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1. THANUJAELEENAMATHEW

2.  Definition: Any opacity in the lens or its capsule whether
developmental or acquired is called a cataract.
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Usually developmental opacities are stationary and
partial
Acquired opacities progress till entire lens is involved
 Damage to the lens by trauma, toxins, hydration or UV
rays affect lens transparency.

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Heredity
Age
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UV radiation
Dietary deficiencies of Vitamins A,C,E
Severe diarrhoea
Diabetes
Smoking
Corticosteroids

4. Classification:
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cause: congenital, senile(age-related),
complicated, metabolitic, drug-induced, toxic,
traumatic, secondary
age: congenital, acquired
location: cortical, nuclear, subcapsular
shape: dot-like, coronary, lamellar
degree: immature, intumescent, mature,
hypermature

5. Symptoms:
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decreased vision: most obvious and important because of
reduced transparency of lens
decreased contrast sensitivty
refractive error like myopia due to change in RI of nucleus and
hence frequent change of glasses
monocular diplopia and coloured halos due to irregular
refraction by different parts of lens
Glare due to scattered light rays
Change in color values ie red is accentuated

6. Grade’s standards of nuclear hardness:
Ⅰ transparent, no nucleus,soft
Ⅱ yellow-white or yellow, soft
Ⅲ dark yellow,moderate hard
Ⅳbrown or amber, hard
Ⅴ brown or black,extremely hard

8.  Most common type
 Most patients are beyond their 50’s.
Occurs equally in men and women
Earlier in tropical countries
Considerable genetic influences

9. The most common type
 Etiopathogenesis :Hydration followed by coagulation of
proteins in the cortex.
 Stages:
(1) Lamellar seperation
(2)Incipient cataract
(3)Immature stage
(4)Mature stage
(5)Hypermature stage

10.  Demarcation of cortical fibres owing to their
separation by fluid.
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Demonstrated by Slit-lamp examination only.
Characteristic grey appearance of pupil due to
scattering of light
Changes are reversible.

11.  Wedge shaped opacities with clear areas in
between( Lens striae).
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Most common in periphery and lower nasal
quadrant.
Only seen in dilated pupil
Irregularities in refraction, visual deterioration
and polyopia.

13. Opacification becomes more diffuse and irregular.
Lens is swollen.
Iris shadow still visible.
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 Anterior chamber becomes shallow.

15. 
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Complete opacification
Whole cortex is involved
Lens appears pearly white in colour
Also known as ripe cataract
 No iris shadow

17. Cortex is disintegrated and transformed into pultaceous
material.
Usually occurs in two forms:-
1. Morgagnian hyper–mature cataract
2. Sclerotic hyper–mature cataract

18.  MORGAGNIAN CATARACT
Complete cortex is liquefied and appears milky
white in colour.
Nucleus settles at the bottom.
Calcium deposits may also be seen on the lens capsule.
 SCLEROTIC HYPER–MATURE CATARACT
Disintegrated cortex.
Shrunken lens sometimes appears yellow
Wrinkled anterior capsule .
Dense white capsular cataract in pupillary area.
Deep Anterior-Chamber.
Tremulous Iris .

19. Morgagnian cataract
Shrunken cataract

20. Etio-pathogenesis:- Intensification of age related degenerative
changes associated with dehydration and compaction of
nucleus ie nucleur sclerosis
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Features:
start earlier, generally on 40’s
Hard cataract is formed.
Significant increase in water insoluble protein.
Lens becomes in-elastic and looses power of accommodation.
Changes begin centrally and slowly spread to periphery.
Cortex is clear

21.  Deposition of tryptophan derived pigments that
gives characteristic colour to nucleus
cataracta brunescens- brown
cataracta nigra- black
Cataracta rubra- dusky red
 Vision: no vision damage early, myopia due to
increase in RI of nucleus
 . slowly progressive, not likely to be mature.

