Nursing care after cataract surgery such as proper position after surgery,

nurse role for relieving postoperative pain, prevention of infection,

signs and symptoms on infected eye, diet to help healing, postoperative
complications, etc.; 4) Pre-discharge instruction for patient and patient
family regarding use of eye drops and ointment, wearing eye shield and
protection of the eye, precautions to prevent infection, food regimen to
reduce straining and constipation, exercise and avoiding heavy lifting,
unusual symptoms, follow–up, etc. For knowledge scoring, a correct
response was scored 1 and the incorrect zero. For each area of knowledge,
the scores of the items were summed-up and the total divided by the number
of the items, giving a mean score for the part. These scores were converted
into a percent score. Knowledge was considered satisfactory if the percent
score was 60% or more and unsatisfactory if less than 60%.

Definition

Cataract is a condition in which the normally clear lens of the eye becomes
cloudy and clear change.

Cataract is the opacity of the progressive lens or the lens capsule.

Cataract is a cloudiness in the lens of each state, which can occur due
to hydration (addition of liquid), lens protein denaturation, or due to
both of them, usually occurs in both eyes and progressive.

Etiology

Physical

Chemical

Elderly
Disease predisposing

Genetic and developmental disorders

Virus infection in the future growth of the fetus.

Classification

Cataracts can be classified according to developmental and degenerative

processes by:

1. Congenital Cataracts

Congenital cataract is a cloudiness in the lens that occur during the

formation of the lens. Turbidity was there at the time the baby is born.
Cataract is often found in infants born to mothers who had rubella,
diabetes, toxoplasmosis, hipoparatiroidismo, galactosemia. There are
also accompanying congenital abnormalities in the eye itself as
microphthalmus, aniridia, coloboma, keratoconus, Ectopia lentis,
megalocornea, hetero cornea iris.

Turbidity can be found in the form: hyaloidea persistent artery, anterior

polar cataract, posterior, Axialis cataract, zonular cataract, stellate
cataract, cataract totalis and congenital totalis membranacea.

2. Primary Cataracts

Primary cataracts by age, there are three groups, namely:

a. Juvenile Cataract (age <20 years)

b. Presenile Cataract (ages up to 50 years)

c. Senile Cataract (age> 50 years)

3. Senile Cataracts

Senile cataract is, all contained lens opacities in the elderly, the age
group above 50 years.

Senile cataract is known in four stages, namely:

a. Incipient cataract

An early stage of cataract is clouding the lens is shaped patches of

irregular opacities. Clients complain visual disturbances such as seeing
double at the sight of one eye. At this stage, the process of degeneration
absorb the liquid so that the anterior chamber has a normal depth. Iris
in a normal position with mild cloudiness in the lens. Impaired visual
acuity has not happened yet.

b. Immature cataract

Lens begins to absorb the liquid, so the lens is slightly convex, causing
myopia and iris pushed ahead with a shallow anterior chamber. Anterior
chamber angle can be closed so that may arise secondary glaucoma.

c. Mature cataract

An advanced lens degeneration process. At this stage, there was

opacification of the lens. Fluid pressure within the lens is in
equilibrium with the liquid in the eye so that the lens will return to
normal size. Visual acuity had decreased and only a positive light
projection.

d. Hypermature cataract

At this stage of the process further degeneration and cortical lens can
melt lens, so the lens nucleus immersed in the lens cortex. At this stage,
it can also happen that the degeneration of the lens capsule and cortical
lens material liquid lenses that can be entered into the anterior chamber.
Lens material to occlude the anterior chamber fluid, causing phacolytic
glaucoma.
Clinical Manifestations

Cataracts develop slowly and do not cause pain accompanied by visual

disturbances that appear gradually. Vision problems can be:

Difficulty seeing at night.

See the circle around the light or the light was blinding.

Decrease in visual acuity (even in daylight).

Frequently changing glasses.

Double vision in one eye. Sometimes cataract lens causing swelling and
increased pressure within the eye (glaucoma), which can cause pain.

As there are dark spots in front of eyes.

Difficult to see objects that are dazzling.

Color change in the pupil or white.

Difficult to do the daily work.

Reading time illumination require brighter light.

Night vision much less.

2. For a while obviously look closely.

Examination Support

Examination of visual acuity.

Check is performed to see visual acuity. This examination is conducted

by the Snellen card is the card to see the person's visual acuity.

Slit lamp examination. See all makeup eye front with enlargement. With
these tools can see the state of the cornea, manic eyes, black lining,
and lenses.
Tonometry

Ophtalmoscope

Ocular examination

Pre Operative Cataract Care

Retinal function should be good, which is checked by the test beam

projection.

There should be no infection in the eye or surrounding tissue.

There should be no glaucoma. In the state of glaucoma, retinal blood

vessels have been adapted to high IOP. If surgery is performed, at the
time the cornea is cut, IOP decreased, blood vessels rupture and cause
severe bleeding. Also can cause bulbus oculi prolap of content, such as
iris, glass body and lens.

Check the vision.

General state must either: no hypertension, no diabetes mellitus (blood
glucose <150 mg / dl), no chronic cough and heart disease, such as cardiac
decompensation.

Instruct the patient to bathe and wash before surgery, to reduce the risk
of infection.

Give premedication drugs, and shaving eyelashes, appropriate advice

doctor.

Cataract surgery is commonly performed and generally safe. After surgery

are rare infections or bleeding in the eye that can lead to serious vision
problems. To prevent infection, reduce inflammation and accelerate
healing, for several weeks after surgery was given eye drops or ointment.
To protect the eyes from injury, patients should wear glasses or
protective goggles made of metal until the surgical wound is completely
healed.

Post Operative Cataract Care

Limit the patient to perform an action that can increase IOP, including:
coughing, bending, straining, sneezing, lifting objects weighing&gt; 7.5
kg, was lying beside the surgery.

Instruct the patient to wear glasses during the day and wear eye protection
at night.

Give eye drops / eye ointment suitable doctor advice.

Observation of increased IOP is characterized by: severe pain, nausea,

vomiting.
Observe for signs of infection, and advise the patient not to rub the eyes
to prevent infection.

Instruct the patient to wash their hands before administering an ointment

/ eye drops.

Observe for signs of bleeding anterior eye chamber is characterized by

changes in vision.

Observation for signs of retinal detachment, which is marked with a black

dot seems, an increasing number of floaters or light and loss of part /
whole field of view.

 A subcapsular cataract begins at the back of the lens. People with diabetes, high farsightedness or retinitis
pigmentosa, or those taking high doses of steroids, may develop a subcapsular cataract.
 A nuclear cataract is most commonly seen as it forms. This cataract forms in the nucleus, the center of the
lens, and is due to natural aging changes.
 A cortical cataract, which forms in the lens cortex, gradually extends its spokes from the outside of the lens
to the center. Many diabetics develop cortical cataracts.

A subcapsular cataract begins at the back of the lens. People with diabetes, high farsightedness or
retinitis pigmentosa, or those taking high doses of steroids, may develop a subcapsular cataract.

A nuclear cataract is most commonly seen as it forms. This cataract forms in the nucleus, the center of
the lens, and is due to natural aging changes.

A cortical cataract, which forms in the lens cortex, gradually extends its spokes from the outside of
the lens to the center. Many diabetics develop cortical cataracts.

DEFINITION: CATARACT IS CAUSED BY OPACIFICATION AND DEGENERATION OF LENS FIBRES ALREADY

FORMED, THE FORMATION OF ABBERENT LENS FIBRES OR DEPOSITION OF OTHER MATERIALS IN
THEIR PLACE.

Rarely, cataracts can present at birth or in early childhood as a result of hereditary enzyme defects,
and severe trauma to the eye, eye surgery, or intraocular inflammation can also cause cataracts to
occur earlier in life. Other factors that may lead to development of cataracts at an earlier age include
excessive ultraviolet-light exposure, diabetes, smoking, or the use of certain medications, such as oral,
topical, or inhaled steroids. Other medications that are more weakly associated with cataracts include
the long-term use of statins and phenothiazines.
Nursing Assessment

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.

Nursing Diagnosis and Nursing Interventions

High risk of injury related to loss of vitreous, intraocular hemorrhage, increased IOP

Marked by :

Any signs of cataract decreased visual acuity

Blurred vision, etc.

Goal :

Expressing understanding of the factors involved in the possibility of injury.

Expected Results :

Indicates changes in behavior, lifestyle to reduce risk factors and to protect themselves from injury.

Changing the environment as an indication to increase security.

Nursing Intervention :

Discuss what happens on the condition of post-surgery, pain, limitation of activity, performance,
bandage the eye.

Give the patient the position back, head high, or tilted to the side that is not ill, according to patient
preference.

Limit activities such as moving heads suddenly, scratched eyes, bent over.

Ambulation with assistance: give special bathroom when recovering from anesthesia.

Encourage deep breathing, coughing to maintain a healthy lung.

Encourage use stress management techniques.

Maintain eye protection as indicated.

Ask the client to distinguish between discomfort and a sudden sharp pain, Investigate anxiety,
disorientation, impaired bandage.

Provide appropriate indication of antiemetic drugs, Asetolamid, analgesics.

Impaired sensory perception: the perceptual vision, related to impaired sensory reception / status of
sensory organs, a therapeutic environment is limited.

Marked by :

Reduced visual acuity

Changes in response to the stimuli normally.

Goal :

Improved visual acuity within the limits of individual situations, recognize sensory disturbance and
compensated against changes.

Expected Results :

Know the sensory disturbances and compensated against changes.

Identify / fix potential hazards in the environment.

Nursing Intervention :

Determine visual acuity, note whether one or two eyes involved.

Orient clients to the environment

Observation signs of disorientation.

Approach from the side that was operated on, talk to touch.

Note about dim or blurred vision and eye irritation, which can occur when using eye drops.

Remind clients use of cataract glasses whose purpose enlarge approximately 25 percent, loss of
peripheral vision and blind spot may exist.

Put the items required / position call bell within reach.

taract: Description A cataract is a lens opacity or cloudiness Cataract is a leading cause of blindness
worldwide (WHO)

3 Cataract: Aetiology/ Risk Factors Ageing An associated eye condition (retinal detachment, uveitis,
herpes) Toxins: corticosteroids, metals, tobacco Malnutrition: obesity, poor nutrition Physical: trauma,
chronic dehydration Systemic disorders: Downs syndrome, DM, renal, musculoskeletal, lipid disorders
4 Cataract: Pathophysiology May develop in one or both eyes Classification according to location in
lens: NuclearCortical Posterior sub-capsular Ageing may cause clumping or breakdown of lens protein
(yellow pigmentation), ↓ O2 uptake, ↑ sodium and calcium

5 Cataract: Classification Nuclear: associated with ↑ myopia Cortical: Anterior, posterior or

equatorial cortex of lens Less effect on vision but vision worse in bright sunlight (also areas of high
sunlight exposure ↑ prevalence) Posterior sub-capsular: younger people, corticosteroids, trauma,
inflammation. Near vision ↓; sensitive to glare

6 Cataract: Clinical Manifestations Painless, blurred vision Reduced visual acuity Reduced light
transmission Sensitivity to glare Colour shift Myopia (short-sightedness) AstigmatismDiploplia

7 Cataract: Diagnosis History and clinical picture Snellen visual acuity test (visual acuity proportional
to lens density) Ophthalmoscopy Slit lamp Above tests establish degree of cataract formation

8 Cataract: Management No medical treatment Surgery if severe visual problems Most common
surgery is extra-capsular cataract extraction with intraocular lens implant (IOL) (posterior chamber
lens): Portion of anterior capsule removed to allow extraction of lens nucleus and cortex Posterior
capsule and zonal support left intact

9 Post-Operative Eye Drops/ Ointment AntibioticsAnti-inflammatoryCorticosteroids

10 Cataract Surgery: Complications Haemorrhage (suprachoroidal: profuse) Rupture of posterior

capsule Infection: acute and persistent low-grade inflammation/ granuloma Suture-related problems
Malposition of IOL (implant) Opacification of posterior capsule Risk of retinal detachment

11 Cataract: Nursing Considerations Monitor degree of visual impairment Lifestyle aids if necessary
Emotional/ psychological support Patient education pre-surgery: Performed under local anaesthetic
Anticoagulants with-held Mydriatic eye-drops dilate pupil to prepare for surgery

12 Cataract: Nursing Considerations (cont) Post-surgery: Verbal and written instructions on eye
protection (ensure patient understands) Eye covered with sterile pad for 24 hours until 1st dressing
by surgeon (avoid sleeping on affected side) Dark glasses by day and shield cover at night to prevent
self-damage Instructions to family about eye-drops. Arrange district nurse if no carer.

13 Cataract Surgery: Follow-up Instructions Always wear dark glasses/ eye shield as instructed Wash
hands before touching eye/ instilling drops Clean eye with clean tissue: wipe closed eye once from
inner to outer canthus Avoid stooping/ climbing stairs/ lifting until instructed Assistance and caution
showering

Cataracts that occur at birth or present very early in life (during the first year of life) are termed
congenital or infantile cataracts. These cataracts require prompt surgical correction or they may
prevent the vision in the affected eye from developing normally. When the central portion of the lens
is most affected, which is the most common situation, these are termed nuclear cataracts. The
outside of the lens is called the lens cortex, and when opacities are most visible in this region, the
cataracts are called cortical cataracts. There is an even more specific change that occasionally
happens, when the opacity develops immediately next to the lens capsule, either by the anterior, or
more commonly the posterior, portion of the capsule; these are called subcapsular cataracts. Unlike
most cataracts, posterior subcapsular cataracts can develop rather quickly and affect vision more
suddenly than either nuclear or cortical cataracts.

thophysiology may vary with each form of cataract. However, cataract development typically goes
through these four stages:
immature — partially opaque lens

mature — completely opaque lens; significant vision loss

tumescent — water-filled lens, which may lead to glaucoma

hypermature — deteriorating lens proteins and peptides that leak through the lens capsule, which
may develop into glaucoma if intraocular outflow is obstructed.

