A cataract is a clouding or opacity that develops in the crystalline lens of the eye or in its envelope, varying in degree from slight opacity to obstructing the passage of light. Progressive, painless clouding of the natural, internal lens of the eye.

1. MEDICAL SURGICAL NURSING- II
UNIT – II
NURSING MANAGEMENT OF
PATIENTS WITH DISORDERS OF EYE
TOPIC : CATARACT
Mrs. SOUMYA. M
LECTURER
CON, SRIPMS, CBE

2. Central Objective:
At the end of this session the students
will gain adequate knowledge regarding
cataract and develop desirable skill and
positive attitude towards utilizing this
withknowledge in care of such patients
cataract in future.
Specific Objectives:
The student will be able to
o Recall the anatomy and physiology
o Define cataract
o State the word meaning

3. • Discuss the epidemiology
• Enlist the etiological factors
• Enumerate pathophysiology
• List out clinical manifestations
• Explain the types
• State the diagnostic measures
• Clarify the surgical measures
• Discuss on pre and post operative nursing
management
• Express the complications after surgery.
CONTINUATION..

5. ANATOMY OF LENS
• Developed from surface ectoderm.
• Biconvex, avascular, transparent
structure suspended by zonules
behind the iris.
• Parts – central nucleus, cortex, anterior
and posterior capsule.
• Composition -65% water, 35%protein
and traces of minerals.ari

6. THE LENS
It’s crystalline.
Cross section:
1. Capsule
2. Cortex
3. nucleus

7. Ciliary muscle
•Function:
• Constricts ciliary body
Ciliary process
•Attaches to the lenses by
suspensory ligament (zonular
fibers)

8. FUNCTIONS
• Acts as refractory surface.
• Helps in the act of accommodation.

9. DEFINITION
• A cataract is a clouding or opacity that
develops in the crystalline lens of the eye or in
its envelope, varying in degree from slight
opacity to obstructing the passage of light.
•Progressive, painless clouding of the natural,
internal lens of the eye.

10. ‘CATARACTA’ (LATIN) = MEANING
‘WATERFALL
MEANING

11. When water is turbulent, it is transformed from a clear
medium to white and cloudy. Keen ancient observers
noticed similar-appearing changes in the eye and
attributed visual loss from "cataracts" as an
accumulation of this turbulent fluid, having no
knowledge of the anatomy of the eye or the status or
importance of the lens.
CONTINUATION..

13. Epidemiology
1. Cataracts remain the
leading cause of blindness.
2. Age-related cataract
is responsible for 48%
of world blindness,
which represents about
18 million people.
3. Cataracts are also an
important cause of low
vision in both developed
and developing countries.

14. CAUSES OF CATARACT
• Old age (commonest) >65 Year
• Ocular & systemic diseases
– DM
– Uveitis
– Previous ocular surgery
• Systemic medication
– Steroids
– Phenothiazines
• Trauma & intraocular foreign
bodies
• Ionizing radiation
– X-ray
– UV
•
Congenital
– Abnormal galactose
metabolism
– Hypoglycemia
• Inherited abnormality
– Myotonic dystrophy
– Marfan’s syndrom
– Rubella
8

15. Any physical or chemical cause
↓
Disturbs the intracellular and extracellular equilbrium of water and
electrolytes
↓
Deranges the colloid system in lens fibres
↓
Aberrant fibres are formed from germinal epithelium of lens
↓
Epithelial cell necrosis
↓
Focal opacification of lens epithelium
(glaucomflecken)
↓
Opacification of lens
PATHOMECHANISM

16. Opacification of lens takeplace by 3 biochemical
changes.
1. Hydration 2.Denaturation of 3.Slow
lens protein sclerosis
Abnormalities of lens
proteins& Disorganisation of
lens fibres
Loss of transparency of lens
Cataract

17. CLASSIFICATION :
BASED ON :
• Age of onset
• Morphology
• Maturity
• Etiology
• Time of occurrence

18. Age of onset:
1.CONGENITAL
2.INFANTILE
3.JUVINILE
4.PRE-SENILE
5.SENILE

19. CONGENITAL CATARACT

20. INFANTILE AND JUVINILE CATARACT

21. Morphological Classification
• Capsular cataract
• Sub capsular
cataract
• Cortical cataract
• Nuclear cataract

22. Capsular cataract
•It involves the capsule and may be
anterior capsule or posterior capsule.
Subcapsular cataract
•It involves superficial part of the cortex (just
below the capsule) and includes anterior
subcapsule or posterior sub capsule.

23. Cortical cataract
• Occur on the outer edge of the lens (cortex).
• Begins as whitish, wedge-shaped opacities.
• The lens fibers of the cortex are mainly affected. 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.

24. 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.

25. CONTINUATION..

26. BASED ON MATURITY
• 1.Immature cataract
• 2.Mature cataract
• 3.Hypermature cataract

27. IMMATURE CATARACT

28. Mature Cataract
• Lens is completely opaque.
• Vision reduced to just perception of
light
• Iris shadow is not seen
• Lens appears pearly white

29. Hypermature Cataract
•Shrunken and wrinkled anterior capsule due
to leakage of water out of the lens.
•This may take any of two forms:
1.Liquefactive/Morgagnian Type
2.Sclerotic Cataract

30. Liquefactive/Morgagnian Type
•Cortex undergoes auto-lytic liquefaction
and turns uniformly milky white.
•The nucleus loses support and settles to
the bottom.

