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Cataract Case Study

Cataract Case Study

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Published by: ibheng_ling on Apr 24, 2011
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04/28/2013

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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 nearsightedness (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 over the years.

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II. REVIEW OF SYSTEMS y y y Cloudy or foggy vision Blurry or distorted vision Changes in color vision Frequent increases in eyeglass or contact lens prescriptions Poor night vision (especially affected by headlights) Progressive loss of vision Halos or glare around lights Double vision A white or "milky" spot over the pupil of the eye Loss of contrast Loss of coordination y y y y y y y No specific clinical symptoms related to cataract No specific clinical symptoms related to cataract No specific clinical symptoms related to cataract No specific clinical symptoms related to cataract No specific clinical symptoms related to cataract No specific clinical symptoms related to cataract No specific clinical symptoms related to cataract Neurosensory y y y y y y y y Cardiovascular Respiratory Integumentary Metabolism Circulatory Endocrine Genitourinary Page | 2 .

The room is generally darkened. eyelashes. tear film. refraction enables images to focus in the retina and directly affects visual acuity. If the patient is wearing contact lenses. unless the test is being performed to evaluate the fit of the contact lenses. y y Page | 3 . Letters and objects are of a size that can be seen by normal eye at the distance of 6 m (20ft) from the chart.  Provides magnification and confirms diagnosis of opacity. y Explain to the patient the test is painless and safe and that it takes about 30 mins. sclera. Slit-Lamp Biomicroscopic Examination (Opthalmoscopy)  An instrument equipped with a special lighting systems and a binocular microscope. Explain that eye drops may be instilled to dilate the pupils and inhibit accommodation by the lens. conjunctiva. iris. lens and anterior portion of vitreous humor. and vitreous humor in the eye. y y y The pt.  This test is done routinely during a complete eye examination or whenever a patient complains of a change in vision. When instilling dilating drops. aqueous humor. Don¶t administer dilating eyedrops to the patient who has angle-closure glaucoma. DIAGNOSTIC TESTS TESTS NURSING CONSIDERATIONS The Snellen Visual Acuity Test y y Each eye is tested separately. tell the patient that his near vision will be blurred for 40 mins-2 hrs. lens. which includes the eyelids. Tell patient he shouldn¶t use any eye drops. and the pupils are dilated. anterior chamber. is hypersensitive to mydriatics. cornea. or has an intraocular lens implants. y y Refraction  Defined as the bending of light rays by the cornea. including prescription eye drops. with and w/o glasses. at least 24 hours before the test. sits with the chin and forehead resting against equipment supports.  It defines the degree of impairment (refractive error) and determines the degree of correction required to improve visual acuity with glasses or contact lenses.III. have him remove them before the test. Advise him to wear dark glasses in bright sunlight until his pupils return to normal diameter.  Allows visualizing in details the anterior segment of the eye.

Ciliary muscles help the eye lens to change its focal length. This controls the size of the pupil. The central part of retina lying on the optic axis of eye is most sensitive to light and is called yellow spot Eye lids are provided to control the amount of light falling on the eye. Optic nerve carries the information to brain. wherethe images of the objects are formed. which are connected to the optical nerve. The light coming from an object enters the eye through cornea Iris is just at the back of cornea. The front part of sclerotic is transparent to light and is termed as cornea. They also protect the eye from dust particles etc Page | 4 Cornea Iris Eye Lens Ciliary Muscles Pupil Aqueous Humour Vitreous Humour Retina Optic Nerve Blind Spot Yellow Spot Eye Lids . which is called pupil. The eye lens is held by ciliary muscles. At the centre of the iris there is a hole through which light falls on the lens.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. Retina serves the purpose of a screen in the eye. Retins is made of light sensitive cells. Retina is at the back of the eye lens. The space between eye lens and retina is filled with a jelly like transparent fluid called vitreous humour. If the image of an object is formed in the blind spot. Eye lens is a double convex lens with the help of which image is formed at retina by refraction of light. The space between cornea and eye lens is filled with a transparent fluid called aqueous humour. The region of eye containing the optic nerve is not at all sensitive to light and is called blind spot. It acts like a shutter of a photographic camer and allows the regulated amount of light to enter the eye. it is not visible.