What to look for

Signs and symptoms of a cataract include:

painless, gradual blurring and loss of vision

with progression, whitened pupil

appearance of halos around lights

blinding glare from headlights at night

glare and poor vision in bright sunlight.

What tests tell you

Ophthalmoscopy or slit-lamp examination confirms the diagnosis by revealing a dark area in the
normally homogeneous red reflex.

Shining a penlight on the pupil reveals the white area behind it (unnoticeable until the cataract is
advanced).

How it’s treated

Treatment consists of surgical extraction of the opaque lens and postoperative correction of vision
deficits. The current trend is to perform the surgery as a 1-day procedure.

What to do

For patient teaching topics on cataract removal, see Cataract teaching tips.

Cataract teaching tips

After surgery, tell the patient to wear sunglasses that filter out ultraviolet rays in bright sunshine.

Explain that he should avoid activities that increase intraocular pressure, such as straining with
coughing or bowel movements and lifting heavy objects.

hat are the types of cataract?

There are three common types of age-related cataracts, named by their location in the lens: nuclear,
cortical, and posterior subcapsular cataract. More than one type can be present in the eye at the
same time.

A nuclear cataract is associated with nearsightedness. As this type of cataract progresses, it can cause
severe blurred or cloudy vision.

A cortical cataract can affect the edge of the lens and may not necessarily interfere with your vision. A
cortical cataract progresses at a variable rate.

Posterior subcapsular cataract is common in younger people, and it develops as a result of prolonged
steroid use or trauma to the eye.

a Snellen test, which is performed using the lettered chart you've seen at your eye care provider's
office with the large black E at the top.

* a slit lamp examination, in which your provider will shine a slit-shaped beam of light into your eye to
see the different layers at the front of the eye.

* an ophthalmoscope examination, in which your provider uses a handheld instrument that allows
him to see into the back of the eye.

If a cataract is very dense, your eye care provider may need to perform other tests as well.

How will my cataract be treated?

In its early stage, a cataract can be managed with regular visits to your eye care provider, who can
revise your eyeglass or contact lens prescriptions to accommodate vision changes. If you don't already
wear corrective lenses, she may prescribe them for you. Using appropriate lighting for reading and
other close-up tasks may also help improve your eyesight.

If a cataract doesn't interfere with your normal everyday activities, you may not need surgery. But if
you do need surgery, the procedure is relatively simple and is typically performed on an outpatient
basis.

If both eyes have cataract, the eye surgeon will treat one eye first, and then the second eye several
weeks later. This allows time for the first eye to heal.

The most common surgical procedure for cataract is to remove the eye's lens and replace it with an
artificial one made of silicone or plastic. The surgeon removes the natural lens using ultrasound
technology that requires a small incision in the cornea (the clear, thin surface layer of the eye that
covers the iris and pupil). Then the artificial lens is inserted through the incision and put in place.

How do I care for my eye after surgery?

After surgery, you'll be given verbal and written instructions about how to protect your eye while it's
healing. The instructions will include tips on how to administer prescription medications, including
eyedrops. You'll also learn how to recognize problems so you'll know whether to contact your eye
care provider.

You'll be given an eye shield to wear over the surgical eye to protect it, or your provider may tell you
to wear eyeglasses at all times. You should wash your hands before and after touching or cleaning
your eye and before and after you instill prescription eyedrops.

Your eye care provider may also recommend that you clean your eye as often as needed by closing
the eye and wiping from the inside corner of your eye using a clean tissue. When you're showering,
bathing, or washing your hair, be careful not to get water, soap, or other substances in your affected
eye. Ask for help if you need it.
Avoid lying on the side of the affected eye on the night after surgery. Light activity is okay, but be sure
to check with your eye care provider before you drive, perform any strenuous activity, or engage in
sexual activity.

A little discharge from the surgical eye on awakening and some redness and scratchiness is normal for
a few days after surgery. You can use a clean damp washcloth to remove morning discharge.

Call your eye care provider if you experience new floaters, flashing lights, decreased vision, increased
redness, or pain that isn't alleviated by your prescription medications.

Classification — Cataracts are classified as having nuclear, cortical, or posterior subcapsular

components, evident on examination. However, these distinctions are mostly important for research
classification rather than clinical management. Most patients have a combination of components.

●Nuclear cataract – Nuclear cataract dulls colors and white significantly; this is rarely a patient
complaint until after the first cataract is removed, at which time the effect on color is noted by
comparison with the brightness of colors in the operated eye.

Nuclear cataract progresses very slowly. Distance vision typically is affected much more than near
vision. It is not unusual to find individuals in their 80s with nuclear cataract degrading acuity to the
20/70 to 20/100 level, with near vision preserved at the 20/25 level. Such an individual may not be
particularly aware of or bothered by the decreased vision from cataract if he or she does not drive.

●Cortical cataract – Although it is a prominent finding on examination with a biomicroscope (a

low-power binocular microscope used with a slit lamp), cortical cataract does not degrade vision very
much. Cortical cataracts may appear suddenly after trauma or other insult but tend to progress
slowly.

●Posterior subcapsular cataract – Posterior subcapsular cataract tends to cause disabling glare in
bright sunlight and from headlights, even if visual acuity is degraded only slightly. Typically, distance
and near vision are affected equally.

Posterior subcapsular cataract tends to progress more quickly than nuclear cataract (over a period of
months rather than years); the explanation for this pattern of progression is not known.

Systemic and topical steroid use is associated with formation of this type of cataract, as is diabetes.
iming of surgery on second eye — Concerns about health care expenditures have raised questions
regarding the value and optimal timing of performing cataract surgery on a second eye. Same-day
second eye surgery is not routine because of concerns related to the possibility of bilateral infection,
optimization of postoperative refractive error, and potential for modification of regimens based on
any complications in the first eye. However, there is potential for cost savings with same-day second
eye surgery. The evidence varies:

●A retrospective study comparing immediate (same-day) with delayed (within one year) surgery on
the second eye found no difference in postoperative best-corrected visual acuity, refractive error, or
complication rate [19]. A retrospective population-based study found that visual outcomes were
better for bilateral, compared with unilateral, cataract surgery only when the second eye had a
significant cataract or poor visual acuity [20]. Another analysis concluded that surgery on a second
eye is highly cost-effective [21].

●One randomized study found only slight differences in binocular vision in patients who received an
expedited second eye surgery (within six weeks) compared with routine second eye surgery (routine
waiting time, 7 to 12 months) [22]. However, there were major benefits for the expedited second
surgery group in terms of reported visual symptoms and quality of life.

Limiting risk of intraoperative floppy iris syndrome — Alpha-1 antagonists, particularly tamsulosin,
and certain second-generation antipsychotic medications (paliperidone and risperidone) have been
associated with intraoperative floppy iris syndrome (IFIS), a surgical condition characterized by a triad
of findings: a flaccid iris billowing through the surgical incision, iris prolapse, and intraoperative
pupillary constriction. This condition may affect 2 to 3 percent of all cataract operations [23]. IFIS both
complicates the surgical procedure and increases risk for postoperative complications (retinal
detachment and endophthalmitis) related to posterior capsular rupture and lens fragments within the
vitreous.

It is important to make sure the surgeon is aware that the patient was or is taking one of these agents,
as there are preoperative and intraoperative regimens (eg, preoperative cycloplegia, low-flow fluids,
iris retractors, and pupillary ring expanders) that can reduce the risk of IFIS [23]. Most surgeons do
not insist that these agents be discontinued, as discontinuing the medication prior to cataract surgery
has not been shown to prevent or decrease the severity of IFIS [24]. For example, IFIS has been
reported years after the discontinuation of alpha-1 antagonists.

●Alpha-1 antagonists – Tamsulosin, with strong affinity for the alpha-1a receptor, has particularly
been associated with IFIS, along with other alpha-1 antagonists (eg, terazosin, doxazosin, tamsulosin,
alfuzosin) [23,25-29].

●Antipsychotic medications – Cases of IFIS have been reported during cataract surgery with the
second-generation antipsychotic medications paliperidone and risperidone [30,31].
Preoperative planning — No routine testing (laboratory, imaging, electrocardiogram [ECG]) is needed
in patients undergoing cataract extraction. A systematic review of randomized trials (21,531 cataract
surgeries) comparing routine preoperative testing with either no testing or selective testing found
that routine preoperative medical testing increased surgical costs but did not reduce the risk of
intraoperative or postoperative medical adverse events [32]. Certain patients may require targeted
preoperative testing, for example, patients with recent cardiac interventions or those with increased
risk of metabolic disturbance or out-of-range coagulation indices.

Management of comorbid conditions

Hypertension — Preoperative blood pressure control is important to avoid complications such as

suprachoroidal hemorrhage. Patients should be given their antihypertensive medications with a sip of
water on the morning of surgery. It is important to avoid intraoperative spikes in blood pressure that
may be dangerous to the eye or to the patient’s overall health. A general rule of thumb is that elective
surgery should not be performed if preoperative systolic pressures are over 180 or if diastolic
pressures are over 110. (See "Anesthesia for patients with hypertension".)

Diabetes — Patients with diabetes should preferably undergo surgery in the early morning so insulin
or oral hypoglycemic drugs can be held until after surgery; this reduces the risk of hypoglycemia
before or during surgery. If patients with type 1 diabetes are scheduled later in the morning or
afternoon, one-third to one-half of the morning insulin dose can be given. Marked derangement of
glycemic control is uncommon in patients with diabetes who undergo cataract surgery since the
procedure is brief.

Coronary heart disease — Patients with coronary heart disease should continue all antianginal
medications, except possibly aspirin. (See 'Aspirin and other antiplatelet agents' below.)

Upper respiratory infection — Elective cataract surgery should be postponed in patients with an acute
upper respiratory infection, since cough may pose some ophthalmic risk during the procedure.

Valvular disease — Endocarditis prophylaxis is not necessary in patients undergoing cataract surgery.
(See "Antimicrobial prophylaxis for the prevention of bacterial endocarditis".)

Management of antithrombotic agents

General considerations — Cataract surgery is considered a low-risk procedure for bleeding [33]. In
general, patients can be continued on their antiplatelet or anticoagulant therapies [34]. However, the
decision to continue or discontinue these medications should be made after discussion with the
ophthalmologist who is performing the surgery. Individual considerations (eg, reason for
anticoagulation, whether the patient has monocular or binocular vision, history of prior hemorrhage
in the fellow eye) should factor into this decision. Individuals with higher bleeding risks (eg,
monocular patients, patients with previous bleeding complications, or in cases where a larger incision
in planned) may have oral anticoagulants stopped prior to surgery.
Aspirin and other antiplatelet agents

●ASA – The 2012 anticoagulation guidelines from the American College of Chest Physicians (ACCP)
recommend that patients who are receiving aspirin and are undergoing cataract removal continue to
receive aspirin around the time of the procedure [35]. The risks associated with either continuing or
stopping aspirin appear to be very small [36,37].

●Clopidogrel – Limited data are available regarding the risk of bleeding with cataract surgery in
patients receiving clopidogrel. Consideration should be given to delaying cataract surgery until the
period of dual antiplatelet therapy (aspirin plus clopidogrel) has passed for patients receiving therapy
for prevention of stent thrombosis. (See "Long-term antiplatelet therapy after coronary artery
stenting in stable patients", section on 'Noncardiac surgery or gastrointestinal endoscopy'.)

Patients with cardiovascular disease who take clopidogrel (or ticlopidine) chronically (eg, other than
the prevention of coronary artery stent thrombosis) are at increased risk for acute cardiovascular
events when these agents are discontinued. Therefore, these agents are usually continued in patients
undergoing cataract removal.

Warfarin — The 2012 anticoagulation guidelines from the ACCP recommend that warfarin be
continued for patients undergoing cataract removal [35]. The risks associated with either continuing
or stopping warfarin appear to be small [36,38-41].

Other oral anticoagulants — In general, as with warfarin, patients may continue other oral
anticoagulants (direct thrombin or factor Xa inhibitors) prior to cataract surgery.

Perioperative management of oral anticoagulants is discussed in detail separately. (See "Perioperative

management of patients receiving anticoagulants".)

SURGICAL TREATMENT

The only treatment for cataract is to surgically remove and replace the opacified lens from the eye to
restore transparency of the visual axis. Modern surgical technique is extremely safe with few major
complications [42], and the intraocular lens allows rehabilitation of one eye so that it is compatible
with vision in the fellow eye with the natural lens.

Surgical techniques — Cataract surgery is typically performed on an outpatient basis under local
anesthesia supplied topically, by block, or by local infusion. Monitored intravenous sedation is also
commonly used. [43,44]. General anesthesia is necessary only for patients who cannot reliably
cooperate under local anesthesia (eg, cognitive impairment or other communication barrier) or
possibly those who had a complication of local anesthesia in the fellow eye. The intraocular
components of cataract surgery can be performed in 10 to 20 minutes by experienced surgeons, but
typically patients spend 30 to 60 minutes in the operating room for positioning, draping, preliminary,
and final steps.

The two techniques most commonly used for cataract extraction are:

●Phacoemulsification – Also called small incision surgery, this has become the most common form of
cataract removal technique in high-resource countries. The lens is removed using a handpiece with a
1 to 3 mm tip inserted through a small incision. This tip, also called a phaco probe, contains a needle
that vibrates with ultrasonic energy to fragment the hard central part of the lens, and an irrigation
and aspiration sleeve. The softer cortex is then aspirated and the lens capsule is left behind as in
extracapsular cataract extraction. A foldable plastic or silicone lens may be passed through this
smaller incision, or the incision can be extended if needed to accommodate a larger, rigid plastic lens.
Phacoemulsification may not be feasible in advanced cataracts in which the lens nucleus may be very
hard.

The small incision may be self-sealing, requiring one or even no sutures. Phacoemulsification has the
advantage of more rapid visual recovery due to the small incision size and decreased likelihood of
suture-induced astigmatism.

●Standard extracapsular cataract extraction – This typically involves removal of the lens nucleus in
one piece. The lens cortex is aspirated from the eye and the lens capsule is left behind to support an
intraocular lens. A rigid plastic lens is inserted through the same incision and placed on or in the
capsule, behind the iris. A modification of this technique which offers some of the advantages of a
smaller incision (although not as small as the phacoemulsification incision) is described below.

