Senile cataract is a common eye disease in the old people. It refers to the case in which the crystalline lens itself gradually becomes aged, denatured and opaque without other systemic or local pathogenic causes. It usually occurs in two eye but the affections of the two eyes may differ in time, degree and progressive speed. Clinically only cortical senile cataract and nuclear senile cataract are common. In addition, there exists a capsular senile cataract as a complication of mature or hypermature stage of cortical cataract. The disease belongs to the category of "yuanyi neizhang" "ruyin neizhang" or "baiyi huangxin neizhang" (cataract) in TCM.  

Main Points of Diagnosis

1. At the early stage, blurred vision or fixed black shadow before the eye or monocular diplopia or monocular polyopia may occur. In the daytime, the patient can not see things as clearly as at night. In the advanced stage, the patient's eyesight becomes gradually weakened until only light sensation exists.

2. Cortical cataract: At the initial stage cortical peripheral opacity of the lens in a zigzag shape can be seen. In the expansive stage, the crystalline lens becomes completely opaque and swollen. The anterior chamber becomes shallow and iridic projection results; at the mature stage, the crystalline lens becomes completely as white as ice, the depth of the anterior chamber remains normal and the projection image of iris disappears; at the hypermature stage, there is opaque crystalline lens, decomposed or dissolved fibra, loosened cyst membrane, sunken lens nucleus and deepened anterior chamber.

3. Nuclear cataract: At the initial stage embryonic nucleus becomes opaque, and then the opacity spreads gradually to the adult nucleus, further to the senile nucleus and the color turns from yellow to dark brown, even to brownish black color.

4. Capsular cataract: It complicates at the mature and hypermature stage of cortical cataract. It is manifested as opacity of cyst membrane of the pupillary collar part, slightly elevated with uneven surface of presence of plicae.  

Differentiation and Treatment of Common Syndromes     

1. Internal Treatment

1) The Type of Deficiency of Liver-Yin and Kidney-Yin

Main Symptoms and Signs: This disease belongs to early cataract characterized by senile debility, dizziness, tinnitus, soreness of the loins, red tongue with scanty fur or absence of tongue fur, thready and rapid pulse.

Therapeutic Principle: Nourishing the kidney and liver.

Recipe: Decoction for Nourishing Yin and Supplementing the Kidney.

prepared rehmannia root

Chinese yam

dogwood fruit

moutan bark

alisma rhizome

poria

schisandra fruit

Chinese angelica root

sesame seed

mulberry fruit

cassia seed

wolfberry fruit

All the above herbs are to be decocted in water for oral administration.

2. The Type of Deficiency of the Liver-Yin and Dampness of the Spleen.

Main Symptoms and Signs: The disease is manifested as early cataract, plump constitution, mental fatigue and lassitude, swollen lower limbs in the afternoon or in fatigue, pale tongue and feeble pulse.

Therapeutic Principle: Tonifying the liver, reinforcing the spleen and eliminating dampness.

Recipe: Decoction of Four Ingredients and Decoction of Two Old Herbs.

prepared rehmannia root

Chinese angelica root

ligusticum root

white peony root

red tangerine peel

prepared pinellia

licorice root

plantain seed (wrapped in a piece of cloth before decocted with other herbs)

areca seed

chrysanthemum flower

pleione rhizome

poria

All the above herbs are to be decocted in water for oral administration.

2. External Treatment

Mature senile cortical cataract and advanced nuclear cataract are indicated to be treated surgically. Here, only the method of using metal needle to pluck the cataract is introduced as follows:

1) Preoperative Preparation: A few days before the operation, anti-inflammatory eye drops should be applied to the patient's affected eye and lacrimal passage irrigated. Two hours prior to operation, 1% atropine solution should be applied to the affected eye so as to have the pupil fully dilated. Then routine sterilization should be done to the palpebral skin and the conjunctival sac and apply the eye pad onto the eye. Just before the operation, sterilization and surface anesthesia should be done once more.

2) Surgical Instruments: Flat-headed cataract needle, dilating needle, eye-lid hook, fixation forceps, smooth conjunctival forceps, eye scissors, double-edged razor blade, needle-holder, mosquito forceps, suturing needle and suturing thread and so on are to be prepared for the operation.

3) Operative Procedure: Take the left eye as an example. The patient should take a semirecumbent position or a sitting position on the eye, ear, nose and throat examining chair, with the head slightly leaning backward. Then a hole-towel is spread and subcutaneous infiltration anesthesia performed at the postbulbar and 1/3 part of lateral lower to pull up the upper palpebra and uses suturing thread to tract the lower palpebra. The operator holds the fixation forceps with is left hand to gripe the bulbar conjunctiva of the corneal margin at 6 o'clock part to have the eyeball fixed and tracted toward the upper part of the nose; meantime takes the hemostatic forceps with the right hand to gripe tight the ready-prepared triangular blade, then at the part 4 mm away from the 4 to 5 o'clock surface of the corneal margin cut a 3 mm-long incision with the point of the knife vertical to the scleara, which is parallel to the corneal margin and passes through the full thickness of the eyeball wall.

The operator should hold the cataract needle with the right hand, with the curved surface of the needle facing downward, and the point of the needle being vertical to the sclera. After the flat part of the cataract needle to inserted 3mm in depth, get the manubrium of the needle to incline toward the face, keep the front part of the front part of the needle between the ciliary body and the lens and have it move forward. When it passes the posterior surface of iris to reach the pupillary center, press the concavity of the front part of the needle close to the crystalline lens, have it steer clear of the 4 to 6 o'clock surface part of the lens. In this way the ligment of the 4 to 6 o'clock surface can be directly cut off.

Lay flat the needle with its front part resting at the retrolental 7 to 8 o'clock surface of the equatoral part, draw it horizontally backward to the 4 to 5 o'clock surface to make the first laceration (scarification) of the vitreous prozonal membrane, At this time the curved surface of the needle has turned upward, therefore, it is necessary to rotate the needle outward so as to get its curved surface facing downward. Then withdraw the needle a little and insert it into anterior surface of the lens again Successively press the 1 to 4 o'clock surface, 9 to 12 o'clock surface of the margin of the lens so as to have the lens incline backward and downward, meantime, ligament of the corresponding part should be cut off, now move the needle horizon tally. from the left to the right to make the second laceration (scarification) of the vitreous prozonal membrane at the lower 1/e of the pupillary zone. Finally move the end of the needle to the lens margin at 8 o'clock surface, pluck the lens to the intraocular subtemporal zigzag margin of the retina. With the exception of leaving a little ligament at the 6 o'clock surface, ligaments of any other parts should all be severed. Press the lens for a few minutes, till it no longer floats up, when the needle is withdrawn. After the needle is withdrawn, insert a dilate needle into the incision, twirl the needle slowly to dilate the incision until a tightened and unsmooth sensation appear in the hand. Use the left hand to let go the fixation forceps, then withdraw the dilating needle, transposite the conjunctival incision and the scleral incision so as to get the scleral incision covered by the conjunctiva.

When the operation is finished, apply 1% atropine eye ointment and antibiotic eye ointment to the operated eye, cover the eye with an eye with an eye pad and wrap it up with bandage.

After the operation the patient should lie on his back with the head slightly raised or on the first or the second day, take semi-recumbent position of 30 to 40 degrees, and have a ordinary diet, take care of himself in shit and urination and other matters in daily life. Dressings should be changed once a day. In 4 or 5 days after the operation, the eye pad may be taken off. Before the pupil contricts to normal, the patient should be forbidden to hang his head down, otherwise, the vitreous may herniate into the anterior chamber. Two months after the operation optometry can be done.  

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