BY: -
ACHOKA CLIFFORD(BSCN)

Table of Contents
1.Patient demographic Data ............................................................................................................ 3
2. Literature review......................................................................................................................... 3
Definition .................................................................................................................................... 3
Epidemiology.............................................................................................................................. 5
Predisposing factor...................................................................................................................... 5
Causes.......................................................................................................................................... 6
Pathophysiology.......................................................................................................................... 7
Clinical manifestation ................................................................................................................. 8
Prevention and control ................................................................................................................ 8
Prognosis ..................................................................................................................................... 8
Differential diagnosis .................................................................................................................. 9
3.Assessment of patient under study............................................................................................... 9
History taking.............................................................................................................................. 9
Chief complaint ....................................................................................................................... 9
History of presenting illness .................................................................................................... 9
Past medical history............................................................................................................... 10
Past surgical history............................................................................................................... 10
Family history........................................................................................................................ 10
Personal history ..................................................................................................................... 10
4.Investigative procedures ............................................................................................................ 10
General Examination ............................................................................................................. 10
Vital signs .............................................................................................................................. 10
5.Management............................................................................................................................... 13
6.NURSING CARE PLAN........................................................................................................... 19

1.Patient demographic Data
Name: A.P.O
Age: 50 yrs.
Sex: Male
Ward: Eye clinic (out-patient)
Medical Diagnosis: Senile Cataracts
Religion: Christian
Address: Kondele
2. Literature review
CATARACT
Normal lens structure
 Th lens is a transparent, biconvex, crystalline structure placed between iris and the
vitreous in a saucer depression the patellar fossa
 It has got two surfaces: the anterior surface is less convex than the posterior. These two
surfaces meet at the equator
 Non-vascular, transparent and colorless
 Consists of stiff elongated prismatic cells known as lens fiber, very tightly packed
together
 Divided into nucleus, cortex and capsule
 The whole lens is enclosed within elastic capsule.
 Its refractive index is 1.39 and total power is 15-16 D
Definition
A cataract is a clouding or capacity that develops in the crystalline lens of the eye or in its
envelope, varying in degree from sight to capacity and obstructing the passage of light.

Cataract is due to degeneration and opacification of formed lens fibers, formation of aberrant
lens fibers or deposition of other materials in their space.
Usually developmental opacities are stationary and partial
Acquired opacities progress till entire lens is involved
Classification
Based on :
 Morphology
 Age of onset
 Maturity
 Etiology
Morphology
1. Capsular cataract
 Anterior capsular cataract
 Posterior capsular cataract
2. Sub Capsular cataract
3. Nuclear cataract
4. Cortical cataract
5. Lamellar cataract
6. Sutural cataract
Age of onset
1. Congenital cataract
2. Infantile cataract
3. Juvenile cataract
4. Pre-senile cataract
5. Senile cataract
Maturity
1. Intusemecent cataract

2. Immature cataract
3. Mature cataract
4. Hypermature cataract
5. Morgangnian cataract
Epidemiology
 Cataract is the leading cause of blindness in the world.
 An estimated of 25 million people were blind due to cataract i.e 50% or more of the
global burden of blindness.
 Annually, at least 25 million eyes develop visual acuity <6/60 due to cataract.
 around 1% of Africans are blind.
 According to the World Health Organization, 2017 cataracts are the number on cause of
blindness worldwide
-50 million persons in the world are BLIND from cataracts
-more than half of people over 65 have cataracts
-60% of people over the age of 75 have cataracts
Predisposing factor
 Heredity
 Age
 UV radiation
 Dietary deficiencies of Vitamins A, C, E
 Severe diarrhea
 Diabetes
 Smoking
 Corticosteroids

