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kataraktes and katarrhaktes, from katarassein meaning "to dash down" (kata-, "down";
arassein, "to strike, dash")]Early in the development of age-related cataract the power of the
lens may be increased, causing near-sightedness (myopia), and the gradual yellowing and
opacification of the lens may reduce the perception of blue colors. Cataracts typically
progress slowly to cause vision loss and are potentially blinding if untreated. The condition
usually affects both the eyes, but almost always one eye is affected earlier than the othe
DEFINITION:-1.Cataract is a condition in which the lens of the eye becomes opaque one or
both eyes may be affected. Acc. To Barbara k.
2.Clouding or opacity of the crystalline lens that impairs a vision. Acc To. Lippincott.
3.Opacity in lens or its capsule wheater developmental or acquired is called cataract. Acc.
To. Renu Jogi
4.As opacification on or side the lens. Functionally it includes only those cases which interfes
with vision. Clinically, it is opacification of lens which obstruct the normal red glow on
distant direct opathalmoscopy. Acc. To. Pradeep Sharma
5.A cataract is a clouding that develops in the crystalline lens of the eye or in its envelope,
varying in degree from slight to complete opacity and obstructing the passage of light.
INCIDENCE:-C ataract is one of the most common causes of visual impairment in the world.
According to the World Health Organisation (WHO), cataract is the leading cause of
blindness all over the world, responsible for 47.8% of blindness and accounting for 17.7
million blind people.In India, 80% of the blindness is due to cataract.Various modifiable risk
factors associated with cataract include UV exposure, diabetes, hypertension, body mass
index (BMI), drug usage, smoking and socioeconomic factors; but advancing age is the single
most important risk factor for cataract.
Nirmalan et al. studied the prevalence of cataract in a rural population (≥40 years) of
Southern India and reported the presence of cataract in 47.5% of their study population,
prevalence being less in men compared to women.
Vashist et al. reported prevalences of 58% in North India and 53% in South India in the
older age group (>60 years) with nuclear cataract being the most common type of cataract in
both parts of the country.In India, a very few population based studies have been
undertaken to explore the risk factors for cataract in older age group, especially since the
proportion of the elderly has been significantly increasing in the country; the 60 +
population which stood at 56 million in 1991 is now estimated to have doubled in 2016.
Cataract refers to a clouding of the lens of the eye causing gradual loss of vision. It is
common in old age but can also be triggered by injuries to the eye.
Sclerea:- is the outer coating of the eye which is white in colour that protects the interior of
the eye and provides the shape to the eye.
Cornea front part of sclerotic is transparent to light and is termed as cornea. The light
coming from an object enters the eye through cornea
Iris is just at the back of cornea. This controls the size of the pupil. It acts like a shutter of a
photographic camer and allows the regulated amount of light to enter the eye.
Eye lens is a double convex lens with the help of which image is formed at retina by
refraction of light.
Ciliary muscle:-The eye lens is held by ciliary muscles. Ciliary muscles help the eye lens to
change its focal length.
Pupil the centre of the iris there is a hole through which light falls on the lens, which is called
pupil.
Aqueous humour:-The space between cornea and eye lens is filled with a transparent fluid
called aqueous humour.
Vitreous humourThe space between eye lens and retina is filled with a jelly like transparent
fluid called vitreous humour.
Retina serves the purpose of a screen in the eye, wherethe images of the objects are
formed. Retina is at the back of the eye lens. Retins is made of light sensitive cells, which are
connected to the optical nerve.
Blind spotThe region of eye containing the optic nerve is not at all sensitive to light and is
called blind spot. If the image of an object is formed in the blind spot, it is not visible.
Yellow spot The central part of retina lying on the optic axis of eye is most sensitive to light
and is called yellow spot
Eye lids are provided to control the amount of light falling on the eye. They also protect the
eye from dust particles etc
ANATOMY OF THE LENS LENS CAPSULE:-A biconvex structure attached to the ciliary process
by the zonular fibre, between iris & vitreous humour Non-vascular, colourless and
transparent Index of refraction 1.336 Consists of stiff elongated, prismatic cells known as
lens fibre, very tightly packed together Divided into nucleus, cortex and capsule The
whole lens enclosed within an elastic capsule Helps to refract incoming light and focus it
onto the retina
Thin transparent, collagen membrane Surrounds lens completely Elastic in nature but
contain no any elastic tissue Anteriorly secreted by lens epithelium and posteriorly by
basal cells of elongating fibers
Single layer below the lens capsule Formed of cuboidal cells Become columnar at
equatorial region LENS FIBER The epithelial cells elongated to form lens fibers which have a
complicated structural forms. Mature lens fibers are cells which have lost their nuclei. As
the lens fibers are formed throughout the life, these are arranged compactly as nucleus &
cortex of the lens. Its is the central part containing the oldest fibres. It consists of different
zones, which are laid down successively as the development proceeds. Different zones: I.
Embryonic nucleus II. Fetal nucleus III. Infantile nucleus IV. Adult nucleus CORTEX Its is the
peripheral part which compromises the youngest lens fibres. Its transparency is due to the
arrangement of its fibres, internal structure and the biochemistry of the lens cells and fibres.
A cataractous lens is when the lens become opaque
2. 2. Maternal factors like intrauterine infections (rubella), malnutrition, drug toxicity and
radiation damage, 20% of cases.
7.Birth trauma
II
ACQUIREDCATARACT:-Any noncongenital cataract; usually the result of trauma, systemic dis
ease or another eye disorder.The opacification of already forced lens fibres in the post natal
period called ‘Acquired Cataract’.
