Cataract.pptx

Gross Anatomy & Physiology of Eye
Introduction to cataract
Epidemiology of cataract
The etiological factors
Pathophysiology
Clinical manifestations
Types
Diagnostic measures
Surgical measures
Pre and post operative nursing management
Complications after surgery.
Summary

1. COMMON GERIATRIC CONDITION & ITS MANAGEMENT PRESENTATOR Ms. Sakun Rasaily PAEDIATRIC WARD BPKIHS [email protected] SENSORY SYSTEM CATARACT.

2. PRESENTATION OUTLINES Gross Anatomy & Physiology of Eye Introduction to cataract Epidemiology of cataract The etiological factors Pathophysiology Clinical manifestations T ypes D iagnostic measures Surgical measures Pre and post operative nursing management Complications after surgery. Summary

3. ANATOMY OF EYE

4. 1 What is cataract ? Detachment of lens Opacity of lens Tear of lens All of above. 2 Causes of cataract… Rediation Medication both of above None 3 Clinical feature of cataract.. Loss of vision Constopation Diverticulitis Severe headache Complication of cataract.. Glaucoma Uvitis Ocular perforation All of above

5. C a tar a c t deri v e s f r o m t he L a t i n w ord ‘ cataracta ’ meaning "waterfall“ Any opacity in the human crystalline lens that causes it to loose it’s transparency and /or scatter light compromising the visual acuity Any opacification of IOL after cataract surgery is known as after cataract INTRODUCTION

6. GLOBAL CATARACT BLINDNESS I t is estimated around 20 million people are blind due to this disease Estimated 50 million people blind due to cataract by 2020 By the year 2020, the final target should be 32 million cataract surgeries annually

7. CATARACT BLINDNESS IN NEPAL According to Nepal Blindness Survey(1980-1981 ): A. Cataract and its sequelae (72%) B. Trachoma (3.6%) C. Ocular infections (24.3%) D. Xerophthalmia (1.65%) E. Glaucoma (12.3 %) Others (13%)

8. CAUSES OF CATARACT • • • • • Old age (commonest) >65 Year Ocular & systemic diseases DM Uveitis Previous o c cular surgery Systemic medication Steroids Phenothiazines Trauma & intraocular foreign bodies Ionizing radiation X-ray UV • • Congenital Abnormal galactose metabolism Hypoglycemia Inherited abnormality M uscular dystrophy Marfan’s syndrom Rubella 8

9. Any physical or chemical cause ↓ Disturbs the intracellular and extracellular equilbrium of water and electrolytes ↓ Deranges the colloid system in lens fibres ↓ Aberrant fibres are formed from germinal epithelium of lens ↓ Epithelial cell necrosis ↓ Focal opacification of lens epithelium (glaucomflecken) ↓ Opacification of len {Symptoms presentation of the cataract} PATHOMECHANISM

10. Opacification of lens takeplace by 3 biochemical changes. 1. Hydration 2.Denaturation of 3.Slow lens protein sclerosis Abnormalities of lens proteins& Disorganisation of lens fibres Loss of transparency of lens Cataract

11. CLASSIFICATION : BASED ON : Age of onset Morphology Maturity Etiology Time of occurrence

12. Age of onset : CONGENITAL INFANTILE JUVINILE PRE-SENILE SENILE

13. CO NG E N I T A l C A T ARA C T Congenital cataracts  refers to a lens opacity which is present at birth.  Congenital cataracts  cover a broad spectrum of severity : whereas some lens opacities do not progress and are visually insignificant, others can produce profound visual impairment.  Congenital cataracts  may be unilateral or bilateral.

14. INFANTILE CATARACT If a  cataract  develops in the first six months of life it is known as an “ infantile cataract ”. Children can have  cataract  in one (unilateral) or both (bilateral) eyes. Most children with  cataract  in only one eye usually have good vision in the other.

15. juvenile cataract is characterized by onset of  cataract  in the first decades of life , associated with variable onset of a severe form of arrhythmic cardiomyopathy, with mild impairJment of left ventricular systolic function but severe ventricular arrhythmias ... JUVENILE CATARACT

16. PRE SENILE CATARACT Presenile cataract  is defined as the opacification of lens and/or its capsule before the age of 40 years when all other known causes of  cataract  have been ruled out.

