ERA UNIVERSITY

ERA COLLEGE OF NURSING

PRACTICE TEACHING
ON

CATARACT
(SUBJECT: MEDICAL SURGICAL NURSING)

Submitted to: Submitted by:

Ms. Godhuli Ghosh Ms. Deeplata sahu
Assistant professor MSc (N) 1st YEAR
Era College of Nursing Era College of Nursing
Lucknow Lucknow

Submitted on: / /

INDEX:
SI CONTENT
NO.
1. Introduction

2. Definition of cataract

3. Classification of cataract

4. Etiological factors

5. Pathophysiology

6. Clinical manifestations

7. Diagnostic evaluation

8. Complications

9. Prevention

10. Medical management

11. Pharmacological management

12. Surgical management

13. Nursing management

14. Research input

15. Summary

16. Conclusion

17. Bibliography

INTRODUCTION:
 A cataract is a dense, cloudy area that forms in the lens of the eye. A cataract begins when proteins in the
eye form clumps that prevent the lens from sending clear images to the retina. The retina works by
converting the light that comes through the lens into signals. It sends the signals to the optic nerve,
which carries them to the brain.

 It develops slowly and eventually interferes with vision. People might end up with cataracts in both eyes,
but they usually don’t form at the same time. Cataracts are common in older people.
 A cataract is a lens opacity or cloudiness. Cataracts rank only behind arthritis and heart disease as a
leading cause of disability in older adults.
 According to the World Health Organization, cataract is the leading cause of blindness in the world
(Preshel & Prevent Blindness America, 2002).

DEFINITION:

“Any congenital or acquired opacity (dullness) in the lens or lens capsule is called as cataract.”

CLASSIFICATION: Cataract Divided to:

• Acquired cataract:
 Age - related cataract(Senile Cataract)
 Presenile cataract
 Traumatic cataract
 Drug induced cataract
 Secondary cataract

• Congenital Cataract :
 Systemic association
 Non-systemic association

Age -related cataract :

It is the Most commonly occurred. Classified according to:
Morphological Classification:
• Nuclear
• Cortical
• Subcapsular
• Christmas tree – uncommon

Maturity classification:
 • Immature Cataract
• Mature Cataract
• Hypermature Cataract

1. Nuclear cataract
• Most common type
• Age-related
• Occur in the center of the lens.
• 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.
• A nuclear cataract is caused by central opacity in the lens and has a substantial genetic component.

2. Cortical cataract:
• A cortical cataract involves the anterior, posterior, or equatorial cortex of the lens.
• Occur on the outer edge of the lens (cortex).
• Begins as whitish, wedge-shaped opacities or streaks.
• 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.

3. 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.

4. Posterior Subcapsular Cataracts:

• Posterior subcapsular cataracts occur in front of the posterior capsule.
• Begins at the back of the lens (posterior pole) & spreads to the periphery or edges 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.

1. Immature Cataract:

Lens is partially opaque Two morphological forms are seen:

i. Cuneiform Cataract:
• Wedge shaped opacities in the peripheral cortex and progress towards the nucleus.
• Vision is worse in low ambient illumination when the pupil is dilated.

ii. Cupuliform Cataract:

• A disc or saucer shaped opacities beneath the posterior capsule.
• Vision is worse in bright ambient illumination when the pupil is constricted.
• Lens appears grayish white in color.
• Iris shadow can be seen on the opacity with oblique illumination.

2. Mature Cataract
• Lens is completely opaque.
• Vision reduced to just perception of light
• Iris shadow is not seen
• Lens appears pearly white Right eye mature cataract, with obvious white opacity at the centre of pupil.

3. Hypermature Cataract
• Shrunken and wrinkled anterior capsule due to leakage of water out of the lense.
• This may take any of two forms:
i. Liquefactive/Morgagnian Type
ii. Sclerotic Cataract

Liquefactive/Morgagnian Type:
• Cortex undergoes auto-lytic liquefaction and turns uniformly milky white.
• The nucleus loses support and settles to the bottom.
Sclerotic Cataract:
• The fluid from the cortex gets absorbed and the lens becomes shrunken.
• There may be deposition of calcific material on the lens capsule.
• Iridodonesis: Anterior chamber deepens and iris becomes tremulous.
• The zonules become weak, increasing the risk of subluxation / dislocation of lens.

