17/8/2017 Senile Cataract (Age-Related Cataract) Clinical Presentation: History, Physical, Causes

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Senile Cataract (Age-Related

Cataract) Clinical Presentation
Updated: May 09, 2017
Author: Vicente Victor D Ocampo, Jr, MD; Chief Editor: Andrew A Dahl, MD, FACS more...

PRESENTATION

History
Careful history taking is essential in determining the progression and functional impairment in
vision resulting from the cataract and in identifying other possible causes for the lens opacity. A
patient with senile cataract often presents with a history of gradual progressive deterioration and
disturbance in vision. Such visual aberrations are varied depending on the type of cataract present
in the patient.

Decreased visual acuity

Decreased visual acuity is the most common complaint of patients with senile cataract. The
cataract is considered clinically relevant if visual acuity is affected significantly. Furthermore,
different types of cataracts produce different effects on visual acuity.

For example, a mild degree of posterior subcapsular cataract can produce a severe reduction in
visual acuity with near acuity affected more than distance vision, presumably as a result of
accommodative miosis. However, nuclear sclerotic cataracts often are associated with decreased
distance acuity and good near vision.

A cortical cataract generally is not clinically relevant until late in its progression when cortical
spokes compromise the visual axis. However, instances exist when a solitary cortical spoke
occasionally results in significant involvement of the visual axis.

Glare

Increased glare is another common complaint of patients with senile cataracts. This complaint may
include an entire spectrum from a decrease in contrast sensitivity in brightly lit environments or
disabling glare during the day to debilitating glare with oncoming headlights at night.

Such visual disturbances are prominent particularly with posterior subcapsular cataracts and, to a
lesser degree, with cortical cataracts. It is associated less frequently with nuclear sclerosis. Many
patients may tolerate moderate levels of glare without much difficulty, and, as such, glare by itself
does not require surgical management.

Myopic shift
The progression of cataracts may frequently increase the diopteric power of the lens resulting in a
mild-to-moderate degree of myopia or myopic shift. Consequently, presbyopic patients report an
increase in their near vision and less need for reading glasses as they experience the so-called
second sight. However, such occurrence is temporary, and, as the optical quality of the lens
deteriorates, the second sight is eventually lost.

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17/8/2017 Senile Cataract (Age-Related Cataract) Clinical Presentation: History, Physical, Causes

Typically, myopic shift and second sight are not seen in cortical and posterior subcapsular
cataracts. Furthermore, asymmetric development of lens-induced myopia may result in significant
symptomatic anisometropia that may itself require surgical management.

Monocular diplopia
At times, the nuclear changes are concentrated in the inner layers of the lens, resulting in a
refractile area in the center of the lens, which often is seen best within the red reflex by retinoscopy
or direct ophthalmoscopy.

Such a phenomenon, which some call lens within a lens phenomenon, may lead to monocular
diplopia that is not corrected with spectacles, prisms, or contact lenses.

Physical
After a thorough history is taken, careful physical examination must be performed. The entire body
habitus is checked for abnormalities that may point out systemic illnesses that affect the eye and
cataract development.

A complete ocular examination must be performed beginning with visual acuity for both near and
far distances. Whether or not the patient complains of glare, visual acuity should be tested in a
brightly lit room or with one of the many commercially available glare-testing devices, such as the
brightness acuity tester (BAT). Contrast sensitivity may also be checked, especially if the history
points to a possible problem.

Examination of the ocular adnexa and intraocular structures may also provide clues to the patient's
disease and eventual visual prognosis.

A very important test is the swinging flashlight test, which is used to detect a Marcus Gunn pupil or
relative afferent pupillary defect (RAPD), indicative of optic nerve lesions or diffuse retinal
involvement. A patient with a RAPD and a cataract is expected to have a very guarded visual
prognosis, even after uncomplicated cataract extraction.

A patient with long-standing ptosis since childhood may have occlusion amblyopia, which may
account more for the decreased visual acuity rather than the cataract. Similarly, checking for
problems in ocular motility in all directions of gaze, as well as anisometropia, is important to rule
out any other amblyogenic causes for the patient's visual symptoms.

Slit lamp examination should not only concentrate on evaluating the lens opacity but the other
ocular structures as well (eg, conjunctiva, cornea, iris, anterior chamber). Corneal thickness and
the presence of corneal opacities, such as corneal guttata, must be checked carefully. Appearance
of the lens must be noted meticulously before and after pupillary dilation.

The visual significance of oil droplet nuclear cataracts and small posterior subcapsular cataracts is
evaluated best with a normal-sized pupil to determine if the visual axis is obscured. However,
exfoliation syndrome is best appreciated with the pupil dilated, revealing exfoliative material on the
anterior lens capsule, as well as the pupillary margin, trabecular meshwork, and other intraocular
structures.

