Cataract

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Cataract

  1. 1. Cataract Gauri S. Shrestha, M.Optom, FIACLE
  2. 2. What is a cataract? <ul><li>Opacification of human crystalline lens </li></ul><ul><li>Functionally, it includes the cases which interferes with vision </li></ul>
  3. 3. Morphological classification <ul><li>Subcapsular cataract </li></ul><ul><ul><li>Anterior subcapsular cataract </li></ul></ul><ul><ul><li>Posterior subcapsular cataract </li></ul></ul><ul><li>Nuclear cataract involves the nucleus of lens. </li></ul><ul><ul><li>Yellow to brown voloration </li></ul></ul><ul><li>Cortical cataract </li></ul><ul><ul><li>wedge shaped or radial spoke-like opacities. </li></ul></ul><ul><li>Polar cataract </li></ul>
  4. 4. Classification according to maturity <ul><li>An immature cataract </li></ul><ul><li>A mature cataract </li></ul><ul><li>A hypermature cataract </li></ul><ul><ul><li>A morgagnian cataract </li></ul></ul>
  5. 5. Etiological classification <ul><li>Congenital and developmental cataract </li></ul><ul><li>Acquired cataract </li></ul><ul><ul><li>Senile cataract </li></ul></ul><ul><ul><li>Traumatic cataract </li></ul></ul><ul><ul><li>Complicated (secondary) cataract . eg, uveitis, pathological myopia, glaucoma, retinal detachment, retinitis pigmentosa etc, </li></ul></ul><ul><ul><li>Metabolic cataract . Eg, Diabetes, hypocalcaemia, Wilson’s disease, Lowe’s syndrome </li></ul></ul>
  6. 6. Etiological classification <ul><li>Acquired cataract </li></ul><ul><ul><li>Electric cataract </li></ul></ul><ul><ul><li>Radiational cataract </li></ul></ul><ul><ul><li>Drug induced cataract eg, corticosteroid, copper, iron, Chlorpromazine, Busulphan, Allopurinol, Amiodarone, etc, </li></ul></ul><ul><ul><li>Cataract associated with skin diseases . Eg, atopic dermatitis, scleroderma, etc, </li></ul></ul><ul><ul><li>Cataract with miscellaneous syndromes . Eg, Dystrophica myotonica, Down’s syndrome etc, </li></ul></ul>
  7. 7. CONGENITAL AND DEVELOPMENTAL CATARACT <ul><li>Congenital cataract develops from some disturbance to normal development of lens . </li></ul><ul><ul><li>The disturbance occurs before the birth </li></ul></ul><ul><ul><li>The opacity may limit to embryonic or foetal nucleus. </li></ul></ul><ul><li>Developmental cataract occurs from infancy to adolescence. </li></ul><ul><ul><li>The opacity involves infantile or adult nucleus. </li></ul></ul><ul><li>3 children out of 10,000 live births. </li></ul><ul><ul><li>Two third of the cases are bilateral. </li></ul></ul>
  8. 8. Etiology <ul><li>Hereditary. </li></ul><ul><ul><li>1/3 rd hereditary, common mode: autosomal dominant inheritance </li></ul></ul><ul><li>Maternal factors. </li></ul><ul><ul><li>Malnutrition during pregnancy . </li></ul></ul><ul><ul><li>Maternal infection . Eg, rubella, toxoplasmosis, cytomegalo-inclusion disease. </li></ul></ul><ul><ul><li>Drug intake during pregnancy. Eg, thalidomide, corticosteroids. </li></ul></ul><ul><ul><li>Radiation exposure during pregnancy. Eg, X-rays, other ionizing radiations. </li></ul></ul>
  9. 9. Etiology <ul><li>Foetal or infantile factors. </li></ul><ul><ul><li>Deficient oxygenation owing to placental haemorrhage . </li></ul></ul><ul><ul><li>Metabolich disorders. Eg, galactokinase deficiency, neonatal hypoglycemia, galactosaemia, </li></ul></ul><ul><ul><li>Chromosomal abnormality. Eg, down syndrome </li></ul></ul><ul><ul><li>Skeletal syndromes. Eg, Hallermann-streiff-Francois syndrome, Nance-Horan syndrome </li></ul></ul>
  10. 10. Etiology <ul><li>Foetal or infantile factors. </li></ul><ul><ul><li>Birth trauma </li></ul></ul><ul><ul><li>Malnutrition early in infancy . </li></ul></ul><ul><ul><li>Prenatal infection. Eg, congenital rubella, toxoplasmosis, cytomegalovirus, herpes simplex and varicella. </li></ul></ul>
