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Latest revision as of 20:49, 29 July 2020

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Template:DiseaseDisorder infobox

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Kenneth J. Hoffer, M.D. [2], Clinical Professor of Ophthalmology, UCLA, St. Mary's Eye Center Associate Editor(s)-in-Chief: Rohan Bir Singh, M.B.B.S.[3]

Overview

A cataract is an opacification of the natural intraocular crystalline lens that transmits the light entering the eye onto the retina in the posterior part of the eye. The opacification leads to a decrease in vision and may lead to complete vision loss if left untreated for long. Cataracts are the leading cause of preventable blindness in the world . At present, there is no preventive intervention for the progression of cataracts. The modern cataract surgery, which is the removal of the opacified lens and implantation of a clear intraocular lens (IOL), is the only known and approved treatment for cataract. The cataract surgery involving removal of natural lens and implantation of IOL is the most effective procedure performed in ophthalmology with 3 million Americans choosing to have cataract surgery each year, and with a success rate of 97 percent or higher.

Historical Perspective

The earliest references to cataract surgery are found in Sanskrit manuscripts dating from the 5th century BC, which show that Sushruta developed specialised instruments and performed the earliest eye surgery in India. In the Western world, bronze instruments that could have been used for cataract surgery, have been found in excavations in Babylonia, Greece and Egypt. The first references to cataract and its treatment in the West are found in 29 AD in De Medicinae, the work of the Latin encyclopedist Aulus Cornelius Celsus.

The first extracapsular cataract surgery using a sharply pointed instrument with a handle fashioned into a trough was described in Susrutasamhita. This technique is known to have existed in India as described and performed by Susruta sometime in early BC. Another early technique to remove cataracts was couching, which involved using a thin needle or stick to remove the clouding. This technique is known to have existed in ancient times and continued to be used throughout the Middle Ages - However, it has now been replaced by extracapsular cataract surgery and, specially, phacoemulsification.

The word cataract, is derived from the Greek word υπόχυσις (kataráktēs) meaning the fall of water. The Latins have known it as "suffusio", which translates to an extravasation and coagulation of humors behind the iris; and the Arabs, call it white water . There is no mention of cataract in ancient Egyptian medical literature, except a similar disease, mentioned in the Ebers Papyrus.

The ancient Greeks believed that the lens was a part of the eye responsible for vision. It led to development of the "Emanation Theory" of vision. They believed that the optic nerves were hollow channels through which “visual spirits” were from the brain to meet visual rays from the outside world at the lens, in the center of the globe. The visual information would then flow back to the brain.

Around 30 AD, the Greek philosopher, Celsus drew the lens in the center of the globe, with an empty space called the locus vacuus anterior to it. This model about lens position and function persisted through the Middle Ages and into the Renaissance, as shown by the drawing of the Belgian anatomist Andreas Vesalius in 1543. The first accurate position of the crystalline lens was illustrated by the Italian anatomist Fabricius ab Aquapendente in 1600.

Swiss physician Felix Plater was the first to the challenge the emanation theory, and suggested that retina was the part of the eye responsible for sight.

In 1748, Jacques Daviel started with modern cataract surgery, in which the cataract is actually extracted from the eye. In the 1940s Harold Ridley introduced the concept of implantation of the intraocular lens which permitted more efficient and comfortable visual rehabilitation possible after cataract surgery. The implantation of foldable intraocular lens is the procedure considered the state-of-the-art.

In 1967, Charles Kelman introduced phacoemulsification, a technique that uses ultrasonic waves to emulsify the nucleus of the crystalline lens in order to remove the cataracts without a large incision. This new method of surgery decreased the need for an extended hospital stay and made the surgery ambulatorial.