ETIOLOGICAL FACTORS:
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)

Associated Ocular Conditions:

• Retinitis pigmentosa
• Myopia
• Retinal detachment and retinal surgery
• Infection (eg, herpes zoster, uveitis)

Toxic Factors:

• Corticosteroids, especially at high doses and in long-term use

• Alkaline chemical eye burns, poisoning
• Cigarette smoking
• Calcium, copper, iron, gold, silver, and mercury, which tend to deposit in the pupillary area of the lens

Nutritional Factors:

• Reduced levels of antioxidants

• Poor nutrition
• Obesity

Physical Factors:
• Dehydration associated with chronic diarrhea, use of purgatives in anorexia nervosa, and use of
hyperbaric oxygenation
• Blunt trauma, perforation of the lens with a sharp object or foreign body, electric shock
• Ultraviolet radiation in sunlight and x-ray

Systemic Diseases and Syndromes:

• Diabetes mellitus
• Down syndrome
• Disorders related to lipid metabolism
• Renal disorders
• Musculoskeletal disorders

PATHOPHYSIOLOGY:

• Cataracts can develop in one or both eyes at any age for a variety of causes.
• Visual impairment normally progresses at the same rate in both eyes over many years or in a matter of
months.
• The three most common types of senile (age-related) cataracts are defined by their location in the lens:
nuclear, cortical, and posterior subcapsular.
• The extent of visual impairment depends on the size, density, and location in the lens.
• More than one type can be present in one eye.
• A nuclear cataract is associated with myopia (ie, nearsightedness), which worsens when the cataract
progresses.
• If dense, the cataract severely blurs vision.
• Periodic changes in prescription eyeglasses help manage this problem.
• A cortical cataract involves the anterior, posterior, or equatorial cortex of the lens.
• A cataract in the equator or periphery of the cortex does not interfere with the passage of light through
the center of the lens and has little effect on vision.
• Cortical cataracts progress at a highly variable rate.
• Vision is worse in very bright light.
• Studies show that people with the highest levels of sunlight exposure have twice the risk of developing
cortical cataracts than those with low-level sunlight exposure (West et al., 1998).
• Posterior subcapsular cataracts occur in front of the posterior capsule.
• This type typically develops in younger people and, in some cases, is associated with prolonged
corticosteroid use, inflammation, or trauma.
• Near vision is diminished, and the eye is increasingly sensitive to glare from bright light (eg, sunlight,
headlights).
 Opacification of lens take place by 3 biochemical changes

Hydration denaturation of lens protein slow sclerosis

Abnormalities of lens proteins

Disorganization of lens fibres

Loss of transparentency of lens

Cataract

CLINICAL MANIFESTATIONS:
Because all light entering the eye passes through the lens, any clouding of the lens can cause poor vision.

 Blurred vision. Blurred vision is usually the first symptom of cataracts.

 Glare. Glare refers to the pain felt when the patient looks directly into the light.
 Halos. Halos are formed when the patient looks at a bright light and there is still the vision of the light
after looking away.
 Double vision. Double vision is also one of the early symptoms of cataract.
 Myopic shift,
 Astigmatism,
 Monocular diplopia (ie, double vision),
 Colour shift (ie, the aging lens becomes progressively more absorbent at the blue end of the spectrum),
 Brunescens (ie, color values shift to yellow-brown), and reduced light transmission.

DIAGNOSTIC EVALUATION:

• History and physical examination

• Snellen visual acuity test: The Snellen visual acuity test measures the degree of visual acuity in the
patient.
 Ophthalmoscopy: Ophthalmoscopy is used to view the extent of cataract.
 Slit-lamp bio microscopic examination: This procedure is used to establish the degree of cataract
formation.
COMPLICATIONS:
Potential complications following cataract surgery include:

 Retro bulbar haemorrhage: Retro bulbar haemorrhage can result from retro bulbar infiltration
of anaesthetic agents if the short ciliary artery is located by the injection.
 Acute bacterial endophthalmitis: Devastating complication that occurs in about 1 in 1000 cases.
 Toxic anterior segment syndrome: Non-infection inflammation that is a complication of anterior
chamber surgery.

PREVENTION
The nurse should instruct the patient to:

 Quit smoking: The patient should avoid smoking because it is one of the greatest contributing factors to
cataract.
 Wear sunglasses: Wearing of sunglasses shields the eye from too much exposure to UV rays that
predisposes to cataract.