  11. 11. NURSING ASSESSMENT <ul><li>General </li></ul><ul><ul><li>History of white pupil, squint, spontaneous movement of eyes, loss of visual attention. </li></ul></ul><ul><ul><li>Assess density of cataract </li></ul></ul><ul><ul><li>Observe the red fundus reflex on ophthalmoscope. Absence of red fundus reflex indicates cataract is visually significant. </li></ul></ul><ul><ul><li>Perform fundus examination under dilatation . </li></ul></ul><ul><ul><li>Examine other associated ocular anomalies . Eg, absence of central fixation, nystagmus, strabismus, corneal clouding, microphthalmos, glaucoma, retinoblastoma, retinal disorders </li></ul></ul>
  12. 12. NURSING ASSESSMENT <ul><li>Investigation </li></ul><ul><ul><li>Serological test for intrauterine infections (TORCH= toxoplasmosis, rubella, cytomegalovirus, and herpes simplex). </li></ul></ul><ul><ul><li>A history of maternal rash during pregnancy for varicella zoster antibody titres. </li></ul></ul><ul><ul><li>Urinalysis for galactosaemia and chromatography for aminoacids. </li></ul></ul><ul><ul><li>Refer to pediatrician to rule out systemic diseases. </li></ul></ul>
  13. 13. AGE RELATED (SENILE) CATARACT <ul><li>Common and bilateral above the age of 50 years. </li></ul><ul><li>Male: Female::1:1 </li></ul><ul><li>Etiology </li></ul><ul><ul><li>Hereditary : Incidence, age of onset and maturation </li></ul></ul><ul><ul><li>Ultravoilet radiation : More exposure to UV-rays = early maturation. </li></ul></ul><ul><ul><li>Dietary factors : Poor diatery factors eg, lack of certain aminoacids, Vitamines (Vitamin E, Vitamin C, riboflavin) and essential minerals. </li></ul></ul><ul><ul><li>Dehydrational crisis : Prior episode of severe dehydration due to diarrhea and cholera. </li></ul></ul>
  14. 14. Mechanism of loss of transparency <ul><li>Cortical cataract </li></ul><ul><ul><li>Denaturation and coagulation of lens proteins. </li></ul></ul><ul><ul><li>Decrease level of aminoacids and protein systhesis </li></ul></ul><ul><ul><li>Increased hydration brought by decrease in potassium due to reversal of Na/K pump mechanism. </li></ul></ul><ul><li>Nuclear cataract: </li></ul><ul><ul><li>Degenerative changes occurring as nuclear sclerosis </li></ul></ul><ul><ul><li>Increase in water insoluble proteins, </li></ul></ul><ul><ul><li>compaction of nucleus resulting in a hard cataract. </li></ul></ul><ul><ul><li>Disturbance of lamellar arrangement in fibres </li></ul></ul>
  15. 15. Symptoms <ul><li>Painless progressive visual loss </li></ul><ul><li>Glare </li></ul><ul><li>Reduced color perception </li></ul><ul><li>Color haloes </li></ul><ul><li>Uniocular diplopia </li></ul><ul><li>Based on the location and density </li></ul>
  16. 16. Sign <ul><li>Opacification of the normally clear lens seen through the pupil </li></ul><ul><li>Indistinct on retina examination </li></ul><ul><li>Red reflex may be dim </li></ul><ul><li>No afferent pupillary defect </li></ul><ul><li>Myopic shift </li></ul>
  17. 17. NURSING ASSESSMENT <ul><li>Assess visual acuity and review report on refraction. </li></ul><ul><ul><li>Surgery is indicated when cataract develops to a degree sufficient to cause difficulty in performing daily essential activities. </li></ul></ul><ul><li>Assess a complete morphology of opacity (size, site, shape, color, and pattern) under slit lamp examination. </li></ul><ul><li>Perform cover test </li></ul>
  18. 18. NURSING ASSESSMENT <ul><li>Test papillary response. </li></ul><ul><li>Examine cornea to rule out any opacities </li></ul><ul><li>Examine ocular adnexa </li></ul><ul><li>Performed dilated fundus examination </li></ul><ul><li>Perform USG B-scan </li></ul><ul><li>Measure intraocular pressure </li></ul><ul><li>Perform potential acuity measurement </li></ul><ul><li>Perform biometry </li></ul>
