As these crystallins begin to denature (lose their native structure) and precipitate (come out of solution), they are

bound by the -crystallins,which have a chaperonelike activity.9 That is, binding by -crystallins maintains solubility of -crystallins and reduces light scattering, but in general, the -crystallins appear not to renature their target proteins and release them into the cytoplasm,as do true chaperones. Rather, they hold them in complexes that, while soluble,increase in size as additional damaged protein is bound over time until they themselves begin to approach sizes sufficient to scatter light.9 Eventually,the available -crystallin is overwhelmed by increasing amounts of modified -crystallin and the complexes precipitate within the lens cell, forming the insoluble protein fraction that is known to increase with age and in cataractous lenses. Whether proteins in the insoluble fraction become insoluble on complete or partial denaturation, as would be implied by the schema described earlier,or whether they simply become less soluble because of modifications that leave their protein folds largely intact is not known currently. However, it seems clear from numerous mouse models of cataract that the presence of large amounts of unstable or precipitated protein does damage to the lens cell and contributes to cataracts not only directly through light scattering by protein aggregates but eventually also through disruption of cellular architecture.10 Similarly,mutations that disrupt intracellular homeostasis of lens cells can damage their constituents over time and contribute to age-related cataract, as discussed later for galactokinase.

Diplopia monokular yaitu diplopia yang hanya terjadi pada satu mata. Penglihatan ganda muncul saat salah satu mata ditutup. Gangguan ini dapat terjadi pada pasien dengan astigmatisme, gangguan lengkung kornea, pterigium, katarak, dislokasi lensa mata, gangguan produksi air mata dan beberapa gangguan pada retina 1

epidemiological evidence implicating genetic factors in age-related cataract Mutations in BFSP2 can cause juvenile cataracts, the Marner and Volkmann cataracts can be progressive mutations in AQP0 (MIP) and C-crystallin can cause progressive cataracts, and the CAAR locus is linked to familial adult-onset pulverulent cataracts. These all suggest that for at least some genes, a mutation that severely disrupts the protein or inhibits its function might result in congenital cataracts inherited in a highly penetrant mendelian fashion, while a mutation that causes less severe damage to the same protein or impairs its function only mildly might contribute to age-related cataracts in a more complex multifactorial fashion. Similarly, mutations that severely disrupt the lens cell architecture or environment might produce congenital cataracts, while others that cause relatively mild disruption of lens cell homeostasis might contribute to age-related cataract. Galactosemic cataracts provide an interesting example of mutations severely affecting a gene, causing early-onset cataracts, while milder mutations simply decreasing its activity contribute to age-related cataracts.49 Deficiencies of galactokinase (GALK1) and galactose 1-phosphate uridyltransferase and severe deficiencies of uridine diphosphate 1-4 epimerase cause cataracts as a result of galactitol accumulation and subsequent osmotic swelling. galactosemic cataracts initially are reversible both in human patients and in animal models. ==============================================

Terdapat tiga tipe dari katarak senil ini yaitu tipe nuklear, kortikal dan subskapsular posterior. Tidak jarang terjadi dua tipe atau lebih pada satu penderita. 1. 1. Tipe nuklear

Katarak nuclear dimulai dengan adanya perubahan secara berlebihan yang dialami oleh nucleus lensa yang diakibatkan karena bertambahnya umur. Tipe ini berhubungan dengan myopia karena terjadi peningkatan indeks refraksi dari nucleus lensa dan juga peningkatan abrasi sperikal. Katarak nuclear cenderung untuk berkembang lambat. Walaupun pada umumnya hanya terjadi bilateral, namun bisa juga terjadi unilateral dan menyebabkan penderitanya tidak dapat melihat jarak jauh dibandingkan dengan jarak dekat. Pada stadium awal, mengerasnya nukleus lensa menyebabkan peningkatan index refraksi dan kemudian menyebabkan terjadinya myopia lentikular. Pada beberapa kasus, hal ini menimbulkan terjadinya second sight atau penglihatan ganda perubahan index refraksi yang secara tiba-tiba antara nukleus sklerotik dan korteks dapat menyebabkan diplopia monocular. Pada kasus lanjut usia, nucleus lensa menjadi lebih keruh dan berwarna coklat yang dinamakan katarak nulear brunescent. 1. 2. Tipe kortikal

