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Catract

  1. 1. surgical CATARACT  INTRODUCTION Cataract derives from the Latin cataracta meaning "waterfall" and the Greek kataraktes and katarrhaktes, from katarassein meaning "to dash down" (kata-, "down"; arassein, "to strike, dash")] Early in the development of age-related cataract the power of the lens may be increased, causing near-sightedness (myopia), and the gradual yellowing and opacification of the lens may reduce the perception of blue colors. Cataracts typically progress slowly to cause vision loss and are potentially blinding if untreated. The condition usually affects both the eyes, but almost always one eye is affected earlier than the other. Human eye cross- sectional view, showing position of human lens.  DEFINITION:- Cataract is a condition in which the lens of the eye becomes opaque one or both eyes may be affected. Acc. To Barbara k. Clouding or opacity of the crystalline lens that impairs a vision. Acc To. Lippincott.
  2. 2. surgical Opacity in lens or its capsule wheater developmental or acquired is called cataract. Acc. To. Renu Jogi As opacification on or side the lens. Functionally it includes only those cases which interfes with vision. Clinically, it is opacification of lens which obstruct the normal red glow on distant direct opathalmoscopy. Acc. To. Pradeep Sharma A cataract is a clouding that develops in the crystalline lens of the eye or in its envelope, varying in degree from slight to complete opacity and obstructing the passage of light.  INCIDENCE:-  CATARACT are a common and significant cause of visual deficit, affecting nearly 20.5 million people over age 40 in the U.S.  By age 80 nearly half of the population is affected. Cataract affects slightly more women than men, and more white than people of color.  Prevalence of cataract in US increases with aging:-  2.5 just over / millions of adult age 40-49 are affected.  The increases to more than 2 million (or 6.8 ) of those ages 50-59 and nearly doubles to 4 million 20% of adult age 60-69  68.3 of adults age 80 and older (cover 6 millions).  The increase in ultraviolet radiation resulting from depletion of the ozone layer is expected to increase the incidence of cataracts.  ETIOLOGY:- 1. AGING:-  Loss of lens transparency  Decreased oxygen uptake  Decreased levels of vit.c, protein  Increase in sodium and calcium 2. Toxic factors:-  Cigarette smoking  Long term use of corticosteroids  Chemical eye burns, poisoning.
  3. 3. surgical 3. NUTRITINAL FACTORS:-  Poor nutrition  Obesity  Reduced antioxidants 4. PHYSICAL FACTORS:-  Trauma, perforation  U.V. radiation and x rays. 5. ASSOCIATED OCULAR CONDITIONS:-  Myopia  Infections  Retinal surgery 6. SYSTEMIC DISEASES AND SYNDROMS:-  D.M.  Down syndrome  Renal disorders  Musculoskeletal disorder.  PATHOPHYSIOLOGY:- Causative factor (trauma, radiation) ↓ Altered metabolic processes with the lens ↓ Cause an accumulation of water ↓ Alteration in the lens fiber structure ↓ These changes affect lens transparency causing vision loss
  4. 4. surgical  CLASSIFICATION The following is a classification of the various types of cataracts. 1. CONGENITAL OR DEVELOPMENT:-  Punctate cataract.  Zonular cataract  Coronary cataract  Anterior capsular cataract  Posterior capsular cataract  Others : coralliform, discoid, axial, sutural cataract 2. ACQUIRED CATARACT:-  Senile – cortical and nuclear cataract  Cataract associated ocular disease  Cataract associated with systemic disease- diabetic’s parathyroid, teteny.  Cataract due to radiation  Traumatic cataract  After cataract.  CONGENITAL CATARACT OR DEVELOPMENTAL:- CONGENITAL:- The disturbance of lens development occurring in intrauterine stage cause a child to be born with congenital cataract. Developmental: - It is used in a broader sense implying a cataract due to defect in development at any stage.  ETIOLOGY: 1. Genetically transmission:- about 20% cases. 2. Maternal factors like intrauterine infections (rubella), malnutrition, drug toxicity and radiation damage, 20% of cases. 3. Metabolic diseases;- like diabetic, hypoparathyroidism, neonatal hypoglycemia etc. 4. Miscellaneous causes:- birth trauma, placental hemorrhage, endocrine dysfunction,
