Cataract

A cataract is a clouding or opacity that
develops in the crystalline lens of the eye or in its envelope, varying in degree from slight opacity to obstructing the passage of light.
Progressive, painless clouding of the natural, internal lens of the eye.

1. MEDICAL SURGICAL NURSING- II UNIT – II NURSING MANAGEMENT OF PATIENTS WITH DISORDERS OF EYE TOPIC : CATARACT Mrs. SOUMYA. M LECTURER CON, SRIPMS, CBE

2. Central Objective : At the end of this session the students will gain adequate knowledge regarding cataract and develop desirable skill and positive attitude towards utilizing this with k n owl e dg e in c a re o f suc h p a ti e nts cataract in future. Specific Objective s: The student will be able to Recall the anatomy and physiology Define cataract State the word meaning

3. Discuss the epidemiology Enlist the etiological factors Enumerate pathophysiology List out clinical manifestations Explain the types State the diagnostic measures Clarify the surgical measures Discuss on pre and post operative nursing management Express the complications after surgery. CONTINUATION..

4. ANATOMY OF LENS Developed from surface ectoderm. Biconvex, avascular, transparent structure suspended by zonules behind the iris. Parts – central nucleus, cortex, anterior and posterior capsule. Composition -65% water, 35%protein and traces of minerals. ari

5. T HE LE NS I t ’ s c ry st al l i n e . C r o s s s e c t i o n : C a p s ule C o r t e x n u c l e u s

6. C i liar y m u s cle • F u n c ti o n: C ons tric ts cilia r y body C i liar y p roc e ss • A ttache s to the le n s e s b y s us pe n s ory liga m ent (zonula r fibe rs)

7. FUNCTIONS Acts as refractory surface. Helps in the act of accommodation.

8. DEFINITION A cataract is a clouding or opacity that develops in the crystalline lens of the eye or in its envelope, varying in degree from slight opacity to obstructing the passage of light. Progressive, painless clouding of the natural, internal lens of the eye.

9. ‘CATARACTA ’ ( LATIN) = MEANING ‘WATERFALL M E AN I NG

10. When water is turbulent, it is transformed from a clear medium to white and cloudy. Keen ancient observers noticed similar-appearing changes in the eye and attributed visual loss from "cataracts" as an accumulation of this turbulent fluid, having no knowledge of the anatomy of the eye or the status or importance of the lens. CONTINUATION..

11. E p i d e m iology 1. Cat a r a c t s rem a in t h e l e a din g ca u s e o f b li ndn e ss . 2. Ag e - rel a t e d c a t a r a c t is re s p o n s ibl e f o r 48% of w or ld blindn ess , w hi c h re p r es e n t s ab o ut 18 m i l l i o n p e o pl e . 3. Cat a r a c t s a re a l s o an i m p o r t an t c au s e o f l o w v i s io n in b ot h d e v e l o p e d and d e v e l o p in g c o un t r i e s.

12. C A U S E S O F C ATA R A C T • O l d a g e ( c o mm o ne s t ) > 65 Y e a r • O cul a r & s y s t e m i c d i s e a s e s – D M – U v e iti s – Pr evi o us o c u l a r s u r ge r y • S y s t e m i c m e d i c a ti on – S t e r oi d s – P h e n o thi a z i n e s • Tr a u ma & i n t r a o c u l a r f o r e i g n b o di e s • I o ni z i n g r ad i a ti on – X - r a y – U V • C o n g e n i t a l – A b nor m a l g a l a c t os e m e t a b o li s m – H y p o gl y ce m i a • I n h er it e d a b n o r m a lit y – M y o t on i c d y s t rop h y – Ma rf a n ’s s yn d r o m – R u b e l l a 8

13. A ny p hysi c al o r c h e m i c al c a u s e ↓ D i s t u r b s t h e i n t r a c e l lula r and e x t r a c e l lu l a r e qu il b r i u m o f w at e r and ele c t r olyt es ↓ De r a n ge s t h e c o l l o id syst e m in l e ns fi b res ↓ A b e rr a n t fib re s a r e f o rm e d fr o m ger m i n al e p it h e l i u m o f lens ↓ E p i th el ia l c el l n e c r os i s ↓ Fo c al o p a c i fic ation o f l e ns e p it h el i u m ( gla u c o mflec k e n) ↓ O p a c ifi c ati o n o f lens PA T H O M EC H A N I S M

