CATARACT

INTRODUCTION
A cataract is a clouding of the lens inside the eye which leads to a decrease in vision. Cataracts are
the most common cause of vision loss in people over age 60 and are the principal cause of blindness
in the world. In fact, there are more cases of cataracts worldwide than there are of glaucoma, macular
degeneration and diabetic retinopathy 

DEFINITION
A cataract is a clouding or opacity within the crystalline lens that leads to gradual painless blurring
and eventual loss of vision. The patient may have a cataract in one or both eyes. If present in both
eyes, one cataract may affect the patient’s vision. The cataracts are third leading cause of preventable
blindness.

ANATOMY AND PHYISOLOGY OF EYE

The eye is the organ of sight (vision). A person has 2 eyes located below the forehead and eyebrows
at the front of the face, within the eye socket (orbit) area of the skull. One eye is located on either
side of the bridge of the nose. Only about one-sixth of the eyeball can be seen. The rest of the eye is
sprotected by bone and surrounding tissues, including muscle and fat.

Structure

The eye is made up of 3 main parts:

 eyeball
 orbit (eye socket)
 accessory (adnexal) structures
The eyeball

The main part of the eye is the sphere-shaped eyeball (also called the globe). The eyeball reaches its
full size of about 2.5 cm (1 inch) in diameter in late childhood. The eyeball is rich in blood vessels.
The inside of the eyeball is filled mostly with a clear, jelly-like fluid called vitreous humour. Vitreous
humour fills the back (posterior) part of the eye. It helps support the internal structures and maintain
the shape of the eye.

The outer part of the eyeball is called the wall of the eye. It can be divided into 3 layers (or tunics)
from the outside to the inside of the eye: the outer, middle and inner layer.

Outer layer

The outermost layer or covering of the wall of the eye is called the fibrous tunic. It is made up of the
sclera and cornea.

 sclera – The sclera is the tough, connective tissue that covers most of the outside of the
eyeball. It is the white part of the eye and serves as the protective covering. The optic nerve
and blood vessels pass through the sclera in the back of the eye. The muscles that control the
movement of the eye attach to the sclera.
 cornea – The cornea is the clear, dome-shaped covering at the front of the eye that lets in
light. The cornea covers the pupil and the iris. It does not contain any blood vessels.

Middle layer

The middle layer of the wall of the eye is called the uvea or vascular tunic. The uvea has 3 main
parts:
  iris – The iris is the thin, muscular, coloured part of the eye. It is located at the front (anterior)
of the eye, between the cornea and the lens. The iris opens and closes the pupil to change the
amount of light entering the eye.
 choroid – The choroid is a thin layer of tissue that supplies oxygen and nutrients to the retina
through many tiny blood vessels.The choroid also contains many cells called melanocytes.
These cells produce pigment and help absorb any extra light and minimize reflections within
the eye.
 ciliary body – The ciliary body lies just behind the iris and extends forward from the choroid.
It is the muscular ring of tissue that helps the eye focus. It changes the shape of the lens so it
can focus on near or far objects. The ciliary body contains cells that make aqueous humour,
which is the clear fluid in the front of the eye between the cornea and lens.

Inner layer

The innermost layer of the wall of the eye is called the retina or neural tunic.

 retina – The retina is the thin layer of cells at the back of the eyeball. It is made up of nerve
cells that are sensitive to light. These cells are connected to the brain by the optic nerve,
which sends information from the eye to the brain and allows us to see. The optic disc is
known as the “blind spot” of the retina. This is the junction of the retina and the head of the
optic nerve.
 fovea – The fovea is a depression on the retina that is the area of sharpest vision. When a
person looks directly at an object, the image falls on this part of the retina.
 retinoblasts – Retinoblasts are present in the developing eyes of babies before they are born.
They are immature cells (or progenitor cells) that divide and fill the part of the eye that will
eventually become the retina.
o Normally, retinoblasts stop dividing and become mature or differentiated retinal cells.
o In retinoblastoma, a mutation in the retinoblastoma 1 (RB1) gene causes retinoblasts
to divide out of control. The abnormal cells may form one or many tumours.
o Some children are born with retinoblastoma (called congenital retinoblastoma), but it
is more commonly diagnosed after birth, usually before age 5.

Lens

The lens is a transparent structure in the inner part of the eye that focuses light on the retina and
changes shape to allow the eye to focus on objects. It lies directly behind the cornea and iris.
Orbit

The orbit (eye socket) is a bowl-shaped cavity in the bone of the skull. It contains the eyeball and the
connective tissues surrounding the eyeball. The bone and connective tissues cushion and protect the
eye. Six muscles attached to the eyeball make it move in different directions. These small muscles
attach to the sclera near the front of the eye and to the bones of the orbit at the back. The orbit also
contains nerves, fat, blood vessels and a variety of connective tissues.

Accessory structures

The accessory (adnexal) structures of the eye include the eyelids, conjunctiva, caruncle and lacrimal
(tear) glands.