Phacoemulsification is commonly performed, although it is technology-dependent and relatively

costly and not available in all countries. A systematic review comparing phacoemulsification with
extracapsular cataract extraction (ECCE) for age-related cataract found lower complication rates with
phacoemulsification but concluded that the lower costs for ECCE support its use when high-volume
surgery is important, since differences in visual outcomes for the two procedures are small [45].

A patient and surgeon may choose phacoemulsification under topical anesthesia for its apparent
short-term advantages. However, traditional ECCE is a reasonable option in certain instances of
advanced cataract or if ECCE is the preferred technique of the ophthalmologist whom the patient has
chosen for surgery.

Two other surgical techniques are sometimes used if standard approaches are not available:

●Intracapsular cataract extraction (ICCE), an approach to cataract surgery in which no lens implant is
placed in the eye.
●Manual small incision cataract surgery (MSICS) or sutureless small-incision extracapsular cataract
surgery (SICS) has many of the advantages of phacoemulsification without the costs. In MSICS, no
phacoemulsification equipment is used; instead, the lens is manually, mechanically divided into
smaller pieces before removal from the eye through a small incision through which a foldable lens can
be implanted. Fewer sutures are used than for ECCE; sometimes none are required. A systematic
review of three randomized trials in Nepal and India comparing short-term outcomes of MSICS and
ECCE found better visual acuity with MSICS, though overall good functional visual acuity was achieved
in less than half of subjects with either method and complications were greater with MSICS in one
trial [46]. A systematic review of eight trials comparing MSICS and phacoemulsification in India, Nepal,
and South Africa found similar results for best corrected visual acuity for the two techniques at six to
eight weeks, but there were quality concerns with the trials and longer-term outcomes are needed
[47]. Comparative trials have not been performed in moderate- and high-resource settings, so these
findings may not be generalizable to these settings.

Preventing endophthalmitis — The application of povidone-iodine to the ocular surface as part of the
surgical preparation of the operative field has been shown to lower the incidence of postoperative
endophthalmitis in intraocular surgery [48], is inexpensive, and is a generally adopted practice in
cataract surgery.

Prophylactic use of topical antibiotics (eye drops) before and after cataract surgery is common,
despite little evidence to support the practice. By contrast, the use of periprocedural intracameral
antibiotics appears to be effective in reducing the low risk of postoperative endophthalmitis, with or
without the addition of topical antibiotics [49,50].

However, we recommend not using prophylactic intracameral vancomycin, alone or in a compounded

drug combining multiple active ingredients, during cataract surgery because of the risk of
hemorrhagic occlusive retinal vasculitis (HORV) [51].

Choice of intraocular lens — Most patients in resource-rich countries will have synthetic intraocular
lenses (IOLs) implanted during these procedures, except in some forms of uveitis, in some cases of
high myopia, and in the event of unusual intraoperative complications. IOLs can also be implanted
secondarily in a subsequent operation. The alternatives to lens implantation are aphakic (cataract)
spectacles (picture 7) or contact lenses. However, results with either of these alternatives are
unsatisfactory for most patients.

There are four types of IOLs: monofocal, multifocal, accommodative, and toric. In general, monofocal
and multifocal lenses are equally effective at improving distance visual acuity. Multifocal IOLs result in
better uncorrected near vision when compared with monofocal IOLs, but multifocal IOL users report
more bothersome visual side effects such as glare or haloes [52]. Toric IOLs can reduce or eliminate
the need for astigmatism correction in spectacles or contact lenses. Multifocal, accommodative, and
toric IOLs are more expensive than monofocal lenses and are typically offered as “premium” lenses;
the additional expense is typically born by the patient because these lenses, which reduce
dependence on glasses, are not covered by insurance.
A 2014 systematic review of four trials in the United Kingdom, Italy, and Germany comparing
accommodative IOL with monofocal IOL found moderate-quality evidence of small gains in near vision
after six months with accommodative IOL [53].

Overall, more data are needed to determine the relative benefits of monofocal, multifocal,
accommodative, and toric lenses. Preoperative education and counseling are warranted to assure
that patient expectations are realistic when “premium” lenses are offered at higher cost to patients.
Studies are needed to correlate patient-reported outcomes with patient expectations [54].

Post-surgical care and follow-up — There may be some mild pain within the first 24 hours, typically
relieved by acetaminophen. Patients can resume normal activity such as reading, walking, eating, and
watching television the evening of surgery.

The eye may be patched, depending upon whether anesthesia was local or topical. All systemic
medications can be resumed immediately, including anticoagulant/antithrombotic agents, assuming
there were no concerns of bleeding during surgery. The eye is typically examined on the first
postoperative day, although some surgeons are eliminating this step for uncomplicated cases and
having staff contact patients by telephone instead. Many surgeons allow resumption of driving at the
level immediately prior to surgery at this time, as long as continued patching is not required.

Patients are then typically seen one week and one month after surgery to monitor for complications
and proper healing. Corticosteroid or nonsteroidal antiinflammatory drug (NSAID; eg, ketorolac,
nepafenac, bromfenac) drops are often prescribed postoperatively to reduce pain, inflammation, and
the likelihood of macular edema, an inflammatory complication that may limit recovery of vision.
Regimens typically start at two to four times daily and usually taper down after the first week,
depending on the drug. The available evidence suggests that NSAIDs may be more effective than
steroids in suppressing cystoid macular edema. [55-57].

Sutures are removed at 6 to 12 weeks if there is astigmatism related to the presence of tight sutures.
However, suturing of wounds is less common in this era of small-incision phacoemulsification.

Recommendations on physical activity restriction vary widely among surgeons depending upon their
confidence in the technique used. Patients with large incisions typically are advised not to undertake
heavy lifting or strenuous activity including sexual activity for several weeks to several months.
Surgeons who perform phacoemulsification tend to restrict heavy lifting or strenuous activity for a
period of only days to weeks. Most patients are able to return to work by one week unless driving or
heavy lifting is required. There is no contraindication to air travel. There are no evidence-based data
for these recommendations.

The final spectacle prescription is determined at any point between one and three months after
surgery depending upon the need for suture removal. Patients usually require spectacles for night
driving and/or reading after cataract surgery. Some patients may note improved vision as soon as the
day after surgery and others may not appreciate the full impact until updated spectacles are
prescribed one to three months after surgery.
Outcomes — Outcomes depends for the most part on the presence or absence of ocular comorbidity.
For example, improvement in vision may be limited by underlying age-related, diabetic, or traumatic
maculopathy; glaucoma; or uveitis or unrecognized amblyopia. Intraoperative challenges and
complications may limit optimal outcome.

A 1994 review from the Cataract Outcome Team found that 95.5 percent of eyes without preexisting
ocular comorbidity had postoperative visual acuity of 20/40 or better (the acuity necessary to obtain
an unrestricted driver's license); if all eyes were included in the pool, 89.7 percent had 20/40 acuity or
better following cataract surgery [58]. A 2013 report from Europe found that a corrected distance
visual acuity (CDVA) of 0.5 (20/40) or better and of 1.0 (20/20) or better was achieved in 94.3 percent
and 61.3 percent of cases, respectively, consistent with the 1994 United States data [59].

A 2014 systematic review and meta-analysis of studies evaluating cataract surgery in patients with
uveitis found that 20/40 visual acuity was achieved in 68 percent of patients following
phacoemulsification and 72 percent following ECCE, with worse visual outcomes in patients with
active uveitis at the time of surgery [60].

A Swedish study of patients with self-assessed poor outcomes found that the majority had
improvement in corrected distance vision after surgery. In this report, younger patients (52 to 68
years) had a lower self-assessed outcome than older adult patients, with surgical complication and
poor near vision correlating with poor self-assessed outcome [61].

Complications — Because of the frequency with which cataract surgery is performed, even infrequent
complications affect large numbers of people. As with most surgical procedures, adverse events are
lower among surgeons who perform more procedures [62]. Cataract surgery is a low-risk procedure
[63], but the surgery is typically performed on older adults, and multiple medical morbidities increase
the risk of any procedure. In a systematic review of 21,531 total cataract surgeries, 707 adverse
medical events related to the surgery were reported, resulting in three deaths and 61 hospitalizations
[32].

Reported complications of the procedure include the following [58]:

●Immediate complications — These complications may limit vision at the end of the one to three
month recovery period:

•Endophthalmitis (bacterial or fungal infection within the eye), a complication that can result in
markedly reduced vision and typically leaves some impairment (0.13 percent). (See "Bacterial
endophthalmitis", section on 'Acute postcataract endophthalmitis'.)

•Corneal edema, which may reduce vision and cause pain (0.3 percent).
•Intraocular lens malposition/dislocation (1.1 percent).

•Clinically apparent cystoid macular edema (retinal thickening and edema involving the macula, 1.4
percent).

•Toxic anterior segment syndrome (TASS) is inflammation of the anterior segment of the eye,
occurring typically within 24 hours of surgery and related to noninfectious contaminants of
equipment, solutions, or other supplies used during the procedure [64]. Clusters of cases have been
traced to faulty preparation of sterilization equipment.

•HORV is a rare and devastating condition that can occur as soon as one day or as much as 21 days
after intraocular use of vancomycin. For this reason, vancomycin is generally not recommended as
prophylaxis against endophthalmitis in cataract surgery [51,65].

●Delayed complications

•Retinal detachment, which typically requires intervention in the form of laser, cryotherapy, or
surgery (0.7 percent). It can result in marked loss of vision and moderate impairment, although
sometimes it can be treated with no loss of vision. (See "Retinal detachment".)

A population-based study suggested that the risk of retinal detachment is increased for up to 20 years
after cataract surgery [66]. In one longitudinal study of 9400 patients, the cumulative rate of retinal
detachment was 2.3 percent at eight years [67].

Highly myopic eyes appear to be at particularly high risk for retinal detachment after cataract surgery
[67,68]. Patients with a history of retinopathy of prematurity (ROP) who develop cataracts at a
relatively early age are also at high risk for postoperative retinal detachment; retinal tear or
detachment occurred in 23 percent of 66 eyes with ROP in one retrospective series [69].

•Risk of macular degeneration – Concerns have been raised that patients undergoing cataract surgery
may be at increased risk for AMD. Proposed mechanisms include an increased post-procedure
susceptibility to light damage, inflammatory changes secondary to surgery, or induction of
angiogenesis. However, this association may be due to overlapping risk factors for the two conditions,
or the fact that AMD may be discovered after cataract surgery and thus may represent prior disease
not recognized due to lens opacity [70,71]. A 2017 systematic review concluded that it is not possible
to draw reliable conclusions from the available data as to whether cataract surgery is beneficial or
harmful in people with AMD after 12 months [72].

●Posterior capsule opacification (19.7 percent) can be successfully treated with

yttrium-aluminum-garnet (YAG) laser capsulotomy and therefore is not considered a complication by
many surgeons. The procedure, which is done as an outpatient in the doctor’s office, surgery center,
or laser center, is painless and yields improvement in vision almost immediately. YAG capsulotomy
does increase the risk of retinal detachment, however, and cannot be considered entirely benign. A
meta-analysis found that biomaterials and edge design of the intraocular lens may influence posterior
capsule opacification; incidence was lower for acrylic or silicone lenses and for those with sharp optic
edges [73].

FINDINGS AFTER CATARACT SURGERY

An eye that has had cataract surgery with lens implantation is described as pseudophakic. Penlight
and fundus examination findings are unchanged, except that sometimes the pupil takes on an
irregular shape due to surgical manipulation. The pupil will appear black as opposed to greyish or
opalescent after removal of the native lens. Some good observers notice a strange reflection of light
in the pupil of younger pseudophakic patients who have larger pupils. This is an optical reflection off
of the intraocular lens that is not present with the native lens. The fundus examination will be
improved due to removal of media opacity.

PREVENTION

There is no proven therapy to either prevent cataract formation or slow progression of lens opacity
once it develops. However, observational studies suggest that some interventions such as a healthy
diet rich in fruits and vegetables, and smoking cessation may be helpful [74-77]. The evidence
supporting vitamin supplementation is mixed, and there is no clear recommendation to support
vitamin use in cataract prevention [78-80].

Although postmenopausal estrogen use (longer than 10 years) may reduce the risk of nuclear
cataracts, this is not a recommended strategy to prevent cataracts. (See "Menopausal hormone
therapy: Benefits and risks".)

Several interventions have been suggested for prevention but have not been proven. Since sunlight
exposure is a risk factor, sunglasses may offer protection, particularly for persons exposed to high
reflected light (eg, water, snow, high desert ground), but there is no evidence that any particular type
of sunglasses are more effective in cataract prevention or progression. Similarly, wearing a brimmed
hat may offer protection against cataracts. Increased dietary glycemic load is not associated with risk
for cataract [81], and no studies have been performed to evaluate whether blood glucose control in
patients with diabetes correlates with cataract risk.

INFORMATION FOR PATIENTS

he lens of the eye must be clear if light is to be able to pass unhindered through it and fall on the
retina. The anatomy and physiology of the lens is described in Box 1. The lens is avascular and
receives nutrition and loses metabolites via the aqueous humour. Any disruption to the structure of
the lens of the eye will result in opacity - a cataract. The causes of cataract are summarised in Box 2
(p38). Any opacity of the lens may be defined as cataractous but a clinically significant cataract is
defined as one where the transparency of the lens has been reduced sufficiently to disturb vision
(Gregory and Talamo, 1996).

Cataract may be present at birth (hereditary) or it may be acquired throughout life. It is associated
with trauma, systemic disease such as diabetes, drugs such as steroids, ocular disease, or heredity.
Ageing is by far the most common cause; 95 per cent of people over 65 years of age have some
degree of lens opacity (Gregory and Talamo, 1996), and in one US study 15 per cent of people aged
52-85 years had a cataract that significantly reduced their vision (Newell, 1996). Reidy et al (1998), in
a UK-based study, found cataract in 30 per cent of people over 65. Cataract is responsible for 17
million cases of treatable blindness in the world and is the major cause of this condition (Gregory and
Talamo, 1996).