23. Features:
start earlier
Subcapsular opacities extending towards equator
posterior subcapsular cataract: cause obvious
vision defect early because near the nodal point
Best seen on retroillumination

25.  Congenital cataract
 (present at birth)
 Developmental cataract
 (develops soon after birth)
 Developmental opacity are usually partial & stationary
Etiology:
(1) Maternal and infantile malnutrition
(2)maternal infection
(3)defective oxygenation

26.  Punctate (blue dot) cataract
 Anterior Capsular cataract
 Anterior cortical cataract
 Pyramidal
 Reduplicated
 Posterior polar cataract
 Embryonal (nuclear) cataract
 Coronary cataract
 Fusiform cataract
 Zonular (Lamellar) cataract
 Total cataract

28. Punctate (blue dot/ cataracta coerulea) cataract:
Most common type
Appears as multiple, tiny blue dots
scattered all over the lens, especially
in the cortex.
Bluish color is due to the effects of
dispersion of light.
When near sutures- sutural cataract
Visual acuity is not affected

29. Anterior Polar Cataract
It is sharply demarcated opacity at the
anterior lens capsule.
Due to delayed formation of the anterior
chamber, during development due to
contact of capsule and cornea
It may project forwards into the anterior
chamber like a pyramid (pyramidal
cataract);
Or underlying cortex becomes opaque
(anterior cortical cataract)
When both are present ther is a clear
zone of subcapsular epithelium in
between (reduplicated cataract)
These opacities are stationary and rarely
interfere with vision.

30. Associated with persistent hyaloid
remnants(mittendorf dots),posterior
lenticonus & persistent anterior
fetal vasculature
Common in minimal degree &
visually insignificant
With persistent hyaloid artery , lens
deeply invaded by fibrous tissue
leading to total cataract
Posterior Capsular ( Polar) Cataract

31. Zonular (Lamellar) Cataract
Accounts for 50% of visually significant
cataract
Zone around embryonic nucleus (usually in
area of fetal nucleus) become opacified, area
around opacity is clear
Linear opacities like spokes of a wheel
(called riders) may run outwards
Usually bilateral,formed just before/shortly
after birth and affect vision
Often hereditary (autosomal dominant)
Associated with hypovitaminosis D or
hypocalcemia &maternal malnutrition

32. Coronary Cataract
Around puberty
Situated in deeper layers of
cortex &superficial layers of
adolescent nucleus
Corona or club shaped opacities
near periphery of lens ,usually
hidden by iris while rest areas
are free
Non progressive & does not
interfere with vision

33. Nuclear Cataract
Associated with rubella
Incidence more if infection
contracted in 2nd month
Development of lens inhibited
at very early stage
Embyonal nuclear cataract
Progressive ,becomes total
cataract
Associated microphthalmos,
salt and pepper retinopathy,
deafness, heart defects

34. Fusiform Cataract
• Anteroposterior spindle shaped opacities sometimes
with offshoots
• Resemble coralhencecalled coralliformorspindle
shaped cataracts
• Genetically determined
• Discoid cataract-disc like opacity behind nucleus in
posterior cortex

35. Cataract that develops secondary to a primary ocular
disease.
Characterstic feature is polychromaticlustreandbread
crumb appearance
Chronic anterior uveitis:
most common
Polychromatic lustre at posterior pole
If persists anterior and posterior opacities
develop

36. Acute congestive angle closure: focal infarcts of lens
epithelium –small grey-white anterior subcapsular, or
capsular opacities- glaukomfecken
Pathological myopia: posterior subcapsular opacities and
early onset nucleur sclerosis that increase myopia
Heridity fundus dystrophies:
Lebers: total cataract
Stickler syndrome: cortical cataract

37.  Diabetic cataract:
Mech: hyperglycemia excess glucose to
metabolize into sorbitol in lens osmotic
overhydration
Is of 2 types
1) classic diabetic cataract :rare, fluid vacuoles in
capsule then dense white subcapsular opacities in
cortex :snowflake cataract
2) age-related cataract of diabetic patients: earlier and
rapid progression of senile cataract