Causes
CONGENITAL
 Familial
 Intrauterine infections
 Maternal drug ingestions
AGE
 Elderly
METABOLIC
 Diabetes
 Hypocalcemia
 Wilson’s Disease
 Galactosemia
DRUG-INDUCED
 Corticosteriods
 Miotics
 Amiodarone
 Phenothiazines
TRAUMATIC AND INFLAMATORY
 Post intra-ocular surgery
 Uveitis
DISEASE ASSOCIATED
 Downs Syndrome
 Dystrophia Myotonica
 Lowe’s Syndrome
 Atopic dermatitis

Pathophysiology
Any Physical or Chemical cause
↓
Disturbs the intracellular and extracellular equilibrium of water and electrolytes
↓
Deranges the colloid system in lens fibers
↓
Aberrant fibers are formed from germinal epithelium of lens
↓
Epithelial cell necrosis
↓
Focal opacification of lens epithelium(glaucomflecken)
↓
Opacification of lens
Opacification of lens takes place by 3 biochemical changes.
1. Hydration
2. Denaturation of lens protein
3. Slow sclerosis
These lead to abnormalities of lens proteins and disorganization of lens fibers which in turn
lead to loss of transparency of lens and hence Cataract.

Clinical manifestation
 Decrease vision most obvious and important because of reduced transparency of lens
 Decreased contrast sensitivity
 Refractive error like myopia due to change in Refractive index of nucleus and hence
frequent change of glasses
 Monocular diplopia and colored halos due to irregular refraction by different parts of lens
 Glare due to scattered light rays
 Change in colour values i.e. red is accentuated.
Prevention and control
 Intake of dietary antioxidants e.g. Vitamin A, C and E prevent cataract formation by
blocking the oxidative modification of the lens
 Wearing sunglasses and a hat with a brim to block ultraviolet sunlight may help to delay
cataract.
 Cessation of smoking
 Ensuring good nutrition especially green leafy vegetables, fruits and other foods with
antioxidants
 If you are age 60 or older, you should have a comprehensive dilated eye exam at least
once every two years
 Adequate control of diabetes mellitus
 Removal of cataractogenic drugs such as corticosteroids, phenothiazines and strong
miotic.
 Early and adequate treatment of ocular disease like uveitis
Prognosis
Most patient do well after cataract surgery provided, they adhere to postoperative instructions
and medications regime.
A high percentage of patients may develop gradual opacification of the posterior capsule that can
reduce the patients vision.

Differential diagnosis
 Diabetic retinopathy
 Age-related macular degeneration
 Glaucoma
 Retinal detachment
 Cornea scarring
 Corneal dystrophy.
3.Assessment of patient under study
History taking
Chief complaint
 Progressively diminished vision in both eyes since childhood
 Loss of vision in Left Eye in the past 5 years
 Sudden loss of vision Right eye 20 days ago
History of presenting illness
Patient presented to the Eye clinic with the above-mentioned complaints. He reported that ever
since he was a small boy, he had faulty vision compared to his peers. He mostly emphasized that
he had difficulty in seeing the blackboard that he had to sit in front. He also reported that the
problem has been growing gradually to the point even reading was a problem. He reported that
the vision was worse during the night with much glare or light and during the day, it relieved
when he looks down. He reported at age of 10, he visited an ophthalmologist who prescribed him
glasses. He claims that with the glasses he could see clearly. The patient reported he had
difficulty in judging depth and distances. He reported since the last 6 years he has been having
difficulty in seeing at night. 7 years back patient started developing increased diminishing in
vision in Left eye and within a period of 1 month he could no more that appreciate light from the
left eye. In the past 3 yrs. he developed some black and blue spots in front of his right eye, which
moved as he moved his eyes and persisted on closing the eyes also. Number of spots
progressively increased. Since 25 days the patient started seeing lighting flashes in front of right
eye even when it was dark at night and there was no light in the room.20 days back patient was
seeing well while heading to work and as he was doing his work he suddenly experienced a

