CATARACT

INTRODUCTION
 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.
 The patient may have a cataract in one or
both eyes. If cataracts are present in both
eyes, one may affect the patient’s vision more
than the other.
 Etiology & Risk Factors
 Although most cataracts are age related (senile
cataracts), they can be associated with other factors.
 These include blunt or penetrating trauma,
congenital factors such as maternal rubella,
radiation or ultraviolet (UV) light exposure, certain
drugs such as systemic corticosteroids or long-
term topical corticosteroids, and ocular
inflammation.
 The patient with diabetes mellitus tends to develop
cataracts at a younger age.
 Pathophysiology
 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.
 CONT..
 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.
 CONT..
 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).
 CLINICAL MANIFESTATIONS
 Painless, blurry vision is characteristic of cataracts.
 The patient perceives that surroundings are dimmer, as if glasses

need cleaning.
 Light scattering is common, and the individual experiences reduced

contrast sensitivity, sensitivity to glare, and reduced visual acuity.

 Glare is due to light scatter caused by the lens opacities, and it may

be significantly worse at night when the pupil dilates.

 Other effects include myopic shift, astigmatism, monocular diplopia

(ie, double vision), color 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.
 ASSESSMENT AND DIAGNOSTIC
STUDIES
 Decreased visual acuity is directly proportionate to cataract
density.
 The Snellen visual acuity test, ophthalmoscopy, and slitlamp
biomicroscopic examination are used to establish the degree of
cataract formation.
 The degree of lens opacity does not always correlate with the
patient’s functional status.
 Some patients can perform normal activities despite clinically
significant cataracts.
 Others with less lens opacification have a disproportionate de
crease in visual acuity; hence, visual acuity is an imperfect
measure of visual impairment.
 MANAGEMENT
 No nonsurgical treatment cures cataracts. Ongoing studies are

investigating ways to slow cataract progression, such as intake

of antioxidants (eg, 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 proper light and 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.
 SURGICAL MANAGEMENT
 Fewer than 15% of people with cataracts suffer vision problems
severe enough to require surgery.
 In general, if reduced vision from cataract does not interfere
with normal activities, surgery may not be needed. However, in
deciding when cataract surgery is to be performed, the patient’s
functional and visual status should be a primary consideration.
 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. Although complications from cataract
surgery are uncommon, they can have significant effects on
vision
 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).
 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
 Phacoemulsification
 This method of extracapsular surgery uses an ultrasonic

device that liquefies the nucleus and cortex, which are

then suctioned out through a tube. The posterior capsule

is left intact.
 Because the incision is even smaller than the standard

ECCE, the wound heals more rapidly, and there is early

stabilization of refractive error and less astigmatism.

 Hardware and software advances in ultrasonic technology

—including new phaco needles that are used to cut and

aspirate the cataract— permit safe and efficient removal

of nearly all cataracts through a clear cornea incision that

 Lens Replacement
 After removal of the crystalline lens,
the patient is referred to as aphakic
(ie, without lens). The lens, which
focuses light on the retina, must be
replaced for the patient to see
clearly. There are three lens
replacement options: aphakic
eyeglasses, contact lenses, and IOL
implants.
 CONT..

 Preoperative Phase

 Intraoperative Phase

 Postoperative Phase
 Nursing Management
 ASSESSMENT
 NURSING DIAGNOSIS
 PLANNING
 IMPLEMENTATION
 EVALUATION
 PROVIDING PREOPERATIVE CARE
 PROVIDING POSTOPERATIVE CARE
 PROMOTING HOME AND COMMUNITY-BASED CARE
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