17. SENILE CATARACT Senile cataract  is an  age-related , vision-impairing disease characterized by gradual progressive clouding and thickening of the lens of the eye. It is the world's leading cause of treatable blindness.

18. M ORPHOLOGOCAL CLASSIFICATION Capsular cataract Sub capsular cataract Cortical cataract Nuclear cataract capsular cataract O ne consisting of an opacity of the capsule of the lens. H ypermature   cataract  one in which the entire lens capsule is wrinkled and the contents have becom solid and shrunken, or soft and liquid.

19. SUB CAPSULAR CATARACT subcapsular cataract  starts as a small, opaque area that usually forms near the back of the lens, right in the path of light subcapsular cataract  often interferes with your reading vision, reduces your vision in bright light, and causes glare or halos around lights at night.

20. CORTICAL CATARACT A  cortical cataract  begins as whitish, wedge-shaped opacities on the outer edge of the lens  cortex . As it slowly progresses, the streaks extend to the center and interfere with light passing through the center of the lens.

21. NUCLEAR CATARACT Nuclear cataracts  are often a normal progression of aging, as the lens of the eye can yellow and become cloudy with age. A  nuclear cataract  is most often associated with aging and forms in the center of the lens (the nucleus).  Nuclear cataracts  can occur in one or both eyes, and they often impact distance vision .

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

23. IMMATURE CATARACT Lens is completely opaque . Vision reduced to just perception of light Iris shadow is not seen Lens appears pearly white I mmature cataract   is an incomplete  cataract ; The lens is only slightly opaque T he cortex clear .

24. H YPERMATURE CATARACT Shrunken and wrinkled anterior capsule due to leakage of water out of the lens. This may take any of two forms : Liquefactive /Morgagnian Type Sclerotic Cataract

25. When we're young, our lenses are usually like clear glass, allowing us to see through them. As we get older, they start to become frosted, like bathroom glass, and begin to limit our vision. Cataracts usually appear in both eyes. They may not necessarily develop at the same time or be the same in each eye. They're more common in older adults and can affect your ability to carry out daily activities such as driving. AGE RELATED CATARACT

26. TRAUMATIC CATARACT Traumatic cataract  is a clouding of the lens that may occur after either blunt or penetrating ocular  trauma  that disrupts the lens fibers . Most  traumatic cataracts  are intumescent, but their type and clinical course depend on  trauma  mechanism and the integrity of the capsular bag.

27.   METABOLIC CATARACT

28. COMPLICATED CATARACT A  complicated cataract  is opacification of the natural lens of the eye due to inflammatory conditions of the eye or uveitis

29. TOXIC CATARACT  A host of ocular adverse reactions may result from the use of systemic medications. Included in these reactions is that of the crystalline lens known as toxic cataract. This paper will consider this response with special reference to lens changes resulting from the use of steroids and certain tranquillizers .

30. REDIATION INDUCED CATARACT Radiation cataract  causes partial opacity or cloudiness in the crystalline lens and results from damaged cells covering the posterior surface of the lens. Symptoms can appear as early as one or two years following high-dose exposure and many years after exposure to lower doses.

31. BASED ON TIME OCCURANCE Acquired cataract Age - related cataract Metabolic cataract Radiation or electric cataract Traumatic cataract Toxic cataract Secondary cataract Congenital Cataract Congenital cataracts  refers to a lens opacity which is present at birth.  Congenital cataracts  cover a broad spectrum of severity: whereas some lens opacities do not progress and are visually insignificant, others can produce profound visual impairment.  Congenital cataracts  may be unilateral or bilateral.

