Cataract

Overview of Cataract

Most cataracts develop slowly as a result of aging, leading to gradual impairment of vision.

Epidemiology of Cataract

Cataract remains a major cause of blindness in India.

According to "Epidemiology of cataract in India: combating plans and strategies" (1998), 80.1% of blindness cases in India were attributed to cataracts, with a backlog of over 22 million blind eyes. [9]

Additionally, "Prevalence of Cataract in an Older Population in India: The India Study of Age-related Eye Disease" (2010) found high rates of unoperated cataracts in older people, especially women. [10]

Causes

Age

• Age is the most common cause. Lens proteins denature and degrade over time, and this process is accelerated by diseases such as diabetes mellitus and hypertension.
• Environmental factors, including toxins, radiation, and ultraviolet light have cumulative effects which are worsened by the loss of protective and restorative mechanisms due to alterations in gene expression and chemical processes within the eye.[2]

Trauma

• Post traumatic rosette cataract of a 60-year-old male
• Blunt trauma causes swelling, thickening, and whitening of the lens fibers. While the swelling normally resolves with time, the white color may remain. In severe blunt trauma, or in injuries that penetrate the eye, the capsule in which the lens sits can be damaged.
• This damage allows fluid from other parts of the eye to rapidly enter the lens leading to swelling and then whitening, obstructing light from reaching the retina at the back of the eye.
• Cataracts may develop in 0.7 to 8.0% of cases following electric injuries, Blunt trauma can also result in star- (stellate) or petal-shaped cataracts.

Radiation

• Cataracts can arise as an effect of exposure to various types of radiation. X-rays, one form of ionizing radiation, may damage the DNA of lens cells.
• Ultraviolet light, specifically UVB, has also been shown to cause cataracts, and some evidence indicates sunglasses worn at an early age can slow its development in later life.
• Microwaves, a type of nonionizing radiation, may cause harm by denaturing protective enzymes (e.g., glutathione peroxidase), by oxidizing protein thiol groups (causing protein aggregation), or by damaging lens cells via thermoelastic expansion.
• The protein coagulation caused by electric and heat injuries whitens the lens.
• This same process is what makes the clear albumen of an egg become white and opaque during cooking. 

Genetics

• Christmas tree cataract (Diffuse illumination)
• The genetic component is strong in the development of cataracts, most commonly through mechanisms that protect and maintain the lens.
• The presence of cataracts in childhood or early life can occasionally be due to a particular syndrome.

Skin diseases

• The skin and the lens have the same embryological origin and so can be affected by similar diseases.
• Those with atopic dermatitis and eczema occasionally develop shield ulcer cataracts.
• Ichthyosis is an autosomal recessive disorder associated with cuneiform cataracts and nuclear sclerosis.
• Basal-cell nevus and pemphigus have similar associations.

Smoking and alcohol

• Cigarette smoking has been shown to double the rate of nuclear sclerotic cataracts and triple the rate of posterior subcapsular cataracts.

Inadequate vitamin C

• Low vitamin C intake and serum levels have been associated with greater cataract rates.

Medications

• Some medications, for example systemic, topical, or inhaled corticosteroids, may increase the risk of cataract development.
• Corticosteroids most commonly cause posterior subcapsular cataracts.
• People with schizophrenia often have risk factors for lens opacities (e.g. diabetes, hypertension, and poor nutrition) but antipsychotic medications are unlikely to contribute to cataract formation.
• Miotics also triparanol may increase the risk.

Post-operative

• Nearly every person who undergoes a vitrectomy—without ever having had cataract surgery—will experience progression of nuclear sclerosis after the operation.
• This may because the native vitreous humour different from the solutions used to replace the vitreous (in other words, vitreous substitutes), such as BSS Plus.
• This may also because the native vitreous humors contains ascorbic acid which helps neutralize oxidative damage to the lens and because conventional vitreous substitutes do not contain ascorbic acid.
• Accordingly, for phasic patients requiring a vitrectomy it is becoming increasingly common for ophthalmologists to offer the vitrectomy combined with prophylactic cataract surgery to prevent cataract formation.[2]

Classification of Cataract

Cataracts may be

• Partial or complete
• Stationary or progressive
• Hard or soft

The main types of age-related cataracts are nuclear sclerosis, cortical, and posterior subcapsular.