After dilation, nuclear size and brunescence as indicators of cataract density can be determined
prior to phacoemulsification surgery. The lens position and integrity of the zonular fibers also
should be checked because lens subluxation may indicate previous eye trauma, antecedent ocular
surgery, metabolic disorders, or hypermature cataracts.

The importance of direct and indirect ophthalmoscopy in evaluating the integrity of the posterior
pole must be underscored. Optic nerve and retinal problems may account for the visual
disturbance experienced by the patient. Furthermore, the prognosis after lens extraction is affected

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17/8/2017 Senile Cataract (Age-Related Cataract) Clinical Presentation: History, Physical, Causes

significantly by detection of pathologies in the posterior pole preoperatively (eg, macular edema,
retinal dystrophy, optic atrophy, severe glaucomatous cupping, age-related macular degeneration).

Causes
Numerous studies have been conducted to identify risk factors for development of senile cataracts.
Various culprits have been implicated, including environmental conditions, systemic diseases, UV
exposure, diet, and age. [14, 15]

West and Valmadrid stated that age-related cataract is a multifactorial disease with different risk
factors associated with each of the different cataract types. [16] In addition, they stated that cortical
and posterior subcapsular cataracts were related closely to environmental stresses, such as UV
exposure, diabetes, and drug ingestion. However, nuclear cataracts seem to have a correlation
with smoking. Alcohol use has been associated with all cataract types.

A similar analysis was completed by Miglior et al. [17] They found that cortical cataracts were
associated with the presence of diabetes for more than 5 years and increased serum potassium
and sodium levels. A history of surgery under general anesthesia and the use of sedative drugs
were associated with reduced risks of senile cortical cataracts. Posterior subcapsular cataracts
were associated with steroid use and diabetes, while nuclear cataracts had significant correlations
with calcitonin and milk intake. Mixed cataracts were linked with a history of surgery under general
anesthesia.

In a population-based, longitudinal study of 3471 Latinos with 4 years of follow-up, Richter et al

found that independent risk factors for incident nuclear-only lens opacities included older age,
current smoking, and the presence of diabetes. Risk factors for cortical-only lens opacities included
older age and having diabetes at baseline. Female gender was a risk factor for posterior
subcapsular-only lens opacities. Presence of diabetes at baseline and older age were risk factors
for mixed lens opacities. [18]

Systemic diseases and senile cataract

Senile cataracts have been associated with numerous systemic illnesses, to include the following:
cholelithiasis, allergy, pneumonia, coronary disease and cardiac insufficiency, hypotension,
hypertension, mental retardation, and diabetes.

Systemic hypertension was found to significantly increase the risk for posterior subcapsular
cataracts. In a related study by Jahn et al, hypertriglyceridemia, hyperglycemia, and obesity were
found to favor the formation of posterior subcapsular cataracts at an early age. [19]

A possible pathway for the role of hypertension and glaucoma in senile cataract formation was
proposed with induced changes in the protein conformational structures in the lens capsules,
subsequently causing alterations in membrane transport and permeability of ions, and, finally,
increasing intraocular pressure resulting in the exacerbation of cataract formation.

UV light and senile cataract

The association of UV light and development of senile cataract has generated much interest. One
hypothesis implies that senile cataracts, particularly cortical opacities, may be the result of thermal
damage to the lens.

An animal model by Al-Ghadyan and Cotlier documented an increase in the temperature of the
posterior chamber and lens of rabbits after exposure to sunlight due to an ambient temperature
effect through the cornea and to increased body temperature. [20]

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17/8/2017 Senile Cataract (Age-Related Cataract) Clinical Presentation: History, Physical, Causes

In related studies, people living in areas with greater UV exposure were more likely to develop
senile cataracts and to develop them earlier than people residing in places with less UV exposure.

Other risk factors

Significant associations with senile cataract were noted with increasing age, female sex, social
class, and myopia. Consistent evidence from the study of West and Valmadrid suggested that the
prevalence of all cataract types was lower among those with higher education. [16] Workers
exposed to infrared radiation also were found to have a higher incidence of senile cataract
development.

Although myopia has been implicated as a risk factor, it was shown that persons with myopia who
had worn eyeglasses for at least 20 years underwent cataract extraction at a significantly older age
than emmetropes, implying a protective effect of the eyeglasses to solar UV radiation.

The role of nutritional deficiencies in senile cataract has not been proven or established. However,
a high intake of the 18-carbon polyunsaturated fatty acids linoleic acid and linolenic acid reportedly
may result in an increased risk of developing age-related nuclear opacity.

In the Blue Mountains Eye Study, pseudoexfoliation increased the risk of cataract and subsequent
cataract surgery. [21]

Differential Diagnoses

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