V. & Enzymes H2O Content Destruction & Breakdown of CHON Sodium (Na) Disrupts the Normal Fibers in the Eyes Density of Lens Opacity/Clouding of the Lens CATARACT FORMATION Vision BLINDNESS Table 1. PATHOPHYSIOLOGY Predisposing/Non-Modifiable Factors y (+) Family History of: o Glaucoma o Hypertension o Diabetes Mellitus Aging (Usually 40 y/o and above) Genetics Sex/Gender (Females)           Precipitating/ Modifiable Factors Smoking Excessive Drinking of Alcohol Unhealthy Diet Sedentary Lifestyle Lack of Exercise Long Term-Ultra Violet Exposure Exposure to Radiation Job/Work Usage of Corticosteroids & Ezetimibe Secondary to other Diseases like Uveitis or Inflammation of the Inner Layer of the Eye. y y y Progressive Oxidative Damage to the Lens Antioxidants. Vitamins. [Mature] Cataract Schematic diagram Book Based Loss of Transparency Page | 5 .

Page | 6 . Place assistive devices (walker. Goals: After the nursing interventions given. crane).  Be free of trauma/injury Monitor environment for potentially unsafe conditions and modify as needed Collaborative: y Refer the patient for an eye care specialist. the patient will be able to: Short-term: Nursing Orders / Interventions: Independent: y Ascertain knowledge of safety needs/injury prevention and motivation Instruct SO to: Maintain client¶s bed/chair in lowest position. y To prevent injury in home/community setting. environment as Scientific Rationale: Evaluation: . NURSING CARE PLANS Nursing Diagnosis: High risk for injury related to poor vision and reduced extremity-eyes coordination. I sometimes fall and outbalanced´ as verbalized by the client. y Long-term: Objective: y A white or "milky" spot over the pupil of the eye.VI.  Modify indicated to enhance safety. y  Express understanding of the factors involved in the possibility of injury. y To have further assessment and interventions regarding health conditions. Subjective: ³I can¶t see clearly. To promote safe physical environment and individual safety.

the patient will be able to: Short-term: Nursing Orders / Interventions: Independent: y y in therapeutic Ascertain type/degree of visual loss. y y Subjective: ³I see dots everywhere. Reduces safety hazards related to changes in visual fields Objective: y A white or "milky" spot over the pupil of the eye. Page | 7 . y Participate regimen Long-term: y Maintain current visual further y Recommend measures to assist client to manage visual limitation y Affects choice and client¶s future expectations Although early interventions can prevent blindness. Dependent: y Demonstrate/have client to administer eye drops using correct procedure y Eyedrop treatment is needed to control IOP and prevent further loss of vision Collaborative: y Prepare for surgical intervention as indicated like cataract extraction. Goals: After the nursing interventions given. Encourage expression of feelings about loss/possibility of loss of vision Scientific Rationale: Evaluation: . y Removing the lens through surgery improves visual acuity.Nursing Diagnosis: Disturbed Visual Sensory Perception r/t changes in sensory acuity. field/acuity without loss. the client may have already experienced partial or complete blindness. especially around lights´ as verbalized by the patient.

Subjective: ³Nobody wants to be blind!´ as verbalized by the patient. y manageable level. y Page | 8 .Nursing Diagnosis: Anxiety related to threat of permanent loss of vision and independence. y These factors affect client¶s perception of threat to self potentiating the cycle of anxiety. Goals: After the nursing interventions given. suddenness of symptoms and current knowledge of condition Scientific Rationale: Evaluation: . Discuss probability that careful monitoring and treatment can prevent additional visual loss Encourage client to acknowledge concerns and express feelings y Objective: y y A white or "milky" spot over the pupil of the eye. the patient will be able to: Short-term: y Appear relaxed and report anxiety is reduced to a Nursing Orders / Interventions: Independent: y Assess anxiety level. honest information. Provides opportunity of the client to deal with reality of situation. Apprehensive y y y Identify helpful resources/people. Reduces anxiety related to unknown/future expectations and provides factual basis for making informed choices about treatment. y Use resources effectively Provide accurate. clarify misconceptions and problem solve concerns Provides reassurance that client is not alone in dealing with problems.