MANAGEMENT

MEDICAL MANAGEMENT:
No nonsurgical treatment cures cataracts or prevent age-related cataracts.

PHARMACOLOGIC THERAPY:

Medications administered pre and postoperatively are:

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

SURGICAL MANAGEMENT:
Common surgical procedures done to correct cataracts:
 Phacoemulsification

 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 consular support are left intact.
o Aphasic glasses: In aphasic glasses, objects are magnified by 25%, making them appear
closer than they actually are.
o 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 of aphasic
glasses.
o 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 youthful, phakic eye.
 Extra-capsular cataract extraction (ECCE): ECCE removes the anterior lens and cortex, leaving
the posterior capsule intact.
 Intra-capsular cataract extraction: This procedure removes the entire lens within the intact
capsule.

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 retro-bulbar haemorrhage.
 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:

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 retro-bulbar

haemorrhage.
 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.

RESEARCH INPUT:

The study was conducted by Yezinsh Addis Alimaw, Mohammed Seid Hussen, Tsehay Kassa Tefera,
Betelhem Temesgen YibekalID.

Department of Optometry, School of Medicine, College of Medicine and Health Science, University of
Gondar, Gondar Town, Ethiopia

Aim: The aim of this study was to assess knowledge regarding cataract and associated factors among adults
in Gondar town Northwest Ethiopia.

Methods: A community-based cross-sectional study was conducted on 836 adults age18years, using multi-
stage systematic random sampling technique, in Gondar town Northwest Ethiopia from April 15-May 7,
2017. Data were collected using pre-tested structured questionnaires through face to face interview. The
collected data was entered to Epi info version 7 and analyzed using SPSS version 20. Binary logistic
regression was used to identify associated factors. Those variables with p-value<0.05 and confidence
interval6¼1 in multivariable logistic regression were considered as statistically significant factors for
knowledge regarding cataract.

Result:Among 845 eligible adults, 98.9% (836) of them were fully participated. The median age of
participants was 28 years with an interquartile range of 17 years. Of the total participants, 67.2% (562) of
them had awareness about cataract [95% CI, 63.8–70.2]. Among 562 participants, 61.7% of them had good
knowledge about cataract [95% CI, 57.5–66.00]. It was also found that higher level of education [AOR =
2.86, 95%CI: 1.37–5.96], higher family monthly income [AOR = 1.92, 95%CI: 1.03–3.57], having previous
eye examination [AOR = 1.53, 95% CI: 1.02–2.31] and positive family history of cataract [AOR = 1.76,
95%CI: 1.03–3.01] were positively associated with good knowledge.
SUMMARY:

A cataract is a clouding of the lens in your eye. It affects your vision. Cataracts are very common in older
people. By age 80, more than half of all Americans either have a cataract or have had cataract surgery. A
cataract can occur in either or both eyes. It cannot spread from one eye to the other. Common symptoms are:

 Blurry vision
 Colors that seem faded
 Glare - headlights, lamps or sunlight may seem too bright. You may also see a halo around lights.
 Not being able to see well at night
 Double vision
 Frequent prescription changes in your eye wear

Cataracts usually develop slowly. New glasses, brighter lighting, anti-glare sunglasses or magnifying lenses
can help at first. Surgery is also an option. It involves removing the cloudy lens and replacing it with an
artificial lens. Wearing sunglasses and a hat with a brim to block ultraviolet sunlight may help to delay
cataracts.

CONCLUSION:

Cataract surgery is the principal refractive surgical procedure performed in older adults. Technological
advances have allowed for improved surgery through smaller incisions, resulting in better outcomes.
Improvements in lens implants provide better visual outcomes than were previously possible.

BIBLIOGRAPHY:

1. Panwar P.K., "Medical Surgical Nursing", 2014, 3rd Edition, AITBS Publishers, India,188-189.
2. Chintamani, "Lewis's Medical Surgical Nursing", 2011, 7th Edition, Elsevier Publishers, 421-423.
3. Polaski Arlene L, Tatro Suzanne E, “Luckman Core Principles and Practice of Medical surgical
nursing”, 2010,IIIrd Edition, Elsevier Publisher,440-443.
4. Et. all, “Brunner and Suddarth’s Textbook of Medical surgical nursing”, Eleventh Edition,2008,
Published by Wolters Kluwer (India)Pvt Ltd, New Delhi,2059- 2063.
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