Diagnosis

Treatment

Case Studies

Case #1

Related Chapters

ca:Cataracta de:Katarakt (Medizin) eo:Katarakto eu:Begi-lauso fa:آب مروارید hr:Katarakta id:Katarak it:Cataratta he:קטרקט lt:Katarakta hu:Szürkehályog ms:Katarak nl:Grijze staar no:Katarakt nn:Katarakt qu:Phuyu ñawi simple:Cataract sr:Катаракта fi:Harmaakaihi sv:Grå starr

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+__NOTOC__
+'''For patient information click [[Cataract (patient information)|here]]'''
 {{DiseaseDisorder infobox |
    Name        = Cataract |
-  ICD10       = {{ICD10|H|25||h|25}}-{{ICD10|H|26||h|25}}, {{ICD10|H|28||h|25}}, {{ICD10|Q|12|0|q|12}} |
-  ICD9        = {{ICD9|366}} |
-  DiseasesDB  = 2179|
-  MedlinePlus = 001001|
    Image       = Cataract in human eye.png|
    Caption     = Magnified view of cataract in human eye, seen on examination with a [[slit lamp]] using diffuse illumination|
 }}
-{{Search infobox}}
-'''Editor-in-Chief:''' Kenneth J. Hoffer, M.D. [mailto:KHofferMD@aol.com], Clinical Professor of Ophthalmology, UCLA, St. Mary's Eye Center
-{{Editor Join}}
-For patient information click [[{{PAGENAME}} (patient information)|here]]
-==Overview==
-[[Image:Human eye cross-sectional view grayscale.png|thumb|220px|left|Human eye cross-sectional view, showing position of human lens.  Courtesy [[National Institutes of Health|NIH]] [[National Eye Institute]]]]
-[[Image:Eyesection.gif|thumb|left|216px|Human [[eye]] cross-sectional view, showing position of human lens. Courtesy [[National Institutes of Health|NIH]] [[National Eye Institute]]]]
-A '''cataract''' is an [[opacity]] that develops in the [[lens (anatomy)|crystalline lens]] of the [[eye]] or in its envelope. Early on in the development of age-related cataract the power of the crystalline lens may be increased, causing near-sightedness ([[myopia]]), and the gradual yellowing and opacification of the lens may reduce the perception of blue colours. Cataracts typically progress slowly to cause [[vision loss]] and are potentially [[blindness|blinding]] if untreated.<ref>http://www.aafp.org/afp/990700ap/99.html</ref> Moreover, with time the cataract cortex liquefies to form a milky white fluid in a '''Morgagnian Cataract''', and can cause severe inflammation if the lens capsule ruptures and leaks. Untreated, the cataract can cause [[glaucoma|phacomorphic glaucoma]]. Very advanced cataracts with weak [[zonules]] are liable to dislocation anteriorly or posteriorly.  Such spontaneous posterior dislocations (akin to the historical surgical procedure of [[couching]]) in ancient times were regarded as a blessing from the heavens, because it restored some perception of light in the bilaterally affected patients.
-''Cataract'' derives from the Latin ''cataracta'' meaning "waterfall" and the Greek ''kataraktes'' and ''katarrhaktes'', from ''katarassein'' meaning "to dash down" (''kata''-, "down"; ''arassein'', "to strike, dash"<ref>http://dictionary.reference.com/wordoftheday/archive/2003/10/29.html]</ref>). As rapidly running water turns white, the term may later have been used metaphorically to describe the similar appearance of mature ocular opacities. In Latin, ''cataracta'' had the alternate meaning, "portcullis"<ref>http://www.etymonline.com/index.php?term=cataract</ref>, so it is also possible that the name came about through the sense of "obstruction".
-== Causes ==
-Cataracts develop from a variety of reasons, including long-term ultraviolet exposure, exposure to radiation, secondary effects of diseases such as [[diabetes]], and advanced age; they are usually a result of [[Denaturation (biochemistry)|denaturation]] of lens [[protein]]s. [[genetics|Genetic]] factors are often a cause of [[congenital]] cataracts and positive family history may also play a role in predisposing someone to cataracts at an earlier age, a phenomenon of "anticipation" in pre-senile cataracts. Cataracts may also be produced by [[eye injury]] or [[physical trauma]]. A study among Icelandair pilots showed commercial airline pilots as three times more likely to develop cataracts than people with non-flying jobs. This is thought to be caused by excessive exposure to radiation coming from outer space.<ref>{{cite journal | last = Rafnsson | first = V | coauthors = Olafsdottir E, Hrafnkelsson J, Sasaki H, Arnarsson A, Jonasson F | title = Cosmic radiation increases the risk of nuclear cataract in airline pilots: a population-based case-control study | journal = Arch Ophthalmol | volume = 123 | pages = 1102-1105}}</ref> Cataracts are also unusually common in persons exposed to infrared radiation, such as glassblowers who suffer from  "exfoliation syndrome". Exposure to microwave radiation can cause cataracts.