  19. 19. Nursing Assessment <ul><li>Specular Microscopy (endothelium cells) </li></ul><ul><ul><li>A normal cell count > 2400 cells/mm 2 </li></ul></ul><ul><ul><li>If a cell count fewer than 1000 cells/mm 2 is risk of postoperative corneal decompensation </li></ul></ul>
  20. 20. Laboratory investigation <ul><li>Complete blood counts </li></ul><ul><li>Blood sugar </li></ul><ul><li>Urine analysis </li></ul><ul><li>Chest X-ray </li></ul><ul><li>Conjunctival swab for C/S </li></ul>
  21. 26. Type of cataract surgery <ul><li>Extracapsular cataract extraction (ECCE). </li></ul><ul><ul><li>Requires a relatively large circumferential limbal incision (8-10mm) through which the lens nucleus is extracted and the cortical matter aspirated, leaving behind an intact posterior capsule. </li></ul></ul><ul><ul><li>The IOL is then inserted. </li></ul></ul><ul><ul><li>It is the universal procedure of operation in cataract. </li></ul></ul><ul><ul><li>Posterior IOL can be transplanted after ECCE. </li></ul></ul>
  22. 27. Type of cataract surgery <ul><li>Intracapsular cataract extraction (ICCE) . </li></ul><ul><ul><li>The entire cataractous lens along with the intact capsule is removed in this procedure. </li></ul></ul><ul><ul><li>Weak and degenerated zonules are a pre-requisite for this method. </li></ul></ul><ul><ul><li>This is the surgery of choice only in markedly subluxated and dislocated lens. </li></ul></ul><ul><ul><li>This technique of surgery has been largely replaced by ECCE nowadays. </li></ul></ul>
  23. 28. Type of cataract surgery <ul><li>Phacoemulsification: </li></ul><ul><ul><li>A small hollow needle containing a piezo-electric crystal vibrates longitudinally at ultrasonic frequencies </li></ul></ul><ul><ul><li>The tip is applied to the lens nucleus; cavitation occurs at the tip as the nucleus is emulsified; </li></ul></ul><ul><ul><li>an irrigation and aspiration system removes this emulsified material from the eye. </li></ul></ul><ul><ul><li>The IOL is then injected through a much smaller incision than in ECCE. </li></ul></ul><ul><ul><li>Safe: avoid compression of eye, results in little postoperative astigmatism and early stabilization of refraction, and eliminate post-operative wound related problem </li></ul></ul>
  24. 29. Type of cataract surgery <ul><li>Lensectomy: </li></ul><ul><ul><li>Most of the lens including anterior and posterior capsule along with anterior vitreous are removed with the help of a vitreous cutter, infusion and suction machine. </li></ul></ul><ul><ul><li>Congenital as well as developmental cataract being soft are easily dealt with this procedure. </li></ul></ul>
  25. 30. NURSING DIAGNOSIS <ul><li>Gradual painless diminution of vision </li></ul>
  26. 31. EXPECTED OUTCOME <ul><li>Immediate. </li></ul><ul><ul><li>Optimal vision will be restored with periodic refractive correction with glasses. </li></ul></ul><ul><ul><li>Patient will be reassured and informed with progression and option of surgery. </li></ul></ul><ul><ul><li>Make patient educate and aware about possibility of fall due to visual impairment. </li></ul></ul>
  27. 32. EXPECTED OUTCOME <ul><li>Preoperative </li></ul><ul><ul><li>Comfort and safety will be maintained. </li></ul></ul><ul><ul><li>Any infection will be treated and prophylaxis treatment will be initiated. </li></ul></ul><ul><ul><li>Surgical procedure and postoperative care will be explained. </li></ul></ul><ul><ul><li>Patient’s anxiety will be eliminated. </li></ul></ul><ul><ul><li>Secondary development of glaucoma will be prevented. </li></ul></ul>