sudden loss of vision. He was rushed to Kisumu county hospital which referred him to Jaramogi
oginga.
Past medical history
He is a known diabetic patient on insulin for the past 10 years. He has been admitted twice due to
hyperglycemia and uncontrolled diabetes. He never been transfused with blood. He has no
known food or drug allergies is currently on insulin therapy. He uses OTC drugs like
paracetamol. He has been
Past surgical history
She has no surgical history
Family history
He was born of a consanguineous marriage; He has 4 siblings and I the third born. Neither his
parents nor any of the siblings had similar complaints. Mother and father are dead. All of the
patient siblings are alive and healthy. He has a 14-year-old son who goes to school, doesn’t sue
glasses and has no ocular complaints. There is no familial history of chronic illness like diabetes
or hypertension.
Personal history
he reported a mixed diet. He reported that his appetite has markedly reduced. Sometime he
experiences disturbed nights. Bowel habits are normal but has increased urination frequency and
urgency. He doesn’t smoke or take alcohol
4.Investigative procedures
General Examination
 Patient is a middle-aged male, moderately built poorly nourished
 He is conscious, cooperative and well oriented to time, place and person
No signs of pallor, jaundice or cyanosis.
Vital signs
BP – 112/72 mmHg
Pulse -71bmin

RR – 16breaths/min
Head
Head was rounded, normocephalic and symmetrical
The skull had no nodules or masses and depression when palpated
Face was smooth and had uniform consistency with absence of nodules and masses.
Ears
Ears: The Auricles are symmetrical and has the same color with his facial skin. The auricles
are aligned with the outer canthus of eye. When palpating for the texture, the auricles are mobile,
firm and not tender. The pinny recoils when folded.
Nose and Sinus
• Nose; Tice nose appeared symmetric, straight and uniform in color. There was no discharge or
flaring. When lightly palpated, there were no tenderness and lesions
Chest and abdomen
• Chest: The chest wall is intact with no tenderness and masses. There's a
full and symmetric expansion and the thumbs separate 2-3 cm during deep
inspiration when assessing for the respiratory excursion. The client manifested
quiet, rhythmic and effortless respirations.
• Heart: There were no visible pulsations on the aortic and pulmonic areas. There
is no presence of heaves or lifts.
• Abdomen: The abdomen of the client has an unblemished skin and rs uniform In
color. The abdomen has a symmetric contour. There were symmetric
movements caused associated with client’s respiration
Extremities
 The extremities were symmetrical in size and length

 Muscles: The muscles are not palpable with the absence of tremors_ They were normally
firm and showed smooth, coordinated movements.
 Bones: There were no presence of bone deformities, tenderness and swelling
 Joints: There were no swelling, tenderness and joints move smoothly.
Hb – 04.8 gm%
Platelet count –
Rbc count- 3.19million/cmm
Blood group- A positive
Mini renal
Serum urea – 23mg/dl
Serum creatinine – 0.6 mg/dl
LFTs
Total bilirubin – 0.8 mg/dl
Direct bilirubin – 0.2 mg/dl
Serum Albumin – 3.3g/dl
TESTS
1. The Snellen Visual Acuity test
 Each eye is tested separately, with and without glasses
 Letters and objects are of a size that can be seen by normal eye at the distance of 6m from
the chart
Results
Right eye HMCF, PL +VE, PR accurate
Left eye PL +VE, PR inaccurate

Colour vision could not be assessed
2. Tonometry
This is a standard test to measure fluid pressure inside the eye
Right eye – 12.2 mmHg
Left eye – Unrecordably low
3. Pupil dilatation/Refraction
The pupil is widened with eye drops to allow the doctor to see more of the lens and retina and
look for eye problems
4. Slit-lamp Biomicroscopic Examination
Visual fields could not be assessed.
5.Management
There is no medical treatment for cataracts, although use of vitamin C and E and beta-carotene is
being investigated. Glasses or contact, bifocal, or magnifying lenses may improve vision.
Mydriatics can be used short term, but glare is increased. But there are take home medications
following a cataract extraction which usually include anti-inflammatory drops containing
antibiotics and cycloplegic to prevent ciliary spams
The aim of treatment is:
1. To improve vision
2. Increase mobility and independence
3. Relief from the fear of going blind
Glasses: Cataract alters the refractive power of the natural lens so glasses may allow good vision
to be maintained
Surgical removal: When visual acuity can’t be improved with glasses.

