Cataract and its management

Cataract and its management

1. CATARACT AND ITS MANAGEMENT PRESENTED BY- MISS SHWETA SHARMA M.SC. NURSING I YEAR AIIMS JODHPUR

2. INTRODUCTION A cataract is a lens opacity or cloudiness. Cataracts can develop in one or both eyes at any age. Visual impairment normally progresses at the same rate in both eyes over many years or in a matter of months. If cataracts are present in both eyes, one may affect the patient’s vision more than the other.

3. EPIDEMIOLOGY •The World Health Organization (WHO) estimates that nearly 18 million people are bilaterally blind from cataract in the world, representing almost half of all global cases of blindness. •By age 65, over 90 percent of people have a cataract and half of the people between the ages of 75 and 85 have lost some vision due to a cataract. •In India cataract is the principal cause of blindness accounting for 62.6% cases of blindness.

4. 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 • Decrease in levels of vitamin C, protein, and glutathione (an antioxidant)

5. Associated Ocular Conditions • Retinitis pigmentosa • Myopia • Retinal detachment and retinal surgery • Infection (e.g., herpes zoster, uveitis) 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

6. Nutritional Factors • Reduced levels of antioxidants • Poor nutrition • Obesity 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

7. Systemic Diseases and Syndromes • Diabetes mellitus • Down syndrome • Disorders related to lipid metabolism • Renal disorders • Musculoskeletal disorders

8. A nuclear cataract is associated with myopia , which worsens when the cataract progresses. If dense, the cataract severely blurs vision. Periodic changes in prescription eyeglasses help manage this problem. 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 centre of the lens and has little effect on vision. Cortical cataracts progress at a highly variable rate. Vision is worse in very bright light. People with the highest levels of sunlight exposure have twice the risk of developing cortical cataracts than those with low-level sunlight exposure.

9. 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.

10. CLINICAL MANIFESTATIONS •Painless, blurry vision •Light scattering •Sensitivity to glare •Reduced visual acuity •Astigmatism •Monocular diplopia • Brunescens (i.e., colour values shift to yellow-brown) •Reduced light transmission

11. DIAGNOSTIC EVALUATION •History collection •Physical examination

12. Visual acuity testing For assessing distant vision- Snellen test Random E test For assessing near vision- Jaeger chart

13. Snellen chart

14. RANDOM E TEST

15. JAEGER CHART

16. Direct ophthalmoscopy

17. Indirect Ophthalmoscopy

18. Slit-lamp examination

19. Keratometry A keratometer , also known as an ophthalmometer , is a diagnostic instrument for measuring the curvature of the anterior surface of the cornea, particularly for assessing the extent and axis of astigmatism.

20. Ultrasonography

21. Perimetry testing

22. Medical Management •No nonsurgical treatment cures 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. • Reducing glare with appropriate lighting can facilitate reading. • Mydriatics can be used as short-term treatment to dilate the pupil and allow more light to reach the retina, although this increases glare.

23. Surgical management Fewer than 15% of people with cataracts suffer vision problems severe enough to require surgery. 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.

24. Intracapsular Cataract Extraction 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).

25. Extracapsular cataract extraction (ECCE) 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. An intact zonular-capsular diaphragm provides the needed safe anchor for the posterior chamber intraocular lens (IOL). 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.

26. COMPLICATIONS Immediate Preoperative •Retrobulbar haemorrhage Intraoperative Complications •Rupture of the posterior capsule •Suprachoroidal (expulsive) haemorrhage Early Postoperative Complications •Acute bacterial endophthalmitis

27. Late Postoperative Complications •Suture-related problems •Malposition of the IOL •Chronic endophthalmitis •Opacification of the posterior capsule (most common late complication of extracapsular cataract extraction)

28. PREOPERATIVE CARE -To reduce the risk for retrobulbar hemorrhage (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 secs is almost reached. -Dilating drops are administered every 10 minutes for four doses at least 1 hour before surgery. 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.

29. 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.

30. NURSING ASSESSMENT •Assess the patient's distant and near visual acuity. •If the patient is going to have surgery, especially note the visual acuity in the patient's unoperated eye. Use this information to determine how visually compromised the patient may be while the operative eye is healing. •Assess the psychosocial impact of the patient's visual disability and the level of knowledge regarding the disease process and therapeutic options. •Postoperatively, assess the patient's level of comfort and ability to follow the postoperative regimen.

31. NURSING DIAGNOSIS Pre-operative 1. Disturbed Sensory Perception: Visual related to cataract as evidenced by diminished visual acuity. 2. Anxiety related to surgery that will be undertaken and the possibility of failure to obtain a sight again. 3. Risk for injury related to decreased vision.

32. Post-operative 1. Deficient knowledge related to the post-operative care as evidenced by frequent questioning by patient and family members. Risk for infection related to trauma to the incision. Risk for injury related to blurring of vision after surgery.

33. Promoting home and community-based care -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. -The nurse instructs the patient and family in applying and caring for the eye shield. -Sunglasses should be worn while outdoors during the day because the eye is sensitive to light. - Importance of complying with postoperative restrictions on head positioning, bending, coughing, and Valsalva maneuver to optimize visual outcomes and prevent increased intraocular pressure.

