What is the leading cause of blindness in the world?

Cataracts. According to the World Health Organization, they affect an estimated 20

million people worldwide!

What is a cataract?
A cataract is a cloudy or opaque region of the normally transparent lens in the eye.

Where is the lens?

The lens is located behind the colored part of the eye, which is called the iris. It consists
of three parts: the capsule, the cortex and the nucleus. The capsule is the outer membrane
that surrounds the cortex, which then surrounds the center of the lens-its nucleus. It is
similar to a peanut M&M, where the colorful shell is the capsule, the chocolate is the
cortex and the peanut is the nucleus.

In which part does this cloudiness occur?

Just like there are three regions of the lens, there are three types of cataracts.

The most common clouding of the lens occurs in the nucleus. Typically this nuclear
cataract is found in older people. The lens gradually grows cloudy as the person ages.
When the opaque area increases, it prevents light rays from passing through the lens to
focus on the retina, the light sensitive tissue at the back of the eye. Typically the person
experiences blurred vision, glare, increased nearsightedness, and distortion of images that
they see in either eye. The longer we live, the more likely we are to develop cataracts.
Over 60% of people whose visual acuity is less than 20/400 (WHO definition of
blindness) have age-related cataracts.

Healthy Eye Eye with a Cataract

Why does light need to be focused?
Since we look at objects that are located at different distances, we need to adjust in order
to see all of them clearly. The lens is able to stretch and thicken in order to make this
adjustment and allow us to see. Sometimes even when the lens doesn't have a cataract,
the person's vision is blurry when looking at things that are either close or very far away.
In such a case, an eye doctor (ophthalmologist) prescribes eyeglasses to help correct the
problem. The eyeglasses have a lens similar to the one in our eyes, except that it's plastic
and isn't able to change

I see, so what exactly happens in a cataract?

I need to tell you about the other two types of cataracts. There is also a cortical cataract
that affects the lens cortex (remember, the chocolate part of an M&M). These opacities
originate on the outside edges of the lens and seem like wedge-shaped spokes of a
bicycle. When they gradually extend toward the center of the lens, they interfere with the
path of light and significantly effect both near and distance vision. People who have
diabetes tend to develop these types of cataracts.

Finally, subcapsular cataracts start to develop as small opacities at the back of the lens.
They are also associated with diabetes. They start to affect vision when they have grown
quite significantly. Sometimes when people have to use drops like corticosteroids in their
eyes to treat inflammation, the active ingredient in these drops can cause the proteins to
become cloudy.

So if someone has diabetes they will develop cataracts,

but certainly not all of the twenty million have
developed cataracts from this reason?
You're right, there are some other known causes of cataracts. Although age is a significant
factor, they are also caused by injuries like inadvertently hitting the eye. Someone can be
born with cataracts or acquire them when they are exposed to damaging sunrays or
certain chemicals.

Can you tell me more about these other causes?

Traumatic cataracts are caused by being hit in the eye. Getting something stuck in the eye
is a very terrible thing. In those cases, the cataract forms in the back of the cortex and
leads to progressive loss of vision. When a sharp object punctures the eye and comes in
contact with the lens capsule, the lens totally opacifies either immediately or at some later
time.

Babies born with cataracts have what is called congenital cataracts. They occur most
often when the mom has some sort of infection, like rubella, or sometimes other family
members also have cataracts and the baby gets them because of a genetic link.

The environment plays a key role in cataract formation. The lens is made up of protein, a
substance that is configured in a way to be completely clear. It's necessary for this protein
to be clear in order for us to see through it. Sun emits high-energy light rays, called
ultraviolet rays, that cause the lens protein to stop being clear. Some chemicals in the
environment may be able to reach through the outer layers of the eye and can affect those
lens proteins, also causing them to become opaque. These types of cataracts are called
"induced" cataracts.

Diet might also have something to do with cataracts. There is not much information as to
how diet and cataracts relate, but vitamin deficiencies, for example, could contribute to
cataracts.

So people go blind and there is nothing we can do for

them?
We CAN treat cataract blindness. The sight is restored to the eye by a surgery that
removes the cloudy lens. What's more important is that cataracts that are due to
environmental factors are preventable!
That's incredible, but why are people still going blind if
they are treatable AND preventable?
Part of the answer lies in the fact that modern cataract techniques are used very
frequently in developed countries. The patients can afford the surgery there. For instance
the United States government alone spends 3.4 billion dollars on approximately 1.35
million surgeries every year.

That's really expensive!

I know, but the story is worse in developing countries. There usually isn't direct access to
an ophthalmologist and the cataracts typically progress to the "absolute cataract" stage
where the pupil glows a "pearly white," instead of being black. At this point the
individual's vision is reduced to seeing only hand motions or just being able to tell light
from dark. These patients will not be able to go for screening unaided, and typically
would have been blind for quite a time prior to being seen. These people are truly blind
and need our help.

This is so discouraging!
I am very hopeful, however. Let me tell you a story that makes me think that we could
help all of the people out there with treatable blindness!

