lesion is bilateral and symmetrical. (6)D: The structure in front of the iris is an anterior chamber IOL.The classical location for implantation is

the posterior chamber, but if cataract surgery was complicated by big posterior capsular tear & the remaining capsular support was not enough to carry the IOL, then implantation in the anterior chamber in front of the iris would be an alternative. (7)F: This is another example of congenital anterior polar cataract. The opacity is away from the nodal point & has little visual affection (unlike posterior polar cataract), cosequently, surgery is usually unneeded. An acquired anterior polar cataract may complicate central small corneal perforations. (8)C: This is the typical appearance of posterior polar cataract.The lesion lies very near to the nodal point, has marked visual affection and usually requires surgery for the fear of stimulus deprivation amblyopia. (9)A: Again this is the typical appearance of zonular or lamellar cataract. (10)E: The lens is opaque and lies on the retina. (11)D:. (12)E: The lens is cataractous and lies on the retina. (13)A: Subluxation means that some of the fibres of the suspensory ligament are torn, consequently the intact fibres pull the lens away from the torn fibres. (14)C: This man has an iris shadow. This sign is seen in either immature or hypermature cataracts. No signs of

hypermaturity are detected. Proper dilation of the pupil is necessary to estimate maturity. The red reflex is more accurate than the iris shadow in grading the density of cataract. (15)A. (16)D: This man has advanced nuclear cataract which has acquired a brown tinge hence the name. (17)B: Pyramidal cataract is a variant of anterior polar cataract in which there is pyramidal projection into the anterior chamber. (18)F: This is termed sutural cataract. (19)C: This is an example of senile cortical cataract. (20)E:. (21)G: This boy has left developmental cataract. Both stimulus deprivation amblyopia & strabismus may complicate developmental cataract. (22)C. (23)F: She has bilateral developmental cataract and may be complicated by nystagmus & stimulus deprivation amblyopia (N.B. Amblyopia may be bilateral). (24)C: She has a clear subluxated lens.The classical presentation in such cases would be uniocular diplopia.

(25)B: This is the typical zonular or lamellar cataract. (26)F: Zonular cataract is the commonest form of developmental cataract.The opacification lies around the fetal nucleus. (27)A: This is the typical appearance of early nuclear cataract. It causes index myopia, 2nd sight and day blindness. Acute iridocyclitis causes discomfort over the ciliary body region. (28)G: This is another example of advanced nuclear cataract which characteristically causes day blindness. Progression is slow and the condition is painless. Near vision may improve in the early stages due to the induced index myopia. (29)F: This patient has intumescent cataract (The anterior capsule is glistening due to high water content). The lens is swollen, the A.Ch. is shallow and he is liable to phacomorphic glaucoma. He has lower lid entropion that should be corrected prior to surgery. (30)F: The opacity is in the posterior subcapsular area (very near to the nodal point). Day vision is markedly affected due to miosis & surgery is usually needed. Steroids may cause complicated cataract in this location (why?). (31)D: He has a subluxated clear lens that typically produces uniocular diplopia (one image is formed by the phakic & the other by the aphakic parts of the pupil).

(32)C: (33)C: (34)D: This is typical hypermature senile cataract as evidenced by wrinkling of the anterior capsule and the long history of visual diminution. The lens is shrunken & the A.Ch. is usually deep. The lens is liable to spontaneous lens dislocation as the suspensory ligaments are weak. Surgery in such cases needs the most experienced surgeon. (35)F: This lens is clear & anteriorly dislocated. It may be complicated by pupillary block, iris bombe` & 2ry angle closure glaucoma (one cause of glaucoma inversus). (36)B: This is typical morgagnian cataract (subtype of hypermature senile cataract in which the cortex has liquefied and the nucleus has dropped down in the capsular bag). The lens capsule in these conditions is leaky and allows the lens proteins to escape into the anterior chamber obstructing the spaces of Fontana. Also the presence of lens proteins in the A.Ch. stimulates the immune system to release macrophages to engulf these lens proteins. These macrophages also obstruct the spaces of Fontana. (37)D: This is typical intumescent cataract as evidenced by glistening of the anterior capsule & shallowing of the anterior chamber. The lens is swollen as there is high osmotic pressure and the lens absorbs aqueous humor from the A.Ch.