Recognition of cataract

Symptoms of cataract formation

Image blur may result as the lens becomes unable to resolve separate points on an image. Vision
becomes blurred, particularly for near vision. As the lens begins to scatter as well as focus light,
because of the opacities within it, glare is likely to result.

The person with cataract may first be aware of changes in vision while driving at night, as light from
headlights is scattered. Night driving may become impossible. Cataract may also cause distortion, and
straight edges may appear wavy or curved. ‘Ghosting’ of images (where one distinct image is seen
with the shadow of another next to it) may occur, and the patient may interpret this as ‘double’ vision
(although true double vision is a binocular phenomenon and disappears when one eye is covered).

The increasing density of the lens tissue results in its yellowing, and this can lead to loss of some
colour perception - objects appear more yellow and less blue than they did. Unusually, cataract
progresses much more quickly in one eye than the other, and loss of vision may be interpreted as
being of sudden onset if the patient happens to close his/her ‘good’ eye.

Signs of cataract formation

It is unusual for the cataract to appear as a white pupil. Cataract matures slowly and is likely to have
caused significant visual problems before this sign can be seen. Varying degrees of haze may be seen
through the pupil. Reduced visual acuity and patient history will indicate the need for slit-lamp
examination, which will reveal the degree and type of cataract. Reduced visual acuity should always
be taken seriously. This may entail referral to an ophthalmologist but often cataracts are identified by
optometrists at routine testing for spectacles.

Surgical treatment of cataract

Surgery is the only treatment for cataract, and cataract operations have been performed for more
than 2000 years, although the approach to surgery has changed. ‘Couching’, a technique that involved
pushing the cataractous lens back into the vitreous gel and therefore away from the pathway of light
through the eye was the initial method of choice in ancient Indian and Arabian medicine and is still
used as a method of vision improvement in parts of the world today.

The first successful removal of a cataractous lens was undertaken in 1750 by Jacques Davial (Albert
and Edwards, 1996). Techniques have moved on significantly since then and the main technique used
now is extracapsular cataract extraction.

Extracapsular cataract extraction

Extracapsular cataract extraction involves opening the anterior capsule of the lens and removing the
contents - the cataractous lens. This can be undertaken in a number of ways. The technique initially
involves making an incision at the corneo-scleral junction - the limbus - and then a small opening into
the anterior chamber. A visco-elastic substance is then introduced into the anterior chamber to help it
retain its shape and to protect the corneal endothelium. Next, circular cuts are made in the anterior
lens capsule, a portion of which is removed. The incision at the limbus is enlarged at this stage to
10-11mm so that the lens nucleus can be removed. Finally, the rest of the lens matter - the cortex - is
removed, either manually or by using an automated irrigation and aspiration method.

An intraocular lens is inserted through the incision and placed in the capsular ‘bag’ which remains
(posterior chamber lens). The wound is then closed with up to five sutures, which remain in place for
several months or even years until they are absorbed, are removed intentionally, or break and cause
irritation to the patient, at which point they are removed. The sutures themselves, and their removal,
can change the contour of the eye and induce astigmatism, which will need to be corrected so that
the patient can see properly after surgery.

Phacoemulsification

Advances in technology have allowed the development of a system of cataract extraction that has
become the standard in most areas of the UK. Charles Kelman in the US developed an instrument that
used oscillating and ultrasonic frequency to emulsify the cataract (Stein et al, 1994). This enabled the
development of small-incision cataract surgery and the further development of small and foldable
intraocular lenses. Phacoemulsi-fication has become a preferred technique. It involves making a small
incision (2-3mm) at the limbus into the anterior chamber, or a little further away from the cornea, in
the sclera. Through this a tunnel is formed, diagonally, into the anterior chamber. Next, a single
continuous circular tear is made in the anterior capsule (capsulorrhexis). The ‘phaco’ probe is then
directed though the incision and the lens nucleus is emulsified and removed from the eye by an
irrigation/aspiration technique. Finally, a small or foldable lens is placed in the remaining capsular
‘bag’ of the lens.

The advantages of small-incision surgery are that it is fast and often no sutures need to be used,
which lessens postoperative astigmatism. Because the wound is smaller there is less likely to be
leakage from it and dislodged sutures are unlikely to cause problems. A small wound also means a
much faster return to good visual function for the patient. Moreover, there is less need for the
patient to be particularly careful of the eye after surgery (although care must still be taken) and so a
more rapid physical rehabilitation takes place. There are disadvantages of this technique, however,
including a longer learning period for practitioners (Stein et al, 1994) and the fact that expensive
equipment is required.

Cool laser

Another technique that is beginning to be used is ‘cool laser’. This is a method that uses a laser to
generate shock waves by striking a titanium target at the end of an aspirating hand piece
(O’hEineachain, 2002). The procedure takes place in a similar way to phacoemulsification, through a
very small incision (1.4mm) but the laser does not generate heat, which is an advantage in that this
prevents burning of the cornea and heating of tissues, which may occur with phacoemulsification.

Intraocular lenses

Historically, a major problem after cataract surgery was the need to wear very strong prescription
lenses, which induced a lot of magnification and distortion of images. The first lens for implantation
within the eye was introduced by Ridley in 1949 (Stein et al, 1994). Further and continuing
development of intraocular lenses that are inert within the eye has massively improved the visual
outcomes of cataract surgery, and magnification and distortion of images have been reduced to zero.

Intraocular lenses are placed in a variety of positions within the eye, depending on the type of surgery
that has been carried out. The preferred position is in the capsular ‘bag’, which remains after
extracapsular cataract extraction, as it is the most anatomically correct.

Most intraocular lenses are single vision, simple lenses (the optic) with fixation devices attached,
often simple curved loops (the haptic). The haptic may be compressed when the lens is implanted
into the capsular bag; the haptics then act as ‘springs’ to keep the lens in place. Lenses may be rigid,
or compressed so that they ‘unfold’ over a number of hours when they are in position inside the eye.

A single vision lens can correct impaired far or near vision but not both, so it is likely that the patient
will still need spectacle correction of some sort after surgery. Further lens development has resulted
in multifocal lenses, which can be very successful. Accommodating lenses, where the lens position
changes as the person changes focus, are also in use and the development of new and better
intraocular lenses continues.

Complications of cataract surgery

No surgery is simple and straightforward. Possible complications during and after cataract surgery
include:

- Rupture of the posterior capsule during surgery, which may result in the nucleus dropping back into
the vitreous cavity, necessitating a further procedure (vitrectomy) either during the surgery or later.
Posterior capsule rupture may also result in the need to use a different type of intraocular lens in the
eye;
- Raised intraocular pressure owing to the blockage of aqueous humour outflow channels with the
viscoelastic substance used at surgery. Pressure may also rise as a reaction to the surgery or as a
result of inflammation. The patient is likely to experience pain and new blurring of vision some hours
after surgery;

- A shallow anterior chamber, which may result from inhibition of aqueous humour production
because of a wound leak following postoperative trauma, or from raised pressure. This is of concern,
because if the chamber becomes very shallow, the corneal endothelium may touch the iris. Damage
to corneal endothelial cells may result in permanent corneal oedema;

- Retinal detachment may occur after cataract surgery in a very small number of cases. Any report by
the patient of new floaters in the eye, flashing lights or the loss of sectors of vision indicates that an
urgent examination is required;

- Cystoid macular oedema (oedema of the retina at the macular) is likely to cause some disturbance of
central vision. It often disappears over time;

- Uveitis (inflammation of the iris and ciliary body) occurs as an inflammatory response to surgery. It is
a normal consequence of surgery and patients are treated postoperatively with eye drops containing
a steroid to reduce and control the inflammation. Pain and redness of the eye may occur if the
inflammation increases, in which case modification of the drop therapy is required;

- Displacement of the intraocular lens may occur after surgery and is likely to necessitate further
surgical intervention to replace the lens or correct its position;

- Posterior capsular opacification is the most frequent long-term complication of surgery and is
reported in between 10 and 50 per cent of all cases (Apple et al, 2001). The posterior portion of the
remaining lens capsule becomes opacified and the patient reports reduction in vision. Posterior
capsular opacities are easily dealt with using a laser to burn a hole in the capsule (YAG capsulotomy).
This is painless, and can easily be undertaken as an outpatient procedure;

- Infection is always a possible complication of surgery, and for this reason a prophylactic antibiotic
drop will be prescribed after cataract extraction. The anti-inflammatory and the antibiotic may be
combined in a single drop such as Maxitrol.

Anaesthesia

Most cataract extraction takes place under local anaesthetic and is the preferred technique for
cataract surgery owing to the much reduced morbidity and mortality associated with local as opposed
to general anaesthesia (SIGN, 2001).
A number of local anaesthetic techniques are used in cataract surgery. Retrobulbar anaesthesia
(involving an injection of local anaesthetic directly into the retrobulbar space) and peribulbar injection
(involving a larger volume of anaesthetic being injected into the orbit outside the muscle cone) have
been the preferred methods of anaesthesia for a long time, particularly because of the good muscle
paralysis that these methods achieve.

However, these techniques have their drawbacks, for example central nervous system symptoms as a
result of the spread of the anaesthetic from the orbit, which may include respiratory arrest and brain
stem anaesthesia (Hamilton et al, 1988; Nicoll et al, 1987). Other techniques of local anaesthesia are
becoming much more common, tending to replace retrobulbar and peribulbar blocks. One technique,
sub-Tenon’s anaesthesia, involves use of a blunt cannula to infiltrate anaesthetic into the retrobulbar
space after dissecting through the conjunctiva. This also tends to achieve good muscle paralysis.

Topical anaesthesia using anaesthetic eye drops is increasingly being used, either alone or with
injection of the anaesthetic into the eye once the incision has been made. This and subconjunctival
injection have the drawback that patients must be able to keep their eye very still during surgery, as
the extraocular muscles are not paralysed. However, some surgeons may find some ocular motility
advantageous in phacoemulsification surgery as they can ask the patient to look in a particular
direction to facilitate aspiration of the lens matter.

Eke and Thompson (1999) found that serious adverse events have been reported with all local
anaesthetic techniques and attribute these to stress during surgery, the oculocardiac reflex, the
systemic effects of topical treatments such as eyedrops, and coincidental effects. Patients must be
monitored during surgery. Rapid access to advanced life support skills is mandatory when retrobulbar
blocks are used and this may mean having an anaesthetist in the theatre suite. The patient should
have access to intravenous infusion and blood pressure monitoring equipment if retrobulbar or
peribulbar blocks are used. Oxygen saturation should be monitored by pulse oximetry and the heart
by electrocardiograph during all ophthalmic surgery, with a member of the theatre team dedicated to
these tasks (SIGN, 2001).

Preoperative assessment

The NHS carried out about 170,000 cataract operations in 1998-1999 (NHS Executive, 2000). The
current waiting time for assessment and surgery, together with the UK’s ageing population, make it
imperative that services are organised in an optimum way in order to enable the best use of time and
resources so that treatment is not unduly delayed.

Action on Cataracts (NHSE, 2000) was published as best practice guidance to assist the ophthalmic
services to streamline care for patients. It has been a major driver in their reorganisation and the
rapid move to day-case surgery, which has become the norm in most areas of ophthalmic practice.
Patients having cataract surgery require more detailed assessment than is possible at a single
consultation with an ophthalmologist. Day surgery in particular requires a comprehensive
preoperative assessment, and this may take place on the same day as the consultation with the
ophthalmologist, thus saving the patient another visit to the hospital (Rose et al, 1999; Prasad et al,
1998; NHSE, 2000).
The preoperative assessment involves:

- A medical evaluation, including recording details of current medication and history of any allergies;

- Biometry - this is a series of measurements of the eye, including assessment of the corneal curvature
and the axial length of the globe so that calculations can be made on the intraocular lens power
needed at surgery. Discussion with patients about their lifestyle will take place at this stage to
determine whether near or far vision is more important to them;

- The identification of social problems that may require support, in which case services may be
arranged and surgery is not delayed;

- The identification and initiation of treatment for any conditions that may increase the risk of severe
post-operative infection (endophthalmitis), such as lid and conjunctival infections.

A large part of the preoperative assessment visit is concerned with information and education so that
patients have all the knowledge they need to consent to surgery and to understand what will happen
during the day-case episode. The benefits and risks must be clear to patients before consent is signed.

It is important that patients are aware of what to expect before, during and after surgery, and are
informed about any medication that will be provided postoperatively. Information must be given in a
form that is intelligible and timely, and creative solutions to the provision of information for people
with vision problems must be considered.

During surgery patients need to be able to lie still and must be aware that they cannot move their
heads or their eyes. They also need to be prepared for their faces to be covered, because this can be a
very frightening experience initially.

A member of the theatre staff who acts as a liaison between the patient and the surgical team usually
supports patients undergoing cataract surgery under local anaesthesia. This health care professional
is often known as the ‘hand-holder’ but this title underestimates the importance of the role.

Postoperative care

All cataract patients used to be examined by an ophthalmologist on the first day after their operation.
This event used to be known as the ‘first dressing’, when a nurse would remove the patient’s eye pad,
examine the eye with a pen torch, clean the eye, instil any medication and then hand over the patient
to an ophthalmologist for examination. This ritualistic approach to care has changed rapidly,
particularly as a result of the new surgical techniques and also because it is now realised that patients
suffer complications of cataract extraction in only a tiny minority of cases.
The SIGN (2001) guidelines suggest that there is no evidence that review is necessary on the first
postoperative day but recommends that complex cases should be seen on the first day. It also
recommends that all patients be seen within the first week. Patients must, therefore, have been given
comprehensive, accurate and comprehensible information about what to do if things ‘go wrong’ or if
they are worried. This means they must be given telephone numbers and lists of possible scenarios
that should lead to their seeking help. The minimum advice a patient should receive is about key
symptoms of pain, loss of vision and discharge.

A further recommendation by SIGN (2001) is that patients should be advised that any activity that
causes pain in the operated eye should be avoided.

Once intraocular inflammation has settled and eye medication is no longer being used, patients have
their eyes tested to record the final outcome of surgery. At this time any corrective lenses are
prescribed. Patients are likely to be discharged from the eye unit at this stage.

