CATARACT SURGERY

Objectives:
At the end of the report the reporter will be able to:
1. Explain what cataract surgery is.
2. Describe indication for cataract surgery.
3. Describe post-operative management.
4. Give nursing diagnosis for cataract surgery.
Definition:
Cataract surgery is a procedure to remove the lens of your eye and, in most cases, replace it
with artificial lens. Normally, the lens of your eye is clear. A cataract causes the lens to become cloudy,
which is eventually affect your vision. Cataract surgery itself is not painless. A typical surgery procedure
doesn’t take very long – only about 15 minutes. If you need surgery in both eyes, your cataract surgeon
will typically wait one to two weeks between procedures to give the first eye a chance to heal.

Indication for surgery:

 Cataract associated visual loss that negatively affects quality of life by limiting ability to drive
safely, read, participate in sports, etc.
 Secondary glaucoma or lens induces uveitis.
 Cataract inhibits optimal management of posterior segment disease such as diabetic
retinopathy.

Type of surgery:
 Phacoemulsification (Phaco)
- This cataract procedure requires a small surgical incision around the edge of the
cornea, creating an opening through the membrane surrounding the lens.
- The next step involves inserting a small ultrasonic probe into the opening to break
up the cloudy lens into tiny fragments using sound waves, which act as a
microscopic jack hammer.
- An attachment on the probe tip is then used for suction of broken-down cataract
fragments.
- Once the lens particles are removed, an intraocular lens implant, also referred
commonly as an IOL, is implanted in the natural lens capsule.
- A hollowed-out tube is used by the ophthalmologist to insert the IOL through a tiny
corneal incision.
 Extracapsular cataract extraction (ECCE)
- This is the cataract procedure used in case of highly advanced cataracts, which is too
dense for phacoemulsification or when phacoemulsification is not possible for
various other reasons.
- A slightly larger incision is required for this cataract removing technique, so that the
cataract can be removed in one piece instead of being fragmented within the eye.
- A number of sutures are required to close the comparatively larger wound, which
also result in slower recovery of the wound as well as visual function.
- To initiate this cataract removal technique, the numbing medication is administered
through an injection around the eye. Am eye patch is also required after this kind of
surgical process.
 Lens replacement
- Referred to as aphakic (i.e, without lens). The lens which focuses light on the retina,
must be replaced for the patient to see clearly.
  There are three lens replacement options:
- Aphakic eyeglasses
- effective but are rarely used. Objects are magnified by 25% making them
appear closer than they actually are.
- Creates distortion. Peripheral vision is also limited, and Binocular vision (ability
of both eyes to focus on one object and fuse the two images into one) is impossible
if the other eye is aphakic (without a natural lens).
- 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.
- Not advisable for patient who have difficulty inserting, removing, and cleaning
them.
- Frequent and improper disinfection increase the risk of infection.
- IOL implants
- Insertion of IOLs during cataract surgery is the most common approach to lens
replacement.
- Cataract extraction and posterior chamber IOLs are associated with a relatively
low incidence of complication (eye infection, loss of vitreous humor, and
slipping of the implant).
- IOL implantation is contraindicated in patients with recurrent uveitis,
proliferative diabetic retinopathy, neovascular glaucoma, or rubeosis iridis.

Preoperative preparation:
Food and medication
- You may be instructed not to eat or drink anything 12 hours before cataract surgery.
- Your doctor may also advise you to temporarily stop taking any medication that
could increase your risk of bleeding during the procedure.
- Let your doctor know if you are taking any medications for prostate problems, as
some of these drugs can interfere with cataract surgery.
- Antibiotic eyedrops may be prescribed for use one or two days before the surgery.
Other precaution
- Normally you can go home on the same day as your surgery, but won’t be able to
drive, so arrange for a ride home. Also arrange for help around home, if necessary,
because your doctor may limit activities, such as bending and lifting, for about a
week after your surgery.
Diagnostic tests:
To determine whether you have a cataract, your doctor will review your medical history and
symptoms, and perform an eye examination. Your doctor may conduct several tests, including:
 Visual acuity test. A visual acuity test uses an eye chart to measure how well you can
read a series of letters. Your eyes are tested one at a time, while the other eye is
covered. Using a chart or a viewing device with progressively smaller letters, your eye
doctor determines if you have 20/20 vision or if your vision shows signs of impairment.
 Slit-lamp examination. A slit lamp allows your eye doctor to see the structures at the
front of your eye under magnification. The microscope is called a slit lamp because it
uses an intense line of light, a slit, to illuminate your cornea, iris, lens, and the space
between your iris and cornea. The slit allows your doctor to view these structures in
small sections, which makes it easier to detect any tiny abnormalities.
  Retinal exam. To prepare for a retinal exam, your eye doctor puts drop in your eyes to
open your pupils wide (dilate). This makes it easier to examine the back of your eyes
(retina). Using a slit lamp or a special device called an ophthalmoscope, your eye doctor
can examine your lens for signs of a cataract.