(38)E: This is an example of sutural cataract which is a form of developmental cataract. It does not affect visual acuity & needs no surgery at all. (39)A: This patient has typical hypermature senile cataract that has progressed into the mogagnian type. Usually the patient has long history of diminution of vision. The capsule has a high concentration of calcium & cholesterol. As the lens is shrunken, the A.Ch. is deep. He is liable to phacolytic glaucoma which is a form of 2ry open angle glaucoma. (40)E: The lens is clear & subluxated. This condition may be heredofamilial in certain syndromes & may be due to blunt ocular trauma disrupting some of the zonules. The anterior chamber is irregular in depth as the aphakic part of the anterior chamber gets deeper (no support of the iris by the crystalline lens) & the phakic part gets shallower (the lens gets more curved). This patient typically presents with uniocular diplopia (two retinal images, one from the phakic and the other from the aphakic part of the pupil). This form of diplopia disappears only on covering the affected eye. Binocular diplopia occurs when reinal images fall on noncorresponding sites on both retinae e.g. in paralytic squint or in symblepharon limiting ocular motility. In contrast with uniocular diplopia, binocular diplopia disappears on covering any eye the right or the left. (41)G: (42)F.

(43)C: This is the typical morgagnian cataract. It is a subtype of hypermature senile cataract in which the lens cortex gets liquefied and the nucleus sinks down in the capsular bag and the upper border of the nucleus becomes apparent behind the anterior capsule. It is liable to all complications of the ordinary hypermature senile cataract.e.g. subluxation, dislocation, phacolytic glaucoma (2ry open angle glaucoma due to obstruction of the spaces of Fontana by lens proteins leaking through the incompetent lens capsule & by the macrophages elaborated by the immune system to engulf the lens proteins released into the anterior chamber). (44)D: This man has a typical posterior subcapsular cataract (opacification just under the posterior capsule). This is the typical location of many complicated cataracts e.g. steroid-induced cataract (the posterior capsule is thin and not lined by subcapsular epithelium). The opacity is very near to the nodal point causing marked visual affection in any condition causing miosis e.g. reading, facing intense lights during driving etc.. Mydriatics like atropine abolish the pupillary light reflex & visual acuity gets improved if tested after atropine application. Surgery is usually indicated at an early time due to marked effect on vision despite the small degree of lenticular opacification. (45)D: This is the typical appearance of morgagnian cataract. (46)F: This is termed rosette-shaped cataract that typically occurs with or after blunt ocular trauma. It is a

visually significant cataract & may be associated with other intraocular injuries. Glaucomflecken is a form of complicated anterior capsular or subcapsular cataract that follow acute attacks of angle closure glaucoma. (47)E:. (48)A: This lady has intumescent cataract (the degenerated lens proteins increase the intralenticular osmotic pressure absorbing water from aqueous humour giving the capsule a glistening appearance & the anterior chamber gets shallower). If the IOP gets elevated, this is termed phacomorphic glaucoma. Phacolytic glaucoma is a 2ry open angle glaucoma that occurs in hypermature senile cataract. The trabecular meshwork pores get obstructed by the lens proteins that has leaked through the incompetent capsule and the macrophages elaborated by the immune system to engulf the lens proteins. Neovascular glaucoma is a 2ry synechial angle closure due to rubeosis irides (in cases with severe widely spread retinal ischemia e.g. in ischemic CRVO & PDR). The new iris vessels obstruct the angle with 2ry formation of peripheral anterior synechiae (PAS). Glaucoma capsulare (pseudoexfoliation syndrome) is a 2ry open angle glaucoma in which a dandruff-like material is deposited in the anterior segment of the eye e.g. on the anterior lens surface, on the iris surface and in the anterior chamber angle [True exfoliation of the anterior lens capsule epithelial cells caused by infrared rays in glass blowers is very rare nowadays]. Phacoanaphylactic (phacoantigenic) uveitis is an immune-mediated granulomatous inflammation initiated by lens proteins released through a ruptured lens capsule (e.g. following