-Cataracts may be partial or complete, stationary or progressive, hard or soft.
-Some drugs can induce cataract development, such as [[Corticosteroids]]<ref name=spencer>{{cite journal |author=SPENCER R, ANDELMAN S |title=STEROIDSAREBAD CATARACTS. POSTERIOR SUBCAPSULAR CATARACT FORMATION IN RHEUMATOID ARTHRITIS PATIENTS ON LONG TERM STEROID THERAPY |journal=Arch Ophthalmol |volume=74 |issue= |pages=38-41 |year= |pmid=14303339}}</ref>
-and [[Ezetimibe]]
-There are various types of cataracts, e.g. nuclear, cortical, mature, hypermature.  Cataracts are also classified by their location, e.g. posterior (classically due to steroid use<ref name=spencer/><ref>{{cite journal |author=Greiner J, Chylack L |title=Posterior subcapsular cataracts: histopathologic study of steroid-associated cataracts |journal=Arch Ophthalmol |volume=97 |issue=1 |pages=135-44 |year=1979 |pmid=758890}}</ref>) and anterior (common (senile) cataract related to aging).
-==Epidemiology==
-Cataracts are the leading cause of blindness in the world.<ref>https://web.emmes.com/study/areds/mopfiles/chp2_mop.pdf</ref>
-In the United States, age-related lenticular changes have been reported in 42% of those between the ages of 52 to 64<ref name="Sperduto">Sperduto RD, Seigel D. Sperduto RD, Seigel D. "Senile lens and senile macular changes in a population-based sample." ''Am J Ophthalmol.'' 1980 Jul;90(1):86-91. PMID 7395962.</ref>, 60% of those between the ages 65 and 74<ref>Kahn HA, Leibowitz HM, Ganley JP, Kini MM, Colton T, Nickerson RS, Dawber TR. "The Framingham Eye Study. I. Outline and major prevalence findings." ''Am J Epidemiol.'' 1977 Jul;106(1):17-32. PMID 879158.</ref>, and 91% of those between the ages of 75 and 85<ref name="Sperduto"/>.
-==Cataract surgery==
-{{main|Cataract surgery}}
-[[Image:Cataract surgery.jpg|thumb|216px|left|Cataract surgery, using a temporal approach phacoemulsification probe (in right hand) and "chopper" (in left hand) being done under operating microscope at a Navy medical center]]
-The most effective and common treatment is to surgically remove the cloudy lens. There are two types of [[surgery]] that can be used to remove cataracts: extra-capsular (extracapsular cataract extraction, or ECCE) and intra-capsular (intracapsular cataract extraction, or ICCE).
-Extra-capsular (ECCE) surgery consists of removing the lens but leaving the majority of the [[lens capsule]] intact. High frequency [[sound wave]]s ([[phacoemulsification]]) are sometimes used to break up the lens before extraction.
+{{Cataract}}
-Intra-capsular (ICCE) surgery involves removing the entire lens of the eye, including the lens capsule, but it is rarely performed in modern practice. In either extra-capsular surgery or intra-capsular surgery, the cataractous lens is removed and replaced with a [[plastic]] lens (an [[intraocular lens]] implant) which stays in the eye permanently.
+{{CMG}}; Kenneth J. Hoffer, M.D. [mailto:KHofferMD@aol.com], Clinical Professor of Ophthalmology, UCLA, St. Mary's Eye Center {{AE}}{{RBS}}
-Cataract operations are usually performed using a [[local anaesthetic]] and the patient is allowed to go home the same day. Recent improvements in intraocular technology now allow cataract patients to choose a multifocal lens to create a visual environment in which they are less dependent on glasses. Under some medical systems multifocal lenses cost extra. Traditional intraocular lenses are monofocal.
+==[[Cataract overview|Overview]]==