 Systemic examination:
1. Complete medical check-up such as
2. Complete ENT examination
3. Complete dental check-up
4. Random blood sugar, if patient has no diabetes
5. Fasting blood sugar and postprandial blood sugar, if the patient has diabetes under
control
6. FBS, PBS, and glycosylated hemoglobin, if patient had diabetes not under control
7. P24 antigen for HIV
8. Australian antigen or hepatitis B
9. HCV or hepatitis C
10. Urine – complete examination
Preoperative systemic examination is a must before all cataract surgeries to prevent
intraoperative complications such as hyphemia or expulsive hemorrhage and postoperative
complications such as infections or delayed healing or non-healing of the surgical wound. It
helps take all the due aseptic and antiseptic precautions to prevent iatrogenic spread of
diseases such as HIV, hepatitis B and hepatitis C. It also helps us in detecting and treating
beforehand any systemic disease the patient might be afflicted with.

Anesthesia
 Topical anesthesia
- Eye drops are placed in the eye to numb it.
 Needle-based eye block
- Often lidocaine, is injected into the eye or surrounding area to numb it completely.
 Facial nerve block
- The entire face is numbed through a needle-based block. It is generally reserved for
only those who may face surgical complication otherwise.
 General anesthesia
- You will be completely sedated for the duration of the procedure through IV
medications.
- General anesthesia is usually only needed for pediatric patients and those with
significant medical or mental conditions what will prevent them from being able to
hold still for the short procedure. Often, the topical options and needle blocks are
enough.

Position
 The patient lying in supine position with his or her head flat to optimized the red reflex and
surgical view.
For patient who has a medical condition that precludes lying supine such as
- Kyphosis, chronic obstructive pulmonary disease, congestive heart failure, cerebral
palsy, myotonic dystrophy, obesity, and Meniere disease can be position in:
1. Face to face position
 a. positioned a patient seated in a standard reclining cataract surgical chair in an
almost upright position
2. Standing phacoemulsification in reverse- Trendelenburg position
a. patient was in reverse-Trendelenburg position. This position may help lower
posterior venous pressure by reducing central venous pressure. Patients with
morbid obesity face a variety of health complications including increased risks of
cataracts and elevated intraocular pressure.
3. Side-saddle position
a. The patient is positioned on the operating table at the lowest inclination
tolerable, and the operating microscope’s axis is tilted back 60º toward the
horizontal. The foot pedals are placed parallel to the long axis of the operating
table. The patient’s head is rotated toward the surgeon and/or in a chin-up
position.
4. Phacoemulsification in a standard waiting room chair
a. the patient to remain seated upright with his or her head tilted back but
supported. Other minor adjustments were made to the chair, such as adding
weights for stability and lowering the height so that a patient’s legs extended
outward to provide counterbalance. This technique is useful for patients who
can tolerate sitting with their head extended back.

Procedure
Cataract surgery, usually an outpatient procedure, takes an hour or less to perform.
First, your doctor will place eyedrops in your eye to dilate your pupil. You'll receive local
anesthetics to numb the area, and you may be given a sedative to help you relax. If you're given a
sedative, you may remain awake, but groggy, during surgery.
During cataract surgery, the clouded lens is removed, and a clear artificial lens is usually
implanted. In some cases, however, a cataract may be removed without implanting an artificial lens.
Surgical methods used to remove cataracts include:
 Using an ultrasound probe to break up the lens for removal. During a procedure called
phacoemulsification, your surgeon makes a tiny incision in the front of your eye (cornea)
and inserts a needle-thin probe into the lens substance where the cataract has formed.
Your surgeon then uses the probe, which transmits ultrasound waves, to break up
(emulsify) the cataract and suction out the fragments. The very back of your lens (the lens
capsule) is left intact to serve as a place for the artificial lens to rest. Stitches may be used
to close the tiny incision in your cornea at the completion of the procedure.
 Making an incision in the eye and removing the lens in one piece. A less frequently used
procedure called extracapsular cataract extraction requires a larger incision than that used
for phacoemulsification. Through this larger incision your surgeon uses surgical tools to
remove the front capsule of the lens and the cloudy lens comprising the cataract. The very
back capsule of your lens is left in place to serve as a place for the artificial lens to rest.
This procedure may be performed if you have certain eye complications. With the larger
incision, stitches are required.
Once the cataract has been removed by either phacoemulsification or extracapsular extraction,
the artificial lens is implanted into the empty lens capsule.

