preceptor

dr. Mustafa KS, SPM

dr. hermansyah, SPM
dr. Henry A. W,SPM
dr. Gartati Ismail, SPM
dr. Agah Gadjali, SPM
dr. Susan Sri A, Sp. M

Cataract
UNIVERSITY YARSI - RS SAID Sukanto

Fathonah Fatimatuzahra Said 1102013108

Patient identity
• Name: Mr. MJ
• Age : 64 year
• Male gender
• Date of birth : duo, 31 July 1954
• Education: S1
• Occupation: entrepreneur
• Address:: Jl. Base teakNo. 9Kel, Cipinang
Malay, excl, Macassar, East Jakarta
• Islam
• Ethnicity: Java, Indonesia
• Status: Married
• Date of Inspection: 23 April 2018
anamnesis

Anamnesis dilakukan secara autoanamnesis pada tanggal 23 April 2018

Keluhan Utama Keluhan Tambahan

Penglihatan buram Pengliahatan ganda
pada mata kanan dan silau sejak 8
sejak 1 tahun SMRS bulan SMRS
Disease History Now
Pasien boys ages 64 year came to Poly clinic mata RS
police with complaints of blurred vision in slow - land right eye
since 1 yearSMRs. patients sayinitially like the misty blurred
vision in the right eye the patient so difficult to see. Since8 last
month, arise complaint vision ganda, Complaints accompanied
by the right eye glare if the light is too bright look. Complaints
are not accompanied by red eyes, itching, and pain. Complaints
seeing halos around light denied. Complaint other no be
accompanied with painful head, nausea, gag,
Disease History Now
8 month that then, patient plead on the patient's
right eye is difficult to see objects that are near be accompanied
opaque when viewing distant objects, The complaints begin to
interfere with daily activities of patients, kemudian 1 the SMRs
pasien complain vision blur increasingly become heavy and
disturbing activity daily, Patients denied ever having a complaint
look like a speck floats that follow the direction of motion of the eye.
Patients admitted to using the previous glasses for left eye vision
impairment. Patients also denied ever taking drugs either in the
form of tablets or eye drops in the long term. Patients had never
experienced collision or trauma to the eye area. The patient had a
history of diabetes and hypertension,
 Patient plead ever treatment to doctor eye previous with
complaint that same on eye right and his left, however already
do operation cataract only on eye left just, because patient reject
for in do operation on eye right, Operation do on month
September 2017 in hospitals Market Rebo, time this patient
plead view eye kanannya blur, making it difficult to see, apart
that patient plead, ever in hospitalization in RS INP on date 11
April 2018 for 8 day with history disease stroke.
 Past medical history

 There riwayat previous similar complaints on eye left

 There riwayat previously denied their impaired vision
 History wearing glasses S + 2.00 OD and S +1.00 OS
 There riwayat surgery on eye left previous with cataract, on month September 2017
in hospitals Market Rebo,
 A history of drug use in the long term be denied
 There riwayat diabetes mellitus
 There riwayat blood high
 A history of collision or trauma foreign object denied
 History of drug allergy denied
Family Disease History

• Family history with the same complaint denied

• History of diabetes mellitus indisputably
• History blood high indisputably
Physical examination
• General appearance: Good
• Awareness: Compos mentis
• Vital sign :
Blood pressure: 130/80 mmHg
Nadi: 78 x / min
Temperature: 36,6˚C
Breathing: 20 x / min
ophthalmological status
OD OS
vision 4/60 4/60
S + 2,00 1,00 C-X60 6/15 F SX180 3.00 +1.00 C-6/85 F
TIO No do with tonometry Schiotz No do with tonometry Schiotz
Eye Ball Position Ortoforia
Eye Ball Movement

Good all directions good to in all directions

Field of View Within normal limits Within normal limits

supra Silia Within normal limits Within normal limits
Superior eyelid Quiet Quiet
Inferior eyelid Quiet Quiet
Superior tarsal conjunctiva Quiet Quiet
ophthalmological status
OD OS
Inferior tarsal conjunctiva Quiet Quiet

conjunctiva Bulbi Quiet Quiet

cornea clear; arcus senilis (+) Clear ; arcus senilis (+);

