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Lang, G. (2007). Opthalmology: a pocket textbook atlas. 2
ed. New York: Thieme
Steinhert, R. (2010). Cataract surgery. 3 ed. Duxbury, MA: Elsevier Inc. Cataract retrieved from www.mayoclinic.com Cataract retrieved from www.merckmanuals.com
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.
Signs and symptoms of cataracts include:
Clouded, blurred or dim vision Increasing difficulty with vision at night Sensitivity to light and glare Seeing "halos" around lights Frequent changes in eyeglass or contact lens prescription Fading or yellowing of colors Double vision in a single eye At first, the cloudiness in your vision caused by a cataract may affect only a small part of the eye's lens and you may be unaware of any vision loss. As the cataract grows larger, it clouds more of your lens and distorts the light passing through the lens. This may lead to signs and symptoms you're more likely to notice.
Most cataracts develop when aging or injury changes the tissue that makes up your eye's lens. Some cataracts are caused by inherited genetic disorders that cause other health problems and increase your risk of cataracts. How a cataract forms The lens, where cataracts form, is positioned behind the colored part of your eye (iris). The lens focuses light that passes into your eye, producing clear, sharp images on the retina — the light-sensitive membrane on the back inside wall of your eyeball that functions like the film of a camera. A cataract scatters the light as it passes through the lens, preventing a sharply defined image from reaching your retina. As a result, your vision becomes blurred. As you age, the lenses in your eyes become less flexible, less transparent and thicker. Aging-related changes to the lens cause tissues to break down and to clump together, clouding small areas of the lens. As the cataract continues to develop, the clouding becomes denser and involves a greater part of the lens. A cataract can develop in one or both of your eyes. Types of cataracts Cataract types include: Cataracts that affect the center of the lens (nuclear cataracts). A nuclear cataract may at first cause you to become more nearsighted or even experience a temporary improvement in your reading vision. But with time, the lens gradually turns more densely yellow and further clouds your vision. Nuclear cataracts sometimes cause you to see double or multiple images. As the cataract 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. Problems with glare are common for people with this type of cataract. 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 on its way to the retina. A subcapsular cataract often interferes with your reading vision, reduces your vision in bright light and causes glare or halos around lights at night. Cataracts you're born with (congenital cataracts). Some people are born with cataracts or develop them during childhood. Such cataracts may be the result of the mother having contracted an infection during pregnancy. They may also be due to certain inherited syndromes, such as Alport's syndrome, Fabry's disease and galactosemia. Congenital cataracts, as they're called, don't always affect vision, but if they do they're usually removed soon after detection.
Factors that increase your risk of cataracts include:
Etiology Cataracts occur with aging. Other risk factors may include the following:
Trauma (sometimes causing cataracts years later) Alcohol use Heat from infrared exposure Uveitis Systemic drugs (eg, corticosteroids) Undernutrition
Many people have no risk factors other than age. Some cataracts are congenital, associated with numerous syndromes and diseases. Increasing age Diabetes Drinking excessive amounts of alcohol Excessive exposure to sunlight Exposure to ionizing radiation, such as that used in X-rays and cancer radiation therapy Family history of cataracts High blood pressure Obesity Previous eye injury or inflammation Previous eye surgery Prolonged use of corticosteroid medications
Tests and diagnosis
To determine whether you have a cataract, your doctor will perform an eye exam that may include: Asking you to read an eye chart (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. Using a light and magnification to examine your eye (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. Dilating your eyes (retinal examination). To prepare for a retinal examination, your eye doctor puts dilating drops in your eyes to open your pupils wide. 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.
Ophthalmoscopy followed by slit-lamp examination
Diagnosis is best made with the pupil dilated. Well-developed cataracts appear as gray, white, or yellowbrown opacities in the lens. Examination of the red reflex through the dilated pupil with the ophthalmoscope held about 30 cm away usually discloses subtle opacities. Small cataracts stand out as dark defects in the red reflex. A large cataract may obliterate the red reflex. Slit-lamp examination provides more details about the character, location, and extent of the opacity
Treatments and drugs
The only effective treatment for cataracts is surgery. Treatment Surgical removal of the cataract
Placement of an intraocular lens
Frequent refractions and corrective lens prescription changes may help maintain useful vision during cataract development. Occasionally, long-term pupillary dilation (with phenylephrine
2.5% q 4 to 8 h) is helpful for small centrally located cataracts. Indirect lighting while reading minimizes pupillary constriction and may optimize vision for close tasks. Polarized lenses reduce glare. Usual indications for surgery include the following:
Best vision obtained with glasses is worse than 20/40 (< 6/12), or vision is significantly decreased under glare conditions (eg, oblique lighting while trying to read a chart) in a patient with bothersome halos or starbursts. Patients sense that vision is limiting (eg, by preventing activities of daily living such as driving, reading, hobbies, and occupational activities). Vision could potentially be meaningfully improved if the cataract is removed (ie, a significant portion of the vision loss must be caused by the cataract).