ETIOLOGICAL Classification: Any of causes after the 1 year of the agecauses to the
catract
III SUBJECTIVE CLASSIFICATION: GRADE 0: CLEAR LENS GRADE 1: SWOLLEN FIBRES AND SUB
CAPSULAR OPACITIES GRADE 2: NUCLEAR CATARACT AND VISIBLE LENS FIBRES GRADE 3:
STRONG NUCLEAR CATARACT WITH PERINUCLEAR AREA OPACITY GRADE 4: TOTAL OPACITY
Morphological Classification
Lamellar or Zonular cataract: The lens opacities (“riders”) are located in only one layer of
lens fibers, often only in the equatorial region.Most common type of congenital cataract.
This type is characterized by white opacities that surround the nucleus with alternating clear
and white cortical lamella like an onion skin. Lamellar cataract usually involves bilateral eyes.
capsular cataract:- An opacity confined only to the capsule of the crystalline lens,anteriorly
subcapsular cataract :- Subcapsular cataract Occur just under the capsule of the lens. Starts
as a small, opaque area It usually forms near the back of the lens, right in the path of light on
its way to the retina. It’s interferes with reading vision Reduces vision in bright light Causes
glare or halos around lights at
night.An agerelated opacity located beneath the anterior or posteriorcapsule. It may spread
from the periphery of the cortex like spokes on a wheel(cuneiform cataract). This is the most
common type of cortical cataract. The opacitiesmay also be confined to the posterior layers
of the cortex with a granular or lace-likeappearance (cupuliform cataract). Subcapsular catar
acts are often the result ofradiation exposure, age, toxic damage (e.g. from corticosteroids),
or secondary to eyediseases (e.g. uveitis, retinitis pigmentosa).
Posterior Subcapsular Cataracts:It is Begins at the back of the lens (posterior pole) &
spreads to the periphery or edges of the lens. Plaquelike opacity near the posterior aspect of
the lens. A posterior polar cataract is a round, discoid, opaque mass that is composed of
malformed and distorted lens fibers located in the central posterior part of the lens.It can be
developed when: Part of the eye are chronically inflamed . Heavy use of some medications
(steroids). Affects vision more than other types of cataracts because the light converges at
the back of the lens. Anything constrict the pupils (bright light) makes it very difficult for
people with this type of cataract to see. Dilating drops useful in this type by keeping the
pupils large and thus allow more light into the eye.
Anterior polar cataract:- Anterior polar cataracts are congenital opacities involving the
anterior capsule and subcapsular cortex-it is a.small,b/l symmetric,non progressive opacities
that do not impair vision. It
may be flat or project as a conical opacity (pyramidal cataract) into the
anterior chamber . Anterior polar cataractMay present as a congenital (autosomal
dominantly inherited) or acquired cataract secondary to uveitis or trauma (associated with
anterior subcapsular opacities). Small anterior polar opacification usually is sharply defined.
sutural:The sutural or stellate cataract is an opacification of the “y” Sutures of the fetal
nucleus -it doesnot impair vision -These opacities often have branches or knobs projecting
from them.It is
a congenital cataract in which the opacities are found along theanterior and/or posterior le
ns sutures. The opacities may appear Y-shaped or flower-shaped. The condition is often asso
ciated with Fabry's disease.
Complete:-also It is also called as total cataract all the lens fibres are opacified. The red
reflex is totally obscured. Retina can’t be seen by direct /indirect opaloscope.
Nuclear cataract:- Most common type Age-related Occur in the center of the lens.It involves
the nucleus of the crystalline lens. The nucleus becomes diffusely cloudy and obstructs the
light rays. In its early stages, as the lens changes the way it focuses light, patient may
become more nearsighted or even experience a temporary improvement in reading vision.
Some people actually stop needing their glasses. • Unfortunately, this so-called 2nd sight
disappears as the lens gradually turns more densely yellow & further clouds vision. • As the
cataract progresses, the lens may even turn brown. Advanced discoloration can lead to
difficulty distinguishing between shades of blue & purple.This later white nuclear will
become yellow, brown, and black, and it is called brunescence cataract (nigra
cataract).Nuclear type has opacity within embryonic/fetal nucleus that can be seen like coral
flower. An opacity affecting the lens nucleus. It can be either congenital orage-related in orig
in. It frequently leads to an increase in myopia (or decrease inhyperopia). In some cases it re
aches such a brown colour that it is called brunescent
Subcapsular cataract •It involves superficial part of the cortex(just below the capsule) and
includes anterior sub capsule or posterior sub capsule cataract right in the path of light on
its way to the retina. Starts as a small, opaque area It involves the capsule and may be
anterior capsule or posterior capsule.It’s interferes with reading vision • Reduces vision in
bright light • Causes glare or halos around lights at night.
Cortical cataract :Cortical cataract Occur on the outer edge of the lens (cortex). Begins as
whitish , wedge-shaped opacities or
streaksor isolated dots or clusters forming the cuneiform or subcapsular type’s ofcataract, b
ut eventually the opacity spreads through the entire cortex.The lens fibers of the cortex are
mainly affected.Begins as whitish, wedge-shaped opacities. • There is hydration due to
accumulation of water droplets in between the fibers and the protein are first denaturated
and then are coagulated forming opacity. It’s slowly progresses; the streaks extend to the
center and interfere with light passing through the center of the lens. Problems with glare
are common with this type of cataract.Early stage cortical cataract demonstrates water
clefts and vacuoles, which may change over time resulting in irreversible opacities. In a more
advanced stage, spoke-like or wedge-shaped peripheral opacities progress circumferentially,
initially sparing the clear central axis of the lens. It can cause glare and often asymptomatic
until central changes develop 15. Cortical cataract • Occur on the outer edge of the lens
(cortex). •
1.Juvenile cataract: cataract which happens after one years old and occurs in young people
under 20 years old. The opacity of lens in juvenile cataract occurs when lens fibers is still
developing, so it has soft consistency (soft cataract).