The anterior chamber/ COA Depth was; clear Depth was; clear

slice chocolate; kripte (+); sinekia (- chocolate; kripte (+); sinekia (-

) )
pupil Round ; 3mm diameter; RL (+); Round ; 3mm diameter; RL (+);
RCTL (+) RCTL (+)
Lens Partly cloudy on the lens; Clear
shadow test (+)
TIO perpalpasi Normal per palpation Normal per palpation
funduskopi Are not done Are not done
examination of an Eye

Examination support Slit-Lamp do, however no there result photo

from examination mentioned,
resume
anamnesis

Male patients aged 64 years come to the Police Hospital Eye Clinic
complaining of blurred vision in the right eye since 1 year SMRs and become heavy
since 8SMRs month. Patients say like the misty blurred vision in the right eye so that
the patient is difficult to see clearly. Complaints accompanied by the right eye glare
when seeing the light be accompanied vision ganda,
Patients say initially perceived blurred vision when viewing distant, but this
time the patient opaque when viewed up close and have disrupted daily activities -
day.

Physical examination
Status Generalists

Blood pressure
Vital signs within Nadi 78 x / Temperature Breathing 20 x
of 130/80
normal limits: min 36,6˚C / min).
mmHg
ophthalmological status
Dextra oculi (OD) EXAMINATION Oculi Sinistra (OS)

4/60 vision 4/60

Quiet Konjugntiva Bulbi Quiet

Clear ; arcus senilis (+) cornea Clear ; arcus senilis (+);

Depth moderate ; clear Eye booth Home Depth was; clear

(COA)
Partly cloudy on the lens; Lens Clear
shadow test (+)
diagnosis

Working diagnosis
I senile cataractmature OD
Governance
• CaCl2 anhidrat 0,075 gram, Kalium Iodida
0,075 gram, Natrium Tiosulfat 0,0075 gram,
Fenilmerkuri nitrat 0,3 mg (per 15 ml – Cendo
Catarlent) 4 x gtt I OD
Medikamentosa • Pemberian kacamata dengan koreksi terbaik
dapat dilakukan kepada pasien karena visus
pada oculi dextra dan oculi sinistra pasien
4/60

• Pada Ocular Dextra: Dapat dilakukan operasi ECCE

Terapi Operatif (Extracapsular Cataract Extraction) + IOL

• Menjelaskan cara pemakaian obat dan pentingnya

menggunakan obat dengan teratur
• Menjelaskan kepada pasien untuk rutin kontrol setelah
Edukasi operasi
• Setelah operasi, pasien tidak diperbolehkan untuk
Pasien menggaruk, menekan, dan terkena air pada mata yang
dioperasi
• Menghindari mengangkat beban, mengejan dan bersin
yang kuat selama kurang lebih dua bulan
Plan Monitor / Evaluation
• Dalam waktu 48 jam setelah operasi
• Untuk mendeteksi dan mengatasi komplikasi dini seperti kebocoran luka yang
menyebabkan bilik mata dangkal, hipotonus, peningkatan tekanan intraokular,
I edema kornea ataupun tanda-tanda peradangan

• Dijadwalkan pada hari ke 4-7 setelah operasi

• Untuk mendeteksi dan mengatasi kemungkinan endoftalmitis yang paling sering
II terjadi pada minggu pertama pasca operasi.

• Dijadwalkan sesuai dengan kebutuhan pasien

• Untuk memberikan kacamata sesuai dengan refraksi terbaik yang diharapkan
III
prognosis

Quo Ad Vitam Ad bonam

Ad Quo Functionam Dubia ad bonam

Ad Quo Sanactionam Dubia Ad bonam

Ad Quo Cosmetican Dubia ad bonam

LITERATURE REVIEW
Anatomy Lens
• Lens is something structure
biconvex, avascular, not colored
and almost transparent perfect
• Thick around 4 mm and
diameter 9 mm
• Depending on the zonula lens
behind the iris (zonula Zinnii)
• In next anterior lens there joke
aquoEUS and next to posterior
there viterus
• Tdd lens 65% water and 35%
protein.
• Capsule lens is something
membrane semipermeable that
could be passed water and
electrolyte
• Next to front there a layer
epithelium subcapsular
• Nukleuas lens louder than
korteksnya
• The nucleus and cortex are
formed from concentric long
lamella, which contains the
essence of sprawl.
• There are no pain fibers, blood
vessels, or nerves in the lens
Physiology Lens