Surgical techniques
- Phacoemusification
- Extracapsular cataract extraction
- Intra capsular cataract extraction
- Intraocular lens implantation
- Cryosurgery
PHACOEMULSIFICATION
It is the widely used cataract surgery in the developed world (Eunbi et al., 2014).This procedure
uses ultrasonic energy to emulsify the cataract lens.
STEPS:
1. Anaestetic – The eye is numbed with either a subtenon injection around the eye or
typical anesthetic eye drops. The former also provides paralysis of the eye muscles
2. Corneal incision – Two cuts are made at the margin of the clear cornea to allow insertion
of instruments in the eye
3. Capsulorhexis – A needle or small pair of forceps is used to create a circular hole in the
capsule in which the lens sits
4. Phacoemulsification – A handheld ultrasonic probe is used to break up and emulsify the
lens into liquid using the energy of ultrasound waves. The resulting emulsion is sucked
away using the same probe
5. Irrigation and aspiration – The cortex, which is the soft outer layer of the cataract, is
aspirated or sucked away. Fluid removed is continually replaced with a saline solution to
prevent collapse of the structure of the anterior chamber
6. Lens insertion – A plastic, foldable lens is inserted in to the capsular bag that formerly
contained the natural lens. Some surgeons also inject an antibiotic in the eye to reduce
risk of infection. The final step is to inject salt water into the corneal wounds to cause the
area o swell and seal the incision
Medications
Betamethasone

Class – Corticosteroid
MOA – It is a corticosteroid with mainly glucocorticoid. It prevents and controls
inflammation by controlling the rate of protein synthesis, depressing migration of
polymorphonuclear leukocytes and fibroblasts and reversing capillary permeability to lysosal
stabilization
Side effects
 Sodium and fluid retention
 Potassium and calcium depletion
 Muscle wasting
 Osteoporosis
 Gi disturbances and bleeding
Nursing responsibilities
 Asses involved systems periodically
 Asses patient for signs of adrenal insufficiency
 If dose is ordered daily, administer in the morning to coincide with the boys normal
secretion of cortisol
Cyclopentolate
Class – Cycloplegic mydriatics
MOA – By blocking muscarinic receptors, it produces dilatation of the pupils and
prevents the eye from accommodating for near vision
Side effects
 Tachycardia
 Skin irritation
 Sever skin rash
 Slow or shallow breathing
Nursing responsibilities

 Use cautiously in patients with history of glaucoma; Systemic absorption may
cause anticholinergic effects such as confusion, unusual behaviour, flushing and
hallucinations
COMPLICATIONS OF CATARACT SURGERY
 Ineffective endophthalmitis(emergency)
 Suprachoroidal hemorrhage
 Uveitis
 Ocular perforation
 Postoperative refractive error
 Posterior capsular rapture
 Vitreous loss
 Retinal detachment
 Cystoid macular edema
 Glaucoma
 Posterior capsular opacification

PERIOPERATIVE CARE OF PATIENT UNDERGOING CATARACT OPERATION
PREOPERATIVE CHECKLIST
 History and physical examination
 Name of procedure on surgical consent
 Signed surgical consent
 Laboratory results
 Allergies have been identified
 Vital signs assessed
 Jewelry removed
 Client is wearing a hospital gown and hair cover
 Client has urinated
 The prescribe preoperative medication has been given.
 Topical antibiotics; tobramycin, gentamycin or ciprofloxacin qid for 3days
 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. Males must get their beard
cleaned
 Acetazolamide 500mg stat 2 hours before surgery
 Instill cycloplegic/mydriatic eye drops every ten minutes on hour before surgery.
 Relieve patient from anxiety with proper counselling
 Make sure patient doesn’t develop nausea or gastritis due to anxiety or preoperative
medicines
 Instruct patient no to touch eyes
 Cataract operation can be performed by ophthalmic surgeon under general or local
anesthesia.