Far less common indications include cataracts that cause glaucoma or that obscure the fundus in patients who need periodic fundus examinations for management of diseases such as diabetic retinopathy and glaucoma. There is no advantage to removing a cataract early. Cataract extraction is usually done using a topical or local anesthetic and IV sedation. There are 3 extraction techniques. In intracapsular cataract extraction, the cataract and lens capsule are removed in one piece; this technique is rarely used. In extracapsular cataract extraction, the hard central nucleus is removed in one piece and then the soft cortex is removed in multiple small pieces. In phacoemulsification, the hard central nucleus is dissolved by ultrasound and then the soft cortex is removed in multiple small pieces. Phacoemulsification requires the smallest incision, thus enabling the fastest healing, and is usually the preferred procedure. In extracapsular extraction (including phacoemulsification), the lens capsule is not removed. A plastic or silicone lens is almost always implanted intraocularly to replace the optical focusing power lost by removal of the crystalline lens. The lens implant is usually placed on or within the lens capsule (posterior chamber lens). The lens can also be placed in front of the iris (anterior chamber lens) or attached to the iris and within the pupil (iris plane lens). Iris plane lenses are rarely used in the US because many designs led to a high frequency of postoperative complications. Multifocal intraocular lenses are newer and have different focusing zones that may reduce dependence on glasses after surgery. Patients occasionally experience glare or halos with these lenses, especially under low-light conditions. In most cases, a tapering schedule of topical antibiotics (eg, moxifloxacin 0.5% 1 drop qid) and topical corticosteroids (eg, prednisolone acetate 1% 1 drop qid) is used for up to 4 wk postsurgery. Patients often wear an eye shield while sleeping and should avoid the Valsalva maneuver, heavy lifting, excessive forward bending, and eye rubbing for several weeks.
Lifestyle and home remedies
To deal with symptoms of cataracts until you decide to have surgery, try to: Make sure your eyeglasses or contact lenses are the most accurate prescription possible Use a magnifying glass to read Improve the lighting in your home with more or brighter lamps When you go outside during the day, wear sunglasses or a broad-brimmed hat to reduce glare Limit your night driving Self-care measures may help for a while, but as the cataract progresses, your vision may deteriorate further. When vision loss starts to interfere with your everyday activities, consider cataract surgery. Assessment Typically, the patient complains of painless, gradual vision loss. He may also report a blinding glare from headlights when he drives at night, poor reading vision, and an annoying glare and poor vision in bright sunlight. If he has a central opacity, the patient may report seeing better in dim light than in bright light, because this cataract is nuclear and, as the pupil dilates, the patient can see around the opacity. Physical examination. Cataract formation causes blurred vision, a loss measured by Use of the snellen chart. Color perception of blue, green, and purple is reported as varying Shades of gray. If the cataract is advanced, shining a penlight on the pupil reveals the white area Behind the pupil. A dark area in the normally homogeneous red reflex confirms the diagnosis.
Nursing Assessment 1. 2. Activity / Rest: The change from the usual activities / hobbies in connection with visual impairment. Neurosensory: Impaired vision blurred / not clear, bright light causes glare with a gradual loss of peripheral vision, difficulty focusing work with closely or feel the dark room. Vision cloudy / blurry, looking halo / rainbow around the beam, changes eyeglasses, medication does not improve vision, photophobia (acute glaucoma). Signs: Looks brownish or milky white in the pupil (cataract), the pupil narrows and red / hard eye and a cloudy cornea (glaucoma emergency, increased tears) Pain / Leisure: Discomfort light / watery eyes. Sudden pain / heavy persist or pressure on or around the eyes, headaches.
Diagnoses that may occur in Nursing Care Plans For Cataract
Anxiety Deficient knowledge (diagnosis and treatment) Risk for infection Risk for injury Sensory and perceptual alterations: visual, related to decreased visual acuity secondary to cataract.
High risk of injury related to loss of vitreous, intraocular hemorrhage, increased IOP
Impaired sensory perception: the perceptual vision, related to impaired sensory reception secondary to cataract
Nursing Interventions 1. 2. 3. 4. 5. 6. Before surgery, monitor for worsening of visual acuity, glare, and ability to perform usual activities. Monitor pain level postoperatively. Sudden onset may be caused by a ruptured vessel or suture and may lead to hemorrhage. Severe pain accompanied by nausea and vomiting may be caused by increased IOP. Assess gradual adaptation to lens implant, contact lens, or glasses. Keep the patient comfortable and advise him not to touch his eyes. If eye patch or shield is in place, advise using it for several days as prescribed, to rest and protect eye, especially at night. Caution the patient against coughing or sneezing, any rapid moment, bending from the waist to prevent increased IOP for first 24 hour. Instruct the patient to avoid heavy lifting or straining for up to 6 weeks, as directed by surgeon. 7. 8. 9. Advise patient to increase activity gradually; can usually resume normal activity the day after the procedure. Teach proper installation of the eye. Encourage to follow up ophthalmologic examinations for corrective lenses and checking of IOP. Adjustment to eye glasses to correct vision may take weeks.
10. Advise the patient not to get soap in the eyes. 11. Advise the patient to avoid tilting the head forward when washing hair, and to avoid vigorous hand shaking, to prevent disruption of the lens until cleared by the surgeon.
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