Eyelid

The eyelid (palpebrae) is a fold of skin that covers and protects the eye. Muscles raise and close the
eyelids. The eyelids contain glands, which produce an oily substance that prevents tears from
evaporating and the eyelids from sticking together.

Eyelashes grow from the edges of the eyelids. They help protect the eye from dust and debris.

Conjunctiva

The conjunctiva is a clear mucous membrane that lines the inner surface of the eyelids and the outer
surface of the eye. The conjunctiva makes mucous that lubricates the eyeball and keeps it moist.

Caruncle

The caruncle is the small, pinkish portion of the innermost corner of the eye (or inner canthus). It
contains oil and sweat (sebaceous) glands and conjunctival tissue.

Lacrimal gland

The lacrimal gland (tear gland) is the almond-shaped gland located inside the orbit at the upper, outer
corner of each eye. The lacrimal gland makes tears to help keep the surface of the eye and lining of
the eyelids moist and lubricated. Tears help reduce friction and remove dust and debris from the eye
to prevent infection. Small lacrimal ducts drain tears from the lacrimal gland through very tiny
openings inside the inner corner of each eyelid.

Function

The eye is the organ that works with the brain to provide us with the sense of sight or vision. It works
much like a camera. The main function of the eye is to collect light and turn it into electric signals,
which are sent to the brain. The brain then turns those signals into a visual image or picture for us to
see. We have 2 eyes, so 2 pictures are usually created. If we lose vision in one eye, we can still see
most of what we could before with just one eye.

When light enters the eye, it first passes through the cornea. The light then passes through the pupil,
where the iris adjusts the amount of light entering the eye. The light then passes through the lens of
the eye. The lens focuses light rays onto the retina, where it is changed into a signal that is
transmitted to the brain by the optic nerve. The signal is received and interpreted by the brain as a
visual imag e.

CLASSIFICATION
1. Senile (associated with aging)
2. Traumatic (associated with injury)
3. Congenital (present at birth )
4. Secondary (occurring after other disease)

THE RISK FACTORS ASSOCIATED WITH CATARACT INCLUDE THE FOLLOWING:

 Age: The incidence increases dramatically after the age of 6o.
 Sex: Cataracts are slightly more common in women than men.
 Ultraviolet light exposure:
– More common in persons living in warm sunny climates.
– More common in persons who have worked outdoor extensively.
High dose radiation exposure.
 Drug effects: Use of corticosteroids, phenothiazines and selected chromotherapeutic agents.
 Poorly-controlled diabetes mellitus accumulation of sorbitol (by product of glucose).
 Trauma to the eye.

ETIOLOGY
 Degenerative changes. Senile cataracts develop in elderly patients, probably because of the
degenerative changes in the chemical state of lens proteins.
 Genetic defects. Congenital cataracts occur in neonates genetic defects or as a sequel of
maternal infections during the first trimester
  Foreign body injury. Traumatic cataracts occur after a foreign body injures the lens with
sufficient force to allow aqueous or vitreous humor to enter the lens capsule and also dislocate
the lens.
 Secondary effects. Complicated cataracts occur as secondary effects in patients with uveitis,
glaucoma, or retinitis pigmentosa, or in the course of a systemic disease, such as diabetes,
hypoparathyroidism, or atopic dermatitis.
 Drug or chemical toxicity. Toxic cataracts result from drug or chemical toxicity with
prednisone, ergot alkaloids, dinitrophenol, naphthalene, phenothiazines, or pilocarpine, or
from extended exposure to ultraviolet rays

PATHOPHYSIOLOGY
 Cataract development is mediated by a number of factors. In senile cataract formation, it
appears that altered metabolic processes (decrease in protein, an accumulation of water and an
increase in sodium content) within the lens that cause an accumulation and disrupts the
normal lens fibre structure.
 These changes affect lens transparency, causing vision changes. The cause of these
pathological changes is not known. Cataracts usually develops bilaterally, but at different rate.
The primary symptom of cataract is a progressive loss of vision.
 The degree of loss depends on the location and extent of the opacity.
 Person with an opacity in the center portion of the lens can generally be better in dim light
when the pupil are dilated.
 The person with presbyopia may find that reading without glass is possible in the early stages
of cataract formation, because the greater convexity of the lens creates an artificial myopia.

CLINICAL MANIFESTATION
 Blurred vision. Blurred vision is usually the first symptom of cataracts.
 Glare. Glare refers to the pain felt when the patient looks directly into the light
 Halos. Halos are formed when the patient looks at a bright light and there is still the vision of
the light after looking away.
 Double vision. Double vision is also one of the early symptoms of cataract.