+A cataract is an opacification of the natural intraocular crystalline lens that transmits the light entering the eye onto the retina in the posterior part of the eye. The opacification leads to a decrease in vision and may lead to complete vision loss if left untreated for long. Cataracts are the leading cause of preventable blindness in the world . At present, there is no preventive intervention for the progression of cataracts. The modern cataract surgery, which is the removal of the opacified lens and implantation of a clear intraocular lens (IOL), is the only known and approved treatment for cataract. The cataract surgery involving removal of natural lens and implantation of IOL is the most effective procedure performed in ophthalmology with 3 million Americans choosing to have cataract surgery each year, and with a success rate of 97 percent or higher.
-Complications after cataract surgery, including endophthalmitis, posterior capsular opacification and [[retinal detachment]], are possible.
+==[[Cataract historical perspective|Historical Perspective]]==
-In ICCE there is the issue of the Jack in the box phenomenon where the patient has to wear [[aphakic]] glasses - alternatives include contact lenses but these can prove to be high maintenance, particularly in dusty areas.
+The earliest references to cataract surgery are found in Sanskrit manuscripts dating from the 5th century BC, which show that Sushruta developed specialised instruments and performed the earliest eye surgery in India. In the Western world, bronze instruments that could have been used for cataract surgery, have been found in excavations in Babylonia, Greece and Egypt. The first references to cataract and its treatment in the West are found in 29 AD in De Medicinae, the work of the Latin encyclopedist [[Aulus Cornelius Celsus]].
-==Prevention==
+The first extracapsular cataract surgery using a sharply pointed instrument with a handle fashioned into a trough was described in ''Susrutasamhita''. This technique is known to have existed in India as described and performed by '''Susruta''' sometime in early BC.   Another early technique to remove cataracts was couching, which involved using a thin needle or stick to remove the clouding. This technique is known to have existed in ancient times and continued to  be used throughout the Middle Ages - However, it has now been replaced by extracapsular cataract surgery and, specially, phacoemulsification.
-Although cataracts have no scientifically proven prevention, it is sometimes said that wearing [[ultraviolet]]-protecting [[sunglasses]] may slow the development of cataracts.<ref>Epidemiology. 2003 Nov;14(6):707-12. Sun exposure as a risk factor for nuclear cataract</ref><ref>http://www.nei.nih.gov/nehep/pdf/NEHEP_5_year_agenda_2006.pdf p.37 quoting Javitt, J. C., F. Wang, and S. K. West. “Blindness Due to Cataract: Epidemiology and Prevention.” Annual Review of Public Health 17 (1996): 159-77.</ref> Regular intake of [[antioxidants]] (such as vitamin C and E) is theoretically helpful, but this has not been proven.
-== Recent research ==
+The word cataract, is derived from the Greek word υπόχυσις (kataráktēs) meaning the fall of water. The Latins have known it as "suffusio", which translates to an extravasation and coagulation of humors behind the iris; and the Arabs, call it white water . There is no mention of cataract in ancient Egyptian medical literature, except a similar disease, mentioned in the Ebers Papyrus.
-Although [[statins]] are known for their ability to lower lipids, they are also believed to have antioxidant qualities.  It is believed that oxidative stress plays a role in the development of nuclear cataracts, which are the most common type of age-related cataract.  To explore the relationship between nuclear cataracts and statin use, a group of researchers took a group of 1299 patients who were at risk of developing nuclear cataracts and gave some of them statins.  Their results suggest that statin use in a general population may be associated with a lower risk of developing nuclear cataract disease. <ref>{{ cite journal | first = Barbara | last = Klein | coauthors = Ronald Klein, Kristine Lee, and Lisa Grady | title = Statin Use and Incident Nuclear Cataract | journal = Journal of the American Medical Association | volume = 295 | issue = 23 | pages = 2752-2758}}</ref>