Katarak kortikal dapat termasuk pada daerah anterior, posterior dan equatorial korteks. Kekeruhan dimulai dari celah dan vakoula antara serabut lensa oleh karena hidrasi oleh korteks. Katarak kortikal disebabkan oleh perubahan komposisi ion dari korteks dan hidarsi
2

lensa. Katarak ini biasanya terjadi bilateral namun dapat juga terjadi asimetris. Dampak terhadap fungsi penglihatan bervariasi tergantung pada lokasinya. Salah satu gejala yang sering timbul adalah penglihatan yang menjadi silau, misalnya silau terhadap lampu mobil. Selain itu monocular diplopia juga bisa terjadi. 1. 3. Tipe subkapsular posterior

Katarak subkapsular posterior ini sering terjadi pada usia yang lebih muda dibandingkan tipe nuklear dan kortikal. Katarak ini terletak di lapisan posterior kortikal dan biasanya axial. Indikasi awal adalah terlihatnya gambaran halus seperti pelangi dibawah slit lamp pada lapisan posterior kortikal. Pada stadium lanjut terlihat granul dan plak pada korteks subkapsul posterior ini. Gejala yang dikeluhkan penderita adalah penglihatan yang silau dan penurunan penglihatan di bawah sinar terang. Dapat juga terjadi penurunan penglihatan pada jarak dekat dan terkadang beberapa pasien juga mengalami diplopia monocular.

KATARAK SEKUNDER, KATARAK KOMPLIKATA

PERSIAPAN OPERASI KATARAK YANG LENGKAP 1. Medical history a. Hipertensi dpt meningkatkan IOP b. DM c. Coronary artery disease d. COPD e. Disability: arthritis, claustrophobia, cognitive dysfunction, hearing loss f. Previous anaesthetics and operations g. Family history: pengalaman dengan anastesi h. Drug history: antikoagulan, antiHT, i. Alergi j. Sosial history: smoking, 2. PF a. Airway assessment b. CARDIOVASCULAR c. RESPI

ANNEL TEST pemeriksaan saluran air mata dengan menggunakan larutan saline hangat
yang diinjeksikan melalui lubang punctum lakrimalis di sudut mata dekat hidung.

1. Lebarkan pungtum lakrimal dengan dilator pungtum 2. Isi spuit dengan larutan garam fisiologis. Gunakan jarum lurus atau bengkok tetapi tidak tajam 3. Masukkan jarum ke dalam pungtum lakrimal dan suntikkan cairan melalui pungtum lakrimal ke dalam saluran eksresi , ke rongga hidung
3

4. Uji anel positif jika terasa asin di tenggorok atau ada cairan yang masuk hidung. Uji anel negatif jika tidak terasa asin. Hal ini berarti ada kelainan di dalam saluran eksresi. Jika cairan keluar dari pungtum lakrimal superior, berarti ada obstruksi di duktus nasolakrimalis. Jika cairan keluar lagi melalui pungtum lakrimal inferior berarti obstruksi terdapat di ujung nasal kananlikuli lakrimal inferior, maka coba lakukan uji anel pungtum lakrimal superior.

RETINOMETRI
ophthalmic diagnostic instruments designed mainly to assess the preoperative retinal acuity in patients with cataracts.

CEK BIOMETRI, APA KAH SEBELUM BIOMETRI HARUS KERATOMETRI? Biometri adalah pemeriksaan mata yang bertujuan untuk mengukur panjang sumbu bola mata, kelengkungan kornea dan kedalaman bilik mata depan, sehingga didapatkan ukuran lensa intra okular yang akan ditanam dalam bola mata Keratometri adalah pemeriksaan mata yang bertujuan untuk mengukur radius kelengkungan kornea
The central corneal power is the second important factor in the calculation formula. To simplify the calculation, the cornea is assumed to be a thin spherical lens with a fixed anterior to posterior corneal curvature ratio and an index of refraction of 1.3375. Central corneal power can be measured by keratometry or corneal topography. By measuring both the length of the eye (A-scan) and the power of the cornea (keratometry), a simple formula can be used to calculate the power of the intraocular lens needed. There are several different formulas that can be used depending on the actual characteristics of the eye. IOL POWER CALCULATION

The SRK formula is calculated easily by hand as , where is the IOL power to be used for emmetropia, is the IOL specific A constant, is the average corneal refractive power (diopters), and is the length of the eye (mm). The SRK II formula adjusts the A constant utilized depending on the axial length: increasing the A constant for short eyes and decreasing the A constant for long eyes.