Incision type:
 Scleral tunnel incision- The first step in this type of incision is to perform a 5 mm conjunctival
peritomy at the limbus where the incision will be made.
 1. Lower rates of endophthalmitis compared to CCI
2. Preferred method in microcornea
3. Preferred method in cases with low endothelial count
 Clear corneal incision- These clear corneal wounds usually are self-sealing, and do not induce
astigmatism as they heal. They have minimal risk of bleeding.
1. Self-sealing, sutureless wound
2. Shorter procedure time
3. Faster visual recovery
4. Decreased risk of bleeding due to minimal to no conjunctival manipulation

Closure
Stromal hydration
- is an effective means to stem the leakage from most spontaneously leaking cataract
incisions. It is typically employed by delivering balanced salt solution via a 30-gauge
cannula into the corners and internal roof of the incision.
Suture
- are routinely used when a leak is observed at the completion of surgery. It is not
clear whether sutured incisions allow a better or similar seal when compared with
stromal hydration. Sutured incisions have been reported to leak

Contraindication for the surgery

 The patient does not desire surgery
 Glasses or visual aids provide vision that meets the patient’s needs.
 Surgery will not improve visual function
 The patient’s quality of life is not compromised
 The patient cannot safely undergo surgery
 Informed consent cannot be obtained from patient or surrogate
 Appropriate post-operative care cannot be arranged

Complication
 Immediate preoperative
- Retrobulbar hemorrhage- can result from retrobulbar infiltration of anesthetic
agents if the short ciliary artery is located by the injectia.
 Intraoperative
- Rupture of the posterior capsule
- Suprachoroidal (expulsive) hemorrhage- profuse bleeding into the suprachoroidal
space
 Early postoperative
- Acute bacterial endophthalmitis- devastating complication that occurs in about 1 in
1000 cases; the most common causative organisms are staphylococcus epidermis,
staphylococcus aureus, pseudomonas, and proteus species.
- Toxic anterior segment syndrome- noninfectious inflammation that is a complication
of anterior chamber surgery; caused by a toxic agent such as an agent used to
sterilized surgical instruments.
 Late postoperative
- Suture-related problems
- Malposition of the IOL
 - Chronic endophthalmitis
- Opacification of the posterior capsule- most common late complication of
extracapsular cataract extraction.

Post-operative management
 After cataract surgery
1. Before you leave the day surgery, you will be prescribed eye drops or other medication to
prevent infection, reduce inflammation and control eye pressure.
2. You will need to have a family member or friend with you to take you home.
3. Once you get home, it is recommended that you rest your eyes and nap.
4. Several hours post-surgery, most people are able to watch some television or look at a
computer screen for a short period of time. Because cataract surgery is only performed on
one eye at a time, you may notice an imbalance in your vision until the second eye is
operated on (usually 1–4 weeks later).
 Days after the surgery
1. It is normal for vision to be blurry in the beginning – your eye needs to heal and adjust.
Vision will normally begin to improve within a few days of the surgery.
2. It’s also normal for your eye to feel itchy and to experience mild discomfort for a couple
of days – your doctor will ask you to wear an eye patch or protective shield at night to
ensure you don’t rub your eye while you sleep. This discomfort should disappear after a
few days.
 Tips for post-cataract surgery
Although most people can resume everyday activities 24 hours after cataract surgery,
there are a few instructions that you will be asked to follow. They include:
1. Don’t do any strenuous activities for a few weeks. Avoid rigorous exercise and heavy
lifting.
2. Don’t drive. The length of time after cataract surgery before you can drive depends on a
number of factors – your doctor will tell you when it is safe to resume driving.
3. Follow your doctor’s orders regarding any antibiotic and anti-inflammatory eye drops.
These are important to prevent infection and inflammation and ensure proper healing.
If you have difficulty in administering them, get a friend or family member to help you
out.
4. Stay away from dusty areas. It’s a great idea to have your house vacuumed and cleaned
before surgery, as your eyes will be sensitive to airborne allergens such as dust.
5. Don’t rub your eye. Eye rubbing is a quick way to develop a nasty infection. It’s never a
good idea, even when you aren’t recovering from surgery.
6. Don’t swim. It’s best to avoid swimming or hot tubs for a week after surgery.
7. Don’t wear make-up. Ask your doctor when you can resume doing so.