14. O p a c i f i c a tion o f l ens t a k e p la ce by 3 b i o c h em i c al c h a n g es. 1 . H yd r a t i on 2 . D e natu r ati on o f 3 . Sl o w l e ns p r o t e i n scl e r os is A bno r m a l iti e s o f l e ns p r o t e ins & D iso rg a n isati on o f l e ns f i b r e s L oss o f t r anspa r e n cy o f l e ns Ca t a r a c t

15. C L A S S I F I C AT IO N : B A SE D O N : A g e o f o n se t Mor p ho l o g y M a t u r i t y E tio l o g y Time of occurrence

16. A g e of o n set : 1. C O N G EN I T AL 2.IN F AN T I L E 3. J U V INI L E 4. PR E - S E N I L E 5. SE N IL E

17. C ONG E N I T A L C A T ARAC T

18. I N F A N T IL E AN D J U V I N IL E C A T A R AC T

19. Morphological Classification Capsular cataract Sub capsular cataract Cortical cataract Nuclear cataract

20. C apsular cataract It involves the capsule and may be anterior capsule or posterior capsule. Subcapsular cataract It involves superficial part of the cortex ( just belo w th e capsu l e ) an d include s anterio r sub capsule or posterior sub capsule.

21. C o rt ic al ca t a rac t O cc ur on the o u t er e d ge of t h e l e ns (c o r t e x ). B egi ns a s w h iti s h , w e d g e - s h a p e d opacitie s. T he le ns f i b e r s o f the c o r te x are m a i nl y a ffecte d. T h e r e i s h y drati on due t o accu m u l a t i on of w ate r d r o p l e ts i n bet w ee n the f i be rs a nd t h e p r otei n are fi r st denat u r a t e d a nd the n a r e coagulate d f o r m i n g o p a cit y .

22. N uc l e ar cata r a c t M os t c o m m o n t y pe A g e - r e l at e d O c c ur i n t h e c e nt er o f t he l e n s. I t i n v olve s t he n ucle u s of t he cr y s t a l l i n e le ns. T h e n u cle us be c o m es di ff u s e l y cl ou d y a n d o b st r u c t s t h e l i g ht r a y s.

23. CONTINUATION..

24. BASED ON MATURITY 1.Immature cataract 2.Mature cataract 3.Hypermature cataract

25. I MM A T U R E C A T A RA C T

26. Mature Cataract Lens is completely opaque . Vision reduced to just perception of light Iris shadow is not seen Lens appears pearly white

27. Hypermature Cataract Shrunken and wrinkled anterior capsule due to leakage of water out of the lens. This may take any of two forms : 1.Liquefactive /Morgagnian Type 2.Sclerotic Cataract

28. Liquefactive/Morgagnian Type Cortex undergoes auto-lytic liquefaction and turns uniformly milky white. The nucleus loses support and settles to the bottom.

29. S c le ro tic C a t a r act • T he flui d f r om t he c o r te x get s a bs orbe d and the lens b eco m e s s hrunke n. • T here m a y be d e pos it i o n o f calcific m a t e r i al on the le ns c a ps ule . • I rid o d o n e s i s : A nteri or c h a m be r deepe n s a nd i r i s beco m e s t r e m ul o u s. • T he z o nu l e s be c o m e w e a k, inc r e a s i ng the r i s k of s ubluxat ion / dis l o c at ion of le ns.