3.Senile cataract:Opacification of lens which occur with advancing age usually above 50 year
or likely above 75-80 years.It mostly occurs in male than in females.
cataract which occurs after 50 years old.Senile cataract is associated with the aging process
in the lens. The changes include increasing thickness of nucleus with the developing of
cortex lens.
a.Incipient cataract: irregular opacity likes cogwheel-like spot. In this stage, polyopia is
common complaints because of the asimilarity of refraction index in all part of lens.
b.Immature cataract: thicker opacity but it hasn’t involve all part of lens. In this stage,
hydration of cortex causes intumescence lens. Intumescence lens causes changes of
refraction index which the eyes becomes myopic. Lens is partially opaque Two
morphological forms are seen:
Cuneiform Cataract: Wedge shaped opacities in the peripheral cortex and progress
towards the nucleus. Vision is worse when the pupil is dilated.
Cupuliform Cataract: A disc or saucer shaped opacities beneath the posterior capsule.
Vision is worse in bright ambient illumination when the pupil is constricted. Lens appears
grayish white in color. Iris shadow can be seen on the opacity with oblique illumination.
2. Sclerotic Cataract:-1.The fluid from the cortex gets absorbed and the lens becomes
shrunken.
4.The zonules become weak, increasing the risk of subluxation / dislocation of lens.
2.Drug-induced CataractDrugs that can induce lens opacities include steroids, miotics,
antipsyhotics.
6. Heat cataract: Catract ocures due to exposure of high temperature such as glass
blowers.
9. Mitotic cataract:- strong cholinterase inhibitors osmotic , if used for long can cause
subcapsular cataract. Other toxic agents: - antimitotic durgs like insectidies, busuflfan, are
known to cause cataract.surgical
A cataract usually develops slowly, so: – Causes no pain.– Cloudiness may affect only a small
part of the lens– People may be unaware of any vision loss.• Over time, however, as the
cataract grows larger, it:– Clouds more on the lens– Distorts the light passing through the
lens.– Impairs vision• Reduced visual acuity (near and distant object)• Glare in sunshine or
with street/car lights.• Distortion of lines.• Monocular diplopia.• Altered colours ( white
objects appear yellowish)• Not associated with pain, discharge or redness of the eye.
Signs:-• Reduced acuity.• An abnormally dim red reflex is seen when the eye is viewed with
an ophthalmoscope.Reduced contrast sensitivity can be measured by theophthalmologist.•
Only sever dense cataracts causing severely impaired vision cause a white pupil.• After
pupils have been dilated, slit lamp examination shows the type of cataract.
Clinical Manifestations •Gradual painless burning •Loss of vision due to lens opacity
•Increased glare in bright light •Decreased color perception •Decreased visual acuity
•Poorvision at night • Photophobia(lightPhotophobia(light sensitivity)sensitivity) • Blurred
or distorted images• Light scattering • Leukokoria or white pupil • Reduced light
transmission • Contrast sensitivity is also lost
Diagnosis:- Snellen visual acuity test. The Snellen visual acuity test measures the degree of
visual acuity in the patient.Slit-lamp examination provides magnification and confirms
diagnosis of an opacity.
There is no medical treatment for cataracts, although use of vitamin C and E and
beta-carotene is being investigated. Glasses or contact, bifocal, or magnifying lenses may
improve vision. Mydriatics can be used short term, but glare is increased. But there are take
home medications following a cataract extraction which usually includes an
anti-inflammatory drop containing antibiotic and cyclopegic to prevent ciliary spasm.
Administer dilating drops every 10 minutes for four doses at least 1 hour before surgery.
Antibiotic, corticosteroid, and NSAID drops may be administered prophylactically to prevent
postoperative infection and inflammation.
There are two types of eye surgery that can be used to remove cataracts:
Extra-capsular (ECCE) surgery consists of removing the lens but leaving the majority of the
lens capsule intact.High frequency sound waves (Phacoemulsification) are sometimes used
to break up the lens before extraction. It is requires a relatively large circumferential limbal
incision (8-10mm) through which the lens nucleus is extracted and the cortical matter
aspirated, leaving behind an intact posterior capsule. The IOL is then inserted. It is the
universal procedure of operation in cataract. Posterior IOL can be transplanted after ECCE.
Intra-capsular (ICCE) surgery involves removing the entire lens of the eye, including the lens
capsule, but it is rarely performed in modernpractice.In either extra-capsular surgery or
intra-capsular surgery, the cataractous lens is removed and replaced with a plastic lens (an
intraocular lens implant) which stays in the eye permanently. Cataract operations are usually
performed using a local anaesthetic and the patient is allowed to go home the same day.
Recent improvements in intraocular technology now allow cataract patients to choose a
multifocal lens to create a visual environment in which they are less dependent on glasses.
Under some medical systems multifocal lenses cost extra. Traditional intraocular lenses are
monofocal.The entire cataractous lens along with the intact capsule is removed in this
procedure. Weak and degenerated zonules are a pre-requisite for this method. This is the
surgery of choice only in markedly subluxated and dislocated lens. This technique of surgery
has been largely replaced by ECCE nowadays.
Phacoemulsification In-this cataract surgery involves insertion of a tiny, hollowed tip that
uses high frequency (ultrasonic) vibrations to "break up" the eye's cloudy lens (cataract). The
same tip is used to suction out the lens
Aphakic glasses. In aphakic glasses, objects are magnified by 25%, making them appear
closer than they actually are.
Contact lenses. Contact lenses provide patients with almost normal vision, but because
contact lenses need to be removed occasionally, the patient also needs a pair pf aphakic
glasses.
IOL implants. The most common IOL is the single focus lens or monofocal IOL that cannot
alter the visual shape; multifocal IOLs reduce the need for eyeglasses; accommodative IOLS
mimic the accommodative response of the Extracapsular cataract extraction (ECCE). ECCE
removes the anterior lens and cortex, leaving the posterior capsule intact.
NURSING MANAGEMENT:-
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.
Glasses: Cataract alters the refractive power of the natural lens so glasses may allow good
vision to be maintained. • Surgical removal: when visual acuity can't be improved with
glasses.
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.
