I. INTRODUCTION OF THE DISEASE 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. 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 colours. Cataracts typically progress slowly to cause vision loss and are potentially blinding if untreated. The condition usually affects both eyes, but almost always one eye is affected earlier than the other. A senile cataract, occurring in the elderly, is characterized by an initial opacity in the lens, subsequent swelling of the lens and final shrinkage with complete loss of transparency. Moreover, with time the cataract cortex liquefies to form a milky white fluid in a Morgagnian cataract, which can cause severe inflammation if the lens capsule ruptures and leaks. Untreated, the cataract can cause phacomorphic glaucoma. Very advanced cataracts with weak zonules are liable to dislocation anteriorly or posteriorly. Such spontaneous posterior dislocations (akin to the historical surgical procedure ofcouching) in ancient times were regarded as a blessing from the heavens, because some perception of light was restored in the cataractous patients. The lens lies behind the iris and the pupil (see diagram). It works much like a camera lens. It focuses light onto the retina at the back of the eye, where an image is recorded. The lens also adjusts the eye's focus, letting us see things clearly both up close and far away. The lens is made of mostly water and protein. The proteins are arranged in a precise way that keeps the lens clear and let’s light pass through it. Page | 1
Transcript
I. INTRODUCTION OF THE DISEASE
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. 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 colours. Cataracts typically progress slowly to cause vision loss and are
potentially blinding if untreated. The condition usually affects both eyes, but almost always one
eye is affected earlier than the other.
A senile cataract, occurring in the elderly, is characterized by an initial opacity in the lens,
subsequent swelling of the lens and final shrinkage with complete loss of transparency.
Moreover, with time the cataract cortex liquefies to form a milky white fluid in a Morgagnian
cataract, which can cause severe inflammation if the lens capsule ruptures and leaks. Untreated,
the cataract can cause phacomorphic glaucoma. Very advanced cataracts with weak zonules are
liable to dislocation anteriorly or posteriorly. Such spontaneous posterior dislocations (akin to
the historical surgical procedure ofcouching) in ancient times were regarded as a blessing from
the heavens, because some perception of light was restored in the cataractous patients.
The lens lies behind the iris and the pupil (see diagram). It works much like a camera lens. It
focuses light onto the retina at the back of the eye, where an image is recorded. The lens also
adjusts the eye's focus, letting us see things clearly both up close and far away. The lens is made
of mostly water and protein. The proteins are arranged in a precise way that keeps the lens clear
and let’s light pass through it.
But as we age, some of the protein may clump together and start to cloud a small area of the lens.
This is a cataract. Over time, the cataract may grow larger and cloud more of the lens, making it
harder to see.
Age-related cataract is responsible for 48% of world blindness, which represents about 18
million people, according to the World Health Organization (WHO). In many countries surgical
services are inadequate, and cataracts remain the leading cause of blindness. As populations age,
the number of people with cataracts is growing. Cataracts are also an important cause of low
vision in both developed and developing countries. Even where surgical services are available,
low vision associated with cataracts may still be prevalent, as a result of long waits for
operations and barriers to surgical uptake, such as cost, lack of information and transportation
problems.
Researchers suspect that there are several causes of cataract, such as smoking and
diabetes. Or, it may be that the protein in the lens just changes from the wear and tear it takes
An instrument equipped with a special lighting systems and a binocular microscope.
Allows visualizing in details the anterior segment of the eye, which includes the eyelids, eyelashes, conjunctiva, sclera, cornea, tear film, anterior chamber, iris, lens and anterior portion of vitreous humor.
Provides magnification and confirms diagnosis of opacity.
The pt. sits with the chin and forehead resting against equipment supports.
The room is generally darkened, and the pupils are dilated.
If the patient is wearing contact lenses, have him remove them before the test, unless the test is being performed to evaluate the fit of the contact lenses.
When instilling dilating drops, tell the patient that his near vision will be blurred for 40 mins-2 hrs. Advise him to wear dark glasses in bright sunlight until his pupils return to normal diameter.
Don’t administer dilating eyedrops to the patient who has angle-closure glaucoma, is hypersensitive to mydriatics, or has an intraocular lens implants.
Refraction
Defined as the bending of light rays by the cornea, aqueous humor, lens, and vitreous humor in the eye, refraction enables images to focus in the retina and directly affects visual acuity.
This test is done routinely during a complete eye examination or whenever a patient complains of a change in vision.
It defines the degree of impairment (refractive error) and determines the degree of correction required to improve visual acuity with glasses or contact lenses.
Explain to the patient the test is painless and safe and that it takes about 30 mins.
Tell patient he shouldn’t use any eye drops, including prescription eye drops, at least 24 hours before the test.
Explain that eye drops may be instilled to dilate the pupils and inhibit accommodation by the lens.
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IV. ANATOMY AND PHYSIOLOGY OF HUMAN EYE
Sclerotic Sclerotic is the outer coating of the eye which is white in colour that protects the interior of the eye and provides the shape to the eye.
Cornea The front part of sclerotic is transparent to light and is termed as cornea. The light coming from an object enters the eye through cornea
Iris Iris is just at the back of cornea. This controls the size of the pupil. It acts like a shutter of a photographic camer and allows the regulated amount of light to enter the eye.
