Introduction:-Cataract derives from the Latin cataracta meaning "waterfall" and the Greek

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.

Fact Check | Cataract in ndia: A focus area, yet miles to cover

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.

Written by Abantika Ghosh |Updated: December 5, 2018 9:25:12 pm

Cataract accounts for 62% of blindness in India.[Cataract extraction with intraocular lens
implantation is the most commonly performed surgical procedure worldwide. Over 6.48
million of cataract surgeries were performed in India in 2016–2017.

Anatomy and physiology

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.

Optic nerve carries the information to brain.

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

ETIOLOGY of the cataract :-

1.Aging- Loss of lens transparency-Clumping or aggregation of lens protein (which leads to

light scattering)-Accumulation of a yellow-brown pigment due to the breakdown of lens
protein-Decreased oxygen uptake-Increase in sodium and calcium-Decrease in levels of
vitamin C, protein, and glutathione (an antioxidant)

2.Associated Ocular Conditions-Retinitis pigmentosa-Myopia-Retinal detachment and

retinal surgery-Infection (eg, herpes zoster, uveitis)

3.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

4.Nutritional Factors-Reduced levels of antioxidants-Poor nutrition-Obesity

5.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

6.Systemic Diseases and Syndromes-Diabetes mellitus-Down syndrome-Disorders related to

lipid metabolism-Renal disorders-Musculoskeletal disorders

CLASSIFICATION : BASED ON : Morphology, Age of onset, Maturity ,Etiology ,Subjective

classification

I CONGENITAL CATARACT:-It is used in a broader sense implying a cataract due to defect in

development at any stage. Congenital cataract develops from some disturbance to normal
development of lens . The disturbance occurs before the birth The opacity may limit to
embryonic or foetal nucleus.cataract that happens before or soon after birth and the baby is
under one years old.The disturbance of lens development occurring in intrauterine stage
cause a child to be born with congenital cataract. A congenital opacity of the crystalline lens.
Cloudiness in the lens of the eye that is present at, or develops shortly afterbirth children 3
out of 10,000 live births. Two third of the cases are bilateral.Developmental cataract occurs
from infancy to adolescence. The opacity involves infantile or adult nucleus.

Congenital cataract or developmental ETIOLOGY:

1. Genetically transmission:- about 20% cases.

2. 2. Maternal factors like intrauterine infections (rubella), malnutrition, drug toxicity and
radiation damage, 20% of cases.

3. Metabolic diseases;- like diabetic, hypoparathyroidism, neonatal hypoglycemia ,

galactokinase deficiency, neonatal hypoglycemia, galactosaemia,etc.

4.Hereditary. 1/3 rd hereditary, common mode: autosomal dominant inheritance

5.Foetal or infantile factors -Deficient oxygenation owing to placental haemorrhage

6.Chromosomal abnormality. Eg, down syndrome Skeletal syndromes. Eg,

Hallermann-streiff-Francois syndrome, Nance-Horan syndrome

7.Birth trauma

8.Malnutrition early in infancy . -

9.Prenatal infection. Eg, congenital rubella, toxoplasmosis, cytomegalovirus, herpes simplex

and varicella.

10 Miscellaneous causes:- birth trauma, placental hemorrhage, endocrine dysfunction,

surgical

11. Idiopathic causes: 50% cases.

Types of Morphological Classification

1.CAPSULAR CATARACT -ANTERIOR CAPSULAR CATARACT -POSTERIOR CAPSULAR CATARACT

2.SUB CAPSULAR CATARACT -ANTERIOR SUBCAPSULAR CATARACT -POSTERIOR
SUBCAPSULAR CATARACT 3.NUCLEAR CATARACT 4.CORTICAL CATARACT

5.LAMELLAR/ZONULAR CATARACT 6.SUTURAL CATARACT7.Sub-capsular- POSTERIOR

SUBCAPSULAR,Anterior subcapsular CATARACT -CORTICAL CATARACT -NUCLEAR
CATARACT -MATURE CATARACT

AGE OF ONSET: 1.CONGENITAL 2.INFANTILE 3.JUVINILE 4.PRE-SENILE 5.SENILE

MATURITY: 1.INTUMESCENT CATARACT 2.IMMATURE CATARCT 3.MATURE CATARACT

4.HYPERMATURE CATARACT 5.MORGAGNIAN CATARCT

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

Types of etiological catract .TRAUMATIC CATARACT METABOLIC CATARACT TOXIC CATARACT

COMPLICATED CATARACT INTRA UTERINE CATARACT HERIDITARY CATARACT RADIATIONAL
CATARACT ELECTRIC CATARACT

CATARACT ASSOSCIATED WITH SKIN DISEASES-ICHTHYOSIS,ATOPIC DERMATITIS

10.CATARACT ASSOSCIATED WITH OSSEOUS DISEASES-PARATHYROID TETANY 11.CATARACT
WITH MISCELLANEOUS DISEASES-DYSTROPHIA MYOTONICA,ALPORTS SYNDROME,DOWNS
SYNDROME AFTER CATARACT

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

or posteriorly. It is usually congenital, although it may be acquired as a resultof trauma or inf

lammation.These cataracts are small opacificationof the lens epithelium & anterior lens
capsule that spare the cortex .

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).