Aktivitas Daya
Metabolisme Akomodasi

Transparansi Elastisitas
lensa Lensa
Lensa
Definition

Menurut Ilyas, 2015

• Katarak adalah setiap keadaan kekeruhan pada lensa yang dapat

terjadi akibat hidrasi (penambahan cairan) lensa, denaturasi protein
lensa atau terjadi akibat kedua-duanya.

Menurut INASCRS (Indonesian Society of Cataract and

Refractive Surgery) 2011
• Katarak adalah kekeruhan lensa kristalin yang menyebabkan
turunnya tajam penglihatan dan menyebabkan keluhan gangguan
penglihatan lainnya seperti kontras sensitivitas, silau dan tidak
nyaman

Menurut WHO

• Katarak adalah kekeruhan yang terjadi pada lensa mata, yang

menghalangi sinar masuk ke dalam mata
classification of Cataracts
classification of Cataracts
Katarak kongenital adalah katarak
yang sudah terlihat pada usia di
bawah 1 tahun

Katarak juvenil adalah katarak yang

terjadi sesudah usia 1 tahun

Katarak senilis : katarak yang

terjadi setelah usia 50 tahun
Epidemiology
• Sebagian besar katarak terjadi karena proses degeneratif atau
bertambahnya usia seseorang.
• Berbagai studi cross-sectional melaporkan prevalensi katarak pada
individu berusia 65-74 tahun adalah sebanyak 50%, prevalensi ini
meningkat hingga 70% pada individu usia di atas 75 tahun

• Berdasarkan National Programme fo Control of Blindness 1992, katarak

merupaan salah satu penyebab kebutaan yang utama, dimana urutan
penyebab kebutaan adalah katarak, kelainan kornea, optic atrofi, dan
kelainan retina
Etio-Pathogenesis

Exposure Degenera
to UV rays tive (age)
Diabetes

Other eye
surgery

Cataract Eye
inflamma
tion
Smoke

Eye
Steroid use trauma
Family
long
history of
cataracts
senile cataract
Definition

Senile cataract lens opacities are all contained in the

elderly, the age group above 50 years. This disease affects
visual acuity someone who is on the mark with thickening of
the lens in the eye that occurs progressively and gradually.
Cataract is the leading cause of blindness are treatable.
Classification of senile cataract
based Stadium
The pathogenesis of senile cataract

Lens nucleus
suppression and
Old cells hardening
Lens epithelial
accumulate
With age cells continue
toward the
to grow
middle
CATARAC
The lens can not
Lens proteins undergo deliver and focus T
chemical modification light onto the retina
and aggregation

Pigmentation
protein The decrease
progressive lens
aggregatio transparency of
becomes patterned
n the lens
amber
 Clinical symptoms
symptom Clinical
Penglihatan menurun, penglihatan seperti berkabut atau
berasap

Merasa Silau

Myopic Shift

Diplopia Monoculara

Melihat Halo sekitar Sinar

Diskriminasi Warna Terganggu

diagnosis

Anamnesis Pemeriksaan Rutin Pemeriksaan Tambahan

Terdapat gejala klinis 1. Pemeriksaan Visus 1. Biometri untuk
katarak dengan Snellen Chart mengukur power IOL jika
Berjalan secara progresif 2. Pemeriksaan dengan slit pasien akan dioperasi
lamp katarak
3. Pemeriksaan TIO 2. Retinometri untuk
mengetahui prognosis
4. Jika TIO normal → tajam penglihatan setelah
Dilakukan dilatasi pupil → operasi
Pemeriksaan slit lamp
3. Shadow Test untuk
5. Pemeriksaan Funduskopi menilai derajat kekeruhan
lensa
Shadow Test
Governance

Non-Bedah Bedah
Indikasi Medis: terjadi penyulit lain yang
disebabkan oleh katarak itu sendiri, seperti
uveitis, dislokasi lensa, glaukoma,
endoftalmitis, dan penyakit retina seperti
retinopati diabetikum dan ablasio retina.
Pasien dengan visus
≥6/12 → diberikan Indikasi Optik dan Sosial: Fungsi
kacamata dengan penglihatan sudah mengganggu untuk
melakukan kegiatan sehari-hari berkaitan
koreksi terbaik dengan pekerjaan pasien.