  5. 5. surgical 5. Idiopathic causes: 50% cases.  CLINICAL TYPES OF CATARACT:- 1. PUNCTATE CATARACT:- It is most common Varity manifests by multiple, small opaque, scattered are seen. On slit limp examination they appear as blue dots hence known as blue dot cataract. It doesn’t interfere with vision. 2. ZONULAR CATARACT:- most common type of cataract 50% occurs. It is bilateral with strony dominant hereditary tendency. Malnutrition and lack of vit.D. May cause zonular cataract along with erosion of permanent incisor and canine. An area around embryonic nucleus become opacified and 2 rings of opacity are seen. The opacity is sharply demarked and the area of lens with in and around the opacity is clear. Linear opacities or riders may run towards the equator. 3. CORONARY CATARACT:- It commonly occurs at puberty ( adult ) . It situated in deep layers of cortex there are gap of club ( ubhar ) shaped opacities in the cortex of lens. 4. ANTERIOR CAPSULAR CATARACT: - it is due to delayed formation of the anterior chamber. It project forwards into anterior chamber like pyramid and the cortex may become opaque. 5. POSTERIOR CAPSULAR CATARACT:- it is due to persistence of posterior part of vascular sheath cause total cataract.  Complication:- Immediate after surgery;- a. Uveitus b. Glaucoma c. Infection Delayed complication: - a. Retinal detachment b. After cataract c. Sympathetic opthalmia.
  6. 6. surgical  ACQUIRED CATARACT:- The opacification of already forced lens fibres in the post natal period called ‘Acquired Cataract’.  ETIOLOGY:- 1. Trauma induced cataract:- called traumatic cataract. 2. Secondary cataract:- occurs due to systemic causes such as diabetes mellitus etc. 3. Complicated cataract: cataract due to any type such as uveitis, old retinal detachment. 4. Radiation cataract: induced by exposure to radiation such as U.V , x rays etc. 5. Heat cataract: exposure to high temperature such as glass blowers. 6. Senile cataract : age related cataract it is commonest type. 7. Toxic cataract: chronic exposure to drugs like corticosteroids. 8. Electric cataract : through uncommonly reported are serious complication of electrical injury.  SENILE CATARCT OR AGE RELATED CATARCT:- Opacification of lens which occur with advancing age usually above 50 year or likely above 75-80 years. It mostly occurs in male than in females. TYPES OF SENILE CATARACT:  NUCLEAR CATARCT:- Most common type • Age-related • Occur in the center of the lens. • In its early stages, as the lens changes the way it focuses light, patient may become more nearsighted or even experience a temporary improvement in reading vision. Some people actually stop needing their glasses. • Unfortunately, this so-called 2nd sight disappears as the lens gradually turns more densely yellow & further clouds vision.
  7. 7. surgical • As the cataract progresses, the lens may even turn brown. Advanced discoloration can lead to difficulty distinguishing between shades of blue & purple.  CORTICAL CATARCT:- • Occur on the outer edge of the lens (cortex). • Begins as whitish, wedge-shaped opacities or streaks. • It’s slowly progresses, the streaks extend to the center and interfere with light passing through the center of the lens. • Problems with glare are common with this type of cataract.  IMMATURE CATARCT:- Lens is partially opaque Two morphological forms are seen: 1. Cuneiform Cataract: – Wedge shaped opacities in the peripheral cortex and progress towards the nucleus. – Vision is worse in low ambient illumination when the pupil is dilated. 2. Cupuliform Cataract: – A disc or saucer shaped opacities beneath the posterior capsule. – Vision is worse in bright ambient illumination when the pupil is constricted. Lens appears grayish white in color. Iris shadow can be seen on the opacity with oblique illumination.
  8. 8. surgical  MATURE CATARCT:-  Lens is completely opaque.  Vision reduced to just perception of light  Iris shadow is not seen  Lens appears pearly white  HYPERMATURE CATARACT:- • Shrunken and wrinkled anterior capsule due to leakage of water out of the lense. • This may take any of two forms: 1. Liquefactive/Morgagnian Type:- A.Cortex undergoes auto-lytic liquefaction and turns uniformly milky white. B.The nucleus loses support and settles to the bottom. 2. Sclerotic Cataract:- 1.The fluid from the cortex gets absorbed and the lens becomes shrunken. 2.There may be deposition of calcific material on the lens capsule. 3.Iridodonesis: Anterior chamber deepens and iris becomes tremulous. 4.The zonules become weak, increasing the risk of subluxation / dislocation of lens.  TRAUMATIC CATARCT:-Cataract can be caused by mechanical injury of penetrating type, and the later may be associated with retained intraocular foreign body.  TOXIC CATARACT:-Several drugs and toxic substances are cataractogenic in humans.  Corticostreiod induced cataract- prolonged oral administration or shorter high dose steroids. Thus oral corticosteroids should be avoided for prolonged administration.A safe dose up to 10 mg/day for adults.  Mitotic cataract:- strong cholinterase inhibitors osmotic , if used for long can cause subcapsular cataract.  Other toxic agents: - antimitotic durgs like insectidies, busuflfan, are known to cause cataract.