ANTERIOR CAPSULAR CATARACT: - it is due to delayed formation of the anterior chamber. It

project forwards into anterior chamber like pyramid and the cortex may become
opaque.A small central opacity located on the anterior lens capsule,either of congenital origi
n or due to a perforating ulcer of the cornea. See Vogt's sign.
POSTERIOR CAPSULAR CATARACT:- it is due to persistence ofposterior part of vascular
sheath cause total cataract. Ohers : coralliform, discoid, axial, sutural cataract

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.

polar cataract :-Lens congenital opacity involves subcapsular cortex&capsule of anterior or

posterior pole of the lens.This type is characterized by small opacities of the lens capsule and
adjacent cortex on the anterior or posterior pole of the lens. This type of cataract has little
effect on vision.

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.

posterior polar catarac:-It is a round, discoid, opaque mass It is composed of malformed

and distorted lens fibers located in the central posterior part of the lens.It is produces
more visual impairment because it tends to be larger in size they may be-familial-usually b/l
sporadic-often unilateral.A posterior polar cataract consists of dysplastic lens fibers, which,
in there migration posterior lens opacity with the formation of a characteristic discoid
posterior polar plaquelike cataract.Glare and reduced vision under bright lighting are
common complaints. This cataract type classically occurs in patients <50 years. Posterior
subcapsular cataract is associated with ocular inflammation, steroid use, diabetes, trauma,
or radiation.
Posterior types may be associated withpersistent hyaloidsremnant (Mittendorf's dot).

Posterior lenticonus:-This type is characterized by a posterior protrusion, usually opacified ,

in the posterior capsule.

Coronary ( supranuclear) cataract :- It is commonly occurs at puberty ( adult ) It is

characterized by a series of opacities having the shape ofa crown round opacities in deep
cortex surrounding nucleus like crown. or ring near the periphery of the lens They can’t be
seen until the pupils are dilated --usually do not affect the visual acuity

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.

Blue dot catract/ cerulean/PUNCTATE CATARACT:

A developmental anomaly of the crystalline lens characterized by-numerous small opacities

in the outer nucleus and cortex, which appear as translucent

bluish dots. The condition is very common and does not usually affect acuity. Syn. Bluecatara
ct; diffuse cataract; punctate cataract.. On slit limp examination they appear as blue dots
hence known as blue dot cataract.

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). •

Membranous cataract:- It is characterized by a collapsed, flattened capsule with little or no

cortex or epithelium on the lens

Age onset types of cataract

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).

2.Pre-senile cataract: cataract which occurs until 50 years old.

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.

Stage of the senile cataract:

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.

MATURE CATARCT:-Lens is completely opaque. Vision reduced to just perception of light.Iris

shadow is not seen Lens appears pearly white.All of lens protein is opaque. The lens fluid will
come out from lens, so the size of lens will be normal again.

HYPERMATURE CATARACT:-Hyper mature Cataract Shrunken and wrinkled anterior

capsule due to leakage of water out of the lenses. Degeneration process will cause the lens
become liquid. This liquid may escape through the intact capsule, leaving a shrunken lens
with a wrinkled capsule. In this lens nucleus floats freely in the capsular bag is called a
morgagnian cataract.This may take any of two forms:
1. Liquefactive/Morgagnian Type:- Cortex undergoes auto-lytic liquefaction and turns
uniformly milky white. The nucleus loses support and settles to the bottom. Degraded lens
proteins may leak into the aqueous humour and cause phacolytic glaucoma. Syn. cysticcatar
act; sedimentary cataract. See intumescent cortical cataract. Iridodonesis : Anterior chamber
deepens and iris becomes tremulous. The zonules become weak, increasing the risk of
dislocation of lens.

2. Sclerotic Cataract:-1.The fluid from the cortex gets absorbed and the lens becomes
shrunken.

2.There may be deposition of calcific material on the lens capsule.

3.Iridodonesis: Anterior chamber deepens and iris becomes tremulous.

4.The zonules become weak, increasing the risk of subluxation / dislocation of lens.

MATURITY: 1.IMMATURE CATARCT 2.MATURE CATARACT 3.HYPERMATURE CATARACT

III ETIOLOGICAL CLASSIFICATION:-

1. Trauma induced cataract:- TRAUMATIC CATARCT:-Cataract can be caused by mechanical

injury of penetrating type or blunt trauma to the eyeball, and the later may be associated
with retained intraocular foreign body. The lens becomes white soon after the entry of a
foreign body, since interruption of the lens capsule allows aqueous and sometimes vitreous
to penetrate into the lens structure.

2.Drug-induced CataractDrugs that can induce lens opacities include steroids, miotics,
antipsyhotics.

3 Secondary cataract:- After-Cataract (Secondary Cataract)After-Cataract denotes

opacification of posterior capsule following extracapsular cataract extraction or
phacoemulcification. This cataract type thickening of posterior capsule caused by
inflammatory cell proliferation in residue cortex, giving the posterior capsule a "fish egg"
appearance (Elschnig's pearls).Cataract secondary to intraocular disease .Cataract may
develop as a direct effect of intraocular disease upon the physiology of the lens, example:
uveitis (posterior subcapsular cataract), glaucoma (cataract vogt: anterior sub capsular
pungtata cataract), retina ablation, and severe myopia.Cataract associated with systemic
disease.This cataract usually involve both of eyes although it may not appear in the same
time. The example of systemic disease that can cause cataract are diabetes mellitus (white
snowflake opacities in the anterior and posterior subcapsular locations), hypoparatyroidism,
myotonia dystrophy, hypocalcemia.

