Cataract and its management

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

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

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

5. Risk Factors for Cataract Formation
Aging
• Loss of lens transparency
• Clumping or aggregation of lens protein
(which leads to light scattering)
• Accumulation of a yellow-brown pigment
due to the breakdown of lens protein
• Decreased oxygen uptake
• Decrease in levels of vitamin C, protein,
and glutathione (an antioxidant)

6. Associated Ocular Conditions
• Retinitis pigmentosa
• Myopia
• Retinal detachment and retinal surgery
• Infection (e.g., herpes zoster, uveitis)
Toxic Factors
• Corticosteroids, especially at high doses and in long-
term use
• Alkaline chemical eye burns, poisoning
• Cigarette smoking
• Calcium, copper, iron, gold, silver, and mercury,
which tend to deposit in the pupillary area of the lens

7. 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

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

11. •A nuclear cataract is associated with myopia, which
worsens when the cataract progresses. If dense, the
cataract severely blurs vision. Periodic changes in
prescription eyeglasses help manage this problem.
•A cortical cataract involves the anterior, posterior, or
equatorial cortex of the lens. A cataract in the equator or
periphery of the cortex does not interfere with the passage
of light through the centre of the lens and has little effect
on vision. Cortical cataracts progress at a highly variable
rate. Vision is worse in very bright light. People with the
highest levels of sunlight exposure have twice the risk of
developing cortical cataracts than those with low-level
sunlight exposure.

12. •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.

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

15. DIAGNOSTIC EVALUATION
•History collection
•Physical examination

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

17. Snellen chart

18. RANDOM E TEST

19. JAEGER CHART

20. Direct ophthalmoscopy

21. Indirect Ophthalmoscopy

22. Slit-lamp examination

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

24. Ultrasonography

25. Perimetry testing

27. Medical Management
•No nonsurgical treatment cures cataracts. Ongoing studies are
investigating ways to slow cataract progression, such as intake of
antioxidants (e.g., vitamin C, beta-carotene, vitamin E)
•In the early stages of cataract development, glasses, contact
lenses, strong bifocals, or magnifying lenses may improve vision.
•Reducing glare with appropriate lighting can facilitate reading.
•Mydriatics can be used as short-term treatment to dilate the
pupil and allow more light to reach the retina, although this
increases glare.

28. Surgical management
•Fewer than 15% of people with cataracts suffer
vision problems severe enough to require
surgery.
•Surgery is performed on an outpatient basis and
usually takes less than 1 hour, with the patient
being discharged in 30 minutes or less afterward.
•When both eyes have cataracts, one eye is
treated first, with at least several weeks,
preferably months, separating the two
operations.

29. Intracapsular Cataract
Extraction
•The entire lens (i.e., nucleus,
cortex, and capsule) is
removed, and fine sutures
close the incision.
•ICCE is infrequently performed
today; however, it is indicated
when there is a need to
remove the entire lens, such as
with a subluxated cataract (i.e.,
partially or completely
dislocated lens).

30. Extracapsular cataract extraction (ECCE)
•Smaller incisional wounds (less trauma to the eye) and
maintenance of the posterior capsule of the lens, reducing
postoperative complications, particularly aphakic retinal
detachment and cystoid macular edema.
•An intact zonular-capsular diaphragm provides the needed
safe anchor for the posterior chamber intraocular lens (IOL).
After the pupil has been dilated and the surgeon has made a
small incision on the upper edge of the cornea, a
viscoelastic substance (clear gel) is injected into the space
between the cornea and the lens. This prevents the space
from collapsing and facilitates insertion of the IOL.

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

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

38. PREOPERATIVE CARE
-To reduce the risk for retrobulbar hemorrhage (after retrobulbar
injection), any anticoagulation therapy that the patient is receiving is
withheld, if medically appropriate.
-Aspirin should be withheld for 5 to 7 days, nonsteroidal anti-
inflammatory medications (NSAIDs) for 3 to 5 days, and warfarin
(Coumadin) until the prothrombin time of 1.5 secs is almost reached.
-Dilating drops are administered every 10 minutes for four doses at
least 1 hour before surgery. Additional dilating drops may be
administered in the operating room (immediately before surgery) if
the affected eye is not fully dilated.
-Antibiotic, corticosteroid, and NSAID drops may be administered
prophylactically to prevent postoperative infection and inflammation.

39. POSTOPERATIVE CARE
-After recovery from anesthesia, the patient receives
verbal and written instruction regarding how to protect
the eye, administer medications, recognize signs of
complications, and obtain emergency care.
-The nurse also explains that there is minimal discomfort
after surgery and instructs the patient to take a mild
analgesic agent, such as acetaminophen, as needed.
-Antibiotic, anti-inflammatory, and corticosteroid eye
drops or ointments are prescribed postoperatively.

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

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

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

43. Promoting home and community-based
care
-To prevent accidental rubbing or poking of the eye, the patient
wears a protective eye patch for 24 hours after surgery, followed
by eyeglasses worn during the day.
-The nurse instructs the patient and family in applying and caring
for the eye shield.
-Sunglasses should be worn while outdoors during the day because
the eye is sensitive to light.
- Importance of complying with postoperative restrictions on head
positioning, bending, coughing, and Valsalva maneuver to
optimize visual outcomes and prevent increased intraocular
pressure.

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

45. Continuing Care
-The eye patch is removed after the first follow-up
appointment.
-Patients may experience blurring of vision for several days to
weeks. Sutures left in the eye alter the curvature of the
cornea, resulting in temporary blurring and some astigmatism.
-Vision gradually improves as the eye heals.
-How to monitor pain, take pain medication, and report pain
not relieved by medication.
-Importance of continued follow-up as recommended to
maximize potential visual outcomes.

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

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

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

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

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

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

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