30. Ca tar a ct Based on time of occurrence, D ivide d t o : • A c q u i re d c a t a r a c t A ge - relate d c a t a r a c t M etabol i c cataract R a d i ati on or electr i c c ata r a ct T r a u m atic cataract Toxic cataract S e c o n da r y cataract Congenital Cataract

31. S U BJE C T I V E C L A S S I F IC A T I O N: G R A D E : C L E A R L E N S G R A D E 1 : S W O L L E N F IB RE S AN D S U B C A PS U L A R O P A C I T I E S G R A D E 2 : N UC L E A R C AT AR A C T A N D V I S I B L E L E N S F IB R E S G R A D E 3 : S T R ON G N U CL E A R C ATA R A C T W I TH P E RI N U CL EA R AR E A O P A C I T Y G R A D E 4 : T O T A L O P A CI T Y

32. SU BJEC T I VE C L A SS I F I C AT I ON

33. Clinical Manifestations Gradual painless burning Loss of vision due to lens opacity Increased glare in bright light Decreased color perception Decreased visual acuity Photophobia(light sensitivity) Blurred or distorted images Light scattering Leukokoria or white pupil Reduced light transmission Contrast sensitivity is also lost

34. B LU R R ED V ISI O N D UE T O SCA T T E RI N G O F L I G H T O N T H E R E T I N A

35. GL AR E D V I EW ( T R O U B LE D RIVI N G AT N I G H T )

36. C H AN GE I N C OLO UR V I SIO N ( D I M N E SS)

37. Diagnostic Measures History collection Snellen visual acuity test - The Snellen visual acuity test measures the degree of visual acuity in the patient. Ophthalmoscopy - Ophthalmoscopy is used to view the extent of cataract. Slit-lamp biomicroscopic examination - This procedure is used to establish the degree of cataract formation. Dilated eye exam Tonometry

38. Risk reduction strategies Smoking cessation Weight reduction Optimal blood sugar control Wear sunglasses outdoors to prevent early cateract formation

39. LENS REPLACEMENT Eye glasses- Aphakic glasses Contact lenses IOL Implants GLASSES : Cataract alters the refractive power of the natural lens so glasses may allow good vision to be maintained. T R E ATM E N T

40. S u r g i c al r e m ova l : w h e n v isual acuit y c a n ' t b e i m p r ov e d w i t h gla ss e s. S u r g i c al techni q u e s – P h a c o e m u l s i f i c a ti o n m e t h o d . – E xt r a c a ps u l a r c a t a r a c t e x t r ac t i o n. – In t r a ca psu l a r c a t a r a c t e x t r a c ti o n. – In t r a o c ul a r l e ns i m pl a nt a ti on – c ryo su r g e r y - surgery using the local application of intense cold to destroy unwanted tissue.

41. P h a c o em uls i f i ca ti o n Phacoemulsification is a modern cataract surgery method in which the eye's internal lens is emulsified with an ultrasonic handpiece and aspirated from the eye. Aspirated fluids are replaced with irrigation of balanced salt solution to maintain the anterior chamber.

42. E x t r a - c a p s u la r Ca ta r a ct E xt r a c t i o n ( E CC E ) E x t ra c a ps u l a r S u r ger y . E x t ra c a psul a r ca t a r a ct e x t rac t i o n ( E CC E ) a c hi ev e s t h e inta c tne s s of s m a ll e r in c isio n a l w o und s ( l e s s t r au ma t o the e ye ) a n d m a i nt e n a nc e o f the p o s t er i o r c apsul e o f the l e n s , r e du c in g p o stop e r a t i ve c o m pli c a t i o ns , pa r t i c u la r l y r e t in al de t a c h m e n t a n d cy sto id m a c u l a r edem a .

43. I n t r a - c a p s u la r C a t a r a ct E x t r a c t i on (ICCE) I nt r a c ap s ula r C a t a r a c t E x t r a c tion . F r o m th e lat e 18 s unti l th e 1 9 7 s , th e t e ch n i q ue of c h o i c e f o r cata r a c t e x t r act i o n w as i n t rac ap s u la r c a t a r act e x t r a c t i on ( I C C E) . T h e en t i r e le n s (i e, n u c l e u s, c or te x , and c ap s u le ) i s r e m o v ed , a n d fi ne s u t u r e s cl o s e t he i n c i s i o n . I CC E i s i nf re q u e n t l y per f o rm e d to da y; h o we v er , i t i s i n d ic a t e d whe n t he r e i s a nee d t o re m o v e t he e n t i r e le n s ( ie, p a rt iall y o r c o m p l e t e l y di s l o cat e d len s ) .