  28. 33. EXPECTED OUTCOME <ul><li>Postoperative </li></ul><ul><ul><li>Pain is relieved, comfort is ensured. </li></ul></ul><ul><ul><li>Haemorrhage and loss of vitreous humour will be prevented. </li></ul></ul><ul><ul><li>Intraocular pressure will be prevented to rise. </li></ul></ul><ul><ul><li>Infection will be prevented. </li></ul></ul><ul><ul><li>Ensure restoration of vision </li></ul></ul>
  29. 34. Implementation: Prepare patient for cataract operation <ul><li>Topical antibiotics tobramycin, gentamycin or ciprofloxacin qid for 3 days. </li></ul><ul><li>Trim or cut upper lid eyelashes </li></ul><ul><li>Obtain written and detailed consent from the patient or first degree relatives. </li></ul><ul><li>Ensure each patient take scrub bath including face and hair. Males must get their beard cleaned. </li></ul><ul><li>Acetazolamide 500mg stat 2 hours before surgery. </li></ul><ul><li>Instill cycloplegic/mydriatic eye drops every ten minutes one hour before surgery </li></ul>
  30. 35. Implementation <ul><li>Relieve patient from anxiety with proper counseling. </li></ul><ul><li>Make sure patient does not develop nausea or gastritis due to anxiety or preoperative medicines. </li></ul><ul><li>Instruct patient not to touch eyes. </li></ul><ul><li>Cataract operation can be performed by ophthalmic surgeon under general or local anaesthesia. </li></ul>
  31. 36. PREOPERATIVE CHECKLIST <ul><li>History and physical examination </li></ul><ul><li>Name of procedure on surgical consent </li></ul><ul><li>Signed surgical consent </li></ul><ul><li>Laboratory results </li></ul><ul><li>Allergies have been identified </li></ul><ul><li>Vital signs assessed </li></ul><ul><li>Jewelry removed </li></ul><ul><li>Client is wearing a hospital gown and hair cover </li></ul><ul><li>Client has urinated </li></ul><ul><li>The prescribed preoperative medication has been given </li></ul>
  32. 37. Implementation: Immediate postoperative care <ul><li>The patient is asked to lie quietly upon the back for about three hours and advised not to take food. </li></ul><ul><li>Instruct patient avoid coughing, sneezing and avoid bending from the waist. </li></ul><ul><li>Give analgesics. </li></ul><ul><li>Provide quite and safe environment. </li></ul><ul><li>Notify physician of sudden pain occurs </li></ul><ul><li>Treat nausea or vomiting immediately if present </li></ul>
  33. 38. DISCHARGE INSTRUCTIONS <ul><li>Care of the incision </li></ul><ul><li>Signs of complications </li></ul><ul><li>Drugs for pain management </li></ul><ul><li>How to self administer prescribed medications </li></ul><ul><li>Amount of weight that can be lifted </li></ul><ul><li>Diet </li></ul><ul><li>Return for a medical appointment </li></ul>
  34. 39. Implementation: Subsequent post-operative care <ul><li>Remove bandage next morning. </li></ul><ul><li>Inspect eye for any postoperative complication. </li></ul><ul><li>Instruct patient and family to instill antibiotic and steroid eye drops prescribed for 2 to 4 weeks. </li></ul><ul><li>Antibiotic ointment at bed time for a week. </li></ul><ul><li>Oral analgesic (sos) </li></ul><ul><li>Provide eye shield. </li></ul><ul><li>Then patient can be instructed to wear sunglasses. </li></ul><ul><li>Ensure patient got prescribed spectacle after 6-8 weeks of operation. </li></ul>
  35. 40. EVALUATION <ul><li>Outcome criteria </li></ul><ul><ul><li>Pain is relieved and infection is prevented. </li></ul></ul><ul><ul><li>Cataract is removed and sight is restored with or without corrective glasses. </li></ul></ul><ul><ul><li>Patient successfully adapts to vision change with planned rehabilitation. </li></ul></ul>
  36. 41. THANK YOU !

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