 Discharge plan
o Medication
1. Anti-inflammatory drop containing an antibiotic ex; G betamethasone (a corticosteroid)
combined with antibiotic neomycin.
2. A cycloplegic may also be prescribed to prevent ciliary spasm; G. cyclopentolate twice daily
and should be stored in a refrigerator between uses.
o Environmental
1. Modified or structured environment to ensure patient’s safety because vision may be blurry
for several weeks after the surgery.
 o Theraphy
1. Protective eye patch to avoid accidental rubbing or poking of the eye.
2. Continuation of prescribed medication
o Outpatient follow-up
1. The patient needs to have a schedule check-up to see the progress of vision or detection of
any complication.
o Diet
1. There is no dietary restriction. However, the restrictions as per pre-existing medical
problems, if any are to continue.
2. The patient must avoid constipation by taking high fiber diet and plenty of fluids.
3. Encourage patient to eat rich in high protein such as meat, fish, and eggs for early wound
healing
o Spirituality
1. Spiritual practices according to one’s faith and religion.

 Health teaching
1. Wearing of eye patch 24 hours after surgery.
2. Sunglasses should be worn while outdoors during the day because the eye is sensitive to
light.
3. Slight morning discharge, some redness, and a scratchy feeling may be expected for a few
days.
4. 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.
Actual video
https://youtu.be/-gf0AAQC8gc
Instrument used
Nursing diagnosis
 Pre-op
o Risk for trauma related to poor vision and reduces hand-eye coordination.
o Anxiety related to threat of permanent loss of vision/independence.
 Post-op
o Risk for infection related to invasive surgical procedure
o Acute pain related to trauma to the incision
o Disturbed visual sensory perception related to altered sensory reception or status or
sense organ.

Drug study
Drugs Classification Mechanism of Action Side effects Nursing responsibilities
Bethamethason Corticosteroid Bethamethasone is a Sodium and  Assess involved systems
e corticosteroid with fluid retention, periodically
mainly glucocorticoid potassium and  Assess patient for signs
activity. It prevents calcium of adrenal insufficiency
and controls depletion.  Monitor intake and
inflammation by Muscle output ratios and daily
controlling the rate wasting, weight
of protein synthesis, weakness,  If dose is ordered daily,
depressing the osteoporosis. administer in the
migration of GI morning to coincide
polymorphonuclear disturbances with the body’s normal
leukocytes and and bleeding. secretion of cortisol
fibroblasts, and
reversing capillary
permeability and
lysosomal
stabilisation.
Cyclopentolate Cycloplegic By blocking  Fast or  Use cautiously in
mydriatrics muscarinic receptors, uneven patients with history of
cyclopentolate heart rate glaucoma; systemic
produces dilation of  Warmth, absorption may cause
the pupil (mydriasis) redness anticholinergic effects
and prevents the eye or tingly such as confusion,
from accommodating feeling unusual behavior,
for near vision under the flushing and
(cycloplegia) skin hallucinations
 Severe
skin rash
 Slow or
shallow
breathing

Prognosis
 Cataract surgery improves the vision of 95 percent of patients who have it. In those patients
who have intraocular lens replacements, 90 percent have 20/40 vision or better. In some patients who
have had extracapsular surgery, part of the lens capsule eventually becomes cloudy, causing a condition
called an after-cataract. This can be corrected with laser surgery, usually as an outpatient.

Reference
Dineen B, Bourne RR,Jadoon Z, Shah SP, Khan MA, Fsoter A, et. Al, Causes of Blinness and Visual
impairment in Pakistan: The Pakistan national blindness and visual impairment surveyr. Br J
Ophalmology 2007; 91:1005-10
http://www.world.federatio.org/Health/Aeimullah+Eye+Clinics/Mianwali+
+Pakistan/Articles/115_Patients_Screened_39_cataract_surgeries_performed_Aeinullhah_Eye_Clinic_p
akistan _month_march_2013.html
https://www.slideshare.net/CliffordAchoka1/cataract-case-presentationcase-study
https://www.healio.com/news/ophthalmology/20140910/incision-creation-and-closure-a-
complex-part-of-cataract-surgery
https://www.mayoclinic.org/diseases-conditions/cataracts/diagnosis-treatment/drc-
20353795#:~:text=To%20determine%20whether%20you%20have,read%20a%20series%20of%20letters.
https://www.verywellhealth.com/testing-for-eye-cataracts-3421560