Instruct patient to wear a protective eye patch for 24 hours after surgery to prevent
accidental rubbing or poking of the eye. After 24 hours, eyeglasses should be worn during
the day and a metal shield worn at night for 1 to 4 weeks.
Nursing Diagnosis
Based on assessment data, the nursing diagnoses for the patient include:
1.Disturbed visual sensory perception related to altered sensory reception or status pf sense
2.organs.
3.Risk for trauma related to poor vision and reduces hand-eye coordination.
5.Deficient knowledge regarding ways of coping with altered abilities related to lack of
exposure or recall, misinterpretation, or cognitive limitations.
Postoperative care
Bending, sneezing, coughing, straining, vomiting, head hyperflexion, tight clothing, sexual
intercourse.
Instruct patient to call physician immediately if: vision changes; continuous flashing lights
appear; redness, swelling, or pain increase; type and amount of drainage increases; or
significant pain is not relieved by acetaminophen
Retinal Disorders
Inflammation
Chronic endophthalmitis
Retinal detachment
Goal:
1. Assess the degree and duration of visual impairment. Encourage conversation to find out
the patient's concerns, feelings, and the level of understanding.
Rational: Information can eliminate the fear of the unknown. Coping mechanisms can help
patients with kegusara compromise, fear, depression, tension, despair, anger, and rejection.
Rationale: The introduction to the environment helps reduce anxiety and increase security.
Rationale: Patients who have a lot of information easier to receive treatment and follow
instructions.
Rationale: Patients who experience visual disturbances rely on other senses salts input
information.
Rationale: Patients may not be able to perform all duties in connection with the handling of
personal care.
Rationale: Social isolation and leisure time is too long can cause negative feelings.
Nursing Diagnosis for Cataract: Risk for injury related to blurred vision
1. Help the patient when able to do until postoperative ambulation and achieve stable vision
and adequate coping skills, using techniques of vision guidance.
Rational: Reduce the risk of falling or injury when the step stagger or have no coping skills
for vision impairment.
Rational: The pressure in the eye may cause further serious damage.
Rational: Injury can occur if the container touch the eye medication.
Nursing Diagnosis for Cataract: Acute pain related to trauma to the incision and increased
IOP
Rational: Use the recipe will reduce pain and the IOP and increase comfort.
Rasioanal: Strong light causes discomfort after use of eye drops dilator.
Nursing Diagnosis for Cataract: Risk for infection related to trauma to the incision
2. Supervise and report immediately any signs and symptoms of complications, such as:
bleeding, increased IOP or infection.
Rational: The discovery of early complications can reduce the risk of permanent vision loss.
Rational: Elevation of the head and avoid lying on the side of the operation may reduce the
edema.
4. Instruct the patient to know bedrest activity restrictions, with flexibility to the bathroom,
according to a gradual increase in activity tolerance.
Rational: Limitation of activity prescribed to speed healing and avoid further damage to the
injured eye.
Rational: It can lead to complications such as vitreous prolapse or dehisensi injury due to
increased tension on the suture wounds that are very subtle.
Rational: Drugs are administered in a way that is inconsistent with prescriptions can
interfere with healing or cause complications.
2.Congenital cataracts occur in neonates as genetic defects or possibly from measles in the
mother.
3.Traumatic cataracts may occur after injury sufficient to force vitreous humor into the lens
capsule.
Surgical Interventions
1.Surgery is the only cure and is recommended when vision causes problems in daily
activities. Extracapsular extraction is usually done by cryosurgery or phacoemulsification
under local anesthesia.Eye drops are given to decrease response to pain and lessen motor
activity of the eye.Medication is given to reduce IOP.
2.An intraocular lens implant is usually inserted at the time of surgery, designed for distance
vision.
3.Congenital cataract is corrected within first 3 months followed by cataract lens to correct
vision.
5.If patient is not candidate for lens implant, the lens and capsule are removed
(intracapsular extraction), and eye glasses and contact lenses are used to correct vision.
Nursing Interventions
1.Before surgery, monitor for worsening of visual acuity, glare, and ability to perform usual
activities.
2.Monitor pain level postoperatively. Sudden onset may be caused by a ruptured vessel or
suture and may lead to hemorrhage. Severe pain accompanied by nausea and vomiting may
be caused by increased IOP.
4.Keep the patient comfortable and advise him not to touch his eyes.
5.If eye patch or shield is in place, advise using it for several days as prescribed, to rest and
protect eye, especially at night.
6.Caution the patient against coughing or sneezing, any rapid moment, bending from the
waist to prevent increased IOP for first 24 hour. Instruct the patient to avoid heavy lifting or
straining for up to 6 weeks, as directed by surgeon.
7.Advise patient to increase activity gradually; can usually resume normal activity the day
after the procedure.
11.Advise the patient to avoid tilting the head forward when washing hair, and to avoid
vigorous hand shaking, to prevent disruption of the lens until cleared by the surgeon.
1. Assess the degree and duration of visual impairment. Encourage conversation to find out
the patient's concerns, feelings, and the level of understanding.
Rational: Information can eliminate the fear of the unknown. Coping mechanisms can help
patients with kegusara compromise, fear, depression, tension, despair, anger, and rejection.
Rationale: The introduction to the environment helps reduce anxiety and increase security.
Rationale: Patients who have a lot of information easier to receive treatment and follow
instructions.
4. Describes intervention much detail as possible.
Rationale: Patients who experience visual disturbances rely on other senses salts input
information.
Rationale: Patients may not be able to perform all duties in connection with the handling of
personal care.
Rationale: Social isolation and leisure time is too long can cause negative feelings.
a. Physical Orientation. The patient will require a thorough orientation to his immediate
hospital environment. This is done to help the patient during the postoperative period, since
he may be blind as a result of the procedure or the need for the eyes to be patched.
(1) Assist the patient to learn details of his room such as the location of furniture, doors,
windows, and so forth.