-Research is scant and mixed but weakly positive for the nutrients lutein and zeaxanthin<ref>Nutrition. 2003 Jan;19(1):21 Lutein, but not alpha-tocopherol, supplementation improves visual function in patients with age-related cataracts: a 2-y double-blind, placebo-controlled pilot study</ref><ref>Invest Ophthalmol Vis Sci. 2006 Sep;47(9):3783-6. Lutein and zeaxanthin and the risk of cataract: the Melbourne visual impairment project</ref><ref>Invest Ophthalmol Vis Sci. 2006 Jun;47(6):2329-35. Plasma lutein and zeaxanthin and other carotenoids as modifiable risk factors for age-related maculopathy and cataract: the POLA Study</ref><ref>J Am Coll Nutr. 2004 Dec;23(6 Suppl):567S-587S Lutein and zeaxanthin and their potential roles in disease prevention</ref>. Bilberry extract shows promise in rat models <ref>Dietary supplementation with bilberry extract prevents macular degeneration and cataracts in senesce-accelerated OXYS rats  Adv Gerontol. 2005;16:76-9</ref><ref>Yamakoshi J, et al.   J Agric Food Chem. 2002 Aug 14;50(17):4983-8. </ref> and in clinical studies.<ref>Ann Ottalmol Clin Ocul, 1989</ref>
+The ancient Greeks believed that the lens was a part of the eye responsible for vision. It led to development of the "Emanation Theory" of vision. They believed that the optic nerves were hollow channels through which “visual spirits” were from the brain to meet visual rays from the outside world at the lens, in the center of the globe. The visual information would then flow back to the brain.
-==Types of cataracts==
+Around 30 AD, the Greek philosopher, Celsus drew the lens in the center of the globe, with an empty space called the locus vacuus anterior to it. This model about lens position and function persisted through the Middle Ages and into the Renaissance, as shown by the drawing of the Belgian anatomist Andreas Vesalius in 1543. The first accurate position of the crystalline lens was illustrated by the Italian anatomist Fabricius ab Aquapendente in 1600.
-[[Image:Cataracts due to Congenital Rubella Syndrome (CRS) PHIL 4284 lores.jpg|thumb|250px|left|Bilateral cataracts in an infant due to [[Congenital rubella syndrome]], courtesy CDC]]
+Swiss physician Felix Plater was the first to the challenge the emanation theory, and suggested that retina was the part of the eye responsible for sight.
-The following is a classification of the various types of cataracts. This is not comprehensive and other unusual types may be noted.
-*Classified by etiology
-:*Age-related cataract
-::*Immature Senile Cataract (IMSC) - partially opaque lens, [[Optic disc|disc]] view hazy
-::*Mature Senile Cataract (MSC) - Completely opaque lens, no disc view
-::*Hypermature Senile Cataract (HMSC) - Liquefied cortical matter: '''Morgagnian Cataract'''
-:*Congenital cataract
-::*Sutural cataract
-::*Lamellar cataract
-::*Zonular cataract
-::*Total cataract
-:*Secondary cataract
-[[Image:Anterior capsular opacification.jpg|thumb|250px|left|[[Slit lamp]] photo of Anterior capsular opacification visible a few months after implantation of Intraocular lens in eye, magnified view]]
-::*Drug-induced cataract (e.g. Corticosteroids)
-:*Traumatic cataract
-::*Blunt trauma (capsule usually intact)
-::*Penetrating trauma (capsular rupture & leakage of lens material - calls for an emergency surgery for extraction of lens and leaked material to minimize further damage)
-*Classified by location of opacity within lens structure (However, mixed morphology is quite commonly seen, e.g. PSC with nuclear changes & cortical spokes of cataract)
+In 1748, Jacques Daviel started with modern cataract surgery, in which the cataract is actually extracted from the eye. In the 1940s Harold Ridley introduced the concept of implantation of the [[intraocular lens]] which permitted more efficient and comfortable visual rehabilitation possible after cataract surgery. The implantation of foldable intraocular lens is the procedure considered the state-of-the-art.
-:*Anterior cortical cataract
-:*Anterior polar cataract
-:*Anterior subcapsular cataract
-[[Image:Posterior capsular opacification on retroillumination.jpg|thumb|left|250px|[[Slit lamp]] photo of Posterior capsular opacification visible a few months after implantation of Intraocular lens in eye, seen on retroillumination]]