4. Complicated cataract: A cataract caused by or accompanying another intraocular

disease, such as uveitis, old retinal detachment,
glaucoma, cyclitis, anterior uveitis or a hereditary retinal disorder such
as retinitis pigmentosa or Leber's disease. Syn. secondary cataract. See cuneiform
cataract; Leber's hereditary optic atrophy; retinitis pigmentosa; Down's syndrome;
5. Radiation cataract: Ionizing radiations like x rays, gamma rays, beta rays are
catarctogenic. It affects the germinal epithelium in the lens equator and effect is more in
younger age. Non-ionizing radiations like infrared rays and U.V microwave radiations can
cause cataract

6. Heat cataract: Catract ocures due to exposure of high temperature such as glass
blowers.

7. Senile cataract : It is occurs due to ageing process. it is commonest type.

8.TOXIC CATARACT:-Several drugs and toxic substances are cataractogenic in

humans.Corticostreiod induced cataract- prolonged oral administration or shorter high dose
steroids. Thus oral corticosteroids should be avoided for prolonged administration.A safe
dose up to 10 mg/day for adults.

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

10.Electric cataract : through uncommonly reported are serious complication of electrical

injury.

11.METABOLIC CATARACT:Diabetic cataract-cataract of the senile type can occurs with

more frequency in earlier in diabetics and grows more rapidly. Hypocalcemic cataract- low
serum calcium levels due toinfantile tetany, cause punctuate opacities

12.after-cataract:-Any membrane of the pupillary area after extraction or absorption of the l

ens.

IV 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

SIGNS AND SYMPTOMS:-

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.

Ophthalmoscopy is used to view the extent of cataract.

Slit-lamp biomicroscopic examination. This procedure is used to establish the degree of

cataract formation.

tonometry (to determine if there is increased intraocular pressure [IOP],

direct and indirect opthalmoscopy ( to rule out disease of retina),

perimetry (to detect any loss of visual field).

MANAGEMENT:-To delay progression of cataract.

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.

Management in congenital cataract:

Management in congenital cataract Bilateral congenital cataract require urgent surgery

(lensectomy and vitrectomy) and the fitting of the contact lens to correct the aphakia. After
the age of 2 years there is a general agreement to use intraocular lenses (IOLs), but before is
still controversial Uniocular congenital cataract treatment remains controversial. Follow-up
for children with congenital cataract should continue because of the risk for developing
Glaucoma Amblyopia Strabismus

Withhold any anticoagulants the patient is receiving, if medically appropriate. Aspirin

should be withheld for 5 to 7 days, nonsteroidal anti-inflammatory drugs (NSAIDs) for 3 to 5
days, and warfarin (Coumadin) until the prothrombin time of 1.5 is almost reached.

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.

Medications(Adults):- 1. Aldose reductase inhibitors- Oral aspirin 50-100 mg/kg orally

2.Ouercetin 200-400 mg/kg.

 3.ANTIOXIDANTS:- beta carotene, alpha tocopherol, victamin c.

4. MEMBRANE STABILIZING AGENTS- benzadac and benzyl alcohol.

5. MISCELLANEOUS- Iodides of calcium , potassium.

SURGICAL REMOVAL: When visual acuity can't be improved with glass.

There are two types of eye surgery that can be used to remove cataracts:

1) Extra-capsular (extracapsular cataract extraction, or ECCE)

2) Intra-capsular (intracapsular cataract extraction, or ICCE).

Cataract surgery:-When a cataract is sufficiently developed to be removed by surgery, the

most effective and common treatment is to make an incision (capsulotomy) into the capsule
of the cloudy lens in order to surgically remove the lens.

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

A small hollow needle containing a piezo-electric crystal vibrates longitudinally at ultrasonic

frequencies The tip is applied to the lens nucleus; cavitation occurs at the tip as the nucleus
is emulsified; an irrigation and aspiration system removes this emulsified material from the
eye. The IOL is then injected through a much smaller incision than in ECCE. Safe: avoid
compression of eye, results in little postoperative astigmatism and early stabilization of
refraction, and eliminate post-operative wound related problem
Lensectomy: Most of the lens including anterior and posterior capsule along with anterior
vitreous are removed with the help of a vitreous cutter, infusion and suction machine.
Congenital as well as developmental cataract being soft are easily dealt with this procedure.

Lens replacement:- There are three lens replacement options:

Phacoemulsification. A portion of the anterior capsule is removed, allowing extraction of

the lens nucleus and cortex while the posterior capsule and zonular support are left intact.

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:-

Assessment:-General History of white pupil, squint, spontaneous movement of eyes, loss of

visual attention. Assess density of cataract Observe the red fundus reflex on
ophthalmoscope. Absence of red fundus reflex indicates cataract is visually significant.
Perform fundus examination under dilatation . Examine other associated ocular anomalies .
Eg, absence of central fixation, nystagmus, strabismus, corneal clouding, microphthalmos,
glaucoma, retinoblastoma, retinal disorders .Investigation Serological test for intrauterine
infections (TORCH= toxoplasmosis, rubella, cytomegalovirus, and herpes simplex). A history
of maternal rash during pregnancy for varicella zoster antibody titres. Urinalysis for
galactosaemia and chromatography for aminoacids. Refer to pediatrician to rule out
systemic diseases. 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 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 Laboratory investigation Complete blood counts Blood sugar Urine
analysis Chest X-ray Conjunctival swab for C/S

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.

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.

