CATARACT

INTRODUCTION
• A cataract is a lens opacity or cloudiness.
• Cataracts rank only behind arthritis and heart
disease as a leading cause of disability in older
adults.
• Cataracts affect about one in every six people
who are 40 years of age or older.
• According to the World Health Organization,
cataract is the leading cause of blindness in the
world.
 DEFINITION
• A cataract is an opacity in the lens of the eye
that may cause a loss of visual acuity.
• Vision is diminished because the light rays are
unable to get to the retina through the
clouded lens.
 TYPES

• Cataracts can develop in one or both eyes at any age for

a variety of causes.
• Visual impairment normally progresses at the same rate
in both eyes over many years or in a matter of months.
• The three most common types of senile (age-related)
cataracts are defined by their location in the lens:
nuclear, cortical, and posterior subcapsular.
• The extent of visual impairment depends on the size,
density, and location in the lens.
• More than one type can be present in one eye.
 NUCLEAR CATARACT
• A nuclear cataract is associated with myopia
(i.e., nearsightedness), which worsens when
the cataract progresses.
• If dense, the cataract severely blurs vision.
• Periodic changes in prescription eyeglasses
help to manage this problem.
 CORTICAL CATARACT
• A cortical cataract involves the anterior, posterior, or
equatorial cortex of the lens.
• A cataract in the equator or periphery of the cortex does
not interfere with the passage of light through the center
of the lens and has little effect on vision.
• Cortical cataracts progress at a highly variable rate.
• Vision is worse in very bright light.
• Studies show that people with the highest levels of sunlight
exposure have twice the risk of developing cortical
cataracts than those with low-level sunlight exposure.
 POSTERIOR SUBCAPSULAR
• Posterior subcapsular cataracts occur in front
of the posterior capsule.
• This type typically develops in younger people
and, in some cases, is associated with
prolonged corticosteroid use, inflammation, or
trauma.
• Near vision is diminished, and the eye is
increasingly sensitive to glare from bright light
(e.g. sunlight, headlights).
 Risk Factors for Cataract Formation

• Aging
• Loss of lens transparency
• Clumping or aggregation of lens protein (which leads to
light scattering)
• Accumulation of a yellow-brown pigment due to the
breakdown of lens protein
• Decreased oxygen uptake
• Increase in sodium and calcium
• Decrease in levels of vitamin C, protein, and glutathione
(an antioxidant)
 CONT’D
• Associated Ocular Conditions
• Retinitis pigmentosa
• Myopia
• Retinal detachment and retinal surgery
• Infection (e.g. herpes zoster, uveitis)
• congenital defects.
 CONT’D
• Toxic Factors
• Corticosteroids, especially at high doses and in
long-term use
• Alkaline chemical eye burns, poisoning
• Cigarette smoking
• Calcium, copper, iron, gold, silver, and
mercury, which tend to deposit in the
pupillary area of the lens
 CONT’D
• Nutritional Factors
• Reduced levels of antioxidants
• Poor nutrition
• Obesity
• alcohol consumption
 CONT’D
• Physical Factors
• Dehydration associated with chronic diarrhea,
use of purgatives in anorexia nervosa, and use
of hyperbaric oxygenation
• Blunt trauma, perforation of the lens with a
sharp object or foreign body, electric shock
• Ultraviolet radiation in sunlight and x-ray
 CONT’D
• Systemic Diseases and Syndromes
• Diabetes mellitus
• Down syndrome
• Disorders related to lipid metabolism
• Renal disorders
• Musculoskeletal disorders
 CLINICAL MANIFESTATIONS

• Painless, blurry vision.

• The patient perceives that surroundings are
dimmer, as if glasses need cleaning.
• Light scattering is common, and the individual
experiences reduced contrast sensitivity,
• sensitivity to glare, and
• reduced visual acuity.
 Cont’d
• halos around lights,
• difficulty reading fine print or seeing in bright
light,
• increased sensitivity to glare such as when
driving at night,
• Decreased color vision.
 CONT’D
Other effects include;
• myopic shift,
• astigmatism,
• monocular diplopia (i.e. double vision),
• color shift (i.e. the aging lens becomes progressively
more absorbent at the blue end of the spectrum),
• brunescens (ie, color values shift to yellow-brown),
and
• reduced light transmission.
 DIAGNOSTIC FINDINGS

• Decreased visual acuity is directly proportionate to

cataract density.
• The degree of lens opacity does not always correlate
with the patient’s functional status.
• Some patients can perform normal activities despite
clinically significant cataracts.
• Others with less lens opacification have a
disproportionate decrease in visual acuity; hence,
visual acuity is an imperfect measure of visual
impairment.
 CONT’D
• The Snellen visual acuity test,
• ophthalmoscopy, and
• Slit lamp biomicroscopic examination are used
• to establish the degree of cataract formation.
 Medical Management

• No nonsurgical treatment can cure cataracts.