-:*Nuclear cataract - Grading correlates with hardness & difficulty of surgical removal
+In 1967, Charles Kelman introduced [[phacoemulsification]], a technique that uses ultrasonic waves to emulsify the nucleus of the crystalline lens in order to remove the cataracts without a large incision. This new method of surgery decreased the need for an extended hospital stay and made the surgery ambulatorial.
-::*1 - Grey
+==[[Cataract classification|Classification]]==
-::*2 - Yellow
+==[[Cataract pathophysiology|Pathophysiology]]==
-::*3 - Amber
+==[[Cataract causes|Causes]]==
-::*4 - Brown/Black (Note: "Black cataract" translated in some languages (like Hindi) refers to [[Glaucoma]], not the color of the lens nucleus)
+==[[Cataract differential diagnosis|Differentiating Cataract from other Diseases]]==
-:*Posterior cortical cataract
+==[[Cataract epidemiology and demographics|Epidemiology and Demographics]]==
-:*Posterior polar cataract (importance lies in higher risk of complication - posterior capsular tears during surgery)
+==[[Cataract risk factors|Risk Factors]]==
-:*Posterior subcapsular cataract (PSC) (clinically common)
+==[[Cataract screening|Screening]]==
-::*After-cataract - posterior capsular opacification subsequent to  a successful extracapsular cataract surgery (usually within 3 months - 2 years) with or without IOL implantation. Requires a quick & painless office procedure with [[Nd:YAG laser]] capsulotomy to restore optical clarity.
+==[[Cataract natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
-==Associations with systemic conditions==
+==Diagnosis==
-*[[Genetic disorders|Chromosomal disorder]]s
+[[Cataract history and symptoms|History and Symptoms]] | [[Cataract physical examination|Physical Examination]] | [[Cataract laboratory findings|Laboratory Findings]] | [[Cataract x ray|X Ray]] | [[Cataract CT|CT]] | [[Cataract MRI|MRI]] | [[Cataract other imaging findings|Other Imaging Findings]] | [[Cataract other diagnostic studies|Other Diagnostic Studies]]
-:*[[Alport's syndrome]]
-:*[[Cri-du-chat syndrome]]
-:*Conradi's syndrome
-:*Myotonia dystrophica
-:*[[Patau's syndrome]]
-:*Schmid-Fraccaro syndrome
-:*[[Trisomy 18]] ([[Edward's syndrome]])
-:*[[Turner's syndrome]]
-*Disease of the [[skin]] and [[mucous membranes]]
-:*[[Atopic dermatitis]]
-:*Basal-cell nevus syndrome
-:*[[Ichthyosis]]
-:*[[Pemphigus]]
-*[[Metabolic disease|Metabolic]] and nutrition diseases
-:*[[Aminoaciduria]] ([[Lowe's syndrome]])
-:*[[Diabetes mellitus]]
-:*[[Fabry's disease]]
-:*[[Galactosemia]]
-:*[[Homocystinuria]]
-:*[[Hypervitaminosis D]]
-:*[[Hyperparathyroidism]]
-:*[[Hypothyroidism]]
-:*[[Mucopolysaccharidoses]]
-:*[[Wilson's disease]]
-*[[Infectious disease]]s
-:*Congenital
-::*[[Congential herpes simplex]]
-::*[[Congenital syphilis]]
-::*[[Cytomegalic inclusion disease]]
-::*[[Rubella]]
-:*Others
-::*[[Cysticercosis]]
-::*[[Leprosy]]
-::*[[Onchocerciasis]]
-::*[[Toxoplasmosis]]
-*Toxic substances introduced systemically
-:*[[Corticosteroids]]
-:*[[Haloperidol]]
-:*[[Miotics]]
-:*Triparanol
-==References==
+==Treatment==
-{{Reflist|2}}
+[[Cataract medical therapy|Medical Therapy]] | [[Cataract surgery|Surgery]] | [[Cataract primary prevention|Primary Prevention]] | [[Cataract secondary prevention|Secondary Prevention]] | [[Cataract cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Cataract future or investigational therapies|Future or Investigational Therapies]]
-*Pavan-Langston, Deborah (1990). ''Manual of Ocular Diagnosis and Therapy.'' Little, Brown and Company.
+== Case Studies ==
+[[Cataract case study one|Case #1]]
-==See also==
+==Related Chapters==
 *[[List of eye diseases and disorders]]
 *[[List of systemic diseases with ocular manifestations]]
-== External links ==
-*[http://www.nei.nih.gov/health/cataract/cataract_facts.asp Cataract] Resource Guide from the National Eye Institute (NEI).
-*[http://www.emedicinehealth.com/articles/14319-1.asp eMedicine Health]
 {{Eye pathology}}
-{{SIB}}
-[[Category:Aging-associated diseases]]
-[[Category:Blindness]]
-[[Category:Ophthalmology]]
 [[ca:Cataracta]]
 [[de:Katarakt (Medizin)]]
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+[[Category:Ophthalmology]]