trauma or cataract surgery if some cortical material gets retained within the eye). Onset is days to weeks after the injury or surgery. The disease is characterized by red, painful eye with chemosis and anterior chamber reaction with cells, flare and keratic precipitates (KPs). Occasionally, 2ry glaucoma develops due to blockage of the trabecular meshwork and synechiae formation. Lens extraction or removal of cortical remnants is the definitive treatment of this condition. Glaucoma inversus is a glaucoma that is relieved with mydriatics instead of miotics. (49)A: (50)D: (51)A: This case has posterior synechiae & festooned pupil indicating a previous iritis. Cataract here is mostly a complication of iritis. (52)D: This man has a traumatic posteriorly dislocated cataractous lens. This is considered a form of aphakia (absence of the crystalline lens from its normal position). Posterior lens dislocation forward vitreous bulge pupillary block iris bombe` 2ry anterior chamber angle closure elevation of IOP headache & haloes around light due to corneal edema. The combined refractive effect of aphakia & corneal edema. defective vision. (53)B: Notice the sunken nucleus inside the capsular bag & the dystrophic calcification in the anterior lens capsule. Brown cataract is a form of nuclear cataract in

which the nucleus acquires a brown color, hence the name. In such cases, the nucleus occupies the normal central position (unlike the morgagnian cataract). (54)B: Gluacomflecken is a type of complicated cataract that follows acute attacks of angle closure glaucoma. Opacification typically involves the anterior capsule & the anterior subcapsular area. (55)A: This is the typical appearance of pseudoexfoliation syndrome in which a whitish dandrufflike material is deposited in the anterior segment of the eye e.g. in the angle of the anterior chamber IOP and on the anterior lens surface. This is termed pseudoexfoliative glaucoma or glaucoma capsulare. (56)A: In incipient cataract, no actual opacification occurs, but just water vesicles & clefts appear between the lens fibres. (57)B: (58)A: In cortical cataract, if viewed with retroillumination, the appearance is that of black triangles against the bright red reflex. (59)B: This is a case of mature or total cataract. Fundus ultrasonography is essential (no fundus details are detectable on fundoscopy) to determine the anatomical details of the fundus e.g. retinal detachment, vitreous hemorrhage, intraocular foreign bodies.etc. Expected visual acuity (VA) is detection of hand motion (HM). If VA is less than this (PL or no PL), associated fundus or

higher visual pathway pathology is suspected. Examining the other eye is necessary to detect similar changes. (60)B: This is a typical illustration of intracapsular cataract extraction (ICCE), in which the whole lens is removed out of the eye. The method applied here is the cryoextraction in which a cryoprobe is applied to the anterior surface of the lens near the equator & on activating the cryoprobe, the whole lens gets frozen and by gentle side to side movement, the lens can be extracted out of the eye. The main drawback is the inability to implant a posterior chamber IOL (hence it is not suitable for pilots who have high visual demands & require optimal & rapid visual rehabilitation) & the high liability to vitreous loss (hence it is not suitable for infantile cataract because the attachment between the posterior capsule & the anterior vitreous face is very strong very high liability to vitreous loss with its all complications e.g. rhegmatogenous retinal detachment). Traumatic cataract with ruptured capsule is best managed with extracapsular cataract extraction in order not to leave any after-cataract. (61)A: This is an illustration of modern phacoemulsification. The incision is very small (about 3 mm) & constructed in a multiplanar manner to achieve a valve effect (no sutures are required). To implant an IOL through such a small incision, a foldable IOL (( is used. The IOL is implanted in the capsular bag (between the posterior capsule & remnants of the anterior capsule) better IOL centration. As the incision is very small, surgically-induced astigmatism is negligible rapid visual rehabilitation. It requires a

relatively long learning curve (many skill requiring successive steps). (62)D: To perform modern ECCE, an operating with good focusing & zoom magnification is mandatory. (63)B: In endophthalmitis, the infection principally involves the vitreous body &other ocular structures are secondarily involved.