EXPULSIF HEMORRHAGE Expulsive Choroidal Haemorrhage (ECH) is the most severe form of suprachoroidal haemorrhage.' It is usually seen as an operative complication of intraocular surgery. Blood escapes into the suprachoroidal space and increases the intraocular pressure posteriorly and pushes the ocular contents forward, out of the eye, through the weakest part of the globe, usually the surgical incision. Whereas limited choroidal haemorrhage does.

Dark choroidal mass with or without vitreous hemorrhage Shallowing of the anterior chamber Hypotony during or after intraocular surgery Firmness of the globe Bleeding through the surgical wound

FUNGSI ENDOTEL KORNEA, KORNEA RUSAK JADI APA?

Epitel dan endotel kornea memiliki fungsi untuk menjaga agar cairan pada stroma kornea tetap dalam keadaan stabil. Sel- sel pada kedua lapisan ini kaya akan lipid dan bersifat hidrofobik (sedangkan stroma bersifat hidrofilik) sehingga solubilitas garam menjadi rendah.
Sifat tembus cahayanya disebabkan strukturnya yang uniform, avaskuler, dan deturgesens. Deturgesens, atau keadaan dehidrasi relatif jaringan kornea, dipertahankan oleh pompa bikarbonat aktif pada endotel dan oleh fungsi sawar epitel dan endotel. Endotel lebih penting daripada epitel dalam mekanisme dehidrasi, dan cedera kimiawi atau fisik pada endotel jauh lebih berat daripada cedera pada epitel. Kerusakan sel-sel endotel menyebabkan edema kornea dan hilangnya sifat transparan. Sebaliknya, cedera pada epitel hanya menyebabkan edema lokal sesaat stroma kornea yang akan menghilang bila sel-sel epitel itu telah beregenerasi.

ENDOFTALMTIS EC CATARAC SURGERY Although most cases of postoperative endophthalmitis occur within 6 weeks of surgery, infections seen in high-risk patients or infections caused by slow-growing organisms may occur months or years after the procedure

The incidence of endophthalmitis has been reported to be between 0.13% and 0.7%.1 The primary source of this intraocular infection is considered to be bacteria from the patient's ocular surface (cornea, conjunctiva) or adnexa (lacrimal glands, eyelids, and extraocular muscles).
increase the presence of bacteria on the ocular surface risk factors for the development of endophthalmitis.1 These conditions include: blepharitis, conjunctivitis, cannuliculitis, lacrimal duct obstruction, contact lens wear, and an ocular prosthesis in the fellow orbit.

The choice of intraocular lens (IOL) can affect the risk of endophthalmitis. The use of IOLs with silicone optics is associated with an increased risk of endophthalmitis, compared with that of IOLs with acrylic optics. It is unlikely that this is due to the hydrophobic nature of silicone, since a comparison of hydrophobic and hydrophilic lenses showed no difference in the rates of endophthalmitis.

Tips for preventing endophthalmitis

Instil povidone-iodine 5% eye drops prior to surgery. Carefully drape the eyelid and lashes prior to surgery. Use sterile gloves, gowns, and face masks. Construct watertight incisions, preferably three-plane. Manage complications (e.g. capsular rupture) effectively. Acrylic optics are better than silicone. Inject intracameral cefuroxime postoperatively (1 mg in 0.1 ml normal saline).

Toxic anterior segment syndrome is an acute, sterile, anterior segment inflammation that can occur after any anterior segment surgery. Toxic anterior segment syndrome most commonly occurs acutely following anterior segment surgery, typically 12-72 h after cataract extraction. Anterior segment inflammation is usually quite severe with hypopyon. Endothelial cell damage is common, resulting in diffuse corneal oedema.

Toxic anterior segment syndrome has numerous causes, and most cases are attributed to 1) contaminants on surgical instruments, resulting from improper or insufficient cleaning; 2) products introduced into the eye during surgery, such as irrigating solutions or ophthalmic medications; or 3) other substances that enter the eye during or after surgery, such as topical ointments or talc from surgical gloves

ENDOPHTHALMITIS acute-onset endophthalmitis (6 weeks after surgery) and delayed-onset endophthalmitis (>6 weeks after surgery).