1.) = To Or Greater Than 15 Seconds	Very Acceptable
2.) 10 To 14 Seconds	Questionable - Be Selective
3.) Less Than 10 Seconds	Not Acceptable "Dry Eyes"

Types Of Corneal Opacities (Scars)

Scar Types	Needed To Be Seen	Effect On Vision
1.) Nebular - No	Need Slit Lamp	Usually No Effect On Vision
2.) Macular - More	Need Slit Lamp	Vision Can Be Effected
3.) Leukoma - Light	Seen Without Slit Lamp	May Be Greatly Reduced

Anterior Uveitis
"Signs And Symptoms"

Clinical Stages of Giant Papillary Conjunctivitis

Preclinical - Baseline Stage	Early Developmental Stage
Little Fluorescein Pooling	Increased Fluorescein Pooling
Clinically Significant Stage	Severe Clinical Stage
Marked Fluorescein Pooling	Extreme Fluorescein Pooling

Grading Giant Papillary Conjunctivitis

Stage	Morning Discharge	Itching on Lens Removal	Size of Papillae	Method of Diagnosis
1	Minimal Increase	Mild	Baseline	Symptoms Only
2	Moderate Increase	Increased	Small Red Dot Papillae Areas Extending to Lid Margin	Slit Lamp Cobalt Filter and Fluorescein Dye that Pools Around Beginning Elevations
3	Moderate Heavy	Moderate to Severe	Increased Number and Size of Elevations	Slit Lamp and Occasionally the Naked Eye
4	Heavy: Lids Stick Together and May Have to be Separated	Moderate to Severe	Flattening of the Elevations and Progression of Stage Three	With the Naked Eye

Adapted and Modified from Allansmith et al.

Cataracts Types 1.) Developmental: Usually Congenital 2.) Pre-Senile & Senile: Age Related Cataracts 3.) Complicated: Secondary To Intraocular Inflammations 4.) Traumatic: Secondary To Eye Trauma Examples I.) Congenital Cataract Types Coronary (Club Or Crown):-- Found in the far periphery of the lens and are seen only with dilation. They have a ball bat or bowling pin shape and may be single or numerous. They are found in about 25% of the population in some shape or form. B. "Y" Suture (Stellate):-- Are opacities located in the fetal nucleus and can involve either the anterior or posterior "y" sutures or both and many times are bilateral. They do not cause a reduction in vision nor will they get any larger. C. Anterior Polar (Pyramidal): -- Usually round, well defined, dense opacity on the anterior surface of the lens. Because of its shape, which might look similar to a pyramid, the name anterior pyramidal cataract is sometimes used. This opacity may have an effect on vision depending on its size and location, though this is rare. D. Posterior Polar (Pyramidal): -- Again, this is usually a round, well defined, dense opacity, but located on the posterior surface of the lens. Because of its shape it may, also, be referred to as a posterior pyramidal cataract. Because this opacity is located on the posterior surface of the lens, closer to the retina, there is a greater chance that it will have an effect on vision depending on its size and location. E. Zonular (Lamellar): -- Some authors feel these are among the most frequent types of congenital cataracts. They may vary in size which is dependent upon what time during the intrauterine stage of development the disruption occurred. They are oval in shape when viewed with an optic section and round when viewed in reto-illumination through a dilated pupil. They surround a clear or almost clear central zone of the embryonic and fetal nucleus and contain a varying number of small grayish to white punctate shaped opacities. These opacities have a tendency to increase in density rather than size, becoming stationary in mid-life "35 to 55" years of age. Because they do increase in density, vision may become reduce to varying degrees. F. Mittendorf`s Dot: -- This is a remnant of the hyaloid artery that has failed to dissolve and usually remains partly attached to the back surface of the lens or may be free floating just behind the lens. There may be a part of the hyaloid artery that trails off into the vitreous in a corkscrew-shape. Though many may think this is a relatively benign finding, "I can assure you vision can be reduced to 20/200 or worse." G. Reduplicating Cataract: -- This is a anterior lens opacity. This condition shows that there has been an intrauterine or, more rarely, postnatal injury or defect of the anterior capsule. This process results in a localized opacity of the anterior capsule with similar opacities behind it, but separated from each other by normal lens tissue. II. Pre-Senile & Senile Cataracts (Age Related) A. Cortical (Spoke - Cuneiform): -- These start in the periphery of the lens and progress toward the pupillary area. They may start in any quadrant, however, the inferior nasal area seems to be more prevalent. They start out as lamellar separations as the lens takes on water and progress to waterclefts as the lamellar fibers are torn apart. These areas rapidly fill with fluid and appear as optically empty spaces when viewed with an optic section. These fluid filled spaces progressively become more opaque until they finally form a fully developed cuneiform cataract. Using Retroillumination Of The Lens And Locs II If the spoke opacities do not invade the pupil and are only seen during dilation you should only grade them as grade 1/2. It is conceivable that one might have one sector extending into the pupil while another sector is only seen when the pupil is dilated, this should be graded as 1 and 1/2 or better yet as a (1+) cortical cataract. It should be kept in mind that these opacities may occur in either the anterior or posterior part of the lens and a cross section drawing should be made to indicate their true location. They are usually slow progressing opacities, however, like any cataract one cannot predict how fast they will progress. B. Posterior Subcapsular ( Cupuliform - PSC ): -- The typical appearance of this opacity is vacuolated and granular in nature. It is a thin area of dense opacification located in the most posterior layers of the lens cortex and usually along visual axis region. Patients past forty (40) it may take on a yellow hue secondary to nuclear sclerosis. Because of its position and granular nature it may cause marked reduction in vision while the remainder of the lens may be very clear. Causative factors may be, age - related, secondary to steroid therapy, trauma, or secondary to a long standing chronic uveitis. The last of these may take on a notable color play for it is a form of complicated cataract. Posterior subcapsular cataracts (PSC) are one of the fastest progressing age-related lens changes and need to be closely monitored. Using Retroillumination Of The Lens C. Nuclear Sclerosis ( NS ): -- It begins soon after the age of 40, as a simple sclerosis of the older central part of the lens. There is ultimately a change in the refractive index of the lens over time in the direction of myopia sometimes referred to as "second sight". In the advancing stages the nucleus will take on a round "oil droplet" like shadow appearance. This is very noticeable when viewed in retro-illumination with the direct ophthalmoscope at a distal distance or reto-illumination with the slit lamp, both with the pupil dilated. Using An Optic Section The Color Change, "Yellowing" Of The Lens, Plus The Overall Central Haziness Is What Determines The Stage Or Grade.