• Ongoing studies are investigating ways to slow cataract
progression, such as intake of antioxidants (e.g.,
vitamin C, beta-carotene, vitamin E).
• In the early stages of cataract development, glasses,
contact lenses, strong bifocals, or magnifying lenses
may improve vision.
• Mydriatics can be used as short-term treatment to
dilate the pupil and allow more light to reach the
retina, although this increases glare.
 SURGICAL MANAGEMENT

• Fewer than 15% of people with cataracts suffer

vision problems severe enough to require surgery.
• In general, if reduced vision from cataract does
not interfere with normal activities, surgery may
not be needed.
• However, in deciding when cataract surgery is to
be performed, the patient’s functional and visual
status should be taken into consideration.
 CONT’D
• Surgery is performed on an outpatient basis
and usually takes less than 1 hour, with the
patient being discharged in 30 minutes or less
afterward.
• When both eyes have cataracts, one eye is
treated first, with at least several weeks,
preferably months, separating the two
operations.
 CONT’D
• Because cataract surgery is performed to improve
visual functioning,
• the delay for the other eye gives time for the patient
and the surgeon to evaluate whether the results
from the first surgery are adequate enough to
preclude the need for a second operation.
• The delay also provides time for the first eye to
recover; if there are any complications, the surgeon
may decide to perform the second procedure
differently.
Intracapsular Cataract Extraction (ICCE)
• This has been the technique of choice for cataract
extraction since 1800s until the 1970s.
• The entire lens (i.e., nucleus, cortex, and capsule)
is removed, and fine sutures close the incision.
• ICCE is infrequently performed today;
• however, it is indicated when there is a need to
remove the entire lens, such as with a subluxated
cataract (i.e., partially or completely dislocated
lens).
 EXTRACAPSULAR SURGERY
• Extracapsular cataract extraction (ECCE) achieves the
intactness of smaller incisional wounds (less trauma
to the eye)
• and maintenance of the posterior capsule of the lens,
• reducing postoperative complications, particularly
aphakic retinal detachment and cystoid macular
edema.
• In ECCE, a portion of the anterior capsule is removed,
allowing extraction of the lens nucleus and cortex.
 CONT’D
• The posterior capsule and zonular support are
left intact.
• After the pupil has been dilated and the
surgeon has made a small incision on the upper
edge of the cornea, a viscoelastic substance
(clear gel) is injected into the space between
the cornea and the lens.
• This prevents the space from collapsing and
facilitates insertion of the IOL.
 PHACOEMULSIFICATION
• This method of extracapsular surgery uses an
ultrasonic device that liquefies the nucleus and
cortex, which are then suctioned out through a
tube.
• The posterior capsule is left intact.
• Because the incision is even smaller than the
standard ECCE,
• the wound heals more rapidly, and there is early
stabilization of refractive error and less astigmatism.
 LENS REPLACEMENT
• After removal of the crystalline lens, the patient is referred to
as aphakic (i.e., without lens).
• The lens, which focuses light on the retina, must be replaced
for the patient to see clearly.
• There are three lens replacement options:
 aphakic eyeglasses,
 contact lenses, and
 IOL implants.
• Aphakic glasses are effective but heavy. Objects are magnified
by 25%, making them appear closer than they actually are.
 CONT’D
• Contact lenses provide patients with almost
normal vision, but because contact lenses need
to be removed occasionally, the patient also
needs a pair of aphakic glasses.
• Contact lenses are not advised for patients who
have difficulty inserting, removing, and cleaning
them.
• Frequent handling and improper disinfection
increase the risk for infection.
 NURSING MANAGEMENT

• The patient with cataracts should receive the usual

preoperative care for ambulatory surgical patients
undergoing eye surgery.
• According to the study on Medical Testing for
Cataract Surgery, routine preoperative testing before
cataract surgery does not improve health or clinical
outcomes.
• Hence, the standard of preoperative tests should be
prescribed only when they would have been
indicated by the patient’s medical history.
 PROVIDING PREOPERATIVE CARE

• To reduce the risk for retrobulbar haemorrhage (after

retrobulbar injection), any anticoagulation therapy
that the patient is receiving is withheld, if medically
appropriate.
• Aspirin should be withheld for 5 to 7 days,
nonsteroidal anti-inflammatory medications (NSAIDs)
for 3 to 5 days, and warfarin (Coumadin) until the
prothrombin time of 1.5 is almost reached.
• Dilating drops are administered every 10 minutes for
four doses at least 1 hour before surgery.
 CONT’D
• Additional dilating drops may be administered
in the operating room (immediately before
surgery) if the affected eye is not fully dilated.
• Antibiotic, corticosteroid, and NSAID drops
may be administered prophylactically to
prevent postoperative infection and
inflammation.
 PROVIDING POSTOPERATIVE CARE

