Cataract

1. CATARACT
BY MITIKU TEKA (AHN STUDENT)

2. Mechanism of Image formation:
1st- light inter in to the lens,
2nd-lens transfer this light to retina
3rd- retina converts this light to signals and send to optic nerve,
4th- then optic nerve carries them to the brain and
5th- image is formed in the brain.

3. Introduction: cataract
The word Cataract comes from the Greek word “CATRA” – meaning
‘Waterfall’ or ‘running water or flowing water’.
Until the mid 1700’s, it was thought that cataract was formed by
opaque material flowing, like a waterfall into the eye.
Also derived from derived from the Latin “Cataracta”, meaning
"waterfall"

4. CATARACT: Definition
A cataract is the opacity of the lens or cloudiness (dense, cloudy area
that forms in the lens of the eye).
It begins when proteins in the eye form clumps that prevent the lens
from sending clear images to the retina
This clouding of the eye lens (clumps or compact mass) obstructs the
passage of light.
It develops slowly and eventually leads to; a decrease in vision, & vision
loss that cannot be corrected with glasses, contact lenses or corneal
refractive surgery.
might develop in both eyes, but they usually don’t form at the same time.

6. Epidemiology:
Cataract is the World’s leading cause of blindness.
Is common in older people.
Age related cataract is responsible for 48% of the world blindness which
affects about18 million people .
Affects both developed and developing countries.
68% of the American aging 80 or older has been found with cataract.
(NEI, 2019).

7. Epidemiology….

8. Epidemiology…
Roughly , 24.4 million Americans had cataracts and that in number is
estimated to grow to 50.2 million by the year 2050.
Modern cataract is one of the most safest and most effective surgical
procedures today .
About 3 million surgeries are performed every year.
(NEI,2020).

9. Causes / Etiology:

10. Risk Factors:
Aging:
lens proteins denature and degrade over time (Loss of lens
transparency).
Clumping or aggregation of lens protein (which leads to light
scattering)
Accumulation of a yellow-brown pigment due to the breakdown of
lens protein
this process is accelerated by diseases such as diabetes mellitus
and hypertension.
Decreased oxygen uptake
Decrease in levels of vitamin C, protein, and glutathione (an
antioxidant)

11. Risk Factors…
Associated ocular conditions:
 Retinitis pigmentosa
 Myopia (It is when the eye is not able to focus properly on objects in the distance)
 Retinal detachment (the retina separates from the layer underneath) & surgery
 Infection (eg, herpes zoster, uveitis)
Toxic factors:
 Corticosteroids, especially at high doses and in long term use
 Alkaline chemical eye burns, poisoning
 Cigarette smoking.
 Calcium, copper, iron, gold, silver, and mercury, which tend to deposit in the pupillary
area of the lens

12. Risk Factors…
Nutritional factors:
 Reduced levels of antioxidants
 Poor nutrition
 Obesity
Physical factors:
 Blunt trauma
 perforation of the lens with a sharp object or foreign body
 Ultraviolet radiations in sunlight and x-ray
 Dehydration associated with chronic diarrhea, use of purgatives in
anorexia nervosa, and use of hyperbaric oxygenation,
 electric shock
 Ultraviolet radiation in sunlight and x-ray

13. Risk Factors…
Systemic Disease and syndromes:
 Diabetes
 Down syndrome
 Disorders related to lipid metabolism
 Renal disorders
 Musculoskeletal disorders
Genetics:
genetic component is strong in the development of cataracts,
most commonly through mechanisms that protect and maintain the lens.
The presence of cataracts in childhood or early life can occasionally be
due to a particular syndrome.
 Maternal rubella
 Familiar congenital cataract.
 Galactosemia

14. Pathophysiology

15. PATHOPHYSIOLOGY:
• The clear lens of the eye transmits light rays entering the
eye and focuses them on retina
• With ageing lens proteins progressively denature causing
increase in density and yellowish-brown coloration of the
lens.
• Other factors such as blunt force trauma can cause
thickening and irreversible whitening of the lens.
• The resultant cloudy lens lacks the ability to transmit and
focus light rays on the retina.
• This manifests as blurry vision or loss of vision in advanced
cases.