  9. 9. surgical  RADIATION CATARCT: -  Ionizing radiations like x rays, gamma rays, beta rays are catarctogenic. It affects the germinal epithelium in the lens equator and effect is more in younger age.  Non-ionizing radiations like infrared rays and U.V microwave radiations can cause cataract.  METABOLIC CATARACT:-  Diabetic cataract-cataract of the senile type can occurs with more frequency in earlier in diabetics and grows more rapidly.  Hypocalcemic cataract- low serum calcium levels due to infantile tetany, cause punctuate opacities. SIGNS AND SYMPTOMS:- A cataract usually develops slowly, so: – Causes no pain. – Cloudiness may affect only a small part of the lens – People may be unaware of any vision loss. • Over time, however, as the cataract grows larger, it: – Clouds more on the lens – Distorts the light passing through the lens. – Impairs vision • Reduced visual acuity (near and distant object) • Glare in sunshine or with street/car lights. • Distortion of lines. • Monocular diplopia. • Altered colours ( white objects appear yellowish) • Not associated with pain, discharge or redness of the eye. Signs:- • Reduced acuity. • An abnormally dim red reflex is seen when the eye is viewed with an ophthalmoscope.
  10. 10. surgical • Reduced contrast sensitivity can be measured by the ophthalmologist. • Only sever dense cataracts causing severely impaired vision cause a white pupil. • After pupils have been dilated, slit lamp examination shows the type of cataract. MANAGEMENT:- Management of cataract depends on tackling the specific cause in addition to overcoming the problems of cataract. In case of toxicity, the specific agent needs to be removed. SPECIFIC MANAGEMENT OF CATARACT:- A) NON SURGICAL: 1.GLASSES: Cataract alters the refractive power of the natural lens so glasses may allow good vision to be maintained. Use dark glasses also helps in such situations by keeping the pupil bigger. 2.MEDICAL TREATMENT :-To delay progression of cataract.  Aldose reductase inhibitors- Oral aspirin 50-100 mg/kg orally  2.Ouercetin 200-400 mg/kg.  ANTIOXIDANTS:- beta carotene, alpha tocopherol, victamin c.  MEMBRANE STABILIZING AGENTS- benzadac and benzyl alcohol.  MISCELLANEOUS- Iodides of calcium , potassium. B) SURGICAL REMOVAL: When visual acuity can't be improved with glass. There are two types of eye surgery that can be used to remove cataracts:  Extra-capsular (extracapsular cataract extraction, or ECCE)  Intra-capsular (intracapsular cataract extraction, or ICCE). Extra-capsular (ECCE) surgery consists of removing the lens but leaving the majority of the lens capsule intact.
  11. 11. surgical High frequency sound waves (Phacoemulsification) are sometimes used to break up the lens before extraction. Phacoemulsification in cataract surgery involves insertion of a tiny, hollowed tip that uses high frequency (ultrasonic) vibrations to "break up" the eye's cloudy lens (cataract). The same tip is used to suction out the lens  Cataract surgery:- When a cataract is sufficiently developed to be removed by surgery, the most effective and common treatment is to make an incision (capsulotomy) into the capsule of the cloudy lens in order to surgically remove the lens. Intra-capsular (ICCE) surgery involves removing the entire lens of the eye, including the lens capsule, but it is rarely performed in modern practice. In either extra-capsular surgery or intra-capsular surgery, the cataractous lens is removed and replaced with a plastic lens (an intraocular lens implant) which stays in the eye permanently. Cataract operations are usually performed using a local anaesthetic and the patient is allowed to go home the same day. Recent improvements in intraocular technology now allow cataract patients to choose a multifocal lens to create a visual environment in which they are less dependent on glasses. Under some medical systems multifocal lenses cost extra. Traditional intraocular lenses are monofocal. NURSING MANAGEMENT:-  Pre-operative assesments 1. The conjunctival sac prepared by using broad spectrum antibiotic for 2-3 days prior to surgery.