There is this woman, Nilima. She is very old and has lived with her son and his wife in a
one-room hut on a remote Tibetan plateau. For the past 5 years she has been unable to
work to help her family. She is blind in both eyes. Ten years ago, she had to move in with
her son because she couldn't provide for herself. Going to market for provisions, she
would come back weary and bruised. The mountain passes became treacherous and the
once hour-long walk to the next valley took a day of near crawling to avoid the obstacles
that seemed to crop up out of nowhere. She had burned her fingers misjudging the
distance to the fire and had to stop helping with the cooking. Her deteriorating vision
made her dizzy and confused. Finally she became reduced to staying in the corner of the
room in hopes of staying out of way of bustle of daily living. She had to be fed and be led
outside, fully relying on her son and daughter-in-law and their two children. In the
mountainous regions every person is vital for survival of the family, therefore Nilima's
family can do little to help her during the day. No one in their village has ever heard of a
name or cure for this blindness, but there are at least one hundred more people that suffer,
both children and adults, out of a village of 300 people.

She must have cataracts, right?

Yes, you're right, but Nilima doesn't know that yet. Besides, what could be done with
them in such a remote region? About a month ago, a traveling physician's assistant came
to the village and asked everyone to bring out their ill relatives, those that have been
blind. Nilima's eldest grandson came back from work and helped her meet the newcomer
just outside their door. There, the assistant shined light in her eye and determined that she
can be cured from the depths of her closed world by a new surgery. He saw the dense
ivory-white of her lens and said that a surgeon can remove the hard as stone lens that is
blocking her vision. He told her that an old school house that is shared with their
neighboring village has been set up as the place for the surgeons to do their work. The
family immediately decided to see if this procedure could help Nilima. Nilima's son
carried her on his back to the place of the surgery.

After a day of travel, the patients were all assembled at the school and prepared for the
night. They had to bring their own sheets since there is nowhere for them to stay. While
Nilima and the other people from her village anxiously awaited the arrival of the doctors
who would perform their miracles, the physician's assistant asked them and their relatives
about the histories of their blindness. Most everyone in the region reported to have been
blind for over three years. Several explained that they were literally struck blind in an
unfortunate accident while working to repair a bridge across a rushing river; they had
fallen on the shaky rocks and hit their eyes in the process. No one owned sunglasses, and
they wear brimmed hats only on special occasions. I must note that the life expectancy of
a blind person is less than half that of a sighted person. And in the mountainous regions it
is less than three years if the person has to survive on their own.

The next day the doctors finally arrived, having trekked from a regional ophthalmology
center. Nilima was prepared for surgery by having iodine swabbed around her left eye,
her eyelashes were also cut to prevent post-operative infection. She will undergo another
cataract surgery to help her see from her right eye a day later. Her eye was numbed and
she is given drops to dilate the pupil and stabilize the pressure in the eye to help the
surgery go smoothly. The doctor used a microscope to help the delicate surgery. The
doctor makes a cut at the junction of the cornea and sclera.

What are those?

The cornea is the clear part in the front of the eye and the sclera is the white tough outer
coat of the eye.

Ok, what happens next in the surgery?

After the initial cut at the junction of the cornea and sclera, the surgeon made a circular
cut in the anterior (front) part of the capsule. He then removed the cataractous lens like a
peanut from the M & M-like lens capsule. Placing a clear plastic intraocular lens into the
capsule completed the surgery. This lens will from now on function to focus light
properly at the back of the eye. The whole surgery takes about 7 minutes. Within 7-8
hours, the surgeons operate on the cataracts of all of Nilima's neighbors as well. At the
conclusion of each surgery, a patch was placed over the eye and the patient taken to wait
in the post-operative section of this schoolhouse.

That's a very quick procedure, how soon will the

patients be able to see?
Ah, they can see immediately, but the patches are important to let the eye start to heal.
There was an incision after all In Nilima's case the next morning started a day of joy.
As physicians were taking off the patches, the patients and their relatives witnessed the
power of surgical miracle. Nilima was able to see her family for the first time in five
years; another patient saw his first sky since developing cataracts as an infant!
That is so impressive! So this is the same surgery that's
done in the United States?
Yes, the basis of the surgery is the same. The conditions of the surgery are a little
different. Instead of an operating room and bulky equipment, the doctors can use portable
microscopes in carefully disinfected locations, such as our schoolroom. Doctors Geoffrey
Tabin and Sanduk Ruit developed the actual technique that cured Nilima. They call it the
high volume extracapsular cataract extraction with intraocular lens implantation and
teach it to local doctors in their camps in the Himalayas. Their goal is to eliminate the
backlog of treatable blindness in the region. The project is part of Vision 2020 initiative.

So we can help treat blindness all over the world after

all?
Yes, this procedure has proven to be extremely effective for treating cataracts in remote
settings, time and time again. After the patients receive surgery on their second eyes, they
are carefully instructed about caring for their eyes while the incisions are healing. Within
a week they should be able to fully function in their communities.

For instance, from the schoolhouse, Nilima walked proudly and on her own. She brought
home sunglasses for her family to protect their eyes from harmful penetrating sunrays.

Quiz
1. Cataracts affect which part of the eye?

2. Cataracts are most common among people of what age group?

3. People blind from cataracts can have their sight restored by:

4. How soon after treatment is sight restored?

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