38.  Myotonic dystrophy: fine dust like opacities with
tiny iridescent spots in cortex- christmas tree
cataract
May progress to stellate opacity at posterior pole
 Atopic dermatitis: shield like dense anterior
subcapsular plaque

39.  Galactosemia: anterior and posterior subcapsular
lamellar opacities- oil drop cataract
 Wilsons disease: sunflower cataract
 Parathyroid tetany:
Children :lamellaropacities
Adults: anterior/ posterior punctate opacity

40. Snowflake cataract Christmas tree cataract
Oil droplet cataract Sunflower cataract

41.  Corticosteroid cataract :posterior subcapsular
cataract
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Chlorpromazine cataract
Miotic cataract :Anterior subcapsular cataract
Trinitrotoluence cataract
Other drugs like busulfan, chloroquine,
amiodarone
Metals like iron, gold, copper

42.  Causes:
Concussion– Rosette cataract
Penetrating trauma
Heat cataract: seen in glassworkers and ironworkers,
small posterior cortex opacity with zonular
exfoliation
Radiation cataract: posterior subcapsular opacities near
posterior pole
Electric cataract :anterior / posterior iridescent
opacities with stellate pattern

43. Rosette cataract
Traumatic cataract

44. SURGICAL MANAGEMENT
TREATMENT OF THE CAUSE OF CATARACT
• Adequate control of diabetes mellitus,
• Removal of cataractogenic drugs such as
corticosteroids, phenothiazenes and strong miotics
• Removal of irradiation (infrared or X-rays)
• Early and adequate treatment of ocular diseases like
uveitis

45. MEASURES TO DELAY PROGRESSION
• Commercially available preparations
containing iodide salts of calcium and
potassium are being prescribed in abundance
in early stages of cataract
• Vit E and aspirin also delays the process of
cataractogenesis

46. MEASURES TO IMPROVE CATARACT IN THE PRESENCE
OF INCIPIENT AND IMMATURE CATARACT
• Refraction should be corrected at frequent
intervals • Arrangement of illumination-patients
with peripheral opacities brilliant illumination • Use
of dark goggles in patients with central opacities •
Mydriatics- 5%phenyephrine or 1% tropicamide
b.i.d in affected eye

47. SURGICAL MANAGEMENT
INDICATIONS
a) Visual improvement
b) Medical indications: -Lens induced glaucoma -
Phacoanaphylactic endophthalmitis -Retinal diseases
like diabetic retinopathy or retinal detachment
c) Cosmetic indication-to obtain black pupil

48. PRE-OP MEDICATIONS AND PREPERATIONS
1. TOPICAL ANTIBIOTICS - Tobramycin and Gentamicin QID for
3days before surgery
2. PREPARATION OF THE EYE TO BE OPERATED
3. CONSENT
4. SCRUB BATH AND CARE OF HAIR
5. DRUGS TO LOWER IOP - Acetazolamide 500mg stat 2hrs before
surgery and Glycerol 60ml mixed with water 1hr before surgery
6. DRUGS TO SUSTAIN DILATED PUPIL - AntiProstaglandin eye
drops(Indomethacin)
ANAESTHESIA Cataract extraction can be performed under gen or
local anaesthesia. Local is preferred.

49. NURSING 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

50. 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.
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.

51. 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.

52.  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.
 Acetazolamide 500mg stat 2 hours before surgery.
 Instill cycloplegic/mydriatic eye drops every ten minutes one hour before surgery
 Relieve patient from anxiety with proper counseling.
 Make sure patient does not develop nausea or gastritis due to anxiety or
preoperative medicines.
 Cataract operation can be performed by ophthalmic surgeon under general or
local anaesthesia.

53. DISCHARGE 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

54. 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.