Eye Lens Eye lens is a double convex lens with the help of which image is formed at retina by refraction of light.
Ciliary Muscles The eye lens is held by ciliary muscles. Ciliary muscles help the eye lens to change its focal length.
Pupil At the centre of the iris there is a hole through which light falls on the lens, which is called pupil.
Aqueous Humour The space between cornea and eye lens is filled with a transparent fluid called aqueous humour.
Vitreous Humour The space between eye lens and retina is filled with a jelly like transparent fluid called vitreous humour.
Retina Retina serves the purpose of a screen in the eye, wherethe images of the objects are formed. Retina is at the back of the eye lens. Retins is made of light sensitive cells, which are connected to the optical nerve.
Optic Nerve Optic nerve carries the information to brain.
Blind Spot The region of eye containing the optic nerve is not at all sensitive to light and is called blind spot. If the image of an object is formed in the blind spot, it is not visible.
Yellow Spot The central part of retina lying on the optic axis of eye is most sensitive to light and is called yellow spot
Eye Lids Eye lids are provided to control the amount of light falling on the eye. They
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Precipitating/ Modifiable FactorsSmoking
Excessive Drinking of AlcoholUnhealthy Diet
Sedentary LifestyleLack of Exercise
Long Term-Ultra Violet ExposureExposure to Radiation
Job/WorkUsage of Corticosteroids & Ezetimibe
Secondary to other Diseases like Uveitis or Inflammation of the Inner Layer of the Eye.
Progressive Oxidative Damage to the Lens
↓ Antioxidants, Vitamins, & Enzymes
↓ H2O Content ↑ Destruction & Breakdown of CHON
↓ Sodium (Na)
Opacity/Clouding of the Lens
↑ Density of Lens
Disrupts the Normal Fibers in the Eyes
Loss of Transparency↓ Vision
Table 1. [Mature] Cataract Schematic diagram Book Based
CATARACT FORMATION
BLINDNESS
also protect the eye from dust particles etcV. PATHOPHYSIOLOGY
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Predisposing/Non-Modifiable Factors
(+) Family History of:o Glaucomao Hypertensiono Diabetes Mellitus
Aging (Usually 40 y/o and above)
Genetics Sex/Gender (Females)
VI. NURSING CARE PLANS
Nursing Diagnosis:
High risk for injury related to poor vision and reduced extremity-eyes coordination.
Subjective:
“I can’t see clearly, I sometimes fall and outbalanced” as verbalized by the client.
Objective:
A white or "milky" spot over the pupil of the eye.
Goals:
After the nursing interventions given,
the patient will be able to:
Short-term:
Express understanding of the
factors involved in the
possibility of injury;
Long-term:
Modify environment as
indicated to enhance safety;
Be free of trauma/injury
Nursing Orders / Interventions:
Independent:
Ascertain knowledge of safety needs/injury prevention and motivation
Instruct SO to:
Maintain client’s bed/chair in lowest position;
Place assistive devices (walker, crane);
Monitor environment for potentially unsafe conditions and modify as needed
Collaborative:
Refer the patient for an eye care specialist.
Scientific Rationale:
To prevent injury in home/community setting.
To promote safe physical environment and individual safety.
To have further assessment and interventions regarding health conditions.
Evaluation:
.
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Nursing Diagnosis:
Disturbed Visual Sensory Perception r/t changes in sensory acuity.
Subjective:
“I see dots everywhere, especially around lights” as verbalized by the patient.
Objective:
A white or "milky" spot over the pupil of the eye.
Goals:
After the nursing interventions given,
the patient will be able to:
Short-term:
Participate in therapeutic
regimen
Long-term:
Maintain current visual
field/acuity without further
loss.
Nursing Orders / Interventions:
Independent:
Ascertain type/degree of visual loss.
Encourage expression of feelings about loss/possibility of loss of vision
Recommend measures to assist client to manage visual limitation
Dependent:
Demonstrate/have client to administer eye drops using correct procedure
Collaborative:
Prepare for surgical intervention as indicated like cataract extraction.
Scientific Rationale:
Affects choice and client’s future expectations
Although early interventions can prevent blindness, the client may have already experienced partial or complete blindness.
Reduces safety hazards related to changes in visual fields
Eyedrop treatment is needed to control IOP and prevent further loss of vision
Removing the lens through surgery improves visual acuity.
Evaluation:
.
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Nursing Diagnosis:
Anxiety related to threat of permanent loss of vision and independence.
Subjective:
“Nobody wants to be blind!” as verbalized by the patient.
Objective:
A white or "milky" spot over the pupil of the eye.
Apprehensive
Goals:
After the nursing interventions given,
the patient will be able to:
Short-term:
Appear relaxed and report
anxiety is reduced to a
manageable level;
Use resources effectively
Nursing Orders / Interventions:
Independent:
Assess anxiety level, suddenness of symptoms and current knowledge of condition
Provide accurate, honest information. Discuss probability that careful monitoring and treatment can prevent additional visual loss
Encourage client to acknowledge concerns and express feelings
Identify helpful resources/people.
