Diagnosis Challenge – What Is This “Waterfall Cataract” Appearance?

Diagnosis Challenge – What Is This “Waterfall Cataract ” Appearance?

Sometimes in clinical practice, we encounter a dramatic anterior chamber picture — milky fluid, floating white material, and a hypermature cataract in the background.

The answer to this diagnosis challenge is:

Waterfall Cataract (Seen in Phacolytic Glaucoma)

Although “waterfall cataract” is not an official textbook term, it is a descriptive clinical expression used for the striking appearance of liquefied cortical lens material streaming into the anterior chamber from a hypermature cataract.

Let us understand what is happening inside the eye.

What Exactly Is Happening?

In advanced cataract, particularly a hypermature or Morgagnian cataract, the lens cortex undergoes liquefaction.

• The cortex becomes milky and fluid.
• The nucleus sinks inferiorly.
• The lens capsule becomes permeable to high-molecular-weight proteins.
• These proteins leak into the anterior chamber.

When this leakage becomes significant, the anterior chamber may show:

• Flocculent white material
• Milky aqueous
• Floating particles
• Heavy inflammatory response

The streaming appearance of this material gives the impression of a “waterfall.”

Why Does This Lead to Glaucoma?

This condition is associated with phacolytic glaucoma.

Mechanism:

1. High-molecular-weight lens proteins escape through microscopic defects in the capsule.
2. Macrophages engulf these proteins.
3. Protein-laden macrophages accumulate in the trabecular meshwork.
4. Aqueous outflow is obstructed.
5. Intraocular pressure rises sharply.

Importantly, the angle remains open — this is a secondary open-angle glaucoma.

Clinical Clues That Point to Waterfall Cataract

• Elderly patient
• Long-standing white or mature cataract
• Sudden onset painful red eye
• Very high IOP
• Deep anterior chamber
• Open angles on gonioscopy
• No history of trauma or recent surgery