The role of the nurse

Although the care of patients with a cataract is a multidisciplinary effort, nurses are increasingly
undertaking much of the care surrounding the surgical procedure.

Assessment is commonly carried out in preadmission clinics, with ophthalmic nurses playing a lead
role in the preassessment of the patient, including examining the eye, performing biometry, and
obtaining informed consent (Stanford, 1998; Gregory and Lowe, 1991). Ophthalmic nurses also
undertake a key role in theatre, including the giving of sub-Tenon’s anaesthesia and acting as first
assistant to the ophthalmologist - a longstanding role within this specialty.

In some areas nurses undertake all postoperative care of patients who have had uncomplicated
cataract surgery and this may include the modification of medication using patient group directives or
supplementary prescribing, auto refraction and final discharge of the patient from the service. Often
the only time the patient is in contact with an ophthalmologist is in theatre at the time of surgery.
While this means that patients may feel that the service has been seamless in that consistent advice
and care have been received from the same group of nurses, and that job satisfaction is enhanced for
ophthalmic nurses because of their ability to carry out truly holistic care, the multidisciplinary
teamwork envisaged by most members of the team sometimes appears to have changed in emphasis.
However, creative ways of service organisation and delivery over the whole of the UK are making an
impact on cataract services so that patients are receiving timely surgery to improve their quality of
vision and therefore their quality of life.

uclear cataract. A nuclear cataract is caused by central opacity in the lens and has a substantial
genetic component.

Cortical cataract. A cortical cataract involves the anterior, posterior, or equatorial cortex of the lens.

Posterior subcapsular cataracts. Posterior subcapsular cataracts occur in front of the posterior
capsule.

Pathophysiology
Cataracts can develop in one or both eyes at any age as a result of a variety of causes.

Cataract

Cataract

Lifestyle. Factors that increase the risk of cataracts are cigarette smoking, long-term use of
corticosteroids, sunlight and ionizing radiation, diabetes, obesity, and eye injuries.

Research. Recent studies have linked cataract risk to lower income and educational level, smoking for
35 or more pack-years, and high-triglyceride levels in men.

Myopia. Nuclear cataract is associated with myopia, which worsens when the cataract progresses.

Density. If dense, the cataract severely blurs vision.

Cataract in the periphery. A cataract in the equator or periphery of the cortex does not interfere with
the passage of light through the center of the lens.

Statistics and Incidences

Catatact ranks behind only arthritis and heart disease as a leading cause of disability in older adults.

Cataracts affect nearly 20.5 million Americans who are 40 years of age or older, or about one in six
people in this age range.

By 80 years of age, more than half of all Americans have cataracts.

According to the World Health Organization, cataract is the leading cause of blindness in the world.

Almost one in five people between the ages of 65 and 74 develop cataract severe enough to reduce
vision.

Causes

Cataracts usually develop without any apparent cause; however they can result from:

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 s genetic defects or as a sequela 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

Clinical Manifestations
Because all light entering the eye passes through the lens, any clouding of the lens can cause poor
vision.

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.

Prevention

The nurse should instruct the patient to:

Quit smoking. The patient should avoid smoking because it is one of the greatest contributing factors
to cataract.

Wear sunglasses. Wearing of sunglasses shields the eye from too much exposure to UV rays that
predisposes to cataract.

Complications

Potential complications following cataract surgery include:

Retrobulbar hemorrhage. Retrobulbar hemorrhage can result from retrobulbar infiltration of

anesthetic agents if the short ciliary artery is located by the injection.

Acute bacterial endophthalmitis. Devastating complication that occurs in about 1 in 1000 cases.

Toxic anterior segment syndrome. Non-infection inflammation that is a complication of anterior

chamber surgery.

Assessment and Diagnostic Findings

Decreased visual acuity is directly proportionate to cataract density.

Snellen visual acuity test. The Snellen visual acuity test measures the degree of visual acuity in the
patient.

Ophthalmoscopy. Ophthalmoscopy is used to view the extent of cataract.

Slit-lamp biomicroscopic examination. This procedure is used to establish the degree of cataract
formation.

Medical Management

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

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

Common surgical procedures done to correct cataracts:

Phacoemulsification

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.

Aphakic glasses. In aphakic glasses, objects are magnified by 25%, making them appear closer than
they actually are.

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.

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.

Nursing Management

The patient with cataract should receive the usual preoperative care for ambulatory surgical patients
undergoing eye surgery.

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

Based on assessment data, the nursing diagnoses for the patient include:

Disturbed visual sensory perception related to altered sensory reception or status pf 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 Care Planning & Goals

Main Article: 2 Cataracts Nursing Care Plans

The major goals for the patient include:

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.

Nursing Interventions

Care for a patient with cataract includes:

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.

Evaluation

Evaluation of the patient may include:

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.

Discharge and Home Care Guidelines

The nurse teaches the patient self-care before discharge:

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.

Documentation Guidelines

The focus of documentation in a patient include:

ndividual findings, noting specific deficit and associated symptoms, perceptions of client/SOs.

Assistive devices needs.

Use of safety equipment or procedures.

Environmental concerns, safety issues.

Level of anxiety and precipitating/aggravating factors.

Description of feelings.

Awareness and ability to recognize and express feelings.

Plan of care.

Teaching plan.

Client involvement and response to interventions, teaching, and actions performed.

Attainment or progress toward desired outcomes.

Modifications to plan of care.

Long term needs.

ataract is a disorder that causes the lens or its capsules to lose its transparency or become opaque.

Cataract are made from a protein that has altered from its natural state,distorting and eventually
prohibiting required light from entering into the retina, the part of the eye that receives light. Often
cataracts cause no problems for many years but as the cataracts mature the cloudiness increases on
the lens, the light reaching the retina decreases and significant sight loss and perhaps blindness can
result.

Most leading cases of blindness among adults in the Philippines are due to untreated cataract.
Treatment is simple and effective yet is not readily available or affordable for those living in the rural
areas.

Clinical Manifestation

Characteristically, a patient with a cataract experiences painless, gradual blurring and loss of vision. As
the cataract progress,the normally black pupil appears hazy and when a mature cataract develops,
the white lens may be seen through the pupil. Some patient complaint of:

Blinding glare from headlights when they drive at night

Poor reading vision

Unpleasant glare and poor vision in bright sunlight.

Patients with central opacities report better vision in dim light than in bright light because the
cataract is nuclear and as the pupils dilate, patients can see around the lens opacity.

Diagnostic test

Slit-lamp examination confirms the diagnosis of lens opacity

Visual acuity testing confirms the degree of vision loss

Retinal examination allows the physician to assess the back of the eye after the pupils are
dilated.Using an ophthalmoscope,the lens of the eye is examined to determine the degree of
cloudiness.

Medical Management

Surgical
Treatment for cataract is surgical removal of the lens. Surgery is indicated when significant vision loss
has occured.The Lens may be removed by Intracapsular and Extracapsular

Intracapsular Cataract Extraction– The ophthalmologist removes the entire lens from the intact
capsule. This procedure is seldom performed

Extracapsular Cataract Extraction- The anterior lens capsule and cortex are removed.This procedure is
commonly used in patients of all ages.

Nursing Intervention

Prepare patient for cataract surgery as appropriate.

Approach patient with a decreased field of vision on the side where visual perception is intact.

Teach patient to turn and look in the direction in the defective visual field to compensate for the loss.

Provide comfort measures and Establish a therapeutic relationship with the patient.

Allow patient to express his fears and anxieties about his visual loss.

Patient Teaching

Tell the patient to avoid activities that increase intraocular preassure such as straining.

Urge the patient to protect the eye from accidental injury at night by wearing a plastic or metal shield
with perforations,a shield or glasses should be worn for protection during the day.

Advise the patient to watch for and immediately report complication such as sharp pain in the eye
that’s uncontrolled by analgesics this can be caused hyphema(a clouding in the anterior chamber) and
may herald an infection.

Nursing Diagnosis for Cataract: Anxiety related to lack of knowledge.

Goal:

Lowering the emotional stress, fear and depression.

Acceptance and understanding instructions surgery.

Nursing Interventions for Cataract:

1. Assess the degree and duration of visual impairment. Encourage conversation to find out the
patient's concerns, feelings, and the level of understanding.

Rational: Information can eliminate the fear of the unknown. Coping mechanisms can help patients
with kegusara compromise, fear, depression, tension, despair, anger, and rejection.
2. Orient the patient to the new environment.

Rationale: The introduction to the environment helps reduce anxiety and increase security.

3. Explain the perioperative routines.

Rationale: Patients who have a lot of information easier to receive treatment and follow instructions.

4. Describes intervention much detail as possible.

Rationale: Patients who experience visual disturbances rely on other senses salts input information.

5. Push to perform daily living habits when able.

Rationale: Self-care and will increase the sense of healthy independence.

6. Encourage participation of family or the people who matter in patient care.

Rationale: Patients may not be able to perform all duties in connection with the handling of personal
care.

7. Encourage participation in social activities and diversion whenever possible (visitors, radio, audio
recording, TV, crafts, games).

Rationale: Social isolation and leisure time is too long can cause negative feelings.

Nursing Diagnosis for Cataract: Risk for injury related to blurred vision

Goal: Prevention of injury.

Nursing Intervenion for Cataract:

1. Help the patient when able to do until postoperative ambulation and achieve stable vision and
adequate coping skills, using techniques of vision guidance.

Rational: Reduce the risk of falling or injury when the step stagger or have no coping skills for vision
impairment.

2. Help the patient set the environment.

Rationale: Providing facilities of independence and lower the risk of injury.

3. Orient the patient in the room.

Rationale: Improving safety and mobility in the environment.

4. Discuss the need for the use of metal shields or goggles when instructed

Rational: shield l; ogam or goggles protect the eyes against injury.

5. Do not put pressure on the affected eye trauma.

Rational: The pressure in the eye may cause further serious damage.

6. Use proper procedures when providing eye drugs.

Rational: Injury can occur if the container touch the eye medication.

Nursing Diagnosis for Cataract: Acute pain related to trauma to the incision and increased IOP

Goal: Reduction of pain and the IOP.

Nursing Interventions for Cataract:

1. Give medications to control pain and the IOP as prescribed.

Rational: Use the recipe will reduce pain and the IOP and increase comfort.

2. Give cold compress on demand for blunt trauma.

Rational: reduce the edema will reduce the pain.

3. Reduce the level of pencayahaan

Rationale: The level of lighting is more nyakan lower after surgery.

4. Encourage use of sunglasses in strong light.

Rasioanal: Strong light causes discomfort after use of eye drops dilator.

Nursing Diagnosis for Cataract: Risk for infection related to trauma to the incision

Goal: Complications can be avoided or promptly reported to the doctor.

Nursing Interventions for Cataract:

1. Maintain strict aseptic technique, do wash your hands frequently.

Rationale: It would minimize infection.

2. Supervise and report immediately any signs and symptoms of complications, such as: bleeding,
increased IOP or infection.

Rational: The discovery of early complications can reduce the risk of permanent vision loss.

3. Explain the recommended position.

Rational: Elevation of the head and avoid lying on the side of the operation may reduce the edema.

4. Instruct the patient to know bedrest activity restrictions, with flexibility to the bathroom, according
to a gradual increase in activity tolerance.

Rational: Limitation of activity prescribed to speed healing and avoid further damage to the injured
eye.

5. Describe the actions that should be avoided, as prescribed by coughing, sneezing, vomiting (ask for
medication for it).

Rational: It can lead to complications such as vitreous prolapse or dehisensi injury due to increased
tension on the suture wounds that are very subtle.

6. Give medications as prescribed, according to prescribed techniques.

Rational: Drugs are administered in a way that is inconsistent with prescriptions can interfere with
healing or cause complications.

cataract is a clouding of the eye's natural lens, which lies behind the iris and the pupil. The lens
works much like a camera lens, focusing light onto the retina at the back of the eye. The lens also
adjusts the eye's focus, letting us see things clearly both up close and far away.

The lens is mostly made of water and protein. The protein is arranged in a precise way that keeps the
lens clear and lets 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, and over time, it may grow larger and cloud more of the lens, making it harder to
see.
Researchers are gaining additional insights about what causes these specific types of proteins
(crystallins) to cluster in abnormal ways to cause lens cloudiness and cataracts. One recent finding
suggests that fragmented versions of these proteins bind with normal proteins, disrupting normal
function.

Cataracts are classified as one of three types :

A subcapsular cataract begins at the back of the lens. People with diabetes, high farsightedness or
retinitis pigmentosa, or those taking high doses of steroids, may develop a subcapsular cataract.

A nuclear cataract is most commonly seen as it forms. This cataract forms in the nucleus, the center of
the lens, and is due to natural aging changes.

A cortical cataract, which forms in the lens cortex, gradually extends its spokes from the outside of
the lens to the center. Many diabetics develop cortical cataracts.

allaboutvision.com

Causes

The lens is made mostly of water and protein. Specific proteins within the lens are responsible for
maintaining its clarity. Over many years, the structures of these lens proteins are altered, ultimately
leading to a gradual clouding of the lens. Rarely, cataracts can present at birth or in early childhood as
a result of hereditary enzyme defects, and severe trauma to the eye, eye surgery, or intraocular
inflammation can also cause cataracts to occur earlier in life. Other factors that may lead to
development of cataracts at an earlier age include excessive ultraviolet-light exposure, diabetes,
smoking, or the use of certain medications, such as oral, topical, or inhaled steroids. Other
medications that are more weakly associated with cataracts include the long-term use of statins and
phenothiazines.

emedicinehealth.com

Signs and symptoms

As a cataract becomes more opaque, clear vision is compromised. A loss of visual acuity is noted.
Contrast sensitivity is also lost, so that contours, shadows and color vision are less vivid. Veiling glare
can be a problem as light is scattered by the cataract into the eye. The affected eye will have an
absent red reflex. A contrast sensitivity test should be performed and if a loss in contrast sensitivity is
demonstrated an eye specialist consultation is recommended.
In the developed world, particularly in high-risk groups such as diabetics, it may be advisable to seek
medical opinion if a 'halo' is observed around street lights at night, especially if this phenomenon
appears to be confined to one eye only.