POSTOPERATIVE CARE
IMMEDIATE POSTOPERATIVE CARE
 The patient is asked to lie quietly upon the back for about three hours and advised not to
take food
 Instruct patient avoid coughing, sneezing and avoid bending from the waist
 Give analgesics i.e. Diclofenac sodium 75mg I.M tds
 Provide quiet and safe environment
 Notify physician if sudden pain occurs
 Treat nausea and vomiting immediately if present.
SUBSEQUENT POSTOPERATIVE 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
 Provide eye shield
 The patient can be instructed to wear glasses
 Ensure patient got prescribed spectacle after 6-8 weeks of operation
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 medical appointment

6.NURSING CARE PLAN
Assessment data Nursing
diagnosis
Goal/expected
outcome
Interventions Rationale Evaluation
1.Blurry vision
2.poor colour
perception
3.Difficulty
focusing
4.Poor visual
acuity
5.Increased glare
6.Patient unable
to walk and see
distance objects
6.Cloudy
appearance on the
eye
7.Poor visual
acuity
8.Right eye
HMCF, PL +VE,
PR accurate
Left eye PL +VE,
PR inaccurate
Disturbed
visual sensory
perception
related to
changes in
sensory acuity
as evidence by
poor visual
acuity, blurry
vision,
difficulty
focusing
Goal
By the end of 48
hours patient will
regain optimal
vision possible and
will adapt to
permanent visual
changes
Expected
outcomes
1.Patient will be
able to verbalize
understanding of
visual loss and
diseases of eyes
2. Patient will be
able to regain
vision to the
maximum possible
extent with
surgical procedure
3. Patient will be
able to deal with
potential for
permanent visual
loss
1. Assess the patient’s
ability to see and
perform activities.
2. Encourage patient
to see an
ophthalmologist at
least yearly.
3. Provide sufficient
lighting for the patient
to carry out activities.
4. Provide large print
objects and visual aids
for teaching
5.Demontstrate/have
client administer eye
drops using correct
procedure
6.Prepare for surgical
intervention as
indicated like a
cataract extraction
1. Provides a
baseline for
determination of
changes
affecting the
patient’s visual
acuity.
2. Can monitor
progressive
visual loss or
complications.
Decreases in
visual acuity can
increase
confusion in the
elderly patient
3. Elderly
patients need
twice as much
light as younger
people.
4. Assists patient
to see larger
print and
Goal was fully met
as evidenced by: -
1.Patient
verbalized
understanding of
visual loss and
disease of eyes
2.Patient regained
partial vision.
3.Patient was able
to verbalize
understanding of
potential loss of
vision.
4.Patient
maintained a safe
environment.
5.Patient was
complaint with
instructions given
to the latter

4. Patient will
maintain a safe
environment with
no injury noted
5. Patient will be
compliant with
instructions given,
and will be able to
notify physician
for emergency
symptoms
promotes a sense
of independence.
5.Eyedrop
treatment is
needed to
control IOP and
prevent further
loss.
6.Removing the
lens through
surgery
improves visual
acuity.
Assessment data Nursing
diagnosis
Goal/expected
outcome
Interventions Rationale Evaluation
1.Blurry vision
2.poor colour
perception
3.Difficulty
focusing
4.Poor visual
acuity
5.Increased glare
6.Patient unable
to walk and see
distance objects
Risk for injury
related to poor
vision and
reduced
extremity-eyes
coordination
Goal
By the of nursing
interventions
patient should be
free from
trauma/injury
Expected outcome
1.Patient should
express
understanding of
the factors
involved in the
1.Ascertain
knowledge of safety
need/injury
prevention and
motivation.
2.Orient patient to
environment.
3.Advice patient to
use sunglasses to
reduce glare.
4.Keep patient’s
visual aids near reach
1.To prevent
injury in home or
community
setting
2.To enable
patient to
perform
activities with
ease
3.To enhance
visual
discrimination
Goal was fully
met as evidenced
by: -
1.Patient was
able to express
understanding of
the factors
involved in the
possibility of
injury
2.Patient was
able to explain