Pre-op assesmentsGeneral health evaluation including blood pressure check Assessment of

patients’ ability to co-operate with the procedure and lie reasonably flat during surgery
Instruction on eye drop instillation The eyes should have a normal pressure, or any
pre-existing glaucoma should be adequately controlled on medications. An operating
microscope is needed, in order to reach the lens, a small corneal incision is made close to
the limbus for the phaco-probe. It is important to appreciate anterior chamber depth and to
keep all instruments away from the corneal endothelium in the plane of the iris.

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.

History collection 2. Visual acuity test 3. Dilated eye exam 4. Tonometry

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.

4.Anxiety related to threat of permanent loss of vision/independence.

5.Deficient knowledge regarding ways of coping with altered abilities related to lack of
exposure or recall, misinterpretation, or cognitive limitations.

Nursing Management of Cataracts

Usual preoperative care for ambulatory surgery

Dilating eye drops or other medications as ordered

Postoperative care

Provide written and verbal instructions

Avoid activities that will increase IOP.

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

COMPLICATION;Complication of cataract surgery are rare but including :

Inflammation

Increased Intra ocular pressure

Subconjunctival hemorrhage with or without edema.

Toxic anterior segment syndrome

Malposition of the intra ocular pressure

Chronic endophthalmitis

Opacification of the posterior capsule.

Retinal detachment

Nursing Diagnosis for Cataract: Anxiety related to lack of knowledge.

Goal:

Lowering the emotional stress, fear and depression.

Acceptance and understanding instructions surgery.

Nursing Interventions for Cataract:

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.

2. Orient the patient to the new environment.

Rationale: The introduction to the environment helps reduce anxiety and increase security.

3. Explain the perioperative routines.

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.

5. Push to perform daily living habits when able.

Rationale: Self-care and will increase the sense of healthy independence.

6. Encourage participation of family or the people who matter in patient care.

Rationale: Patients may not be able to perform all duties in connection with the handling of
personal care.

7. Encourage participation in social activities and diversion whenever possible (visitors,

radio, audio recording, TV, crafts, games).

Rationale: Social isolation and leisure time is too long can cause negative feelings.

Nursing Diagnosis for Cataract: Risk for injury related to blurred vision

Goal: Prevention of injury.

Nursing Intervenion for Cataract:

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.

2. Help the patient set the environment.

Rationale: Providing facilities of independence and lower the risk of injury.

3. Orient the patient in the room.

Rationale: Improving safety and mobility in the environment.

4. Discuss the need for the use of metal shields or goggles when instructed

Rational: shield l; ogam or goggles protect the eyes against injury.

5. Do not put pressure on the affected eye trauma.

Rational: The pressure in the eye may cause further serious damage.

6. Use proper procedures when providing eye drugs.

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

Goal: Reduction of pain and the IOP.

Nursing Interventions for Cataract:

1. Give medications to control pain and the IOP as prescribed.

Rational: Use the recipe will reduce pain and the IOP and increase comfort.

2. Give cold compress on demand for blunt trauma.

Rational: reduce the edema will reduce the pain.

3. Reduce the level of pencayahaan

Rationale: The level of lighting is more nyakan lower after surgery.

4. Encourage use of sunglasses in strong light.

Rasioanal: Strong light causes discomfort after use of eye drops dilator.

Nursing Diagnosis for Cataract: Risk for infection related to trauma to the incision

Goal: Complications can be avoided or promptly reported to the doctor.

Nursing Interventions for Cataract:

1. Maintain strict aseptic technique, do wash your hands frequently.

Rationale: It would minimize infection.

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.

3. Explain the recommended position.

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.

5. Describe the actions that should be avoided, as prescribed by coughing, sneezing,

vomiting (ask for medication for it).

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.

6. Give medications as prescribed, according to prescribed techniques.

Rational: Drugs are administered in a way that is inconsistent with prescriptions can
interfere with healing or cause complications.

1.senile cataracts commonly develop in elderly patient because of degenerative changes in

lens proteins.

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.

4.Secondary cataracts may occur following other eye or systemic

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.

4.Nonsteroidal anti-inflammatory agents, antibiotic ointments, and possible corticosteroids

may be necessary after lens implantation to reduce inflammation on other eye structures
and prevent infection.

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.

3.Assess gradual adaptation to lens implant, contact lens, or glasses.

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.

8.Teach proper installation of the eye.

9.Encourage to follow up ophthalmologic examinations for corrective lenses and checking of

IOP. Adjustment to eye glasses to correct vision may take weeks.

10.Advise the patient not to get soap in the eyes.

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.Anxiety related to lack of knowledge.

Goal:1.Lowering the emotional stress, fear and depression.2.Acceptance and understanding

instructions surgery.

Nursing Interventions for Cataract:

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.

2. Orient the patient to the new environment.

Rationale: The introduction to the environment helps reduce anxiety and increase security.

3. Explain the perioperative routines.

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.

5. Push to perform daily living habits when able.

Rationale: Self-care and will increase the sense of healthy independence.

6. Encourage participation of family or the people who matter in patient care.

Rationale: Patients may not be able to perform all duties in connection with the handling of
personal care.

7. Encourage participation in social activities and diversion whenever possible (visitors,

radio, audio recording, TV, crafts, games).

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.

(1) The head must be kept very still.

(2) No reading.

(3) No showers, no shampooing, no tub baths.

(4) No bending over at the waist.

(5) No lifting of heavy objects.

(6) No sleeping on the operative side. If both eyes are affected, the patient must sleep on his
back.

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

POSTOPERATIVE NURSING CARE OF THE PATIENT UNDERGOING OPHTHALMIC SURGERY

a. Return from Surgery.