34. - How to instill eye medications using aseptic techniques and adherence with prescribed eye medication routine to prevent infection. -Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days. A clean, damp washcloth may be used to remove slight morning eye discharge. -Because cataract surgery increases the risk for retinal detachment, the patient must know to notify the surgeon if new floaters (i.e., dots) in vision, flashing lights, decrease in vision, pain, or increase in redness occurs.

35. 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. -How to monitor pain , take pain medication, and report pain not relieved by medication. -Importance of continued follow-up as recommended to maximize potential visual outcomes.

36. RESEARCH ARTICLES 1.The prevalence and risk factors for cataract in rural and urban India Sumeer singh et al conducted a study to report the prevalence and risk factors of cataract and its subtypes in older age group in 2017 .A total of 6617 subjects were recruited from both rural and urban areas. Lens opacity was graded according to the Lens Opacity Classification System III (LOCS III).Cataract was present in 1094 of the rural and 649 subjects in the urban population. In baseline characteristics history of diabetes, alcohol intake and presence of age-related macular degeneration were the risk factors in urban group. Overweight was found to be a protective factor, and lower social economic status a risk factor for cataract in urban population. It concluded that the risk factors for any cataract in older age group are increasing age and HbA1c in rural group. Age and lower social economic status were found to be the risk factors in urban area. A statistically significant difference was found on comparison of the prevalence of cataract and its subtypes between the rural and urban population.

37. 2.Prevalence and Visual Outcomes of Cataract Surgery in Rural South India: A Cross-Sectional Study. Paul P et al conducted a cross-sectional survey to determine the prevalence of cataract surgery and postoperative vision-related outcomes, especially with respect to gender, socioeconomic status (SES) and site of first contact with eye care, in a rural area of South India in 2016. 5530 individuals aged 50 years or older who had undergone cataract surgery in one or both eyes were identified. Outcomes were classified as good if visual acuity of the operated eye was 6/18 or better, fair if worse than 6/18 but better than or equal to 6/60, and poor if worse than 6/60. Prevalence of cataract surgery in this age group (771 persons) was 13.9%. Place of surgery and duration since surgery of 3 years or more were risk factors for blindness, while SES, gender and site of first eye care contact were not. The high prevalence of avoidable causes of visual impairment in this rural setting indicates the scope for preventive strategies.

38. CONCLUSION •As discussed throughout the presentation, learning about cataract and its management will help nurses to care for a cataract patient. •Nurses can do assessment of a cataract patient, observe the sign and symptoms, provide the necessary nursing care and support the patient psychologically. •Nurses can also counsel the patients and their family for various options available in treatment for cataract.

39. REFERENCES 1. Janice L. Hinkle, Kerry H. Cheever. Brunner and Suddarth’s Textbook of Medical Surgical Nursing. 2015. New Delhi. Wolters Kluwer.13th Edition. Volume 2. Pg. no. 1761-1764. 2. Lewis. Medical Surgical Nursing Assessment and Management of clinical problems.2015. New Delhi. Elsevier. 2nd Edition. Volume I. Pg. no. 409-412. 3. World Health Organization. Blindness and vision impairment prevention. Available from https://www.who.int/blindness/causes/priority/en/index1.html [cited 7 April 2020] 4. Singh S, Pardhan S, Kulothungan V, Swaminathan G, Ravichandran JS, Ganesan S, Sharma T, Raman R. The prevalence and risk factors for cataract in rural and urban India. Indian J Ophthalmol [serial online] 2019 [cited 2020 Apr 7]; 67:477-83. Available from: http://www.ijo.in/text.asp?2019/67/4/477/254705 [cited 7 April 2020] 5. PubMed. Prevalence and Visual Outcomes of Cataract Surgery in Rural South India: A Cross-Sectional Study. Ophthalmic Epidemiol . 2016 Oct;23(5):309-15. doi : 10.1080/09286586.2016.1212991. Epub 2016 Aug 23.

40. Q. Which of the following statement is true regarding the visual changes associated with cataracts? A. Both eyes typically cataracts at the same time B. The loss of vision is experienced as a painless, gradual blurring C. The patient is suddenly blind D. The patient is typically experiences a painful, sudden blurring of vision. Ans- B

41. Q. The following are appropriate nursing interventions after cataract extraction EXCEPT: A. Place the client in supine position or turn towards unoperated side B. Advise the client to avoid bending, stooping or lifting heavy objects for several weeks postop C. Instruct the client to limit fluid intake D. Advise the client to protect his eyes with eye pad and eye shield for a week Ans- C

42. Q. A 55-year old client underwent cataract removal with intraocular lens implant. Nurse Oliver is giving the client discharge instructions. These instructions should include which of the following? A. Avoid lifting objects weighing more than 5 lb (2.25 kg). B. Lie on your abdomen when in bed C. Keep rooms brightly lit. D. Avoiding straining during bowel movement or bending at the waist. Ans- D