44. Pharmacologic Therapy Medications administered pre and postoperatively are: Dilating drops. Dilating drops are administered every 10 minutes for four doses at least 1 hour before surgery. Antibiotic drugs. Antibiotic drugs may be administered prophylactically to prevent postoperative infection and inflammation. Intravenous sedation. Sedation may be used to minimize anxiety and discomfort before surgery.

45. Nursing Management Nursing Assessment The nurse should assess: Recent medication intake. It is a common practice to withhold any anticoagulant therapy to reduce the risk of retrobulbar hemorrhage. Preoperative tests. The standard battery of preoperative tests such as complete blood count, electrocardiogram, and urinalysis are prescribed only if they are indicated by the patient’s medical history.

46. Vital signs. Stable vital signs are needed before the patient is subjected to surgery. Visual acuity test results. Test results from Snellen’s and other visual acuity tests are assessed. Patient’s medical history. The nurse assesses the patient’s medical history to determine the preoperative tests to be required.

47. Possible Pre & Post Operative Nursing Diagnosis Dis t urbed v i s u a l s e n s ory pe r c e p t i o n related to opacification of eye lens. Self care deficit related to visual deficit. Anxiety related to lack of knowledge about post operative care. Risk for injury related to sensory deficit while operated eye is patched. Risk for infection related to surgical incision.

48. P o s t Ope r a ti v e Ca r e Limit the patient to perform an action that can increase IOP, including: coughing, bending, straining, sneezing, lifting objects after the surgery.

49. Observation of increased IOP is characterized by: severe pain, nausea, vomiting. Advice to wear glasses during the day and wear eye protection at night. Give eye drops / eye ointment.

50. Observe for signs of infection, and advise the patient not to rub the eyes to prevent infection. Instruct the patient to wash their hands before administering an ointment / eye drops.

51. Observe for signs of bleeding anterior eye chamber is characterized by changes in vision. Observation for signs of retinal detachment, which is marked with a black dot seems, an increasing number of floaters or light and loss of part / whole field of view.

52. Discharge and Home Care Guidelines The nurse teaches the patient self-care before discharge: Protective eye patch. To prevent accidental rubbing or poking of the eye, the patient wears a protective eye patch for 24 hours after surgery, followed by eyeglasses worn during the day and a metal shield worn at night for 1 to 4 weeks.

53. Patient Education on Activities to be Avoided Don't drive on the first day. Don't do any heavy lifting or strenuous activity for a few weeks. Immed i ately af t er the pro c edure, avoid bending over, to prevent putting extra pressure on eye. I f poss i ble, do n ' t sneeze or vomit r i ght a ft e r surgery.

54. Be careful walking around after surgery, and don't bump into doors or other objects. To reduce risk of infection, avoid swimming or using a hot tub during the first week. Don't expose eye to irritants such as grime, dust and wind during the first few weeks after surgery. Don't rub eyes. CONTINUATION..

55. Expected side effects. Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days, and a clean, damp washcloth may be used to remove slight morning eye discharge. Notify the physician. Because cataract surgery increases the risk of retinal detachment, the patient must know to notify the surgeon if new floaters in vision, flashing lights, decrease in vision, pain, or increase in redness occurs. CONTINUATION..

56. Complications of cataract surgery Infective endophthalmitis This is an ophthalmic emergency. Low grade infection with pathogen such as Propionibacterium species can lead patients to present several weeks after initial surgery with a refractory uveitis. Suprachoroidal haemorrhage . Severe intra operative bleeding can lead to serious and permanent reduction in vision.

57. Uveitis Ocular perforation Postoperative refractive error Posterior capsular rupture vitreous loss Retinal detachment Cystoid macular oedema Glaucoma Posterior capsular opacification CONTINUATION..

58. REFERENCES Brunner and Suddarth’s , (2001), “Text book of Medical Surgical Nursing”,9 th edition, Lippincott company, Newyork. Joyce M. Black, Jane Howks, (2005), “Medical Surgical nursing”, 7 th edition, Elsevier, New Delhi. 3 Sha r on L . L e wis , (2 1 1 ) , “The t e xt boo k o f Medi c al Su r gic a l Nursing”, 8 th edition, Elsevier, New Delhi. 9 th 4 R o ss a nd Williso n , “An a tomy an d Ph y s i ol o g y ” , e d it i o n , Churchchill livingstone publication.