Grading Based On Lens Color

Grade	Color
1/2	Slight-Yellowing
1	Definitely-Yellowing
2	Very-Very-Yellow
3	Yellow-Orange
4	Orange-Brown (Brunescent)

There have been attempts to correlate the different and varying grades of color change with visual acuity. This in my opinion does not work out very consistently. It is not uncommon to have all types of these age related cataracts present at the same time and they will have an additive reduction on vision. Their location within the undilated pupil is the most important factor related to reduced vision. III.) Complicated Cataracts: -- This type of cataract is usually reserved for opacities developing within the lens secondary to an ocular disease or some other atypical type of ocular condition. Causative factors may include, high myopia, retinal detachment, chronic uveitis, retinitis pigmentosa, ocular tumor, etc. Complicated cataracts begin with a change in the posterior lens capsule, notably the lens shagreen, taking on a play of colors "not" seen in senile (age-related) lens changes. In the later stages the posterior subcapsular part of the cortex becomes involved. There are two main features that help distinguish it from other forms of cataracts. 1.) Definite multicolored luster appearance, in the early stages, of the posterior lens capsule. 2.) The opacities are not clearly separated from the other lens structures, but rather are surrounded by a cloudy haze. IV.) Traumatic Cataracts A. Vossius Ring: -- There is an ongoing controversy over whether or not the anterior subepithelium of the lens tissue is effected. It is agreed that it only occurs in the young and is a pigment ring corresponding to the pupil margin of the iris following a contusion to the eye. Also, that the pigment is brown and in many cases the pigment may disappear completely. The controversy may be link to other lens findings following a contusion which may be related to hyphema (blood) in the anterior chamber. The hemosiderin (iron) from the blood is deposited within the lens surface epithelium. Questionable theory, but one that has been proposed. B.) Rosette Cataract: -- This opacity may occur under the anterior or posterior capsule or both and may be complete or sectored with a flower peddle or feather shape. One can get a very close estimation as to when the injury occurred by viewing the lens with an optic section and determining at which nucleus it appears. Like any other cataract the effect that it has on vision depends on its location and density. There are a great number of other forms of cataracts that have not been discussed and you should review. DR. FREDERICK C. CORDES' MANUAL CATARACT TYPES: ON RESERVE IN THE LIBRARY. Cataract Patient Referrals Doctors must decided when to refer a patient for cataract surgery. It is most important that the patient's retina can still be evaluated by the surgeon. "The general rule of thumb for referring is as follows: when the patient's visual acuity has dropped to 20/80 in dim illumination or when the cataract starts to have an effect on their ability to perform their normal daily tasks". You cannot predict how fast a patient's cataracts will progress, however, patients are going to ask you how soon it will be before they will need surgery. The best policy is to monitor these patients on a four (4) to six (6) month bases or sooner if the patient becomes concerned because of a noticeable visual change. Vitreous Evaluation A.) Normal Vitreous: -- The anterior vitreous is adhered to the back of the lens in an area approximately 9mm in circular diameter and is known as the "Ligament Of Wieger." Within this area is an optically empty retrolental space known as "Berger's Space." The anterior vitreous of the young individual is grayish in color with optically empty spaces between the collagen fibers. Small white dots (nodosities ) may be seen where fibers cross one another and this is normal. B.) Aging Vitreous: -- With increasing maturity (aging) the collagen fibers lose their fluid binding ability and the fibers and fluid start to separate. The collagen fibers start to clump together forming an increase in the so-called vitreous floaters, noticed by the patient and the doctor. Further aging plus shirking and liquefaction of the vitreous the fluid may escape through the hyaloid membrane causing the vitreous body to pull and separate from its posterior attachment to the optic nerve. The posterior vitreous detachment (PVD) may be seen, at a distal distance with the direct ophthalmoscope, as a annular ring in retro-illumination and dilated pupil. Other reasons for floaters are vessels that fill the eye in the fetal state do not totally dissolve and remnants remain in the vitreous body. Also, myopic individual's cystoidal areas near the ora rupture easier allowing their fluid to be released into the vitreous causing somewhat of a earlier aging effect. C.) Asteroid Hyalosis: -- This condition was once thought to be secondary to an ocular inflammation, which it is not. It is usually diagnosed in patients in their sixties or later and is considered to be an aging vitreous condition of unknown etiology. It is thought to occur more frequently in males than females. The condition is usually unilateral, but may be bilateral. These round spherical opacities (containing calcium soaps) within the vitreous are attached to the vitreous collagen fibers and will move with the vitreous like floaters which always return to their original position. They are disturbing to patients like floaters, but to a much greater degree for they have a disorientating effect. When viewed in direct illumination with either the slit lamp or direct ophthalmoscope they appear as bright yellow opacities. This is secondary to the nuclear sclerosis of the lens. These opacities are really white in color. D. ) Synchisis Scintillans: -- Is a condition of a younger vitreous and is either secondary to an injury or inflammation that has involved the vitreous cavity. This is considered to be a rather rare condition which is usually bilateral. Unlike asteroid hyalosis the opacities are free floating in the vitreous, not attached to the collagen fibers, controlled by gravity and seeking the lowest point within the vitreous cavity. The opacities are cholesterol crystals and are truly yellow in color in direct illumination. E.) Shafer's Sign: -- The presence of pigment granules suspended in the anterior vitreous or floating in Berger's space, sometimes termed "tobacco dust," can be very significant clues to a retinal break or detachment. Hamilton and Taylor found that 98% of patients in their clinical review with this sign had retinal detachments and 60% had flat retinal holes. The source of the pigment granules is not known, though is suspected to arise from the retinal pigment epithelium (RPE). There are a large number of patients with retinal detachments that are totally asymptomatic an simply checking the retrolental (Berger's Space) & anterior vitreous for cells is important. The failure to check for this sign on a symptomatic patient could be considered gross negligence ( symptoms being flashes of lights in their peripheral fields and or an increase in the number of floaters). Red blood cells, secondary to a vitreous hemorrhage, may be difficult to differentiate from the pigment granules. However, when a red free filter (green) is introduced the red blood cells will appear black and not be seen while the pigment granules will. The pigment granules will not absorb the red-free light and will still be seen. If the vitreous cells are white in color, they are most likely inflammatory white blood cells. Their presence usually indicates a posterior segment inflammation; although, an anterior uveitis may cause cells in the anterior vitreous also.

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