1. Nuclear sclerosis:

• It is the most common type of cataract, and involves the central or ‘nuclear’ part of the lens.
• This eventually becomes hard, or ‘sclerotic’, due to condensation on the lens nucleus and the deposition of brown pigment within the lens.
• In its advanced stages it is called a brunescent cataract. In early stages, an increase in sclerosis may cause an increase in refractive index of the lens.
• This causes a myopic shift (lenticular shift) that decreases hyperopia and enables presbyopia patients to see at near without reading glasses.
• This is only temporary and is called second sight.[2]

2. Cortical cataract:

• It is due to the lens cortex (outer layer) becoming opaque. They occur when changes in the fluid contained in the periphery of the lens causes fissuring.
• When these cataracts are viewed through an ophthalmoscope, or other magnification system, the appearance is similar to white spokes of a wheel.
• Symptoms often include problems with glare and light scatter at night.

3. Posterior subcapsular cataracts:

• It is cloudy at the back of the lens adjacent to the capsule (or bag) in which the lens sits. Because light becomes more focused toward the back of the lens, they can cause disproportionate symptoms for their size.

4. An immature cataract:

• It has some transparent protein, but with a mature cataract, all the lens protein is opaque.
• In a hypermature or Morgagnian cataract, the lens proteins have become liquid.

5. Congenital cataract:

• Which may be detected in adulthood, has a different classification and includes lamellar, polar, and sutural cataracts.

Cataracts can be classified by using the lens opacities classification system LOCS III. In this system, cataracts are classified based on type as

• Nuclear
• Cortical
• Posterior[2]

Risk factors

• The formation of cataract occurs more rapidly in patients with a history of ocular trauma, uveitis, or diabetes mellitus.[1]
• Moreover, Trauma
• Radiation exposure, Radiation therapy also glucocorticoid treatment can induce cataract as a side effect. Additionally, The cataracts associated with either radiation or glucocorticoids have a typical posterior subcapsular location.
• Diabetes
• Besides this, Long standing use of Corticosteroids
• Lastly, Prolong used of alcohol, smoking tobacco [2]

Pathogenesis of Cataract

Cataract pathogenesis as a multifactorial process involving various mechanisms:

• Oxidative Damage: Reactive oxygen species (ROS) generated by metabolic processes and environmental factors damage lens proteins and lipids, leading to protein aggregation and lens opacification.
• Protein Modifications: Post-translational modifications like glycation, deamidation, and oxidation alter protein structure and function, contributing to lens insolubilization and light scattering.
• Lens Dehydration: Disruption of lens water and ion balance due to impaired membrane transport systems leads to dehydration, increased protein concentration, and subsequent aggregation.
• Genetic Factors: Mutations in genes encoding crystallins and other lens proteins can predispose to congenital or early-onset cataracts.
• Environmental Factors: Exposure to UV radiation, smoking, and certain medications can accelerate cataract development. [11]

Pathophysiology of Cataract

Accumulation of clumps of protein or yellow-brown pigment in the lens that reduces transmission of light to the retina at the back of the eye.[1]

Cataracts acquired in a variety of genetic diseases, such as Myotonic dystrophy, neurofibromatosis type 2, and galactosemia.[1]

Cataract can detected by noting an impaired red reflex when viewing light reflected from the fundus with an ophthalmoscope or by examining the dilated eye with the slit lamp.[1]

The only treatment for cataract surgical extraction of the opacified lens. Millions of cataract operations performed each year around the globe. The operation generally done under local anesthesia on an outpatient basis.

A plastic or silicone intraocular lens placed within the empty lens capsule in the posterior chamber, substituting for the natural lens and leading to rapid recovery of sight. More than 95% of patients who undergo cataract extraction can expect an improvement in vision.

In some patients, the lens capsule remaining in the eye after cataract extraction eventually turns cloudy, causing secondary loss of vision. A small opening, called a posterior capsulotomy, made in the lens capsule with a laser to restore clarity.[1]

Clinical Features of Cataract

Let’s Kanski’s Clinical Ophthalmology" (9th edition, 2020), authors Brad Bowling and Jack J. Kanski outline the clinical features of cataracts:

• Gradual, Painless Loss of Vision: Cataracts typically progress slowly over time, causing a gradual decline in visual acuity. This vision loss is usually painless and can affect both distance and near vision.

• Glare and Halos: Patients often experience increased sensitivity to light (photophobia) and glare, especially from bright sunlight or headlights at night. They may also see halos around lights.

• Decreased Contrast Sensitivity: Cataracts reduce the eye’s ability to distinguish between shades of light and dark, making it difficult to perceive subtle details and variations in contrast.