The symptoms of cataracts are very similar to the symptoms of ocular citrosis.

wikipedia

Nursing Care Plan for Cataract

Nursing Assessment

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.

Nursing Diagnosis and Nursing Interventions

High risk of injury related to loss of vitreous, intraocular hemorrhage, increased IOP

Marked by :

Any signs of cataract decreased visual acuity

Blurred vision, etc.

Goal :

Expressing understanding of the factors involved in the possibility of injury.

Expected Results :

Indicates changes in behavior, lifestyle to reduce risk factors and to protect themselves from injury.

Changing the environment as an indication to increase security.

Nursing Intervention :

Discuss what happens on the condition of post-surgery, pain, limitation of activity, performance,
bandage the eye.

Give the patient the position back, head high, or tilted to the side that is not ill, according to patient
preference.

Limit activities such as moving heads suddenly, scratched eyes, bent over.

Ambulation with assistance: give special bathroom when recovering from anesthesia.

Encourage deep breathing, coughing to maintain a healthy lung.

Encourage use stress management techniques.

Maintain eye protection as indicated.

Ask the client to distinguish between discomfort and a sudden sharp pain, Investigate anxiety,
disorientation, impaired bandage.

Provide appropriate indication of antiemetic drugs, Asetolamid, analgesics.

Impaired sensory perception: the perceptual vision, related to impaired sensory reception / status of
sensory organs, a therapeutic environment is limited.

Marked by :

Reduced visual acuity

Changes in response to the stimuli normally.

Goal :

Improved visual acuity within the limits of individual situations, recognize sensory disturbance and
compensated against changes.

Expected Results :

Know the sensory disturbances and compensated against changes.

Identify / fix potential hazards in the environment.

Nursing Intervention :

Determine visual acuity, note whether one or two eyes involved.

Orient clients to the environment

Observation signs of disorientation.

Approach from the side that was operated on, talk to touch.
Note about dim or blurred vision and eye irritation, which can occur when using eye drops.

Remind clients use of cataract glasses whose purpose enlarge approximately 25 percent, loss of
peripheral vision and blind spot may exist.

Put the items required / position call bell within reach.

eratively:

Anxiety related to lack of knowledge of cataract surgery procedures

Intraoperative:

Acute pain related to surgery

Postoperative:

Risk for infection related to inflammation of postoperative wound

Nursing Outcome and Interventions Nursing Care Plan (NCP) for Cataract

Anxiety decreased after nursing actions, with expected outcomes:

1. the patient calm and relaxed

2. can reveal the cause of anxiety

3. patients were able to control anxiety

4. patients may explain the action operations

Interventions:

1. examine the patient's anxiety level, measuring vital signs

2. give patients the information needed prior to surgery

3. provide mental relaxation techniques as well as suport involving elements of religious

4. give patients the opportunity to express his feelings before surgery

Acute pain decreased after nursing actions, with expected outcomes:

1. patients expressed reduced pain

2. the patient's face looked relaxed

Interventions:

1. recommended for, uses management techniques of relaxation, visualization, and breathing in

Infections do not occur during nursing actions

Interventions:

1. Discuss the importance of washing hands before touching or treating the eye

2. Show the proper techniques to clean the eye from the inside out with a wet tissue / cotton ball for
each swabs, bandages and anti-insert contact lenses when using

3. Emphasize not to touch or scratch the operated eye

4. Observation / discuss examples of signs of infection redness, eyelid swelling, purulent drainage.

ataract

A cataract is opacity of the lens that produces an effect similar to one a person would get when
looking through a sheet of falling water (Figure 27-5). A cataract causes a blurring of vision because
the lens, which is normally transparent, becomes cloudy and opaque.

image

FIGURE 27-5 Cloudy appearance of eye with cataract.

Etiology and Pathophysiology

Congenital cataracts are most often due to maternal infection with rubella or Toxoplasma gondii.
Most often cataracts occur as a result of aging and are found in people over age 50 (adult-onset
[senile] cataracts).

Traumatic cataracts may occur from a physical blow, extreme heat, or chemical toxins. Cigarette
smoking increases the risk of developing cataracts. Heavy drinking also is implicated. Chronic use of
corticosteroids predisposes to the development of cataracts.
 image

Health Promotion

Cataract Prevention

Encouraging the habit of wearing sunglasses that protect from ultraviolet light and a hat when
outdoors can help prevent the development of cataracts. Cumulative exposure to ultraviolet light is
the greatest risk factor for cataracts.

image

Think Critically

What would you teach the person with rheumatoid arthritis about eye care, if that person is on
corticosteroids most of the time?

Signs, Symptoms, and Diagnosis

In addition to the blurred vision that is typical of opacity of the lens, with cataracts there may be
decreased color perception. Uncomplicated cataracts are usually painless, but the patient may have
photophobia (intolerance of light). Assessment may reveal the following symptoms:

• Hazy, blurred, or double vision (diplopia)

• Increasing complaints about glare

• Increasing nearsightedness

• Complaints that colors are faded or appear yellowish or brownish

• Desire for increased light by which to read

• Difficulty with night vision

• Frequent need for eyeglass prescription change

The loss of vision associated with cataracts is progressive and sometimes is partially due to secondary
glaucoma. As an untreated cataract progresses, the lens of the eye becomes cloudy or milky white,
then may turn yellow, and eventually may become brown or black (see Figure 27-5).

Diagnosis of a cataract is confirmed by examining the dilated pupil with a slit lamp, which enables the
examiner to see opacities more clearly. Glaucoma should first be ruled out as a possible cause of the
symptoms. Tonometry is used to determine intraocular pressure (IOP). For screening purposes, the
Tono-Pen may be used.

Treatment

Cataract surgery is performed when the loss of vision greatly affects the quality of the person’s life.
The only effective method of treating cataracts is surgical removal of the affected lens with clear lens
implantation; cataract surgery is the most commonly performed surgical procedure in the United
States. Surgical techniques are (1) extracapsular extraction, in which the lens is removed along with
the anterior portion of the lens capsule; and (2) intracapsular extraction, in which both the capsule
and the lens are removed. Extracapsular extraction is most frequently performed because it allows an
intraocular lens to be inserted inside the remaining capsule. Lenses are now available that allow for
multifocal vision rather than monovision where vision is good at only one distance without glasses.
One type of lens is hinged to the ciliary muscle, allowing for accommodation of vision for various
distances (Harvard Eye Associates, 2010). If a monovision lens is chosen, vision is corrected for
nearsightedness or farsightedness by the lens implant and further correction of vision is achieved with
regular eyeglasses or contact lenses. Vision is improved within 2 weeks and is usually fully recovered
within 3 months of surgery (Nursing Care Plan 27-1).

One technique for intracapsular cataract extraction (ICCE) utilizes cryosurgery, in which the lens is
frozen by a super-cooled probe and then removed.

Scenario

Mrs. Fort, age 79, is admitted to the outpatient surgery unit for extraction of a cataract of the left eye
with lens implant. The vision in her right eye also is affected by a cataract, but the visual loss is not as
severe in that eye. Mrs. Fort suffers from a crippling osteoarthritis of the hands, but her general
health is good. She is well oriented, outgoing, and physically active. She lives alone in an apartment
building for retired senior citizens. Her daughter and son-in-law live nearby and are in daily contact
with her. Mrs. Fort has only been in the hospital once in her life for pneumonia and is concerned
about what to expect preoperatively and postoperatively.

Problem/Nursing Diagnosis

Lack of knowledge/Knowledge deficient related to preoperative and postoperative procedures and

care.
Supporting Assessment Data

Subjective: “I have never had surgery before.”

Goals/Expected Outcomes Nursing Interventions Selected Rationale Evaluation

Patient will verbalize preoperative routine activities and postoperative procedures and expectations.
Teach patient and daughter about eye medications to be used at home and how to instill them;
how to dress and shield eye properly, how to remove bandage without contaminating eye. To
comply with instructions, teaching must occur on how to instill drops and how to dress and shield the
eye and perform care needed. Provided teaching for patient and daughter. Will ask for return
demonstration before discharge. Left printed instructions.

Problem/Nursing Diagnosis

Potential postoperative complications/Risk for injury related to postoperative complications such as

hemorrhage and increased intraocular pressure.

Supporting Assessment Data

Objective: Undergoing cataract extraction; hemorrhage and increased intraocular pressure are
potential complications.

Goals/Expected Outcomes Nursing Interventions Selected Rationale Evaluation

Intraocular hemorrhage will not occur, and there will not be an increase in intraocular pressure.
Teach signs and symptoms of complications that are to be reported to physician immediately:
increasing eye pain, purulent discharge, decreasing vision, fever or chills, increasing brow headache.
Patient must know what to look for in order to report complications. Gave instructions and
left printed list. Will ask for feedback before discharge.

Instruct to refrain from straining at stool; encourage to use milk of magnesia or stool softener to
prevent straining as needed. Preventing the Valsalva maneuver will help prevent an increase in
intraocular pressure. Verbalizes the ways to prevent raising intraocular pressure.

Perform hand hygiene thoroughly before instilling eye medications or changing dressing; teach
patient and daughter to wash hands before approaching eye area. Aseptic techniques help prevent
infection.Maintaining asepsis aids in protecting the surgical site from infection and prevents
complications. Patient and daughter state that they understand hand hygiene and aseptic techniques
for postoperative eye care.

Demonstrate how to put on eye shield for sleep.

Instruct patient to avoid rapid or sudden movements and bending from the waist. Bending from the
waist increases intraocular pressure. Instructed to crouch rather than bend at the waist and to
avoid sudden movements.
Instruct patient to take medication immediately for nausea and vomiting. Quickly medicating for
nausea may avert vomiting. Instructions given and a written instruction sheet at bedside.

Remind patient not to lie on affected side.

Encourage patient to seek assistance with ambulation while vision is blurred.

Problem/Nursing Diagnosis

Limited use of hands/Self-care deficit related to disabilities imposed by osteoarthritis.

Supporting Assessment Data

Objective: Severe osteoarthritis of the hands with limited dexterity.

Goals/Expected Outcomes Nursing Interventions Selected Rationale Evaluation

Assistance with administration of postoperative eye medications and eye care will be given by
daughter. Teach daughter techniques needed for postoperative eye care and give her a written
schedule for that care. Written instructions and a schedule reinforce the teaching and help care to
occur on time. Daughter observed care and administration of eye medications today; will
demonstrate postoperative eye care when meds are next due.

Critical Thinking Questions

1. Why should one wait 5 minutes between instilling one type of eyedrop and the next type of
eyedrop?

2. What is one of the most important things to teach someone who is to instill eyedrops or ointment
postoperatively?

Phacoemulsification, in which the tissue is pulverized and the debris is removed by suction, is often
used for extracapsular cataract extraction (ECCE). These outpatient surgical procedures are
performed under procedural sedation and local anesthesia. An intraocularlens implant is placed after
cataract extraction. Postoperative care is covered later in this chapter.

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Patient Teaching

General Care After Eye Surgery

Instructions for the patient and/or family caregiver:

• Always wash the hands before instilling medication. Check the label of the container to be certain it
is the right medication. Do not contaminate the applicator tip of the medication.

• Instill only the number of drops ordered; apply pressure at the inner canthus to prevent systemic
absorption; close the eye gently (do not squeeze the eye shut).

• Change the eye patch dressing at least once a day; change as needed to keep the area clean.

• Follow the medication schedule prescribed by the physician exactly. (Send home a written
schedule.)

• Maintain designated head position and activity restrictions.

• Report signs of complications: sudden, increasing pain in the eye, which can indicate hemorrhage;
purulent drainage; decreasing vision; signs of increased intraocular pressure, such as brow headache.

• Keep the follow-up appointment with the surgeon.

• Use caution to prevent getting water in the eye.

• Protect the eye during the day with glasses; use sunglasses for outside wear; wear a protective eye
shield at night.

Nursing Management

The patient must be told that there is a period of visual adjustment after cataract surgery. The
surgeon may prescribe miotic eyedrops after surgery to constrict the pupil and lessen the danger of
lens dislocation. Patient adherence to the schedule for postoperative medications is critical to
preventing complications and promoting healing.

omplications

Cataract surgery is the most commonly performed operation worldwide

Technological progress has enables major advances in this procedure

As with any surgery there are inherent risks, some of which are related to the increased complexity of
the operation

Intraoperative complications
Postoperative complications

3 IntrA operative complications

ICCE

Was the main cataract surgery performed at the beginning of the 20th century

Method:

180 degree limbal incision was created

The lens & the capsule were removed together by breaking the zonular ligaments

No IOL was inserted- patients wore aphakic spectacles; or an ACIOL was inserted

Operative complications:

Vitreous loss

Haemorrhage

Chronic cystoid macular edema

High astigmatism

4 IntrA operative complications

ECCE

Involves a smaller limbal incision- less operative complcations

Operative complications:

Reduced risk of vitreous loss

Remaining undetected cortical material not removed

Results in server post operative inflammation & significant PCO (= posterior capsular opacification)

5 IntrA operative complications

PE (Phaco)

Method of choice

Incisions required are smaller

Procedure much safer

time of recovery, the stabilization of post-operative refraction & amount of induced astigmatism is
less

However the technique itself is more complicated

Requires extensive training & manual dexterity

\
6 IntrA operative complications

Tear/rupture of the posterior capsule

Can result in vitreo-retinal tractions & eventually RD

Increases risk of endophthalmitis

Nuclear fragments falling into vitreous--> severe inflammatory reaction

Increased risk if weak zonules

PXF, hypermature cataracts & CT disease

Dislocation of nucleus

Loss of lens fragments

Pupil constriction

Small non-dilating pupil can cause visibility issues

Use iris hooks or iris expanders

Useful in patients with floppy iris syndrome

Bleeding

Rare

Anterior capsule tear

Wound leak

7 Posterior Capsular Tear

8 The Routine Routine Postoperative Care: F/U visit schedule

Examination components

Medication Schedule

Early & late post-operative complications

Management of complications

9 Post-op instructions The norm- May remain for 6-8 weeks

Blurry, fluctuating, shimmering vision

Mild discomfort

Drops may sting

Drops may leave harmless white residue in the corner of the eye

Eye may feel scratchy or dry- provide patients with AT

Slight redness
Watering

Mild irritation

Glare

Slight drooping

10 Post-op instructions The DOs:

Wash hands before and after using eye drops

Wear your glasses during the day and wear the eye shield at night x 7 days

Unless doctor instructions specify otherwise

Wear sunglasses when out x 1 week during daylight

To protect the eyes from sunlight & injuries

Shake the drops and use as instructed

Only use clean tissues to wipe the eye

Make sure eyelids are always clean after surgery

Use warm compresses at least twice a day

Use OTC reading glasses until Rx is finalized 4-6 weeks after surgery

If any minimal pain use two Tylenol tablets for relief

Severe pain should be reported to the doctor immediately

Report to the doctor ASAP if:

Persistent pain- not relieved by Tylenol

Redness

Discharge

Unexpected loss of vision &/or field vision

Flashes or floaters

11 Post-op instructions The DONTs:

Activity: Normal activity except heavy labor or sports can be resumed immediately

No heavy lifting (anything over 5 pounds) or bending (below waistline) x 1 week

No driving the day of or after surgery

At 4 weeks all normal activities can resume

Avoid hard rubbing or squeezing eye x 1 month

straining, squeezing or a blow to eye can result in disastrous complications

Face wash: For the first few days, close your eyes when washing face
Bathing:

Avoid any water splashing into the eye x 1 week

Can bathe with head tilted backwards or keep eyes closed during shower

Games:

Avoid strenuous activities like jogging, lifting weights, swimming, gardening, aerobics, contact sports x
2 weeks

Normal daily activities including walking, reading and watching TV may be resumed immediately
following the surgery

Makeup: Avoid eye makeup x 2 weeks

Diet: No dietary restrictions

Driving: You should not begin driving until indicated by your doctor

Job: Can resume 2 days s/p surgery

Travel:

Can travel 1 week after surgery

Keep eyes well lubricated during flight

Avoid aspirin

12 F/U Schedule 1 Day 1 week 1 month 3-6 month

*Case Hx: status since surgery? pain? dry? discomfort? sleep? sick? vision?

*VA (s)

*SLE: Wound site (&sutures); K; AC; IOL condition & centration

* IOP

Review Postoperative instructions

1 week

*Case Hx: status since surgery? pain? dry? discomfort? vision? review of complaints & instructions

*VA (s) + SLE + IOP

*DFE: IOL centration & position; Posterior capsule; macula; peripheral retina

*AB drops usually stopped after this visit

*Case Hx: status since surgery? dry? discomfort? vision?

*VA (s) + Refraction/Keratometry + SLE + IOP

*Rx released at this visit

*Steroids & NSAIDs- almost done

1 month

3-6 month
Complete Eye Exam

13 Medication Schedule Week 1 P.O. Week 2 P.O. Week 3 P.O. P.O.

3 Days Before

AntiBiotic QID

NSAID BID-QID

**ATs PRN

Week 1 P.O.

AntiBiotic QID x 1 week

NSAID QIDx 1 week

Steroid QIDx 1 week

**ATs PRN

Week 2

P.O.

AntiBiotic Discontinued

NSAID TIDx 1 week

Steroid TIDx 1 week

**ATs PRN

Week 3

P.O.

NSAID BIDx 1 week

Steroid BIDx 1 week

**ATs PRN

NSAID QDx 1 week then discontinued

Steroid QDx 1 week then discontinued

**ATs PRN

Week 4

P.O.

14 Medication Schedule

Vigamox

Zymar

Besivance
15 Medication Schedule

Acular

Acuvail

Xibrom

16 Medication Schedule

PredForte

4. CATARACT

6. <ul><li>ETIOLOGY: </li></ul><ul><li>EYE INJURY </li></ul><ul><li>SUN EXPOSURE

</li></ul><ul><li>SMOKING </li></ul><ul><li>HYPERTENSION </li></ul><ul><li>KIDNEY DISORDERS
</li></ul><ul><li>DIABETES MILLETUS </li></ul><ul><li>LONG TERM USE OF STEROIDS
</li></ul><ul><li>TOXIC SUBSTANCES </li></ul><ul><li>HEREDITARY </li></ul>

7. <ul><li>PATHOGENESIS: </li></ul><ul><li>DEGENERATION </li></ul><ul><li>OPACIFICATION

</li></ul><ul><li>DEPOSITION OF OTHER MATERIAL </li></ul><ul><li>ABNORMALITY OF LENS
PROTEIN </li></ul><ul><li>DISORGANISATION OF FIBRES </li></ul>

8. <ul><li> Blurred vision </li></ul><ul><li> Need for frequent changes in your eyeglasses or
contacts </li></ul><ul><li>Trouble in driving at night ( Glare ) </li></ul><ul><li>Sensitivity to
bright light </li></ul><ul><li>Change in color vision ( yellow , orange , and red appear brighter and
WHITE appears dull). </li></ul><ul><li>Polyopia and monocular diplopia </li></ul><ul><li>Coloured
haloes </li></ul>SYMPTOMS:

9. BLURRED VISION DUE TO SCATTERING OF LIGHT ON THE RETINA

10. blurred vision

11. GLARED VIEW(TROUBLE DRIVING AT NIGHT)

12. CHANGE IN COLOUR VISION(DIMNESS)

13. <ul><li>CLASSIFICATION : </li></ul><ul><li>BASED ON : </li></ul><ul><li>MORPHOLOGY

</li></ul><ul><li>AGE OF ONSET </li></ul><ul><li>MATURITY </li></ul><ul><li>ETIOLOGY </li></ul>

14. MORPHOLOGIC: 1.CAPSULAR CATARACT -ANTERIOR CAPSULAR CATARACT -POSTERIOR CAPSULAR

CATARACT 2.SUB CAPSULAR CATARACT -ANTERIOR SUBCAPSULAR CATARACT -POSTERIOR
SUBCAPSULAR CATARACT 3.NUCLEAR CATARACT 4.CORTICAL CATARACT

15. 5.LAMELLAR/ZONULAR CATARACT 6.SUTURAL CATARACT

16. - POSTERIOR SUBCAPSULAR CATARACT -CORTICAL CATARACT -NUCLEAR CATARACT -MATURE

CATARACT

17. AGE OF ONSET: 1.CONGENITAL 2.INFANTILE 3.JUVINILE 4.PRE-SENILE 5.SENILE

18. CONGENITAL CATARACT

19. INFANTILE AND JUVINILE CATARACT

20. MATURITY: 1.INTUMESCENT CATARACT 2.IMMATURE CATARCT 3.MATURE CATARACT
4.HYPERMATURE CATARACT 5.MORGAGNIAN CATARCT

21. MATURE AND IMMATURE CATARACT

22. IMMATURE CATARACT

23. <ul><li>ETIOLOGIC: </li></ul><ul><li>TRAUMATIC CATARACT </li></ul><ul><li>METABOLIC

CATARACT </li></ul><ul><li>TOXIC CATARACT </li></ul><ul><li>COMPLICATED CATARACT
</li></ul><ul><li>INTRA UTERINE CATARACT </li></ul><ul><li>HERIDITARY CATARACT
</li></ul><ul><li>RADIATIONAL CATARACT </li></ul><ul><li>ELECTRIC CATARACT </li></ul>

24. 9. CATARACT ASSOSCIATED WITH SKIN DISEASES-ICHTHYOSIS,ATOPIC DERMATITIS 10.CATARACT

ASSOSCIATED WITH OSSEOUS DISEASES-PARATHYROID TETANY 11.CATARACT WITH MISCELLANEOUS
DISEASES-DYSTROPHIA MYOTONICA,ALPORTS SYNDROME,DOWNS SYNDROME AFTER CATARACT

25. <ul><li>SUBJECTIVE CLASSIFICATION: </li></ul><ul><li>GRADE 0: CLEAR LENS

</li></ul><ul><li>GRADE 1: SWOLLEN FIBRES AND SUB CAPSULAR OPACITIES </li></ul><ul><li>GRADE
2: NUCLEAR CATARACT AND VISIBLE LENS FIBRES </li></ul><ul><li>GRADE 3: STRONG NUCLEAR
CATARACT WITH PERINUCLEAR AREA OPACITY </li></ul><ul><li>GRADE 4: TOTAL OPACITY </li></ul>

26. SUBJECTIVE CLASSIFICATION

Classification (Aetiological) 1. Senile 2. Traumatic: Penetrating injuries Blunt injuries Infrared radiation
Ionising radiation

8. By Dr Banumathi Gurusamy, HPP Classification (Aetiological) 3. Metabolic: Diabetes Mellitus

Galactosemia Hypocalcemia Wilson’s disease Galactokinase Deficiency

9. By Dr Banumathi Gurusamy, HPP Classification (Aetiological) 4. Toxic: Corticosteroids

Chlorpromazine Miotics 5. Secondary (complicated) Anterior Uveitis High myopia Chronic vitreo
retinal disorders

10. By Dr Banumathi Gurusamy, HPP Classification (Aetiological) 6. Congenital & Developmental

Hereditary Maternal Prenatal Infections as Rubella/ Toxoplasmosis. Maternal drug ingestion Inborn
errors of metabolism 7. Presenile Cataract Dystrophia myotonica Atopic Dermatitis

11. By Dr Banumathi Gurusamy, HPP Classification according to the stage of maturity Immature
Mature Intumuscent (swollen lens) Leads to Phacomorphic glaucoma Hypermature Leads to
subluxation/ dislocation of lens and phacolytic glaucoma. Morgagnian cataract

12. By Dr Banumathi Gurusamy, HPP Nuclear cataract • Exaggeration of normal nuclear ageing change
• Causes increasing myopia • Increasing nuclear opacification • Initially yellow then brown
Progression

13. By Dr Banumathi Gurusamy, HPP Cortical cataract Initially vacuoles and clefts Progressive radial
spoke-like opacities Progression

14. By Dr Banumathi Gurusamy, HPP Classification according to maturity Immature Mature

Hypermature Morgagnian

15. By Dr Banumathi Gurusamy, HPP Other causes of cataract - diabetes Juvenile • White punctate or
snowflake posterior or anterior opacities • May mature within few days Adult • Cortical and
subcapsular opacities • May progress more quickly than in non-diabetics
16. By Dr Banumathi Gurusamy, HPP Causes of traumatic cataract Penetration Concussion ‘Vossius’
ring from imprinting of iris pigment Flower-shaped • Ionizing radiation • Electric shock • Lightning
Other causes

17. By Dr Banumathi Gurusamy, HPP Drugs Chlorpromazine • Long-acting miotics Other drugs •
Amiodarone • Busulphan - initially posterior subcapsular Systemic or topical steroids - central,
anterior capsular granules

18. By Dr Banumathi Gurusamy, HPP Secondary (complicated) cataract • Chronic anterior uveitis •
High myopia Posterior subcapsular • Hereditary fundus dystrophies • Central, anterior subcapsular
opacities Glaukomflecken • Follows acute angle- closure glaucoma

19. By Dr Banumathi Gurusamy, HPP Symptoms Progressive decrease in visual acuity for near and
distant. Glare in bright light and sun light. difficulty in driving. Uniocular diplopia or polyopia. Fixed
dark spots in field of vision. Nuclear sclerosis making the patient short sighted (good near vision).aka
myopic shift

20. By Dr Banumathi Gurusamy, HPP Signs Reduction in visual acuity. Diminished red reflex on
ophthalmoscopy. Opacity covering the pupillary area. Slit lamp examination details and location of
cataract.

21. By Dr Banumathi Gurusamy, HPP Treatment: Surgical Indications: Decreased visual acuity which
causes disturbance in his or her daily work. Lens induced glaucoma Phacomorphic/ Phacolytic To
permit photocoagulation. If cataract blocks the posterior segment for posterior segment surgery.
Cosmetic to obtain black pupil.

22. By Dr Banumathi Gurusamy, HPP Management In Children Unilateral should be removed as early
as possible to avoid amblyopia. Bilateral dense cataracts immediate surgery. Bilateral immature
cataract if fundus details seen, op can be postponed until lens becomes more denser. Vision should
be corrected with contact lens or intraoular lens.

23. By Dr Banumathi Gurusamy, HPP Surgical techniques (1/3) Intracapsular cataract extraction with
IOL (ICCE). The entire lens is removed using cryo probe. Anterior chamber IOL. This method is for
subluxated cataractous lens.

24. By Dr Banumathi Gurusamy, HPP Surgical techniques (2/3) Extracapsular cataract extraction with
IOL. (ECCE) 1. Open the anterior capsule. 2. Nucleus expression. 3. Aspiration of lens cortex. 4.
Posterior chamber IOL implant. 5. Incision size is about 10 mm.

25. By Dr Banumathi Gurusamy, HPP ECCE

26. By Dr Banumathi Gurusamy, HPP ECCE with IOL

27. By Dr Banumathi Gurusamy, HPP ECCE Step 1- Incision

28. By Dr Banumathi Gurusamy, HPP ECCE Step 2- Anterior capsulotomy

29. By Dr Banumathi Gurusamy, HPP ECCE Step 3- Deepening the wound

30. By Dr Banumathi Gurusamy, HPP ECCE Step 4- Nucleus expression

31. By Dr Banumathi Gurusamy, HPP ECCE Step 5- Cortex aspiration

32. By Dr Banumathi Gurusamy, HPP ECCE Step 6- IOL insertion

33. By Dr Banumathi Gurusamy, HPP ECCE Step 7- Suture

34. By Dr Banumathi Gurusamy, HPP ECCE Complete suture

35. By Dr Banumathi Gurusamy, HPP Surgical techniques (3/3) Phacoemulsification (sophisticated
form of ECCE) with IOL: 1. Open the anterior capsule 2. Using the ultrasonic power nucleus is
fragmented and removed. 3. Aspiration of lens cortex. 4. Posterior chamber IOL implant. 5. Incision
size 3mm only.