(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.

(3) Sandbags should be used to immobilize the patient's head, if ordered.

(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.

(2) Orient the patient to other people 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.

(2) Restrain the arms of children and disoriented or uncooperative patients, as

appropriate.

(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.

(3) Continue to reinforce his orientation to the surroundings.

(4) Always let the patient know when you are leaving his area.

e. Diversional Activity. Diversional activities will promote a relaxed atmosphere for

convalescence and prevent the patient from dwelling on his situation.

(1) Provide activities that are not fatiguing to the eyes if the eyes are not bandaged.

(a) No reading.

(b) Minimal television.

(2) Encourage visitors to chat with the patient or read to him.

(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

Goal: Prevention of injury.

Nursing Intervenion for Cataract:

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.

2. Help the patient set the environment.

Rationale: Providing facilities of independence and lower the risk of injury.

3. Orient the patient in the room.

Rationale: Improving safety and mobility in the environment.

4. Discuss the need for the use of metal shields or goggles when instructed

Rational: shield l; ogam or goggles protect the eyes against injury.

5. Do not put pressure on the affected eye trauma.

Rational: The pressure in the eye may cause further serious damage.

6. Use proper procedures when providing eye drugs.

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

Goal: Reduction of pain and the IOP.

Nursing Interventions for Cataract:

1. Give medications to control pain and the IOP as prescribed.

Rational: Use the recipe will reduce pain and the IOP and increase comfort.

2. Give cold compress on demand for blunt trauma.

Rational: reduce the edema will reduce the pain.

3. Reduce the level of pencayahaan

Rationale: The level of lighting is more nyakan lower after surgery.

4. Encourage use of sunglasses in strong light.

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

Goal: Complications can be avoided or promptly reported to the doctor.

Nursing Interventions for Cataract:

1. Maintain strict aseptic technique, do wash your hands frequently.

Rationale: It would minimize infection.

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.

3. Explain the recommended position.

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.

5. Describe the actions that should be avoided, as prescribed by coughing, sneezing,

vomiting (ask for medication for it).

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.

6. Give medications as prescribed, according to prescribed techniques.

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.

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

ostoperative 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

Complication:-

Immediate after surgery;-

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:

Postoperative care after cataract surgery Steroid drops (inflammation) Antibiotic drops
(infection) Avoid Very strenuous exertion (rise the pressure in the eyeball) Ocular trauma.

Toxic anterior segment syndrome. Non-infection inflammation that is a complication of

anterior chamber surgery.

Retrobulbar hemorrhage. Retrobulbar hemorrhage can result from retrobulbar infiltration

of anesthetic agents if the short ciliary artery is located by the injection.

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.

Suprachoroidal haemorrhage – Severe intraoperative bleeding can lead to serious and

permanent reduction in vision.

Uveitis

Ocular perforation.

Postoperative refractive error

Posterior capsular rupture and vitreous loss

Retinal detachment

Cystoid macular oedema Glaucoma

Posterior capsular opacification

Nursing Care Planning & Goals

The major goals for the patient include:

Regaining of usual level of cognition.

Recognizing awareness of sensory needs.

Be free of injury.

Identifying potential risk factors in the environment.

Appearing relaxed and reporting anxiety is reduced at manageable level.

Verbalizing feelings of anxiety.

Identifying healthy ways to deal with and express anxiety.

Nursing Interventions

Care for a patient with cataract includes:

Providing preoperative care. Use of anticoagulants is withheld to reduce the risk of

retrobulbar hemorrhage.

Evaluation

Evaluation of the patient may include:

Regained usual level of cognition.

Recognized awareness of sensory needs.

Free of injury.

Identified potential risk factors in the environment.

Appeared relaxed and reporting anxiety is reduced ti a manageable level.

Verbalized feelings of anxiety.

Identified healthy ways to deal with and express anxiety.

Discharge and Home Care Guidelines

The nurse teaches the patient self-care before discharge:

Activities. Activities to be avoided are instructed by the nurse.

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

Instruct patient to restrict bending and lifting heavy objects.

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.

Spiritual practices according to one’s faith and religion.

Modified or structured environment to ensure patient’s safety because vision may be blurry
for several weeks after the surgery.

oProtective eye patch to avoid accidental rubbing or poking of the eye.

Continuation of prescribed medications.

Cyclopentolatse cautiously in patients with history of glaucoma; systemic absorption may

cause anticholinergic effects such as confusion, unusual behavior, flushing and
hallucinationsfast or uneven heart rate;warmth, redness, or tingly feeling under the
skin;severe skin rash;slow or shallow breathing;Because cataract surgery increases the risk
for retinal detachment, the patient must know to notify the surgeon if new floaters (dots) in
vision, flashing lights, decrease in vision, pain or increase in redness occurs.

Documentation Guidelines

The focus of documentation in a patient include:

Individual findings, noting s

Individual findings, noting specific deficit and associated symptoms, perceptions of

client/SOs.

Assistive devices needs.

Use of safety equipment or procedures.

Environmental concerns, safety issues.

Level of anxiety and precipitating/aggravating factors.

Description of feelings.

Awareness and ability to recognize and express feelings.

 Plan of care.

Teaching plan.

Client involvement and response to interventions, teaching, and actions performed.

Attainment or progress toward desired outcomes.

Modifications to plan of care.

Long term needs.