(2) Familiarize the patient with the voices of those who will care for him after surgery.
Familiarize him with the daily sounds and noises in the environment, since he will be more
aware of sound without his vision.
b. Observation. The patient should be observed for tendencies to cough or sneeze (smoker's
cough, allergies, and so forth). Such observations should be reported to the professional
nurse for consideration in the plan of care. Such violent movements of the head during the
postoperative course may cause increased intraocular pressure, leading to hemorrhage or
rupture of incisions.
c. Education. The patient must receive a thorough education about the postoperative course
of events and his responsibilities and restrictions. The patient must understand the objective
of resting the eyes and avoiding actions that increase intraocular pressure.
(2) No reading.
d. Physical Preparation.
(1) A bowel prep is done the evening prior to surgery to prevent the patient from straining at
stool during the immediate post-op period.
(2) Shaving of eyebrows, cutting of eyelashes, and shaving of face should be done only on
the order of the surgeon.
After the patient has been taken to surgery, prepare a post-op bed, ensuring that the bed is
equipped with side rails.
(4) Sand bags should be made available for use in immobilizing the head.
e. Family. Often, if the patient must be kept absolutely still or will be temporarily blinded
after surgery, a member of the family may be asked to stay with the patient. If this is the
case, the family member should receive the same orientation and education given to
patient
(1) The patient must be lifted off the litter, he is not to move himself.
(2) The patient should be positioned in the bed as prescribed by the physician.
(4) If both eyes are bandaged (they normally are), the side rails MUST be raised at all times
to protect the patient in the event he becomes disoriented and attempts to get out of bed.
(5) Place the call bell within easy reach of the patient's head and let the patient know
exactly where it is located.
(6) Remind the patient that he should not cough, sneeze, or blow his nose. Instruct him to
inform the staff if he feels the urge, since these actions will increase intraocular pressure.
b. Orientation.
(1) Reinforce the physical orientation given during the preoperative period by verbally
reviewing the locations of objects in the room.
(3) The patient should have an awareness of his surroundings and know what to expect to
avoid being startled or frightened.
c. Precautions.
(1) Avoid dislodgement of the eye dressings by securing them with an eye shield or
reinforcing loose tape.
(3) A sleeping patient must be watched constantly to ensure that proper positioning is
maintained. Often, a family member may be asked to stay with the patient for this purpose.
(4) Avoid jarring or bumping the bed, as this may startle the patient.
(5) If the patient is newly blinded as a result of the surgery, observe for depression and
take precautions if patient is potentially suicidal.
(6) Check the physician's orders before giving anything by mouth. Nausea and vomiting
must be avoided. Additionally, the motion of chewing may be contraindicated.
d. Approaching the Patient. An important consideration in the care of a patient who has
both eyes bandaged is the method of approaching him.
(1) ALWAYS speak to the patient upon entering his area and before touching him.
(2) Allay the patient's fears by explaining each procedure or activity fully.
(4) Always let the patient know when you are leaving his area.
(1) Provide activities that are not fatiguing to the eyes if the eyes are not bandaged.
(a) No reading.
(3) Encourage the use of a radio for entertainment and to keep the patient "in touch" with
current events if he is unable to read the daily newspaper.
2.Nursing Diagnosis for Cataract: Risk for injury related to blurred vision
1. Help the patient when able to do until postoperative ambulation and achieve stable vision
and adequate coping skills, using techniques of vision guidance.
Rational: Reduce the risk of falling or injury when the step stagger or have no coping skills
for vision impairment.
4. Discuss the need for the use of metal shields or goggles when instructed
Rational: The pressure in the eye may cause further serious damage.
Rational: Injury can occur if the container touch the eye medication.
3.Nursing Diagnosis for Cataract: Acute pain related to trauma to the incision and increased
IOP
Rational: Use the recipe will reduce pain and the IOP and increase comfort.
Rasioanal: Strong light causes discomfort after use of eye drops dilator.
4.Nursing Diagnosis for Cataract: Risk for infection related to trauma to the incision
2. Supervise and report immediately any signs and symptoms of complications, such as:
bleeding, increased IOP or infection.
Rational: The discovery of early complications can reduce the risk of permanent vision loss.
Rational: Elevation of the head and avoid lying on the side of the operation may reduce the
edema.
4. Instruct the patient to know bedrest activity restrictions, with flexibility to the bathroom,
according to a gradual increase in activity tolerance.
Rational: Limitation of activity prescribed to speed healing and avoid further damage to the
injured eye.
Rational: It can lead to complications such as vitreous prolapse or dehisensi injury due to
increased tension on the suture wounds that are very subtle.
Rational: Drugs are administered in a way that is inconsistent with prescriptions can
interfere with healing or cause complications.
Postoperative care after cataract surgery • Steroid drops (inflammation) • Antibiotic drops
(infection) • Avoid • Very strenuous exertion (rise the pressure in the eyeball) • Ocular
trauma.
Infective endophthalmitis – Rare but can cause permanent severe reduction of vision. –
Most cases within two weeks of surgery. – Typically patients present with a short history of a
reduction in their vision and a red painful eye. – 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
• Ocular trauma.
Complications of cataract surgery
Complication:-
a. Uveitus
b. Glaucoma c. Infection
Delayed complication: -
a. Retinal detachment
b. After cataract
c. Sympathetic opthalmia
Infective endophthalmitis – Rare but can cause permanent severe reduction of vision. –
Most cases within two weeks of surgery. – Typically patients present with a short history of a
reduction in their vision and a red painful eye. – 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
Postoperative care after cataract surgery Steroid drops (inflammation) Antibiotic drops
(infection) Avoid Very strenuous exertion (rise the pressure in the eyeball) Ocular trauma.
Complications of cataract surgery Infective endophthalmitis Rare but can cause permanent
severe reduction of vision. Most cases within two weeks of surgery. Typically patients
present with a short history of a reduction in their vision and a red painful eye. 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 intraoperative bleeding can lead to serious and
permanent reduction in vision .
