CASE REPORT
A 10-year-old girl with newly diagnosed type 1 diabetes mellitus presented with progressive deterioration of vision in both eyes within 4 weeks of diagnosis. She had a 3-month history of polyuria, polydipsia, nocturia, and generalized hair loss prior to diagnosis.
Physical and neurological examination was unremarkable. The baseline ophthalmological examination did not show any diabetic retinopathies.
However, the patient’s mother was concerned about her daughter’s loss of independence due to a rapid decline in vision. Physical examination showed visual acuity limited to the identification of color and seeing moving shadows ( hand motion vision ) due to lens opacities in both eyes.
Red reflex with direct ophthalmoscope revealed blunted, whitened reflex bilaterally. Ophthalmologist confirmed the presence of bilateral dense, white cataracts.
DISEASE
A cataract is defined as the opacification of the natural crystalline lens. Cataracts are mainly age-related, but may also occur secondary to other causes such as uveitis, trauma, medications, and metabolic diseases as described elsewhere.
If left untreated in the long term, a cataract may advance to become an opaque, mature cataract, often causing extreme visual impairment. Mature, totally opaque cataracts prevent the organized transmission of light to the retina, reducing vision in the affected eye to hand motion or light perception.
Mature cataracts can either be dark, such as brown or black, or white. When a white cataract is termed “intumescent”, it is defined as having swelling of the lens because of epithelial impairment and fluid influx, leading to a rapid decline in visual function.
Given its surgical challenges, it is important to recognize these types of cataracts in order to achieve better outcomes during surgery.
The normal history of a cataract evolves from lens changes that are minuscule (incipient), immature, intumescent, mature corticonuclear, hypermature Morgagnian, and in its most extreme form, shrunken Morgagnian.
Patients usually present when they either have incipient or immature cataracts, so it is relatively rare to see senile intumescent and more severe forms of cataracts such as white cataracts. its higher prevalence in low socioeconomic communities reflects poor or limited access to care.
A study in India found that 8% of the total 3634 patients present with white cataracts.
Many causes can lead to white/intumescent cataracts including:
- Exposure to:
- Radiation
- UV rays
- Heatwaves
- Infrared lights
- Ocular trauma (rupture of the eye)
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From Choroida — the team behind this siteMANAGEMENT of White cataracts
White cataracts present a high risk for complications even for experienced surgeons. One of the greatest challenges in managing a white cataract is the creation of a continuous circular capsulorhexis (CCC).
Studies have shown that capsulorhexis which was not totally successful in the management of white cataracts may be observed in 3.85% to 28.3% of cases with an increased incidence of posterior capsular rupture and vitreous loss.
These difficulties are mainly driven by two factors. First, the high lens density results in poor visibility given the loss of red reflex making it difficult to differentiate the edge of the anterior capsule from the white lens matter. This can be partially mitigated by using trypan staining dye but is still worse than the visibility provided when a red reflex is present.
Second, the raised intralenticular pressure causes liquified cortex escape as soon as the capsule is compromised which results in capsular tears extending to the periphery in addition to making visibility even worse. Depending on the classification, different surgical techniques may be advised.
As the OCT-based classification system was the most common, the treatments discussed will be based on those subtypes. For Type I, it is advised that the surgeon uses a single-stage forceps/needle cystotome capsulorhexis.
For Type 2, the forceps-assisted 2-stage capsulorhexis technique should be used followed by bimanual irrigation and aspiration to lower the elevated intra-lenticular pressure.
For Type 3, aspiration of the turbid fluid with needle aspiration and forceps-assisted capsulorhexis should be used. For the last type, anterior chamber decompression is needed to take out the milky fluid present with forceps-assisted capsulorhexis.
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From Choroida — the team behind this siteREFERENCES
- Feldman MD B, Heersink MD S. Cataract.
- Devgan MD U. Understanding subtypes key to removing white cataracts. Healio.com.
- Brown N, Bron A. Lens disorders. Oxford: Butterworth-Heinemann; 1996.
- Rewri P, Lohan A, Aggarwal S, Chodhary P, Singhal A. Cataract surgical reach: Falling short to catch white cataracts!. Indian J Ophthalmol. 2021;69(6):1575. doi:10.4103/ijo.ijo_2560_20
- Intumescent Cataract – Symptoms, Causes, Diagnosis, Treatment & Prevention. Dr. Agarwals
- Sacu S, Ségur-Eltz N, Horvat R, Lukas J, Zehetmayer M. Intumescent cataract after topical mitomycin-C for conjunctival malignant melanoma. Am J Ophthalmol. 2003;136(2):375-377. doi:10.1016/s0002-9394(03)00207-1
- Gelender H, Gelber E. Cataract Following Radial Keratotomy. Archives of Ophthalmology. 1983;101(8):1229-1231. doi:10.1001/archopht.1983.01040020231014.
Test yourself
A few questions straight from this article.
-
What defines a white cataract as intumescent?
A white cataract is termed intumescent when the lens swells because of epithelial impairment and fluid influx, which causes a rapid decline in visual function. -
A 10-year-old develops rapidly worsening bilateral white cataracts. Which systemic diagnosis had just been made in the article's case?
The girl had newly diagnosed type 1 diabetes after 3 months of polyuria, polydipsia and nocturia, and her vision fell to hand motion within 4 weeks of diagnosis. -
In the child with bilateral dense white cataracts, what did the red reflex show on direct ophthalmoscopy?
Direct ophthalmoscopy showed a blunted, whitened red reflex bilaterally, and an ophthalmologist confirmed dense white cataracts in both eyes. -
In the natural history of cataract, what is the most extreme form?
Cataract evolves from incipient and immature through intumescent, mature corticonuclear and hypermature Morgagnian stages to its most extreme form, the shrunken Morgagnian cataract. -
Why are intumescent and white cataracts relatively rarely seen in routine practice?
Patients usually present with incipient or immature cataracts; the higher prevalence of white cataracts in low socioeconomic communities reflects poor or limited access to care. -
In an Indian study of 3634 cataract patients, what proportion presented with white cataracts?
A study in India found that 8% of 3634 patients presented with white cataracts. -
What is one of the greatest surgical challenges in managing a white cataract?
White cataracts carry a high complication risk, and creating a continuous circular capsulorhexis (CCC) is one of the greatest challenges in their management. -
An incompletely successful capsulorhexis in white cataract surgery increases which complications?
Studies report an incompletely successful capsulorhexis in 3.85% to 28.3% of white cataracts, with an increased incidence of posterior capsular rupture and vitreous loss. -
Which adjunct partially improves anterior capsule visibility when the red reflex is lost in white cataract?
Dense lens matter abolishes the red reflex, making the capsule edge hard to distinguish; trypan staining helps partially, but visibility stays worse than with a red reflex. -
In the OCT-based classification of white cataract, which technique is advised for Type 2?
Type 2 calls for a forceps-assisted two-stage capsulorhexis followed by bimanual irrigation and aspiration to lower the raised intralenticular pressure; Type 1 uses a single-stage capsulorhexis.