(64)A. (65)B: The mentioned scenario is that of an acute attack of angle closure glaucoma. The intravenous fluid is 2025 mannitol. Glaucomflecken is a complicated cataract following acute congestive glaucoma involving the anterior capsule & anterior subcapsular area. (66)E. (67)B. (68)B: This is an example of posterior chamber intraocular lenses (PC-IOL) used to correct aphakia. This lens is implanted behind the iris in the capsular bag (between the posterior capsule & remnanats of the anterior capsule) & left forever inside the eye. Foldable varieties are available to be implanted during phacoemulsification .N.B. The optical diameter of most posterior chamber intraocular lenses varies between 5 to

7 mm. Phacoemusification incision is about 3 mm. Foldable lenses save enlarging the incision in such cases. Anterior chamber lenses are not used except in cases with deficient capsular support (e.g. torn posterior capsule & the remaining parts can not withstand the IOL). (69)A: This man has a typical morgagnian cataract. This usually takes many years to reach this advanced stage. (70)C: All other uncomplicated conditions do not cause blurring of vision. (71)C: This is an illustration of foldable intraocular lenses (IOLs) implanted inside the capsular bag (the space between the posterior capsule & the remnants of the anterior capsule) in phacoemulsification. No need to use these lenses in ECCE as the incision is large & implantation utilizes the hard PMMA lenses. In ICCE, no possibility for posterior chamber lens implantation (no posterior capsule). Only anterior chamber lenses or sclerally sutured IOLs could be used. (72)G: In lens subluxation, lost zonular tension asymmetrical in the curvature of the anterior lens surface curvature myopia & astigmatism. Uniocular diplopia occurs because two images are formed, one through the phakic & the other through the aphakic part of the pupil. (73)C: The left condition is the zonular or lamellar cataract (a visually significant opacity that if untreated

as early as possible would stimulus-deprivation amblyopia). The middle condition is the anterior polar cataract (little effect on vision as the opacity is away from the nodal point). The right condition is the sutural cataract which no or little effect on vision. (74)C: The left condition represents an anterior dislocation of a clear crystalline lens causing pupillary block & secondary angle closure glaucoma (notice the ciliary injection). The middle condition is a mature cataract. The right condition is a subluxated clear lens. (75)A: The peripheral iridectomy serves to prevent pupillary block caused by the presence of the anterior chamber IOL. (76)D: This patient has a pupillary block due to an anterior chamber intraocular lens (AC-IOL). Notice the iris bombe` & ciliary injection. (77)D: Both dental caries & bronchitis are septic foci & carry the risk of hematogenous dissemination of infection to the eye. Dacryocystitis with positive regurge carry the risk of direct introduction of infection intraocularly during surgery. High systemic blood pressure could produce retrobulbar bleeding and/or the more serious expulsive choroidal hemorrhage. A noninfected chalazion carries no added risk in such cases. (78)A: This lady has a typical morgagnian cataract. Zonular weakness in such cases would predispose to lens subluxation, anterior or posterior dislocation. IOP may

be elevated due to blockage of the pores of the trabecular meshwork (spaces of Fontana) by lens proteins that leak from the lens capsule & by the macrophages elaborated by the immune system to engulf lens proteins (Phacolytic glaucoma which is a 2ry open angle glaucoma). Stimulus-deprivation amblyopia develops in the sensitive period of visual maturation (the 1st 9-10 years of life) & not in this old age. (79)C: This is a nice example of pupillary block glaucoma due to a dislocated cataractous lens (2ry angle closure glaucoma with pupillary block). Cyclopentolate being a mydriatic could relieve the pupillary block, decrease the IOP & relieve the associated ciliary injection. On the contrary miotics like pilocarpine would aggravate the pupillary block & worsen the condition. Pupillary diameter in such cases plays a definite role as regards the IOP. The definitive treatment of course is lens extraction. (80)D: This is a case of anterior lens dislocation of a completely cataractous lens. In the supine position, the lens may fall backwards in the vitreous cavity. Blunt traumatizing agents (like a stone) could explain both the cataract & lens dislocation. Lens extraction is required to restore media clarity & relieve pupillary block. The lens curvature is increased due to loss of tension exerted by the zonules.