Indikasi Kosmetik: terkadang pasien

dengan katarak matur meminta
ekstraksi katarak agar pupil kembali
CIM (Compendium of Indonesian menjadi hitam
Medicine) 1st Edition
Technique Operation
A. intracapsular cataract extraction
• The entire lens will be issued together with the lens capsule
including posterior capsule.
• Such techniques are becoming obsolete because of the high
incidence of postoperative complications
• In addition, the superior limbus incision required 140-160˚
thus requiring a longer recovery time
• This technique can still be used if there is not enough facilities
to do extracapsular cataract extraction technique
 B. extracapsular cataract extraction
• Issued with the anterior lens capsule, while the left posterior
capsule
• The incision is made in the limbus or next to the periphery of
the cornea, usually in the superior part (sometimes
temporal),
• Opening made in the anterior capsule, the nucleus and the
cortex is removed and replaced with an intraocular lens
placed in the "capsular bag" which is supported by the
posterior capsule
• Advantages of this technique compared intracapsular
extraction:
- Smaller incisions to minimize trauma and recovery time
becomes shorter
- Complications aderensi corpus vitreous to the cornea and
iris can be minimized.
- anatomical location of the intraocular lens is more stable
because it is supported by the posterior capsule
- an intact posterior capsule may act as a barrier against
bacteria and microorganisms that may be entered during the
operation as well as hold an exchange of molecules between
akuos humor and vitreous.
 c. phacoemulsification
• Using ultrasonic vibrator useful for destroying
the hard lens nucleus so that the material of
the nucleus and the cortex can be aspirated
through an incision of + 3mm
• The same incision is used to insert a foldable
intraocular lens
• The advantage of a small incision is the incision
did not need stitches, wound healing faster
with less corneal distortion, reduce
postoperative intraocular inflammation, and a
faster recovery of visual function
• Risk: the release of the posterior lens material
through a posterior capsular tear is inevitable.
Post-Surgical Care
Frekuensi pemeriksaan
pasca bedah
ditentukan
berdasarkan tingkat
pencapaian visus
optimal yang
diharapkan
Pada pasien yang dianggap
tidak bermasalah → dapat
mengikuti petunjuk
pemeriksaan lanjutan (follow
up):
-Kunjungan pertama: 24-48 jam
pasca operasi
-Kunjungan kedua: pada hari ke
4-7 pasca operasi
-Kunjungan ketiga: sesuai
dengan kebutuhan pasien
Pada pasien dengan
risiko tinggi →
pemeriksaan harus
dilakukan satu hari
setelah operasi
Obat-obatan yang
digunakan pasien pasca
operasi : penggunaan tetes
mata kombinasi antibiotika
dan steroid harus
diberikan kepada pasien
untuk digunakan setiap
hari selama minimal 4
minggu pasca operasi
Post-Surgical Complications

Hilangnya
Prolaps iris Endoftalmitis
vitreous

Astigmatisma Edema makular

Ablasio retina
pasca operasi sistoid

Katarak
Sekunder
prognosis

If on process maturation cataract do handling that right

so that no inflict complication and do action surgery that right
then prognosis on cataract senile generally good
Prevention

• Tidak could prevented because cause occurrence cataract

senile is by because factor age
• NAmun could do prevention to things that aggravate as
control disease metabolic, prevent shelf directly terhatap
beam ultraviolet with use glass eye dark, etc
Case analysis
based on the theory based on case
Definition Senile cataract lens opacities are all contained in Male patients aged 64 year
the elderly, the age group above 50 years.