16. Types of Cataract:

17. A. Etiological Cataract:
1.Congenital Cataract:
are present at birth or form during a baby’s first year,
are less common than age-related cataracts.
33% of the cases are idiopathic, but can be due to;
 Hereditary causes: Chromosomal disorder (trisomy 21), sticker syndrome,
lowe’s syndrome
 Maternal factors (DRIM):
disease during 1st trimester pregnancy (measles , mumps , chicken pox ,
hepatitis , rubella, toxoplasmosis, & Malnutrition
 Drugs like corticosteroids, & Radiation.
 Foetal factors: Oxygen deficiency, birth trauma, malnutrition, etc.

18. Etiologic Cataract…
2. Acquired Cataract:
Here the opacification occurs due to degeneration of
the already formed lens fibers.
A) Senile cataract:
 also called age related cataract.
 It is characterized by an initial opacity in the lens , subsequent swelling
of the lens and final shrinkage with complete loss of transparency .
 It may occur due to denaturation of the lens proteins and opacification
lens fibers .

19. 2. Acquired Cataract…
Simply remember the etiology of senile cataract & Pre-senile
cataract by mnemonic “UDDASH” & “DAM-H” respectively;
Senile Cataract: UDDASH:
U: UV radiation
D: Dietary factors deficiency
D: Dehydration crisis
A: Age >50 yrs.
S: Smoking (denaturation of protein)
H: Hereditary
Pre-senile Cataract: DAM-H:
D: Diabetes
A: Atopic dermatitis
M: Myotonic dystrophy
H: Hereditary

20. Acquired cataract…
B. Traumatic Cataract:
 due to penetrating or blunt injury to the eye , laceration and foreign
body.
C. Secondary cataracts:
 Are caused by disease or medications.
 Due to diseases such as glaucoma and diabetes.
 The use of the steroid prednisone and other medications.
D. Metabolic Cataract:
 Occurs due to endocrine disorders and biochemical abnormalities .
E. Toxic Cataract:
 medications those are phototoxic such as tetracycline , phenothiazines ,
thiazides , tranquilizers , oral contraceptives and corticosteroids also
cause cataract .
F. Radiation Cataract:
 exposure to all type of causes radiation damage to the lens epithelium.

21. B. Morphologic Cataracts
1. Capsular Cataract:
 involves capsule ; maybe anterior or posterior capsule .
2. Sub-capsular Cataract:
 involves superficial part of the cortex (just below the capsule ) includes
anterior and posterior sub-capsule.
3.Posterior capsular Cataract:
 form faster than the other and affect the back of the lens.
 Typically develops in younger people and is associated with prolonged
corticosteroid use, diabetes, or ocular trauma.

22. Morphologic Classifications…
4.Cortical cataracts:
are wedge-shaped and form around the edges of the nucleus.
work their way to the center in a spoke-like fashion;
• Age related changes plus DHN,
• Hardening of the lens,
• Degenerations of the lens.
Sunlight exposure is its risk factor.

23. 5.Nuclear Cataract :
Form in the middle of the lens and cause the
nucleus, or the Centre, to become yellow or
brown.
6.Supra-nuclear Cataract:
 it involves only the deeper parts of the cortex (just outside the nucleus ).
7. Polar Cataract :
 it involves the capsule and superior part of the cortex in the polar region
only and may be anterior polar cataract or posterior polar cataract.
Morphologic Classifications…

24. Morphologic types of Cataract

25. RISK FACTORS OF CATARACT:
older age
heavy alcohol use
smoking
obesity
high blood pressure
 previous eye injuries
a family history of cataracts
too much sun exposure
diabetes
exposure to radiation from X-rays and cancer treatments