31. 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.

33. Cataract
Based on time of occurrence, Divided
to :
• Acquired cataract
Age - related
cataract Metabolic
cataract
Radiation or electric
cataract Traumatic
cataract
Toxic cataract
Secondary
cataract
• Congenital Cataract

34. SUBJECTIVE
CLASSIFICATION:
• GRADE 0: CLEARLENS
• 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

35. SUBJECTIVE CLASSIFICATION

36. Clinical Manifestations
• Gradual painless burning
• Loss of vision due to lens opacity
• Increased glare in bright light
• Decreased color perception
• Decreased visual acuity
• Photophobia(light sensitivity)
• Blurred or distorted images
• Light scattering
• Leukokoria or white pupil
• Reduced light transmission
• Contrast sensitivity is also lost

37. BLURREDVISION DUE TO SCATTERING
OF LIGHT ON THE RETINA

39. GLARED VIEW(TROUBLE DRIVING AT
NIGHT)

40. CHANGE IN COLOUR VISION(DIMNESS)

41. Diagnostic Measures
• History collection
• 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 biomicroscopic examination -
This procedure is used to establish the
degree of cataract formation.
• Dilated eye exam
• Tonometry

42. Risk reduction strategies
• Smoking cessation
• Weight reduction
• Optimal blood sugar control
• Wear sunglasses outdoors to prevent early cateract
formation

43. LENS REPLACEMENT
• Eye glasses- Aphakic glasses
• Contact lenses
• IOL Implants
•GLASSES: Cataract alters the refractive power of the
natural lens so glasses may allow good vision to be
maintained.
TREATMENT

44. • Surgical removal: when visual acuity can't be
improved with glasses.
• Surgical techniques
–Phacoemulsification method.
–Extracapsular cataract extraction.
–Intra capsular cataract extraction.
–Intraocular lens implantation
–cryosurgery- surgery using the local
application of intense cold to destroy unwanted
tissue.

45. Phacoemulsification
Phacoemulsification is a modern cataract surgery
method in which the eye's internal lens is emulsified
with an ultrasonic handpiece and aspirated from the eye.
Aspirated fluids are replaced with irrigation of balanced
salt solution to maintain the anterior chamber.

48. 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 retinal
detachment and cystoid macular edema.

50. Intra-capsular Cataract Extraction
(ICCE)
• 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 (ie, partially or completely dislocated lens).

52. 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.

53. Nursing Management
• 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.

54. • 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.

55. Possible Pre & Post Operative Nursing
Diagnosis
• Disturbed visual sensoryperception related
to opacification of eye lens.
• Self care deficit related to visual deficit.
• Anxiety related to lack of knowledge
about post operative care.
• Risk for injury related to sensory deficit
while operated eye is patched.
• Risk for infection related to surgical incision.

56. Post Operative Care
• Limit the patient to perform an action that
can
increase IOP, including: coughing,
bending, straining, sneezing, lifting
objects after the surgery.

57. • Observation of increased IOP is characterized
by: severe pain, nausea, vomiting.
• Advice to wear glasses during the day and
wear eye protection at night.
• Give eye drops / eye ointment.

58. • Observe for signs of infection, and advise the
patient not to rub the eyes to prevent infection.
• Instruct the patient to wash their hands before
administering an ointment / eye drops.

59. • Observe for signs of bleeding anterior eye
chamber is characterized by changes in vision.
• Observation for signs of retinal detachment,
which is marked with a black dot seems, an
increasing number of floaters or light and loss of
part / whole field of view.

60. Discharge and Home Care Guidelines
• The nurse teaches the patient self-care before
discharge:
• 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.

61. Patient Education on Activities
to be Avoided
• Don't drive on the first day.
• Don't do any heavy lifting or strenuous activity for
a few weeks.
• Immediately after the procedure, avoid bending
over, to prevent putting extra pressure on eye.
• If possible, don't sneeze or vomit right after
surgery.

62. •Be careful walking around after surgery, and
don't bump into doors or other objects.
•To reduce risk of infection, avoid swimming or
using a hot tub during the first week.
•Don't expose eye to irritants such as grime,
dust and wind during the first few weeks after
surgery.
•Don't rub eyes.
CONTINUATION..

63. • Expected side effects. Slight morning discharge,
some 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.
CONTINUATION..

64. Complications of cataract surgery
• Infective endophthalmitis
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 intra operative bleeding can lead to serious and
permanent reduction in vision.

65. • Uveitis
• Ocular perforation
• Postoperative refractive error
• Posterior capsular rupture
• vitreous loss
• Retinal detachment
• Cystoid macular oedema
• Glaucoma
• Posterior capsular opacification
CONTINUATION..

66. REFERENCES
1 Brunner and Suddarth’s , (2001), “Text book of Medical Surgical
Nursing”,9th edition, Lippincott company, Newyork.
2 Joyce M. Black, Jane Howks, (2005), “Medical Surgical nursing”,
7th edition, Elsevier, New Delhi.
3 Sharon L. Lewis,(2011), “The text book of Medical Surgical
Nursing”, 8th edition, Elsevier, New Delhi.
9th4 Ross and Willison, “Anatomy and Physiology”, edition,
Churchchill livingstone publication.