symptom 1. The sharp decline in vision that occur 1. Blurred vision in the right eye since 1
progressively or gradually year ago
2. Vision like a foggy or smoky 2. Patients describe blurred vision as
3. Eye feel glare covered in fog
4. See the halo around the rays 3. Complaints accompanied by eye was
5. Melihat color distracted dazzled when seeing the light is too
6. Seeing double bright be accompanied vision ganda
7. The improvement in near vision without
glasses

Examination Ophthalmological status OD 1. vision OD 4/60

Physical 1. The sharp decline of progressive vision, 2.
depending on the degree kekruhan lens case. 3.
Can acuity> 6/12 to <1/60 4.
2. There is cloudiness in the lens, depending on 5.
the stage of turbidity occur. In the immature
stage, lens opacities in part, increased fluid
lens, iris compelled, COA shallow, narrow
chamber angle and shadow test (+)
The cornea is clear, arcus senilis (+)
COA: medium depth, clear
Iris: there are no anterior synechiae
OD cloudy lens on most lenses and
shadow test (+)
Case analysis
Examination 1. Examination with tonometry IOP Schiotz: if • No do pemeruksaan TIO with
Support the IOP in the normal range (less than 21 tonometry Schiotz,
mmHg) performed dilated pupils with eye • Do appraisal TIO with tonometry
drops Tropicanamide 0.5%. Once the pupil is digital
wide enough to slit lamp examination to see
whether the degree of opacification of the
lens in accordance with the vision of patients
2. Funduskopi examination if still possible

Therapy 1. Management non surgery for vision more 1. at OD and OS: The patient may be
good or same with 6/12, that is given sunglasses with best correction
administration eyeglasses with correction for visual acuity patients 6/15 and 6 /
best, 8.5
2. If vision still more good from 6/12 but already
disturb untuk do activity that be related with 2. Surgical therapy: the patient is
work patient or there is indication medical advised to do surgery or
other for operation, patient could do Phacoemulsification ECCE + IOL at
operation cataract OD
3. Governance patient cataract with vision best
less from 6/12 is operation cataract the form 3. Therapy education : educate how the
Jays + IOL or phacoemulsification + IOL with use of drugs and the use of regular,
consider availability tool, level turbidity routine control after surgery, and
cataract and level ability expert surgery postoperative care.
Bibliography
1. Riordan-Eva P, Cunningham E. Vaughan & Asbury General Ophthalmology. 18th ed. McGraw-Hill
Professional. 2011.
2. Harper RA, Shock JP lens. In: Susanto D, Pendit BU eds. Vaughan & Asbury General Ophthalmology. 17th
Edition Book Medical Publishers EGC. 2015.
3. Ilyas S, SR Yulianti Eye Disease Studies. Fifth edition. Agency Publisher Faculty of Medicine, Indonesia,
Jakarta. 2015.
4. Kanski JJ.J, Bowling B. Clinical Ophthalmology: Systemic Approach. 7th ed. Saunders. 2012.
5. Hutauruk J, Istiantoro, Tri B. Cataracts. In: IPD's CIM (Compendium of Indonesian Medicine). Unity
Ophthalmologist Indonesia (PERDAMI). 1sr Edition. 2009.
6. Cataracts In Adult Patients. Free Medical Management (PPM).Indonesian Society of Cataract and
Refractive Surgery (INASCRS). 2011.
7. Andrew I Jobling, Robert C Augustey: What causes steroids Cataracts? A review of steroid-induced
posterior su bcapsular Cataracts; n,Clin Exp optom2002; 85: 2: 61-75,
8. Review Article Diabetic Cataract-Pathogenesis, Epidemiology and Treatment; Hindawi Publishing
Corporation Journal of Ophthalmology Volume 2010,
9. KV Raju, SisiraSivan NV: A clinical study of Complicated Cataract In Uveitis. Kerala Journal of
Ophthalmology Vol. XXII, 1, March 2010,
10. Jungmook Lyu, Jung-A Kim, Sung kun Chung, Ki-San Kim, and Choun-Ki Joo: Alteration of Cadherin in
Dexamethasone-Induced Cataract Lens Organ-Cultured Rat ;. Investigative Ophthalmology & Visual
Science, May 2003, Vol. 44, No. 5
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