Uveitis Postoperative inflammation is more common in certain types of eyes for example in
patients with diabetes or previous ocular inflammatory disease. Ocular perforation.
Postoperative refractive error Most operations aim to leave the patient emmetropic or
slightly myopic, but in rare cases biometric errors can occur or an intraocular lens of
incorrect power is used. Posterior capsular rupture and vitreous loss If the very delicate
capsular bag is damaged during surgery or the fine ligaments ( zonule ) suspending the lens
are weak (for example, in pseudoexfoliation syndrome ), then the vitreous gel may prolapse
into the anterior chamber. This complication may mean that an intraocular lens cannot be
inserted at the time of surgery. Patients are also at increased risk of postoperative retinal
detachment .
Retinal detachment . This serious postoperative complication is, fortunately rare, but is more
common in myopic patients after intraoperative complications. Cystoid macular oedema
Accumulation of fluid at the macula postoperatively can reduce the vision in the first few
weeks after successful cataract surgery. In most cases this resolves with treatment of the
post-operative inflammation. Glaucoma Persistently elevated intraocular pressure may need
treatment postoperatively. Posterior capsular opacification Scarring of the posterior part of
the capsular bag, behind the intraocular lens, occurs in up to 20% of patients. Laser
capsulotomy may be needed.
Uveitis
Ocular perforation.
Retinal detachment
Be free of injury.
Evaluation
Free of injury.
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.
Expected side effects. Slight morning discharge, sone 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
Caution patient that vision may blur for several days to weeks.
Inform patient that vision gradually improves as the eye heals; IOL implants improve
vision faster than glasses or contact lenses.
Home instructions
Reinforce that vision correction is usually needed for remaining visual acuity deficit.
oWearing of eye patch 24 hours after surgery.
oSunglasses should be worn while outdoors during the day because the eye is sensitive to
light.
oSlight morning discharge, some redness, and a scratchy feeling may be expected for a few
days.
The patient needs to have a scheduled check up to see the progress of vision or detection of
any complications.
oThere are no dietary restrictions. However, the restrictions as per pre-existing medical
problems, if any, are to continue.
The patient must avoid constipation by taking high fiber diet and plenty of fluids.
Modified or structured environment to ensure patient’s safety because vision may be blurry
for several weeks after the surgery.
Documentation Guidelines
Description of feelings.
Teaching plan.
References
1.Ilyas S, Mailangkay HHB, Taim H, editor. Lensa Mata. Ilmu Penyakit Mata. Ed ke-2. CV
Sagung Seto. 2010: 143.
2.Ilyas HS. Penglihatan Turun Perlahan Tanpa Mata Merah. Ilmu Penyakit Mata. Ed ke-3.
Balai Penerbit FKUI. 2009: 200.
3.Ehlers JP, Shah CP, editor. Acquired Cataract. The Wills Eye Manual. Ed ke-4. Lippincott
Williams & Wilkins. 2004: 368.
4.Eva PR, Whitcher JP, editor. Cataract. Vaughan & Asbury ‘s General Opthalmology. Lange.
2007.
www.nhs.uk/conditions/cataracts-age-related/Pages/Introduction.aspx
http://www.nei.nih.gov/health/cataract/webcataract.pdf
www.nccah-ccnsa.ca/.../vision_cataracts_web.pdf
http://www.aoa.org/documents/CPG-8.pdf
http://whqlibdoc.who.int/bulletin/2001/issue3/79(3)249-256.pdf
Pre-op assesments:
Nursing Diagnosis:
High risk for injury related to poor vision and reduced extremity-eyes coordination.
Instruct SO to:
Maintain client’s bed/chair in lowest position;
Collaborative:
Dependent:
Provide accurate, honest information. Discuss probability that careful monitoring and
treatment can prevent additional visual loss
Provide accurate, honest information. Discuss probability that careful monitoring and
treatment can prevent additional visual loss
Intracapsular cataract extraction. This procedure removes the entire lens within the intact
capsule.
Phacoemulsification::
Extra-capsular Cataract Extraction (ECCE) The nucleus and the cortex is removed out of the
capsule leaving behind: Intact posterior capsule Peripheral part of the anterior capsule
Zonules. This method: Provides support of placement of IOL Prevents vitreous from bulging
forwards Acts as a barrier between anterior and posterior segment. All this results in
decreasing the incidence of complications.
Intra-capsular Cataract Extraction The lens is removed as one single piece i.e., the nucleus
and the cortex are removed within the capsule of the lens after breaking the zonules. There
is no support left for posterior chamber IOL, therefore, only anterior chamber IOL (ACL) can
be implanted which has risk of adverse corneal complications . There is no barrier left
between anterior and posterior segment, which increases the incidence of other
complications. The only advantage is that after-cataract does not develop as the entire
capsule is removed.
Phacoemulsification in cataract surgery involves insertion of a tiny, hollowed tip that uses
high frequency (ultrasonic) vibrations to "break up" the eye's cloudy lens (cataract). The
same tip is used to suction out the lens .
Cataract Surgery
a.ICCE is Intracapsular Cataract Extraction, all the component of the lens is removed, include
the capsule. Usually perform when zonula zinn is damaged.
b.ECCE (ExtraCapsular Cataract Extraction): classic, SICS (Small Incision Cataract Surgery),
Micro incision with Phacoemulsification. ECCE is performed by making an opening on
anterior pole capsule, leaving a bowl-shape to put an Intra Ocular Lens.
A) NON SURGICAL
1.GLASSES: Cataract alters the refractive power of the natural lens so glasses may allow good
vision to be maintained. Use dark glasses also helps in such situations by keeping the pupil
bigger.
alcohol.
Extra-capsular (ECCE) surgery consists of removing the lens but leaving the majority of the
lens capsule intact.High frequency sound waves (Phacoemulsification) are sometimes used
to break up the lens before extraction.