• Altered Color Perception: Colors may appear faded or yellowish due to the scattering and absorption of light by the cloudy lens.

• Myopic Shift: Some types of cataracts, particularly nuclear cataracts, can cause a temporary improvement in near vision as the lens hardens and becomes more convex.

• Monocular Diplopia: Double vision in one eye can occur due to irregular refraction of light by the cataractous lens.

• Opacification of the Lens: On examination, the cataract can be seen as an opacity or cloudiness in the normally clear lens. The appearance of the opacity varies depending on the type and stage of the cataract. [12]

Sign & Symptoms

• People with nuclear sclerotic or brunescent cataracts often notice a reduction of vision.
• Nuclear cataracts typically cause greater impairment of distance vision than of near vision.
• Those with posterior subcapsular cataracts usually complain of glare as their major symptom.
• Other symptoms include frequent changes of glasses and colored halos due to hydration of lens.
• Congenital cataracts can result in amblyopia if not treated in a timely manner. 

Clinical examination of Cataract

• Well-developed cataracts appear as grey, white, or yellow-brown opacities in the lens.
• Examination of the red reflex through the dilated pupil with the ophthalmoscope.(6)

Diagnosis

To determine whether you have a cataract, your doctor will review your medical history and symptoms, and perform an eye examination. Your doctor may conduct several tests, including:

• Visual acuity test

  A visual acuity test uses an eye chart to measure how well you can read a series of letters. Your eyes are tested one at a time, while the other eye is covered. Using a chart or a viewing device with progressively smaller letters, your eye doctor determines if you have 20/20 vision or if your vision shows signs of impairment.

• Slit-lamp examination

  A slit lamp allows your eye doctor to see the structures at the front of your eye under magnification. The microscope is called a slit lamp because it uses an intense line of light, a slit, to illuminate your cornea, iris, lens, and the space between your iris and cornea. The slit allows your doctor to view these structures in small sections, which makes it easier to detect any tiny abnormalities.

• Retinal exam

  To prepare for a retinal exam, your eye doctor puts drops in your eyes to open your pupils wide (dilate). This makes it easier to examine the back of your eyes (especially retina). Using a slit lamp or a special device called an ophthalmoscope, your eye doctor can examine your lens for signs of a cataract.

• Applanation tonometry

  This test measures fluid pressure in your eye. There are multiple different devices available to do this.[5]

Differential diagnosis of Cataract

• Glaucoma. 
• Refractive errors. 
• Macular degeneration.(8)

Complications of Cataract

The following complications of cataracts are described:

• Phacomorphic Glaucoma: In advanced cataracts, particularly intumescent white cataracts, the swelling of the lens can push the iris forward, leading to angle closure and a sudden rise in intraocular pressure, causing pain, redness, and vision loss.
• Phacolytic Glaucoma: Leakage of lens proteins through an intact but permeable lens capsule can trigger an inflammatory response in the trabecular meshwork, obstructing aqueous outflow and causing glaucoma.
• Lens-Induced Uveitis: Rarely, cataracts can induce an inflammatory response in the uveal tract (iris, ciliary body, and choroid), leading to pain, redness, photophobia, and decreased vision. [13]

Investigations

To determine whether you have a cataract, your doctor will review your medical history and symptoms, and perform an eye examination.
Your doctor may conduct several tests, including:

Treatment of Cataract

Surgery

• Phacoemulsification the most widely used cataract surgery in the developed world. This procedure uses ultrasonic energy to emulsify the cataract lens.[2]
• Extracapsular cataract extraction (in other words, ECCE) consists of removing the lens manually, but leaving the majority of the capsule intact.[2]
• Manual small incision cataract surgery (MSICS) has evolved from ECCE. In MSICS, the lens removed through a self-sealing scleral tunnel wound in the sclera which, ideally, is watertight and does not require suturing. Although "small", the incision still markedly larger than the portal in phacoemulsion. This surgery is increasingly popular in the developing world where access to phacoemulsification still limited.
• Intracapsular cataract extraction ( in other words, ICCE) rarely performed. The lens and surrounding capsule removed in one piece through a large incision while pressure applied to the vitreous membrane. The surgery has a high rate of complications.

Complications and Risks of Cataract Surgery

These complications i.e.

• Infection
• Retinal detachment
• Inflammation inside the eye
• Swelling in certain parts of the eye
• Retention of a piece of the cataract inside the eye
• Glaucoma
• Hemorrhage (bleeding)[4]

Prevention

Risk factors such as UVB exposure and smoking can addressed.