Scientific Rationale:
These factors affect client’s perception of threat to self potentiating the cycle of anxiety.
Reduces anxiety related to unknown/future expectations and provides factual basis for making informed choices about treatment.
Provides opportunity of the client to deal with reality of situation, clarify misconceptions and problem solve concerns
Provides reassurance that client is not alone in dealing with problems.
Evaluation:
.
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VII. MEDICAL 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 includes an anti-inflammatory drop
containing antibiotic and cyclopegic to prevent ciliary spasm.
Drugs Drug
Classification
Mechanism of
Action
Side Effects Nursing
Responsibilities
Betamethasone Corticosteroid
Betamethasone is a corticosteroid with mainly glucocorticoid activity. It prevents and controls inflammation by controlling the rate of protein synthesis, depressing the migration of polymorphonuclear leukocytes and fibroblasts, and reversing capillary permeability and lysosomal stabilisation.
Sodium and fluid retention, potassium and calcium depletion. Muscle wasting, weakness, osteoporosis. GI disturbances and bleeding
Assess involved systems periodically
Assess patient for signs of adrenal insufficiency
Monitor intake and output ratios and daily weight
If dose is ordered daily, administer in the morning to coincide with the body’s normal secretion of cortisol.
Cyclopentolate Cycloplegic
Mydriatics
By blocking muscarinic receptors, cyclopentolate produces dilatation of the pupil (mydriasis) and prevents the eye from accommodating for near vision (cycloplegia).
fast or uneven heart rate;
warmth, redness, or tingly feeling under the skin;
severe skin rash;
slow or shallow breathing;
use cautiously in patients with history of glaucoma; systemic absorption may cause anticholinergic effects such as confusion, unusual behavior, flushing and hallucinations
VIII. SURGICAL MANAGEMENT
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SURGERIES DEFINITIONNURSING RESPONSIBILITIES
PRE-OP POST-OP
Cataract Extraction:
1. Intracapsular2. Extracapsular
ICCEThe entire lens is removed and fine sutures are used to close the incision
ECCEInvolves smaller incisional wounds (fewer traumas to the eye) & maintains the posterior capsule of the lens, reducing post-operative complications.
Withhold any anticoagulants the patient is receiving, if medically appropriate. Aspirin should be withheld for 5 to 7 days, nonsteroidal anti-inflammatory drugs (NSAIDs) for 3 to 5 days, and warfarin (Coumadin) until the prothrombin time of 1.5 is almost reached.
Administer dilating drops every 10 minutes for four doses at least 1 hour before surgery. Antibiotic, corticosteroid, and NSAID drops may be administered prophylactically to prevent postoperative infection and inflammation.
Instruct patient to wear a protective eye patch for 24 hours after surgery to prevent accidental rubbing or poking of the eye. After 24 hours, eyeglasses should be worn during the day and a metal shield worn at night for 1 to 4 weeks.
Provide postoperative discharge teaching concerning eye medications, cleansing and protection, activity level and restrictions, diet, pain control, positioning, office appointments, expected postoperative course, and symptoms to report immediately to the surgeon.
Instruct patient to restrict bending and lifting heavy objects.
Caution patient that vision may blur for several days to weeks.
Inform patient that vision gradually improves as the eye heals; IOL implants improve vision faster than glasses or contact lenses.
Reinforce that vision correction is usually needed for remaining visual acuity deficit.
Phacoemulsifi-cation
Uses an ultrasonic device that device that liquefies the nucleus and cortex which are then suctioned out through a tube.
Lens Replacement
The lens, which focuses light on the retina, must be replaced for the patient to see clearly. 3 lens replacement options:
1. Aphakic Eyeglasses
2. Contact Lenses3. IOL implants
IX. DISCHARGE PLAN
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Medication
o Anti-inflammatory drop containing an antibiotic ex: G
betamethasone (a corticosteroid) combined with antibiotic
neomycin.
o A cycloplegic may also be prescribed to prevent ciliary spasm:
G. cyclopentolate twice daily and should be stored in a
refrigerator between uses.
Environmento Modified or structured environment to ensure patient’s safety
because vision may be blurry for several weeks after the
surgery.
Therapyo Protective eye patch to avoid accidental rubbing or poking of
the eye.
o Continuation of prescribed medications.
Health Teaching
o Wearing of eye patch 24 hours after surgery.
o Sunglasses should be worn while outdoors during the day
because the eye is sensitive to light.
o Slight morning discharge, some redness, and a scratchy feeling
may be expected for a few days.
o Because cataract surgery increases the risk for retinal
detachment, the patient must know to notify the surgeon if new
floaters (dots) in vision, flashing lights, decrease in vision, pain
or increase in redness occurs.
Outpatient Follow-up o The patient needs to have a scheduled check up to see the
progress of vision or detection of any complications.
Dieto There are no dietary restrictions. However, the restrictions as
per pre-existing medical problems, if any, are to continue.
o The patient must avoid constipation by taking high fiber diet
and plenty of fluids.
Spirituality o Spiritual practices according to one’s faith and religion.
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