32. RADE 0: CLEAR LENS G R AD E 1 : S W G O L L E N F I B R E S AN D SUB CAPSULAR PACITIES GR AD E 2 : N UC L E A R C AT ARA C T A N D VISIBLE LENS FIBRES GRADE 3: STRONG NUCLEAR CATARACT WITH PERINUCLEAR AREA OPACITY GRADE 4: TOTA L OPACITY SUBJECTIVE CLASSIFICATION

33. SUBJECTIVE CLASSIFICATION

34. C LINICAL PICTURES 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 white pupil Reduced light transmission Contrast sensitivity is also lost

35. B L U RR E D V IS I O N DU E T O SC A T T E R I NG OF LIGHT ON THE RETINA

36. GLARED VIEW (TROUBLE DRIVING AT NIGHT )

37. CHANGE IN COLOUR VISION(DIMNESS )

38. 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

39. Smoking cessation Weight reduction Optimal blood sugar control Wear sunglasses outdoors to prevent early cateract formation TREATMENT MODIFICATION

40. LENS REPLACEMENT GLA S S E S : C a taract a l ters the ref r active po w er of the natural lens so glasses may allow good vision to be maintained. Contact lenses IOL Implants TREATMENT

41. Surgical removal : when visual acuity can't be improved with glasses. Surgical techniques – Phacoemulsification method. – Extracapsular cataract extraction. – Intra capsular cataract extraction. – Intraocular lens implantation – cryosurgery- surgery using the local application of intense cold to destroy unwanted tissue. SURGICAL TREATMENT

42. Phacoemulsification 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.

43. Extra-capsular Cataract Extraction (ECCE) Extracapsular Surgery. Extracapsular cataract extraction ( E C C E ) i nt a c t ne s s o f s m a l l e r i nc is i o na l a c h i eve s wounds t h e ( l e s s trauma to the eye) and maintenance of the posterior capsule of the lens, reducing postoperative complications, particularly retinal detachment and cystoid macular edema.

44. Intra-capsular Cataract Extraction (ICCE) I n t r a c ap s u l a r C a t a r a c t E x t r a c ti o n . F r o m th e l at e 1800 s u n ti l t h e 1970 s , t h e t e c hn iq u e o f c h o i c e f or c a t a r a c t extraction was intracapsular c a t a r a c t e x t r a c t i on (ICCE). The entire lens (ie, nucleus, c o r te x , an d c ap s u le ) i s r e m o v e d , a n d f i ne is infrequently sutures close the incision. p er f o rm e d t o da y ; h o w e v er , I CC E i t i s e nt i r e i ndi c a t e d wh e n t h e r e i s a n e e d t o re m o v e t he lens (ie, partially or completely dislocated lens).

45. PHARMACOLOGICAL MANAGEMENT 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.

46. 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.

47. 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.

48. Possible Pre & Post Operative Nursing Diagnosis Disturbed visual sensory perception related to opacification of eye lens . 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.

49. Self care deficit related to visual deficit . Keep psychological support continue. Explain post operative potential complication. Note to the psychological reaction of the patient. Tell about some precaution till some days after surgery . Anxiety related to lack of knowledge about post operative care. Psychological support is most and more important. Keep environment kalm . Reading patients vital signs timely.

50. Risk for injury related to sensory deficit while operated eye patched. Observe for signs of infection, and advise the patient not to rub the eyes to prevent infection . Instruct the patient to wash their hands befor administering an ointment / eye drops.

51. Risk for infection related to surgical incision 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. Discha rge Education 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. Don't drive on the first day. Don't do any heavy lifting or strenuous activity for a few weeks. I m me d i ately a f t er the pr o cedure, avoid bending over, to prevent putting extra pressure on eye. I f pos s i ble, don ' t sneeze or vom i t r i ght a f t 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. CON .......

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 vi s i o n, fl a shi n g no t ify the s u rgeo n if ne w fl oa t er s in li g hts, de cre a se in vi s i on , pa i n, or increase in redness oc c ur s . 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 opacifica tion CON T…… ..

58. American Academy of Ophthalmology (section - 11 Lens & Cataract) Clinical Ophthalmology ( Kanski fouth edition) Clinical Ophthalmology (Myron Yanoff ) Oxford hand book of ophthalmology (second edition) Cataract surgery and its complications (6 th edition, N.JAFFE, M. JAFFE, G.JAFFE) REFERENCES

59. CATRACT SURGERY VIDEO

60. 1 What is cataract ? Detachment of lens Opacity of lens Tear of lens All of above. 2 Causes of cataract… Rediation Medication both of above None 3 Clinical feature of cataract.. Loss of vision Constopation Diverticulitis Severe headache Complication of cataract.. Glaucoma Uvitis Ocular perforation All of above