Phacoemulsification in cataract surgery involves insertion of a tiny, hollowed tip that uses
high frequency (ultrasonic) vibrations to "break up" the eye's cloudy lens (cataract). The
same tip is used to suction out the lens
Intra-capsular (ICCE) surgery involves removing the entire lens of the eye, including the lens
capsule, but it is rarely performed in modernpractice.In either extra-capsular surgery or
intra-capsular surgery, thecataractous lens is removed and replaced with a plastic lens (an
intraocular lens implant) which stays in the eye permanently. Cataract operations are usually
performed using a local anaesthetic and the patient is allowed to go home the same day.
Recent improvements in intraocular technology now allow cataract patients to choose a
multifocal lens to create a visual environment in which they are less dependent on glasses.
Under some medical systems multifocal lenses cost extra. Traditional intraocular lenses are
monofocal.
Type of cataract surgery Extracapsular cataract extraction (ECCE). Requires a relatively large
circumferential limbal incision (8-10mm) through which the lens nucleus is extracted and the
cortical matter aspirated, leaving behind an intact posterior capsule. The IOL is then
inserted. It is the universal procedure of operation in cataract. Posterior IOL can be
transplanted after ECCE.
Intracapsular cataract extraction (ICCE) . The entire cataractous lens along with the intact
capsule is removed in this procedure. Weak and degenerated zonules are a pre-requisite for
this method. This is the surgery of choice only in markedly subluxated and dislocated lens.
This technique of surgery has been largely replaced by ECCE nowadays.
13. AGE RELATED (SENILE) CATARACT Common and bilateral above the age of 50 years.
Male: Female::1:1 Etiology Hereditary : Incidence, age of onset and maturation Ultravoilet
radiation : More exposure to UV-rays = early maturation. Dietary factors : Poor diatery
factors eg, lack of certain aminoacids, Vitamines (Vitamin E, Vitamin C, riboflavin) and
essential minerals. Dehydrational crisis : Prior episode of severe dehydration due to diarrhea
and cholera.
Symptoms Painless progressive visual loss Glare Reduced color perception Color haloes
Uniocular diplopia Based on the location and density
Sign Opacification of the normally clear lens seen through the pupil Indistinct on retina
examination Red reflex may be dim No afferent pupillary defect Myopic shift
NURSING ASSESSMENT Assess visual acuity and review report on refraction. Surgery is
indicated when cataract develops to a degree sufficient to cause difficulty in performing
daily essential activities. Assess a complete morphology of opacity (size, site, shape, color,
and pattern) under slit lamp examination. Perform cover test
18. NURSING ASSESSMENT Test papillary response. Examine cornea to rule out any opacities
Examine ocular adnexa Performed dilated fundus examination Perform USG B-scan Measure
intraocular pressure Perform potential acuity measurement Perform biometry
Specular Microscopy (endothelium cells) A normal cell count > 2400 cells/mm 2 If a cell
count fewer than 1000 cells/mm 2 is risk of postoperative corneal decompensation
20. Laboratory investigation Complete blood counts Blood sugar Urine analysis Chest X-ray
Conjunctival swab for C/S
Postoperative care after cataract surgery • Steroid drops (inflammation) • Antibiotic drops
(infection) • Avoid • Very strenuous exertion (rise the pressure in the eyeball) • Ocular
trauma.
• Infective endophthalmitis – Rare but can cause permanent severe reduction of vision. –
Most cases within two weeks of surgery. – Typically patients present with a short history of a
reduction in their vision and a red painful eye. – 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
A.
Nursing management
The patient with cataract should receive the usual preoperative care for ambulatory surgical
patients undergoing eye surgery.
Nursing Assessment
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.
Nursing Diagnosis
Based on assessment data, the nursing diagnoses for the patient include:
Disturbed visual sensory perception related to altered sensory reception or status pf sense
organs.
Risk for trauma related to poor vision and reduces hand-eye coordination.
Deficient knowledge regarding ways of coping with altered abilities related to lack of
exposure or recall, misinterpretation, or cognitive limitations.
Be free of injury.
Nursing Interventions
Providing postoperative care. Before discharge, the patient receives verbal and written
instructions about how to protect the eye, administer medications, recognize signs of
complications, and obtain emergency care.
Evaluation
Free of injury.
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.
Expected side effects. Slight morning discharge, sone 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.
Documentation Guidelines
ADVERTISEMENT
Description of feelings.
Plan of care.
Teaching plan.
Nurse Kaye is carrying out her operative teachings for an older client who will have cataract
surgery on the right eye. The nurse concludes that the client needs further understanding
about the teachings if he says:
"I will call my physician if I have sharp and sudden pain or a fever after surgery."
"I will bend below my waist frequently to increase circulation after surgery."
pon assessment, the patient told the nurse that she was experiencing the three common
symptoms found with cataracts and these are listed below except for:
Blurred vision
Glare.
Halos.
Eye pain.
Taking anticoagulants.
D
Using eye glasses when going outsid
www.nhs.uk/conditions/cataracts-age-related/Pages/Introduction.aspx
http://www.nei.nih.gov/health/cataract/webcataract.pdf
www.nccah-ccnsa.ca/.../vision_cataracts_web.pdf
http://www.aoa.org/documents/CPG-8.pdf
http://whqlibdoc.who.int/bulletin/2001/issue3/79(3)249-256.pdf
Pre-Operative
Post Operative
Pre-Operative
Nursing Intervention:
6-Introduce patient to another patient that had gone the same operation
7-Explain all physical preparation and post operative expectations pre operatively
1-Transfer patient with care from trolley to the bed with hand support the head
3- Ensure patient had eye pad/ Castella shield over the operated eye
® So client easy to grab things and avoid putting pressure on operated eye
8. Assist patient to ambulated when permitted
® As a prophylaxis
5-Take eye swab for culture and sensitivity if there is eye disharge
® To reduce inflammation
Remind patient to inform nurse immediately for any pain over the operated eyes
Objective:
Clean the eye using cool boiled water, cotton swabs and clean container
Wear castella shield day and night for 1 week, at night for 2-3 weeks
Prevent photophobia
Can wash face but ensure soap doesn’t get into the eyes
3- Can reading or watch tv but not for prolong time. Rest eye in between
4. Muslim can pray but cannot bend head below waist level
Genereal ake a well balanced diet with more fluids, fruit and fiber
Advise patient to seek prompt treatment if any complications arise eg severe eye pain
Nursing diagnosis
• Risk for injury related to sensory deficit while operated eye is patched.