Although no means of preventing cataracts has been scientifically proven, wearing sunglasses that counteract ultraviolet light may slow their development.

While adequate intake of antioxidants (such as vitamins A, C, and E) has thought to protect against the risk of cataracts, clinical trials have shown no benefit from supplements; though evidence mixed, but weakly positive, for a potential protective effect of the nutrient’s lutein and zeaxanthin.[2]

Homeopathic Treatment

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.

Which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. Now a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improve with homeopathic medicines.

Homeopathic Medicines for Cataract:

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).

Medicine:

CALCAREA CARB :

• Very useful medicine for cataract when a person has the feeling of looking through a mist.
• Given when person feel chilliness, having swollen glands, weight problems and get easy tired from exertion

CALCAREA FLOUR :

• Well indicated medicine for cataract when tissues harden or thicken abnormally.
• There is tendency toward hard swollen lymph nodes, joint pains, fibrous growths, or bone-spurs.
• Given when person generally feels worse during weather changes and improved by warmth.

CAUSTICUM : 

• Helpful in developing cataracts when person had problems moving the eyes, as if the muscles around the eyeballs were either stiff or weak.
• Given when symptoms get worse especially after getting cold in the either wind or open air.
• generally, There is feeling of sand in the eyes.
• Given to those persons who may tend to have muscular stiffness in many body areas.
• Recommended when symptoms get generally worse from cold and improved by warmth, also often feel best in damp or rainy weather.

SILICEA : 

• Helpful for cataract on those who developed cataracts after extended periods of eyestrain, or after perspiration of the feet had suppressed.
• There is  tendency toward chill (although they often sweat at night) and often have low resistance to infection.
• Especially suited to those person who has fine hair, weak nails, easy tired, and swollen lymph nodes.

NATRUM MUR : 

• Mostly indicated when cataracts begin to develop.
• Given when muscles around the eyes can feel bruised and weak, especially when the person looks down.
• There is feeling of gauze across the eyes, and parts of the field of vision may be hard to focus on.
• There is craving of salt. Patient feels worse from being in the sun, and has deep emotions yet appears to reserve.

PHOSPHORUS : 

• Useful for cataract with feeling that dust or mist in the eyes is obscuring vision.
• There soreness that feels like eyestrain after very little use .Given when there appearance of little bright dots of colored light when the eyes closed.
• Suited to those people who are sympathetic and fond of company, but can tire easily.
• There is an active imagination (including many fears) and a strong desire for cold drinks and refreshing things.

Diet & Regimen

• Adequate light, especially while reading and writing
• Proper eye glasses or contact lenses should be worn as prescribed by the physician
• Avoid night driving as much as possible
• Take proper rest and practice eye movement exercises [3]

Terminology 

References use for Article Cataract

1. Harrison-s_Principles_of_Internal_Medicine-_19th_Edition-_2_Volume_Set
2. https://en.wikipedia.org/wiki/Cataract
3. https://www.drhomeo.com/homeopathic-treatment/homeopathic-medicines-for-cataract/
4. https://visionaware.org/your-eye-condition/cataracts/risks-of-cataract-surgery/#:~:text=These%20complications%20can%20include%20infection,retinopathy)%2C%20and%20failure%20to%20improve
5. https://www.mayoclinic.org/diseases-conditions/cataracts/diagnosis-treatment/drc-20353795
6. https://www.google.com/search?q=cataract+physical+examination+findings&newwindow
7. https://www.google.com/search?q=investigation+of+cataract&newwindow
8. https://www.google.com/search?q=differential+diagnosis+of+cataract&newwindow
9. Epidemiology of cataract in India: combating plans and strategies (1998)
10. Prevalence of Cataract in an Older Population in India: The India Study of Age-related Eye Disease (2010)
11. Vaughan & Asbury’s General Ophthalmology (19th edition, 2021), authors Riordan-Eva, Whitcher, and Vaughan 
12. Kanski’s Clinical Ophthalmology (9th edition, 2020), authors Brad Bowling and Jack J. Kanski 
13. Yanoff & Duker Ophthalmology (5th edition, 2019), edited by Jay S. Duker

Cataract Also Search As

Homoeopathic Perspective:

• Homeopathic Remedies for Cataracts: A Comprehensive Guide
• Treating Cataracts Naturally with Homeopathy
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