Provide postoperative discharge teaching concerning eye medications, cleansing and

protection, activity level and restrictions, diet, pain control, positioning, office appointments,
expected postoperative course, and symptoms to report immediately to the surgeon.how to
protect the eye, administer medications, recognize signs of complications, and obtain
emergency care.The patient receives verbal and written instructions about instructions.

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.

Ascertain knowledge of safety needs/injury prevention and motivation

Instruct SO to:
Maintain client’s bed/chair in lowest position;

Place assistive devices (walker, crane);

Monitor environment for potentially unsafe conditions and modify as needed

Collaborative:

Refer the patient for an eye care specialist.

Disturbed Visual Sensory Perception r/t changes in sensory acuity.

Ascertain type/degree of visual loss.

Encourage expression of feelings about loss/possibility of loss of vision

Recommend measures to assist client to manage visual limitation

Dependent:

Demonstrate/have client to administer eye drops using correct procedure

repare for surgical intervention as indicated like cataract extraction.

Anxiety related to threat of permanent loss of vision and independence.

Assess anxiety level, suddenness of symptoms and current knowledge of condition

Provide accurate, honest information. Discuss probability that careful monitoring and
treatment can prevent additional visual loss

Encourage client to acknowledge concerns and express feelings

Identify helpful resources/people.

Assess anxiety level, suddenness of symptoms and current knowledge of condition

Provide accurate, honest information. Discuss probability that careful monitoring and
treatment can prevent additional visual loss

Encourage client to acknowledge concerns and express feelings

Intracapsular cataract extraction. This procedure removes the entire lens within the intact
capsule.

• • Surgical techniques –Phacoemulsification method. –Extracapsular cataract extraction.

–Intra capsular cataract extraction.

–Intraocular lens implantation –cryosurgery

Treatment 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. Surgical techniques Phacoemulsification method. Extracapsular method.
Intracapsular method

Phacoemulsification::

Phacoemulsification : 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

Extra-capsular Cataract Extraction (ECCE):

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:

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 .

Intra-capsular Cataract Extraction:_Intracapsular Cataract Extraction from the late 1800s

until the 1970s, the technique of choice for cataract extraction was intracapsular cataract
extraction (ICCE). The entire lens (ie, 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 (ie,
partially or completely dislocated lens).

Extra-capsular Cataract Extraction (ECCE) •Extracapsular Surgery. Extracapsular cataract

extraction (ECCE) achieves the intactness of smaller incisional wounds (less trauma to the
eye) and maintenance of the posterior capsule of the lens, reducing postoperative
complications, particularly aphakic retinal detachment and cystoid macular edema.

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.

Phacoemulsification: is a method to remove the hard part of cataract by using an

ultrasound, then drain the remnant.

Management of cataract depends on tackling the specific cause in addition to overcoming

the problems of cataract. In case of toxicity, the specific agent needs to be removed.

SPECIFIC MANAGEMENT OF CATARACT:-

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.

2.MEDICAL TREATMENT :-To delay progression of cataract.

1. Aldose reductase inhibitors- Oral aspirin 50-100 mg/kg orally

2.Ouercetin 200-400 mg/kg.

3.ANTIOXIDANTS:- beta carotene, alpha tocopherol, victamin c.

4. MEMBRANE STABILIZING AGENTS- benzadac and benzyl

alcohol.

5. MISCELLANEOUS- Iodides of calcium , potassium.

B) SURGICAL REMOVAL: When visual acuity can't be improved withglass.

There are two types of eye surgery that can be used to remove cataracts:

Extra-capsular (extracapsular cataract extraction, or ECCE)

Intra-capsular (intracapsular cataract extraction, or ICCE).

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

Cataract surgery:-When a cataract is sufficiently developed to be removed by surgery, the

most effective and common treatment is to make an incision (capsulotomy) into the capsule
of the cloudy lens in order to surgically remove 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.

Phacoemulsification: A small hollow needle containing a piezo-electric crystal vibrates

longitudinally at ultrasonic frequencies The tip is applied to the lens nucleus; cavitation
occurs at the tip as the nucleus is emulsified; an irrigation and aspiration system removes
this emulsified material from the eye. The IOL is then injected through a much smaller
incision than in ECCE. Safe: avoid compression of eye, results in little postoperative
astigmatism and early stabilization of refraction, and eliminate post-operative wound
related problem
Lensectomy: Most of the lens including anterior and posterior capsule along with anterior
vitreous are removed with the help of a vitreous cutter, infusion and suction machine.
Congenital as well as developmental cataract being soft are easily dealt with this procedure.
<

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.

14. Mechanism of loss of transparency Cortical cataract Denaturation and coagulation of

lens proteins. Decrease level of aminoacids and protein systhesis Increased hydration
brought by decrease in potassium due to reversal of Na/K pump mechanism. Nuclear
cataract: Degenerative changes occurring as nuclear sclerosis Increase in water insoluble
proteins, compaction of nucleus resulting in a hard cataract. Disturbance of lamellar
arrangement in fibres

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.

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

A.

Nursing management

The patient with cataract should receive the usual preoperative care for ambulatory surgical
patients undergoing eye surgery.

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.

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.

Anxiety related to threat of permanent loss of vision/independence.

Deficient knowledge regarding ways of coping with altered abilities related to lack of
exposure or recall, misinterpretation, or cognitive limitations.

Nursing Care Planning & Goals

Main Article: 2 Cataracts Nursing Care Plans

The major goals for the patient include:

 Regaining of usual level of cognition.

Recognizing awareness of sensory needs.

Be free of injury.

Identifying potential risk factors in the environment.