possibility of
injury
2.Patient explains
methods to prevent
injury
3.Patient relates
intent to practice
selected
prevention
measures
4.Patient increases
daily activity, if
feasible
5.Ensure the
environment has
sufficient lighting and
all furniture moved to
the walls
6.Monitor
environment for
potentially unsafe
conditions and
modify as needed
and reduce risk
for injury
4.To provide
patient assistance
and for optimal
visual acuity.
5.To provide
safe environment
to minimize the
potential injury.
6.To provide
safe physical
environment and
individual safety
methods to
prevent injury
3.Patient was
able to relate
intents to
practice selected
prevention
measures
4.Patient
increased his
daily activity.

Assessment data Nursing diagnosis Goal/expected
outcome
Interventions Rationale Evaluation
1.Patient looks
worried and
fidgeting before
the surgery
2.Patient is
worried about
possible
permanent loss of
vision on the other
eye.
3.Patient asks a lot
of questions about
the outcome and
prognosis of the
cataract surgery.
4.Pa
Anxiety related to
threat of permanent
loss of vision and
independence as
evidenced by patient
looking worried and
fidgeting.
Goal
Within a 4 days
patient should be
free from Anxiety
Expected outcome
1.Patient should
appear relaxed and
report anxiety is
reduced to a
manageable level.
2.Patient should be
able to use
resources
effectively.
3.Patient should
have enough
knowledge about
the condition
4.Patient will
verbalize
understanding of
the prognosis of
the condition
1.Familiarize
patient with the
environment
and new
experiences or
people as
needed.
2.Encourage
client to
acknowledge
concerns and
express
feelings.
3.Identify
helpful
resources and
people.
4.Provide
accurate, honest
information.
Discuss
probability that
careful
monitoring and
treatment can
1.Awareness of
the environment
promotes
comfort and may
decrease anxiety
experiences by
the patient.
2.Provides
opportunity of
the client to deal
with the reality
of situation,
clarify
misconception
and problem
solve concerns.
3.Provides
reassurance that
client is not
alone in dealing
with problems
4.Reduces
anxiety related to
unknown/future
expectations and
Goal was fully
met as evidenced
by: -
1.Patient was
relaxed and
reported reduced
anxiety.
2.Patient used
available
resources
effectively
3.Patient
reported
understanding of
everything about
the condition
4.Patient
verbalized
understanding of
the prognosis of
the disease
5.patient
consented for the
surgery to be
done

5.Patient will
consent to the
cataract surgery
prevent
additional
visual loss
provides factual
basis for making
informed choices
about treatment

REFERENCES
1. Dineen B, Bourne RR,Jadoon Z, Shah SP, Khan MA, Fsoter A, et. Al, Causes of Blinness
and Visual impairment in Pakistan: The Pakistan national blindness and visual
impairment surveyr. Br J Ophalmology 2007; 91:1005-10.
2. Eunbi Kim., Sam Young Yoon., Young Joo Shin.,(2014)., Studies on the cornea and
Lens, p.4.
3. http://www.world.federatio.org/Health/Aeimullah+Eye+Clinics/Mianwali+-
+Pakistan/Articles/115_Patients_Screened_39_cataract_surgeries_performed_Aeinullhah
_Eye_Clinic_pakistan _month_march_2013.htm
4. Suddarth and Brunner text book Medical Surgical Nursing (Edi: 12th,2010) published by
health |Lipponcott Williams & Wilkins South Asia Advisory Penal.
5. World Health Organization 2017.