26. Clinical Manifestations
 Blurry vision or distorted images
 Trouble seeing at night
 increased sensitivity to glare .
 seeing colors as faded .
 halos surrounding light .
 Poor vision at night .
 Photophobia .
 Light scattering .
 leukokoria or white pupil
 double vision in the affected eye
 a need to frequent change in
prescription glasses .
 gradual painless burning .
 loss of vision due to lens opacity
 decreased color perception .
 decreased visual acuity .
 reduced light transmission .
 contrast sensitivity is also lost

27. DIAGNOSTIC STUDIES:
 History of patient
 Comprehensive eye exam to check for cataracts and to assess
vision Which includes:-
 Snellen visual acuity test :
–eye chart test measures how well you see at various distances.
Pupil dilatation:
– the pupil is widened with eye drops to allow doctor to see more
of the lens and retina and look for other eye problem.

28. Diagnosis…
Tonometry:
standard test to measure fluid pressure inside the eye.
The most common tonometry test uses a painless puff of air to
flatten cornea and test eye pressure.
Your doctor will also put drops in your eyes to make your pupils
bigger.
This makes it easier to check the optic nerve and retina at the
back of your eye for damage.

29. DIAGNOSTIC EVALUATION:
Other tests include:
o Direct ophthalmoscopy
o Slit lamp biomicroscopy
o Refraction and retinoscopy
o Glare testing- checking sensitivity to glare and perception of colors.
o Penlight examination of pupil and lens.

31. Diagnosis…

32. MANAGEMENTS:
If The Patient is unable or uninterested in surgery;
 manage the symptoms and suggest;-stronger eyeglasses, magnifying
lenses, or sunglasses with an anti-glare coating.
When both eyes have cataracts, one eye is treated first, with at least
several weeks.
preoperative antibiotic eye drops may be given.
instill dilating eye drops [mydriatics (Phenylephrine HCL) and cycloplegics
(Tropicamide, Atropine)] and
non-steroidal anti-inflammatory eye drop to reduce inflammation and to
help maintain pupil dilation.

34. Mgt…
 Surgery: is recommended when cataracts;
prevent from daily activities, such as reading or driving.
interfere with the treatment of other eye problems.

35. Mgt….
Surgical Management:
is recommended when cataracts prevent from daily activities, such as
reading or driving.
is the definitive treatment for cataract .
The most effective and common treatment is to make incision
(capsulotomy) into the capsule of the cloudy lens in order to surgically
remove the lens.
Two types of eye surgeries used:
1. Extra capsular cataract examination (ECCE )
2. Intra capsular cataract examination (ICCE)

36. Surgical Management…

37. Surgical Mgt…
PHACOEMULSIFIATION:
A titanium needle vibrating at ultrasonic frequencies (high frequently
sound waves )used to disrupt the lens nucleus .
The needle vibrates at ultrasonic frequency (40,000hz )and the lens
material is emulsified .
A 2nd fine instrument (called cracker or chopper ) may be used from a
side port to facilitate cracking or chopping of the nucleus into smaller
pieces.
The anterior capsule and the lens particles are removed from eye by
irrigation and aspiration through a sleeve around the needle , the
posterior capsule is left to support on IOL.

39. Management… Irra deebi’ii ilaali??? With slide 36
PHACOEMULSIFICATION:
In this method, a portion of the anterior capsule is removed, allowing extraction of
the lens nucleus and cortex while the posterior capsule is left intact.
An ultrasonic device is used to liquefy the nucleus and cortex, which are then
suctioned out through a tube.
The pupil is dilated to 7 mm or greater.
The surgeon makes a small incision on the upper edge of the cornea and a
viscoelastic substance (clear gel) is injected into the space between the cornea and
the lens.
This prevents space from collapsing and facilitates insertion of IOL. Because the
incision is smaller, the wound heals more rapidly, and there is stabilization of
refractive error and less astigmatism.