Appearing relaxed and reporting anxiety is reduced at manageable level.

Verbalizing feelings of anxiety.

Identifying healthy ways to deal with and express anxiety.

Nursing Interventions

Care for a patient with cataract includes:

Providing preoperative care. Use of anticoagulants is withheld to reduce the risk of

retrobulbar hemorrhage.

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

Evaluation of the patient may include:

Regained usual level of cognition.

Recognized awareness of sensory needs.

Free of injury.

Identified potential risk factors in the environment.

Appeared relaxed and reporting anxiety is reduced ti a manageable level.

Verbalized feelings of anxiety.

Identified healthy ways to deal with and express anxiety.

Discharge and Home Care Guidelines

The nurse teaches the patient self-care before discharge:

Activities. Activities to be avoided are instructed by the nurse.

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

The focus of documentation in a patient include:

ADVERTISEMENT

Individual findings, noting s

Individual findings, noting specific deficit and associated symptoms, perceptions of

client/SOs.

Assistive devices needs.

Use of safety equipment or procedures.

Environmental concerns, safety issues.

Level of anxiety and precipitating/aggravating factors.

Description of feelings.

Awareness and ability to recognize and express feelings.

Plan of care.

Teaching plan.

Client involvement and response to interventions, teaching, and actions performed.

Attainment or progress toward desired outcomes.

Modifications to plan of care.

Long term needs.

After cataract surgery, the patient is encouraged to:

Maintain bed rest for 1 week.

Lie on his or her stomach while sleeping.

Avoid bending his or her head below the waist.

D

Lift weights to increase muscle strength

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 sleep on my left side after surgery."

"I will wipe my nose gently if it is congested after surgery."

"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.

The nurse is right when she instructs the patient to avoid:

Getting up from bed for 2 weeks after surgery.

Chewing on the same side of the operated area.

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

# Fear and anxiety related to the surgery

Post Operative

# Risk of Fall due to Impaired Vision

#Risk of Eye Infection related to Surgery

#Pain related to surgical wound

#Knowledge Deficit related to Eye Care

Pre-Operative

Fear and Anxiety related to the Surgery

Objective: Patient express less fear and anxiety

Nursing Intervention:

1-Introduce self and ward staff. Establish a therauputic relationship.

®: So client feel comfortable

2- Orientate patient to ward routine

®: To make client at ease and gain client confidence

3-Demonstrate a caring and polite attitude

®: So client feel comfortable and less fear

4- Assess client’s knowledge regarding the operation

®: To facilitate health education

5-Reinforce doctor’s explanation

®: Makes client understand better

6-Introduce patient to another patient that had gone the same operation

® To gain client’s confidence

7-Explain all physical preparation and post operative expectations pre operatively

8- encourage family members to visit

® To give a continous moral support

Post-Operative:Risk of Fall related to Impaired Vision

Objective: Client does not sustain any eye injury

1-Transfer patient with care from trolley to the bed with hand support the head

® Aggrassive movemoent can cause eye bleeding

2-Place patient in unoperated side (recumbent/lateral)

® To avoid pressure on the operated eye

3- Ensure patient had eye pad/ Castella shield over the operated eye

® To protect from injury

4-Advise patient to rest in bed for 24hours

® To prevent from increase in IOP

5-Teach patient to use call bell

® To call for assisstance

6-Reorientate patient when fully conscious

® Help patient to remember the surrounding

7-Place locker on the side of the good eye

® So client easy to grab things and avoid putting pressure on operated eye
8. Assist patient to ambulated when permitted

®Prevent from fall

Risk of Eye Infection related to Surgery

Patient are at no risk of eye infection

1-Observe condition of eye 24 hours post-op

® To detect any signs of infection eg redness, tearing, discharge

2-Perform eye dressing QID using aspetic technique

® To prevent cross infection

3-Instill antibiotics drops- Gutt Chloramphenicol pre and post-op

® As a prophylaxis

4-Take vital signs QID especially temperature

® To detect fever that indicate sign of infection

5-Take eye swab for culture and sensitivity if there is eye disharge

®To detect causative organism and treat appropriately

6-Instill Gutt Dextrosone (Maxidex) as ordered

® To reduce inflammation

7- Cover operated eye with castella shield

® To protect from dust

8-Instill antibiotic drops every 15minutes as ordered eg Gutt Gentamycin

® To treat eye infection

Pain related to Surgical Wound

Remind patient to inform nurse immediately for any pain over the operated eyes

® For rapid intervention can be taken

2- Assess patient’s level of pain and document in nursing report

® So right intervention depends on level of pain can be taken

3- Administer analgesics as ordered by the doctor

Eg- Oral Tramal 500mg prn

® To reduce level of pain

4-Reassess effect of analgesics after half an hour

® To evaluate the effectiveness of the medication

5-Check patient eye pad/ bandage

® To detect any bloood stain, discharge

6-Advise patient to rest in bed

® To decrease level of pain

Knowledge Deficit related to Eye Care after Discharge

Objective:

Patient is knowlegable about the eye care

1- Teach patient how to:

a- Prevent eye infection

Wash hand with soap and water, rinse and dry.