  12. 12. surgical 2. The patient is asked to keep his face and hair clean and properly tied. 3. The intraocular pressure should be controlled. Raised acetazolamide or I.V. mannitol may be given 1-2 hours prior to surgery. 4. The pupils should be dilated for extracapsular surgery. To ensure that dilatation is maintained during surgery, anti prostaglandin NSAIDs are used prior to surgery. 5. The patient should not be anxious and if necessary anxiolytic durg and sedation is given. 6. General health evaluation including blood pressure check 7. Assessment of patients’ ability to co-operate with the procedure and lie reasonably flat during surgery. 8. Anticoagulant therapy (aspirin, warfarin) to reduce the risk for retrobulbar hemorrhage for 7 days before surgery. Dilating drops are administered in the every 10 minutes for 4 doses at least 1 hour before surgery.  Providing post operative care:- After recovery from anesthesia the patient receives verbal and written instruction about how to protect the eye, administer medication, recognize signs of complications and obtain emergency care. The nurse also explain that there should be minimal discomfort after surgery and instructs the patient to take a mild analgesic agent, such as eye drops or ointments. 1 NURSING DIAGNOSIS:-Risk of injury related to increased intraocular pressure, trauma. GOAL : - Decrease the risk for injury. INERVENTION:-  Keep the head of bed elevated.  Instruct the patient not to impose stress on operative eye.  Instruct the patient not to lean forward or lie on the affected side.  Change damp pads as allowed.  Administers eye drops as prescribed by physicians such as antibiotic, corticosteroids.
  13. 13. surgical  Administer antiemetic to prevent nausea and vomiting. 2 NURSING DIGNOSIS:-Disturbed sensory perception related to surgical trauma, lens removal, patching. GOAL : - The patient will adapt to visual impairment and function in environment without injury. INTERVENTION:-  Keep the bed in low position  Approach the left side place the call bell in lift and instruct the use  Remove obstacles in room  Assist the activities of daily living as needed. 3 NURSING DIGNOSIS:-Acute pain related to tissue trauma. GAOL : - To reduce the pain. INTERVENTIONS:-  Asses the level of pain.  Advice not to take stress on the effected part.  Give proper side lying position .  Administer analgesic as prescribed by the physicians. 4 NURSING DIGNOSIS:-Anxiety related temporary vision , impairment activity restrictions. GOAL :-To reduce the anxiety. INTERVENTIONS:-  Asses the level of anxiety  Explain the patient what is doing and why.  Explore the feeling of patient for surgery.  Answer the questions.  Responds to the needs.
  14. 14. surgical 5.NURSING DIGNOSIS:- Ineffective therapeutic regimen management related to lack of understanding of a conditions, self care and limitations. GOAL :-To provide effective regimen management. INTERVENTIONS:-  Explain post operative limitations  No lifting over 5lb, bending forward or straining until cleared by physician.  Review of procedure for eye drops and have patient or family member demonstrate instillations.  Supplement verbal instructions, written informations. TEACHING PATIENTS SELF CARE:  To prevent accidental rubbing or poking of the eye.  The patient wears a protective eye patch for 24 hours after surgery.  The nurse instructs the patient and family in applying and caring for the eye shield.  Sun glasses should be worn while outdoor during the day because the eye is sensitive to light.  Clean, damp wash cloth may be used to remove slight the risk for retinal detachment.  The eye patch is removed after the first follow up.  The patient may experience blurring of vision for several days to weeks.  Patient with ILO implants have functional vision on the first days after surgery.  Signs and symptoms of infection and when and how to report those to allow recognition and treatment of possible infection.
  15. 15. surgical  Advice the patient to use hand rails while walking and doing steps and to reach out slowly for objects to picked up. COMPLICATION;- Complication of cataract surgery are rare but including :  Inflammation  Increased Intra ocular pressure  Subconjunctival hemorrhage with or without edema.  Toxic anterior segment syndrome  Malposition of the intra ocular pressure  Chronic endophthalmitis  Opacification of the posterior capsule.  Retinal detachment.

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