41. LENS REPLACEMENT
After removal of the crystalline lens, the patient is referred to as aphakic.
There are three lens replacement options:
1. aphakic eyeglasses,
2. contact lenses and
3. IOL implants.
 Aphakic glasses: are rarely used. Peripheral vision is also limited.
 Contact lenses: provide patients with almost normal vision, but because contact lenses
need to be removed occasionally, the patient also needs a pair of aphakic glasses.
 Insertion of IOLs: during cataract surgery is the most common approach to lens
replacement. After cataract extraction, or phacoemulsification, the surgeon implants an
IOL.

43. COMPLICATIONS OF CATARACT SURGERY
Immediate Preoperative:
 Retro bulbar hemorrhage can result from retro bulbar infiltration of
anesthetic agents.
 It can manifests as increased IOP, proptosis, lid tightness and subconjunctival
hemorrhage with or without edema.
Intraoperative:
 Rupture of the posterior capsule
Early postoperative:
 Acute bacterial endophthalmitis characterized by marked visual loss, pain, lid
edema.

45. Late postoperative:
Suture related problems
Malposition of the IOL
Chronic endophthalmitis
Opacification of the posterior capsule

46. NURSING DIAGNOSIS:
• 1. High risk of injury related to loss of viterous , intraocular
hemorrhage , increased IOP. 2. Impaired sensory perception vision ,
related to impaired sensory reception / status of sensory organs , a
therapeutic environment is limited . 3. Acute pain related to trauma
to the incision and increased IOP. 4. Anxiety related to lack of
knowledge about the disease and its treatment . 5. Risk of infection
related to trauma to the incision.

47. NURSING INTERVENTIONS:
• 1. Asses the visual acuity of the client’s non-operative eye prior to
surgery . 2. Discuss what happens on the condition of post surgery ,
pain , limitation of activity, performance , bandage the eye. 3.
Comfort the patient with semi-fowler’s or tilted to the side ,
preferable to patient . 4. Ask patient to avoid activities such as
vomiting , coughing , sneezing , straining , or bending over . 5.
Ambulation with assistance ; give special bathrooms when recovering
from anesthesia . 6. Encourage deep breathing / coughing to maintain
eye protection as indicated . 7. Encourage use of stress management
techniques.

48. Nursing Intervention…
• 8. Remove all the eye makeup and contact lenses or glasses prior to
surgery .
• 9. Administer antiemetic medications as needed.
• 10. Orient the client to the environment . Approach from the side that was
operated on , talk and touch.
• 11. Note for dim or blurred vision and eye irritation , which can occur when
using eye drops . use correct techniques for administration of eye
medications.
• 12. Remind clients to use cataract glasses . 13. Place the required items /
call bells within reach. 14. Administer antibiotics , anti-inflammatory and
other systemic and eye medications as prescribed . 15. Encourage the
patient to wear dark glasses after eye dressing is removed.

50. COMPLICATIONS:
• 1. PCO 2. Intraocular lens dislocation 3. Eye inflammation 4. Light
sesitivity 5. Photopsia 6. Macular edema 7. Ptosis 8. Ocular
hypertension

51. HEALTH TEACHINGS
• Explain for the care of eye to prevent contamination of the surgical
site . Encourage the patient to use eye shield to protect the operated
eye from injury while sleeping. •Ask patient to wear dark sunglasses
to provide comfort to eyes from sunlight. •Encourage Patients to take
proper antioxidants vitamins ( vit. C and E) and good nutrition. •Ask
patients to avoid lifting heavy objects , isometric exercises , straining
during defecation . •Teach the family and the patient , how to instill
the opthalmic ointment or drops . •If the patient has increased eye
discharge , sharp eye pain , or deterioration in vision , intruct to
immediately notify the physician.

52. SUMMARY
• Cataract is an opacification or clouding of eyes. Common causes are
exposure to UV radiations , smoking , congenital malformations , etc. .
Higher age group are at high risk . The pathophysiology says that –
due to nuclear sclerosis , there is a decrease in transport of water ,
antioxidants and nutrients causing progressive oxidant damage to the
lens , leads to cataract. It can be treated through surgeries, the most
frequently used surgery is PHACOEMULCIFICATION.