CASE STUDY

Description

A cataract is a clouding of the normally clear lens of your eye. For people who have cataracts,
seeing through cloudy lenses is a bit like looking through a frosty or fogged-up window. Clouded vision
caused by cataracts can make it more difficult to read, drive a car (especially at night) or see the
expression on a friend's face.

Most cataracts develop slowly and don't disturb your eyesight early on. But with time, cataracts
will eventually interfere with your vision.

At first, stronger lighting and eyeglasses can help you deal with cataracts. But if impaired vision
interferes with your usual activities, you might need cataract surgery. Fortunately, cataract surgery is
generally a safe, effective procedure.transmission of light to the retina at the back of the eye. Diagnosis
is by an eye examination.

Etiology

Most cataracts develop when aging or injury changes the tissue that makes up your eye's lens.

Some inherited genetic disorders that cause other health problems can increase your risk of
cataracts. Cataracts can also be caused by other eye conditions, past eye surgery or medical conditions
such as diabetes. Long-term use of steroid medications, too, can cause cataracts to develop.

Types of cataracts

 Cataracts affecting the center of the lens (nuclear cataracts). A nuclear cataract may at first
cause more nearsightedness or even a temporary improvement in your reading vision. But with
time, the lens gradually turns more densely yellow and further clouds your vision. As the
cataract slowly progresses, the lens may even turn brown. Advanced yellowing or browning of
the lens can lead to difficulty distinguishing between shades of color.

 Cataracts that affect the edges of the lens (cortical cataracts). A cortical cataract begins as
whitish, wedge-shaped opacities or streaks on the outer edge of the lens cortex. As it slowly
progresses, the streaks extend to the center and interfere with light passing through the center
of the lens.

 Cataracts that affect the back of the lens (posterior subcapsular cataracts). A posterior
subcapsular cataract starts as a small, opaque area that usually forms near the back of the lens,
right in the path of light. A posterior subcapsular cataract often interferes with your reading
vision, reduces your vision in bright light, and causes glare or halos around lights at night. These
types of cataracts tend to progress faster than other types do.

 Cataracts you're born with (congenital cataracts). Some people are born with cataracts or
develop them during childhood. These cataracts may be genetic, or associated with an
 intrauterine infection or trauma. These cataracts also may be due to certain conditions, such as
myotonic dystrophy, galactosemia, neurofibromatosis type 2 or rubella. Congenital cataracts
don't always affect vision, but if they do they're usually removed soon after detection.

Medical Management

No nonsurgical treatment cures cataract or prevent age-related cataracts.

When your prescription glasses can't clear your vision, the only effective treatment for cataracts is
surgery.

Pharmacologic Therapy

Medications administered pre and postoperatively are:

 Dilating drops. Dilating drops are administered every 10 minutes for four doses at least 1 hour
before surgery.

 Antibiotic drugs. Antibiotic drugs may be administered prophylactically to prevent

postoperative infection and inflammation.

 Intravenous sedation. Sedation may be used to minimize anxiety and discomfort before surgery.

Surgical Management

Phacoemulsification is the most widely used cataract surgery in the developed world. This procedure
uses ultrasonic energy to emulsify the cataract lens. Phacoemulsification typically comprises six steps:

1. Anaesthetic – The eye is numbed with either a subtenon injection around the eye or topical
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 into 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.

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 (the front part of the eye).

6. Lens insertion – A plastic, foldable lens is inserted into the capsular bag that formerly contained
the natural lens. Some surgeons also inject an antibiotic into the eye to reduce the risk of
 infection. The final step is to inject salt water into the corneal wounds to cause the area to swell
and seal the incision.

Nursing Management

 The nurse should assess:

1. Recent medication intake. It is a common practice to withhold any anticoagulant therapy to

reduce the risk of retrobulbar hemorrhage.

2. Preoperative tests. The standard battery of preoperative tests such as complete blood count,
electrocardiogram, and urinalysis are prescribed only if they are indicated by the patient’s
medical history.

3. Vital signs. Stable vital signs are needed before the patient is subjected to surgery.

4. Visual acuity test results. Test results from Snellen’s and other visual acuity tests are assessed.

5. Patient’s medical history. The nurse assesses the patient’s medical history to determine the
preoperative tests to be required.

 Care for a patient with cataract includes:

6. Providing preoperative care. Use of anticoagulants is withheld to reduce the risk of retrobulbar
hemorrhage.

7. Providing postoperative care. Before discharge, the patient receives verbal and written
instructions about how to protect the eye, administer medications, recognize signs of
complications, and obtain emergency care.

 Discharge and Home Care Guidelines

The nurse teaches the patient self-care before discharge:

1. Activities. Activities to be avoided are instructed by the nurse.

2. Protective eye patch. To prevent accidental rubbing or poking of the eye, the patient wears a
protective eye patch for 24 hours after surgery, followed by eyeglasses worn during the day and
a metal shield worn at night for 1 to 4 weeks.

3. Expected side effects. Slight morning discharge, sone redness, and a scratchy feeling may be
expected for a few days, and a clean, damp washcloth may be used to remove slight morning
eye discharge.

4. Notify the physician. Because cataract surgery increases the risk of retinal detachment, the
patient must know to notify the surgeon if new floaters in vision, flashing lights, decrease in
vision, pain, or increase in redness occurs.