Clean the eye using cool boiled water, cotton swabs and clean container

Instill eye drops as ordered

Not to go over crowded area- Night market, shopping mall

b- Prevent Injuries to the eye

Wear castella shield day and night for 1 week, at night for 2-3 weeks

Avoid pressure, squeezing and wrinkles eyes, carrying infant

Touch eye unnessarily

Purposely wink on the operated eye

Wipe away tears with hand

Bend head agrresively

Lie on operated eye

Do not eat on the operated side

Do not bite hard food

Do not cough or sneeze with mouth closed

Do not shave his beard (men)

Prevent photophobia

Wear dark sunglasses outdoors to prevent from UV rays

d. Prevent strain on the eye

Do not try to reach for objects that are out of reach

Straining during defecation

Sneezing/coughing with mouth closed

Avoid driving for 1 month

Do not reading or watching TV for prolonged time

Do not lifting heavy objects >5kg

Do no participating on certain sport-Rugby

Inform patient activities he can do:

Can wash face but ensure soap doesn’t get into the eyes

2-Can shower but face held away from shower head

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

5. Ladies can makeup but not for 1-2 weeks post-operatively

Genereal ake a well balanced diet with more fluids, fruit and fiber

Regular follow up to evaluate progress

Advise patient to seek prompt treatment if any complications arise eg severe eye pain

Nursing diagnosis

• Anxiety related to lack of knowledge about post operative care.

• Risk for infection related to surgical incision and self care after surgery.

• 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.

6. General health evaluation including blood pressure check

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.

1 NURSING DIAGNOSIS:-Risk of injury related to increased intraocular pressure, trauma.

GOAL : - Decrease the risk for injury.

INERVENTION:-

Keep the head of bed elevated.

Instruct the patient not to impose stress on operative eye.

Instruct the patient not to lean forward or lie on the affected side.

Change damp pads as allowed.

Administers eye drops as prescribed by physicians such as antibiotic, corticosteroids.

Administer antiemetic to prevent nausea and vomiting.

2 NURSING DIGNOSIS:-Disturbed sensory perception related to surgical trauma, lens

removal, patching.
GOAL : - The patient will adapt to visual impairment and function in environment without
injury.

INTERVENTION:-

Keep the bed in low position

Approach the left side place the call bell in lift and instruct the use

Remove obstacles in room

Assist the activities of daily living as needed.

3 NURSING DIGNOSIS:-Acute pain related to tissue trauma.

GAOL : - To reduce the pain.

INTERVENTIONS:-

Asses the level of pain.

Advice not to take stress on the effected part.

Give proper side lying position .

Administer analgesic as prescribed by the physicians.

4 NURSING DIGNOSIS:-Anxiety related temporary vision , impairment activity restrictions.

GOAL :-To reduce the anxiety.

INTERVENTIONS:-

Asses the level of anxiety

Explain the patient what is doing and why.

Explore the feeling of patient for surgery.

Answer the questions.

Responds to the needs.

5.NURSING DIGNOSIS:-Ineffective therapeutic regimen management related to lack of

understanding of a conditions, self care and limitations.

GOAL :-To provide effective regimen management.

INTERVENTIONS:-

Explain post operative limitations

No lifting over 5lb, bending forward or straining until cleared by physician.

 Review of procedure for eye drops and have patient or family member
demonstrateinstillations.

Supplement verbal instructions, writteninformations.

TEACHING PATIENTS SELF CARE:

To prevent accidental rubbing or poking of the eye.

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 eye patch is removed after the first follow up.

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.

NURSING DIAGNOSIS Gradual painless diminution of vision

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.

EXPECTED OUTCOME Postoperative Pain is relieved, comfort is ensured. Haemorrhage and

loss of vitreous humour will be prevented. Intraocular pressure will be prevented to rise.
Infection will be prevented. Ensure restoration of vision

Implementation: Prepare patient for cataract operation Topical antibiotics tobramycin,

gentamycin or ciprofloxacin qid for 3 days. Trim or cut upper lid eyelashes Obtain written
and detailed consent from the patient or first degree relatives. Ensure each patient take
scrub bath including face and hair. Males must get their beard cleaned. Acetazolamide
500mg stat 2 hours before surgery. Instill cycloplegic/mydriatic eye drops every ten minutes
one hour before surgery

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.

PREOPERATIVE CHECKLIST History and physical examination Name of procedure on surgical

consent Signed surgical consent Laboratory results Allergies have been identified Vital signs
assessed Jewelry removed Client is wearing a hospital gown and hair cover Client has
urinated The prescribed preoperative medication has been given

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.

Symptoms to watch for after cataract surgery

If you experience any of the following symptoms, please contact your ophthalmologist:

Vision loss

Pain that persists despite the use of over-the-counter pain medications

Light flashes or multiple spots (floaters) in front of your eye

Nausea, vomiting or excessive coughing

No information here is intended to substitute for advice from a qualified medical
practitioner. If you or someone else you know are about to have cataract surgery, make sure
you ask your ophthalmologist to outline the best steps for recovery.

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

39. Implementation: Subsequent post-operative care Remove bandage next morning.

Inspect eye for any postoperative complication. Instruct patient and family to instill
antibiotic and steroid eye drops prescribed for 2 to 4 weeks. Antibiotic ointment at bed time
for a week. Oral analgesic (sos) Provide eye shield. Then patient can be instructed to wear
sunglasses. Ensure patient got prescribed spectacle after 6-8 weeks of operation.

EVALUATION Outcome criteria Pain is relieved and infection is prevented. Cataract is

removed and sight is restored with or without corrective glasses. Patient successfully adapts
to vision change with planned rehabilitation.

Cataracts

Painless, blurry vision

Sensitivity to glare

Reduced visual acuity

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

Complications are rare but may be significant

Types of Cataract Surgery

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