THE DIAGNOSTIC TESTS OF CATARACT INCLUDE THE FOLLOWING:

 Visual acuity measurements.
 Ophthalmoscopy (direct or indirect).
 Slit lamp microscopy.
 Blood testing and potential acuity testing in selected patients.
 Keretometrics and A-scan ultrasound (if surgery is planned).
 Visual field perimetry.
MANAGEMENT
Diagnosis of cataract based on decreased visual acuity or other complaints of visual dysfunction.
Medical management
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
Lens replacement. There are three lens replacement options:
 Phacoemulsification. A portion of the anterior capsule is removed, allowing extraction of the
lens nucleus and cortex while the posterior capsule and zonular support are left intact.
o Aphakic glasses. In aphakic glasses, objects are magnified by 25%, making them appear
closer than they actually are.
o Contact lenses. Contact lenses provide patients with almost normal vision, but because
contact lenses need to be removed occasionally, the patient also needs a pair pf aphakic
glasses.
o IOL implants. The most common IOL is the single focus lens or monofocal IOL that
cannot alter the visual shape; multifocal IOLs reduce the need for eyeglasses; accommodative
IOLS mimic the accommodative response of the youthful, phakic eye
 Extracapsular cataract extraction (ECCE). ECCE removes the anterior lens and cortex,
leaving the posterior capsule intact.
 Intracapsular cataract extraction. This procedure removes the entire lens within the intact
capsule.

IMMEDIATE CARE OF THE PERSON AFTER CATARACT SURGERY INCLUDES THE

FOLLOWING:
 Position patient on back or un operated side to prevent pressure in operated eye.
 Keep side rails up as necessary for protection.
 Place bedside table onside of un operated eye (Patient then turns towards the un operated
side).
 Place call light within reach.
 Stress avoidance of actions that increases IOP (for example, sneezing, coughing, vomiting,
straining, or sudden bending over with the head below the waist).
 The nurse instructs the patient to be careful to prevent soap or water from entering the
operative eye during face or hair-washing.
 The nurse also instructs the patient to avoid heavy lifting, active exercises, isometric
exercises, or straining during defecation until cleared by the surgeon to prevent abrupt
fluctuation in IOP.
 
NUTRITIONAL MANAGEMENT
NURSING MANAEMENT
Nursing assessment
The nurse should assess:
 Recent medication intake. It is a common practice to withhold any anticoagulant therapy to
reduce the risk of retrobulbar hemorrhage.
 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.
 Vital signs. Stable vital signs are needed before the patient is subjected to surgery.
 Visual acuity test results. Test results from Snellen’s and other visual acuity tests are
assessed.
 Patient’s medical history. The nurse assesses the patient’s medical history to determine the
preoperative tests to be required.

Nursing diagnosis
 Disturbed visual sensory perception related to altered sensory reception or status of sense
organs.
 Risk for trauma related to poor vision and reduces hand-eye coordination.
 Anxiety related to threat of permanent loss of vision/independence.
 Deficient knowledge regarding ways of coping with altered abilities related to lack of
exposure or recall, misinterpretation, or cognitive limitations.
Nursing goal
 Regaining of usual level of cognition.
 Recognizing awareness of sensory needs.
 Be free of injury.
 Identifying potential risk factors in the environment.
 Appearing relaxed and reporting anxiety is reduced at manageable level.
 Verbalizing feelings of anxiety.
 Identifying healthy ways to deal with and express anxiety.
  Evaluation
 Regained usual level of cognition.
 Recognized awareness of sensory needs.
 Free of injury.
 Identified potential risk factors in the environment.
 Appeared relaxed and reporting anxiety is reduced ti a manageable level.
 Verbalized feelings of anxiety.
 Identified healthy ways to deal with and express anxiety.
Intervention
 Providing preoperative care. Use of anticoagulants is withheld to reduce the risk of
retrobulbar hemorrhage.
 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.
HEALTH EDUCATION:
 Teach patient and family proper hygiene and eye care techniques to ensure that medications
dressing, and/or surgical wound are not contaminated during necessary eye care.
 Teach patient and family about signs and symptoms of infection and how to report those to
allow early recognition and treatment of possible infection.
 Instruct patient to comply with postoperative restrictions on head positioning, bending,
coughing and valsalvas manoeuvre to optimize to visual outcomes and prevent increased IOP.
 Instructs patient to instil eye medications using aseptic techniques and to comply with
prescribed eye medications routine to prevent infection.
 Instruct patient to monitor pain and take prescribed medication for pain as directed and to
report pain not relieved by prescribed drug.
 Activities. Activities to be avoided are instructed by the nurse.
 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.
 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.
 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.

Conclusion
 Cataract is a clouding of the lens in the eye which leads to a decrease in vision. Cataract surgery is
the principal refractive surgical procedure performed in older adults. Technological advances have
allowed for improved surgery through smaller incisions, resulting in better outcomes. Improvements
in lens implants provide better visual outcomes than were previously possible.
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 Scott IU, Smiddy WE, Schiffman J, Feuer WJ, Pappas CJ. Quality of life of lowvision patients and the
impact of low-vision services. Am J Ohthalmol 1999;128:54-62.