Pre-operative assesments
1. The conjunctival sac prepared by using broad spectrum antibiotic for 2-3 days prior to
surgery.The patient is asked to keep his face and hair clean and properly tied.
3. The intraocular pressure should be controlled. Raised acetazolamide or I.V. mannitol may
be given 1-2 hours prior to surgery.
4. The pupils should be dilated for extracapsular surgery. To ensure that dilatation is
maintained during surgery, anti prostaglandin NSAIDs are used prior to surgery.
5. The patient should not be anxious and if necessary anxiolytic durg and sedation is given.
7. Assessment of patients’ ability to co-operate with the procedure and lie reasonably flat
during surgery.
8. Anticoagulant therapy (aspirin, warfarin) to reduce the risk for retrobulbar hemorrhage
for 7 days before surgery. Dilating drops are administered in the every 10 minutes for 4
doses at least 1 hour before surgery. Providing post operative care:-After recovery from
anesthesia the patient receives verbal and written instruction about how to protect the eye,
administer medication, recognize signs ofcomplications and obtain emergency care. The
nurse also explain that there should be minimal discomfort after surgery and instructs the
patient to take a mild analgesic agent, such as eye drops or ointments.
INERVENTION:-
Instruct the patient not to lean forward or lie on the affected side.
INTERVENTION:-
Approach the left side place the call bell in lift and instruct the use
INTERVENTIONS:-
INTERVENTIONS:-
INTERVENTIONS:-
The patient wears a protective eye patch for 24 hours after surgery.
The nurse instructs the patient and family in applying and caring for the eye shield.
Sun glasses should be worn while outdoor during the day because the eye is sensitive to
light.
Clean, damp wash cloth may be used to remove slight the risk for retinal detachment.
The patient may experience blurring of vision for several days to weeks.
Patient with ILO implants have functional vision on the first days after surgery.
Signs and symptoms of infection and when and how to report those to allow recognition
and treatment of possible infection
Advice the patient to use hand rails while walking and doing steps and to reach out slowly
for objects to picked up.
EXPECTED OUTCOME Immediate. Optimal vision will be restored with periodic refractive
correction with glasses. Patient will be reassured and informed with progression and option
of surgery. Make patient educate and aware about possibility of fall due to visual
impairment.
Preoperative Comfort and safety will be maintained. Any infection will be treated and
prophylaxis treatment will be initiated. Surgical procedure and postoperative care will be
explained. Patient’s anxiety will be eliminated. Secondary development of glaucoma will be
prevented.
Implementation Relieve patient from anxiety with proper counseling. Make sure patient
does not develop nausea or gastritis due to anxiety or preoperative medicines. Instruct
patient not to touch eyes. Cataract operation can be performed by ophthalmic surgeon
under general or local anaesthesia.
Implementation: Immediate postoperative care The patient is asked to lie quietly upon the
back for about three hours and advised not to take food. Instruct patient avoid coughing,
sneezing and avoid bending from the waist. Give analgesics. Provide quite and safe
environment. Notify physician of sudden pain occurs Treat nausea or vomiting immediately
if present
38.DISCHARGE
Don’t do any strenuous activities for a few weeks. Avoid rigorous exercise and heavy lifting.
Don’t drive. The length of time after cataract surgery before you can drive depends on a
number of factors – your doctor will tell you when it is safe to resume driving.
Follow your doctor’s orders regarding any antibiotic and anti-inflammatory eye drops.
These are important to prevent infection and inflammation and ensure proper healing. If
you have difficulty in administering them, get a friend or family member to help you out.
Stay away from dusty areas. It’s a great idea to have your house vacuumed and cleaned
before surgery, as your eyes will be sensitive to airborne allergens such as dust.
Don’t rub your eye. Eye rubbing is a quick way to develop a nasty infection. It’s never a
good idea, even when you aren’t recovering from surgery.
Don’t swim. It’s best to avoid swimming or hot tubs for a week after surgery.
Don’t wear make-up. Ask your doctor when you can resume doing so.
If you experience any of the following symptoms, please contact your ophthalmologist:
Vision loss
39.INSTRUCTIONS Care of the incision Signs of complications Drugs for pain management
How to self administer prescribed medications Amount of weight that can be lifted Diet
Return for a medical appointment
Cataracts
Sensitivity to glare
Other effects include myopic shift, astigmatism, diplopia (double vision), and color shifts
including brunescent cataract. (color value shift to yellow-brown- very advanced)
Diagnostic findings include decreased visual acuity and opacity of the lens by
ophthalmoscope, slit-lamp, or inspection
Surgical Management
If reduced vision does not interfere with normal activities, surgery is not needed
Surgery is performed on an outpatient basis with local anesthesia
Surgery usually takes less than 1 hour and patients are discharged soon afterward
Intracapsular cataract extraction (ICCE): removes entire lens; rarely done today
Extracapsular cataract extraction (ECCE): maintains the posterior capsule of the lens,
reducing potential postoperative complications
Phacoemulsification: an ECCE that uses an ultrasonic device to suction the lens out through a
tube; incision is smaller than with standard ECCE
Lens replacement: after removal of the lens by ICCE or ECCE, the surgeon inserts an
intraocular lens implant (IOL), which eliminates the need for aphakic lenses; however, the
patient may still require glasses