warmth. severe skin rash. administer in the morning to coincide with the body¶s normal secretion of cortisol. GI disturbances and bleeding y y y y Cyclopentolate Cycloplegic Mydriatics By blocking y muscarinic receptors. Drugs Drug Classification Mechanism of Action Betamethasone is a corticosteroid with mainly glucocorticoid activity. systemic absorption may cause anticholinergi c effects such as confusion. redness. and reversing capillary permeability and lysosomal stabilisation. osteoporosis.VII. slow or shallow breathing . potassium and calcium depletion. 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. y y fast or uneven heart rate. cyclopentolate produces dilatation of the pupil y (mydriasis) and prevents the eye from accommodating for near vision (cycloplegia). but glare is increased. MEDICAL MANAGEMENT There is no medical treatment for cataracts. unusual behavior. It prevents and controls inflammation by controlling the rate of protein synthesis. flushing and hallucinations Page | 9 . Muscle wasting. depressing the migration of polymorphonuclear leukocytes and fibroblasts. y Assess involved systems periodically Assess patient for signs of adrenal insufficiency Monitor intake and output ratios and daily weight If dose is ordered daily. use cautiously in patients with history of glaucoma. or tingly feeling under the skin. weakness. although use of vitamin C and E and betacarotene is being investigated. Side Effects Nursing Responsibilities Betamethasone Corticosteroid Sodium and fluid retention. or magnifying lenses may improve vision. Mydriatics can be used short term. Glasses or contact. bifocal.

cleansing and protection. Contact Lenses inflammation.VIII. 3.  Inform patient that vision gradually improves as the eye heals. and symptoms to report immediately to the surgeon. must be NSAID drops replaced for the may be patient to see clearly.  Provide postoperative discharge teaching concerning eye medications.Uses an ultrasonic device that device that cation liquefies the nucleus  Administer dilating drops and cortex which are every 10 minutes then suctioned out for four doses at through a tube. IOL implants improve vision faster than glasses or contact lenses. IOL implants Page | 10 .  Instruct patient to restrict bending and lifting heavy objects.  Reinforce that vision correction is usually needed for remaining visual acuity deficit. The lens. Extracapsular close the incision appropriate.5 is almost reached. Aspirin should be ECCE Involves smaller withheld for 5 to 7 incisional wounds days. and retina. Intracapsular sutures are used to medically 2. positioning. the lens. After 24 hours. eyeglasses should be worn during the day and a metal shield worn at night for 1 to 4 weeks. focuses light on the Replacement corticosteroid. SURGICAL MANAGEMENT SURGERIES Cataract Extraction: DEFINITION NURSING RESPONSIBILITIES PRE-OP POST-OP  Instruct patient to wear a protective eye patch for 24 hours after surgery to prevent accidental rubbing or poking of the eye. activity level and restrictions. office appointments. diet. reducing and warfarin post-operative (Coumadin) until complications. administered 3 lens replacement prophylactically options: to prevent 1. which Lens Antibiotic. pain control.  Caution patient that vision may blur for several days to weeks. Aphakic postoperative Eyeglasses infection and 2. the prothrombin time of 1. if 1. expected postoperative course. nonsteroidal (fewer traumas to the anti-inflammatory eye) & maintains the drugs (NSAIDs) posterior capsule of for 3 to 5 days.  Withhold any ICCE The entire lens is anticoagulants the removed and fine patient is receiving. Phacoemulsifi. least 1 hour before surgery.

o Wearing of eye patch 24 hours after surgery. some redness. Outpatient Follow-up o The patient needs to have a scheduled check up to see the progress of vision or detection of any complications. pain or increase in redness occurs. cyclopentolate twice daily and should be stored in a refrigerator between uses. o Protective eye patch to avoid accidental rubbing or poking of Therapy the eye. flashing lights. o There are no dietary restrictions. o Sunglasses should be worn while outdoors during the day Health Teaching because the eye is sensitive to light. o Continuation of prescribed medications. the restrictions as per pre-existing medical problems. decrease in vision. Diet o The patient must avoid constipation by taking high fiber diet and plenty of fluids. o Modified or structured environment to ensure patient¶s safety Environment because vision may be blurry for several weeks after the surgery. DISCHARGE PLAN o Anti-inflammatory drop containing an antibiotic ex: G betamethasone (a corticosteroid) combined with antibiotic Medication neomycin. if any. Spirituality o Spiritual practices according to one¶s faith and religion. o A cycloplegic may also be prescribed to prevent ciliary spasm: G. the patient must know to notify the surgeon if new floaters (dots) in vision. o Slight morning discharge. However. are to continue. o Because cataract surgery increases the risk for retinal detachment.IX. and a scratchy feeling may be expected for a few days. Page | 11 .

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