• After recovery from anesthesia, the patient receives

verbal and written instruction regarding how to
protect the eye, administer medications, recognize
signs of complications, and obtain emergency care.
• The nurse also explains that there is minimal
discomfort after surgery and instructs the patient to
take a mild analgesic agent, such as acetaminophen,
as needed.
• Antibiotic, anti-inflammatory, and corticosteroid eye
drops or ointments are prescribed postoperatively.
 CONTINUING CARE
• The eye patch is removed after the first follow
up appointment.
• Patients may experience blurring of vision for
several days to weeks.
• Sutures left in the eye alter the curvature of
the cornea, resulting in temporary blurring
and some astigmatism.
• Vision gradually improves as the eye heals.
 CONT’D
• Patients with IOL implants have visual
improvement faster than those waiting for
aphakic glasses or contact lenses.
• Vision is stabilized when the eye is completely
healed, usually within 6 to 12 weeks, when final
corrective prescription is completed.
• Visual correction is needed for any remaining
nearsightedness or farsightedness (even in
patients with IOL implants).
COMPLICATIONS OF CATARACT
SURGERY
 Potential Complications of Cataract Surgery

• COMPLICATION EFFECTS MANAGEMENT AND

OUTCOME
• Increased IOP, proptosis, lid tightness, and
subconjunctival hemorrhage with or without
edema
• May result in loss of vitreous Extrusion of
intraocular contents from the eye or opposition of
retinal surfaces
• Characterized by marked visual loss, pain, lid
edema, hypopyon, corneal haze, and chemosis
 CONT’D
 Toxic reactions or mechanical injury from
broken or loose sutures
• Results in astigmatism, sensitivity to glare, or
appearance of halos
 Persistent, low-grade inflammation and
granuloma
• Visual acuity is diminished.
 CONT’D
• Immediate Preoperative
• Retrobulbar hemorrhage: can result from
retrobulbar infiltration of
• anesthetic agents if the short ciliary artery is
located by the injectia
• Intraoperative Complications
• Rupture of the posterior capsule
• Suprachoroidal (expulsive) hemorrhage:
• profuse bleeding into the suprachoroidal space
 CONT’D
• Early Postoperative Complications
• Acute bacterial endophthalmitis: devastating
complication that occurs in about 1 in 1000
cases; the most common causative organisms
are Staphylococcus epidermitus, aureus,
Pseudomonas and Proteus species
 CONT’D
• Late Postoperative Complications
• Suture-related problems
• Malposition of the IOL
• Chronic endophthalmitis
• macular edema
• retinal detachment,
• vitreous loss
 CONT’D
• Opacification of the posterior capsule (most common
late complication of extracapsular cataract extraction)
• Emergent lateral canthotomy (slitting of the canthus) is
performed to stop central retinal perfusion when the
IOP is dangerously elevated.
• If this procedure fails to reduce IOP, a puncture of the
anterior chamber with removal of fluid is considered.
• The patient must be closely monitored for at least a
few hours.
 CONT’D
• Postponement of cataract surgery for 2 to 4
weeks is advised.
• Complications such as iris prolapse, vitreous
loss, and choroidal hemorrhage could result in
a catastrophic visual outcome.
• Anterior vitrectomy is required if vitreous loss
occurs.
 CONT’D
• Closure of the incision and administration of a
hyperosmotic agent to reduce IOP or
corticosteroids to reduce intraocular
inflammation.
• Vitrectomy is performed 1 to 2 weeks later.
• Visual prognosis is poor; some useful vision
may be salvaged on rare occasions.
• Managed by aggressive antibiotic therapy.
 CONT’D
• Broadspectrum antibiotics are administered
while awaiting culture and sensitivity results.
• Once results are obtained, the appropriate
antibiotics are administered via intravitreal
injection.
• Corticosteroid therapy is also administered.
 CONT’D
• Suture removal relieves the symptoms.
• Topical corticosteroids are used when the incision is not
healed and sutures cannot be removed.
• Miotics are used for mild cases, whereas IOL removal
and replacement is necessary for severe cases.
• Corticosteroids and antibiotics are administered
systemically.
• If the condition persists, removal of the IOL and
capsular bag, vitrectomy, and intravitreal injection of
antibiotics are required.
 NURSING DIAGNOSIS

• Disturbed sensory perception: visual related

to altered sensory reception
• Deficient knowledge related to preoperative
and postoperative eye care
• Risk for infection related to surgical procedure
• Risk for injury related to altered visual acuity
• Anxiety related to visual alteration
• Fear related to surgery