36. By Dr Banumathi Gurusamy, HPP Phaco

37. By Dr Banumathi Gurusamy, HPP Phaco Step 1- Incision

38. By Dr Banumathi Gurusamy, HPP Phaco Step 2- ccc- Anterior capsulorhexis

39. By Dr Banumathi Gurusamy, HPP Phaco Step 3- Nucleofractis

40. By Dr Banumathi Gurusamy, HPP Phaco Step 4- Fragments removal

41. By Dr Banumathi Gurusamy, HPP Phaco Step 5- Aspiration of cortex

42. By Dr Banumathi Gurusamy, HPP Phaco Step 6- IOL Insertion

43. By Dr Banumathi Gurusamy, HPP Phaco Complete

44. By Dr Banumathi Gurusamy, HPP ECCE Vs Phaco

45. By Dr Banumathi Gurusamy, HPP Advantages of Phaco Small incision. Fewer wound problems.
Less astigmatism. More rapid physical rehabilitation.

46. By Dr Banumathi Gurusamy, HPP Disadvantages of Phaco Machine dependent. Larger learning
curve. Expensive equipment. Difficult with hard nucleus.

47. By Dr Banumathi Gurusamy, HPP Intraocular lenses Optical advantage of its natural counterpart
when it is placed in the eye. IOL power is calculated by measuring the curvature of cornea and length
of the eye (measured by ultrasonography). Types of IOL: posterior chamber IOL : rigid PMMA.
foldable silicone/acrylic. anterior chamber IOL.

48. By Dr Banumathi Gurusamy, HPP

49. By Dr Banumathi Gurusamy, HPP Optical Correction (1/3) If no IOL correction should be made
with aphakic glasses or contact lenses. Problems with aphakic glasses: 1. Thick and heavy 2. The
corrected image is 30% larger than that seen with the normal eye with increased distortion hence
image cannot be fused with that from the unoperated eye.

50. By Dr Banumathi Gurusamy, HPP Optical correction (2/3) 3. Objects are perceived closer than they
are. Eg: pouring tea into one’s lap rather than into the cup. 4. Corrective glasses are maximally
effective only when the patient looks through the optical centre. 5. The field of vision is restricted and
there is blind area all round within this field.

51. By Dr Banumathi Gurusamy, HPP Optical Correction (3/3) Contact lenses: Size of image is only 10%
larger than the image in the unoperated eye Disadvantages: most of the patients are elderly with
inadequate tearfilm, so difficult to use CL. difficulty in handling/ risk of infection.

52. By Dr Banumathi Gurusamy, HPP Post op management Steroid drops to reduce inflamation.
Antibiotic drops to treat infection. Relative contra indications for IOL: 1. Intraocular inflamation. 2.
Severe diabetic retinopathy.

53. By Dr Banumathi Gurusamy, HPP Complications of Cataract Surgery (1/4) During surgery: 1.
Posterior capsule rupture with vitreous loss will lead to: Updrawn pupil Vitreous touch syndrome with
sec. Glaucoma/ pupillary block glaucoma. Uveitis Chronic cystoid macular oedema Retinal
detachment
54. By Dr Banumathi Gurusamy, HPP Complications of cataract surgery (2/4) 2. In phaco
emulcification nucleus can drop into the vitreous when the posterior capsule ruptures. 3. Expulsive
chroidal haemorrhage (caused by rupture of choroidal vessels). EXTREMELY RARE

55. By Dr Banumathi Gurusamy, HPP Complications of cataract surgery (3/4) Early Post op.
complications: 1. Wound leak . 2. Hyphaema. 3. Iris prolapse. 4. Uveitis 5. Increase IOP. 6. Bacterial
endophthalmitis.

56. By Dr Banumathi Gurusamy, HPP Complications of cataract surgery (4/4) Late complications: 1.
Chronic cystoid macular oedema. 2. Posterior capsule opacity. (Elschnig’s pearls) To be treated with
YAG laser capsulotomy. 3. Retinal detachment. 4. Displacement of IOL pupillary capture/ sunset
syndrome.

57. By Dr Banumathi Gurusamy, HPP Thank You

Lens Biconvex, transparent, non-innervated and non-vascularized structure Anterior surface less
convex than posterior surface The equator in perpendicular to the anteroposterior axis Lens is 3.5 mm
away from the cornea

5. I. Structure of the lens 3 compartments: Capsule Elastic membrane Capsule is permeable

Constantly reproduced : basal membrane of the lens epithelium anteriorly basal membrane of
elongating fiber cells posteriorly Thickest near the equator Thinnest region is at the posterior surface

6. Collagen Laminin Heparin sulfate proteoglycan Enatacin Fibronectin •Composed of stacked

lamellae, made up off:

7. Epithelial cells: Single layer of cuboidal cells Below the capsule, extending anteriorly to reach the
equator

8. Distribution and reproductive capacity of EP cells: At the central zone, high concentration but low
reproductivity At the pregerminative zone, rare reproductive capacity At the germinative zone, At the
equator proliferative capacity increases At the transitional zone, epithelial cells elongate and
differentiate stem cells formation of new fibers continuous growth of the size and weight of the lens

9. Cortex: Made of densely packed secondary fibers Formed after sexual maturity Very little
extracellular space Nucleu s

10. II. Sutures Formed by overlapping of secondary fibers in each growth shell Erect Y-shaped sutures
appear at the anterior surface of the fetal nucleus The suture contribute in transforming the spherical
shape of the lens into flattened biconvex shape

11. III. Lens characteristics Growth of the lens: Is greatest in youngsters Decrease with the growth of
age During first 2 decades of life, EP cells and lens fibers increase rapidly. Mass of the lens: Mass
increase from 65 mg at birth to 125 mg after the first year Then increases at a rate of 2.8 mg/year till
age 10 The rate decreases to a rate of 1.4 mg/year until the age of 90.

12. Dimensions:

13. I. Transport of ions II. pH of the lens III. Amino acid and sugar transport B. Physiology of the lens

14. I. Transport of ions Crystallins are negatively charged Attracts the positively charged ions from the
extracellular fluid to maintain intracellular neutrality

15. When the extracellular Ca2+ decreases Calmodulin‐regulated Ca2+‐ATPase pump transport Ca2+
out of the cell.
16. II. pH of lens: pH in the lens increases from the nucleus towards the peripheral Is about 7
Neutrality is maintained due to ion transporters

17. III. Amino Acid and Sugar Transport Amino acid Active transport Anterior Posteri or Keto acid Keto
to amino Aqueous humor Glucos e glucose‐6‐phosph ate Glycolysi s In lens fibers Glycolytic pathway
Pentose phospha te Energ y

18. C. Embryogenesis of the lens

19. The lens plate originates from the surface ectoderm germinal layer arising from the gastrula cells
of the embryo during the 27th day of ocular embryogenesis Lens pit at the inferior center of the lens
plate invaginates to form the lens vesicle Primary lens fibers begin forming during the 6th week
Embryonic lens nucleus starts forming during the 7th week

20. Lens development First step: Elongation of posterior cells into the cavity towards the anterior cell
layer Primary lens fibers Crystallins

21. Second step: Primary lens fibers lose their nuclei and other cellular organelles Anterior cells will
continue to divide Cells along the equatorial edges will begin to form secondary lens fibers (cells in
red)

22. Third step: Anterior cells at the edges begin to grow to form secondary lens fibers By elongating
along the posterior surface of the primary lens fiber Newly formed lens fibers have consistent
hexagonal shape When migrating to the center of the lens the cell start loosing its structure:
Cytoskeleton and Crystallin

23. Fourth step: Secondary lens fibers have finished forming and they form rings around the primary
lens fibers. The process of secondary lens fiber repeats as the lens gain size and weight

24. Fifth step: The cortex of secondary lens fibers increase in size. The original primary lens fibers
persist to form the nucleus Only outer most secondary lens fibers contain nuclei

25. New secondary lens fibers continue to form throughout the life of the individual. Lens doesn’t
increase in size in adulthood, the density of secondary lens fibers increases. Compression of the
primary lens fiber nucleus.

26. I. Light transmission II. Accommodation of the lens B. Functions of the lens

27. I. Light transmission The lens allows the passage of 90% of light while absorbing the UVA and UVB
light rays Proteins in the lens are arranged for minimal scattering Any increase of size of these
proteins or more spacing, would result in the development of cataract.

28. Ways to lose transparency: Formation of opaque fibers Fibrous metaplasia Epithelial opacification
Accumulation of pigment Formation of deposits of extracellular materials

29. II. Accommodation of the lens The Lens is biconvex which intensifies the focusing power The lens
is flexible and can change curvature For far away objects For close objects

30. I. Congenital II. Cataracts E. Abnormalities of the lens

31. I. Congenital Abnormalities of growth Description Treatment Primary Aphakia Rare eye condition
that is present at birth in which the lens is missing. glasses, contact lenses, or IOL(can’t accommodate)
Secondary Aphakia disappearance of a part or whole of the lens as a result of degeneration or
absorption. glasses, contact lenses, or IOL Duplication of the lens abnormality during invagination of
lens placode from ectoderm surface associated with corneal metaplasia and coloboma (fissure) of the
iris and choroid. Microspherophakia the lens of the eye is smaller than normal and spherically
Eyeglasses , laser iridotomy, IOL
32. Abnormalities of growth Description Treatment Lens coloboma •characterized by notching of the
equator of the lens. •Caused by faulty development of the zonule. •The lens is thicker and more
spherical Glasses, contact lenses Lenticonus and lentiglobus thinning of the lens capsule and
deficiency of the epithelial cells. •conical protrusion of the lens in Lenticonus • spherical protrusion in
lentiglobus Removal of lens and IOL implantation Ectopia of the lens • Abnormal positioning of the
lens can be partial or complete • Due to abnormalities in the zonular fibers • Increased pressure in
the eye (glaucoma) or retinal detachment Pain relievers, anti- glaucoma treatment In severe cases
surgery to remove the lens

33. Abnormalities of growth Description Treatment Mittendorf’s dot • The presence of a small dense
floating opacity behind the posterior lens capsule • Remnant of the hyaloid artery No treatment is
generally necessary. Epicapsular star •Star shaped distribution of brown or golden flecks on the
central anterior lens capsule • Remnants of the vascular network that surrounds the lens during
embryogenesis. Phacoemulsification, IOL implantation Aniridia •Complete absence of the iris
•Anteroposterior pole opacities • Antiglaucoma treatment, • Corrective lenses with shaded screens
to reduce light sensitivity

34. Other abnormalities Type of abnormality Reason Effects Correction Myopia Lens is thickened
Image focused in front of the retina Concave lenses Hypermetropia Thin lens or shortened eyeball
Image is focused behind the retina Convex lenses Presbyopia Aging, lens looses elasticity Decline of
accommodation, close objects difficult to see Reading glasses (concave lenses)

35. II. Cataracts A cataract is a clouding of the lens inside the eye which leads to a decrease in vision.
Symptoms of cataracts Diminished visual acuity: gets worse when the opacity is central or axial and
diffuse, but is mild when its peripheral Glare: sensitivity to bright light Myopic shift: increase of the
dioptric power of the lens causing a mild to moderate myopia Monocular diplopia: formation of a
refractile area in the center of the lens Signs of cataracts Changes in lens appearance: lens shows a
brownish tone and in severe cases, a grey to white opacity Ophtalmoscopic red reflex drop: any
opacity is detected as black opacity

36. Causes and kinds of cataract: Congenital cataract Present at birth Infantile cataract Develops
during the first year of life

37. Morphological classification of congenital and infantile cataracts Classification Cataract location
Polar cataracts Opacities in the lens capsule and subcapsular cortex Sutural cataracts Opacification of
the Y-suture of the fetal nucleus Nuclear cataract Opacification of the embryonic nucleus alone or
both the embryonic and fetal nuclei

38. Classification Cataract location Capsular cataract Small opacification of the lens EP and anterior
lens capsule Lamellar cataract Most common type of congenital cataracts, occur from the
opacification of specific layers or zones of the lens fibers Complete cataract Complete opacification of
the lens, Retina cannot be viewed

39. Causes of congenital and developmental cataracts Heredity Genetic disorders (trisomy 21, 13, 18)
Metabolic disorders (diabetes, galactosemia, hypothyroidism, hypoglycaemia …) Congenital rubella
Ocular anomalies (coloboma…) Systemic syndromes (solo’s syndrome, potter’s syndrome…)
Dermatological diseases

40. Acquired age related cataract Types of age related cataracts Description Nuclear cataract •
Gradual hardening and yellowing of the nucleus • Leading to an impairment of distant vision Cortical
cataract • Hydration of the cortex • The development of subcapsular vacuoles • Transparency of the
cortex changes Anterior subcapsular cataract • EP cells become elongated spindle shaped and
myofibroblast • Caused by trauma to the central epithelium • Caused by exposition of UV rays. As the
eye ages the lens gains in weight and thickness and decreases in accommodative power.
41. Types of age related cataracts Description Posterior subcapsular cataract • Dysplastic change in
the germinal epithelium • Cells are distorted and unorganized • Swelling of Cortical lens fibers and
degeneration of nuclei of the superficial fibers. • Massive water intake: swelling of the lens. •
Liquefaction of the cortex leads to leakage of crystallin fragments into the anterior chamber
Advanced cataract •lens swells and increase in volume •complete opacification leads to mature
cataract. •Hypermature cataract is caused by absorption of the milky cortex reducing the lens volume
causing folds to form. a) Acquired age related cataract

42. b) Traumatic and toxicity related cataracts Physical factors • Traumatic insults, high velocity
foreign bodies or electric shock. • If the capsule is not ruptured : cataract • If the capsule is ruptured:
mature cataract Radiation cataract • Ionization of the water • Releases of free radicals • Altered
protein synthesis leading to a cataract Toxicity related cataract • Corticosteroids • anticholinesterase
• hypocalcemia • Antimalarial drugs • Iron and gold deposits • Toxic chemicals • Basic compounds

43. c) Systemic Disorders Systemic disorders Description Galactosemia Absence of enzymes that
convert galactose to glucose. Cataract associated with the accumulation of galactitol and lens swelling
Diabetes Mellitus Increase of glucose level in lens fibers causing accumulation of sorbitol and leakage
of water into the lens Fabry’s disease X-linked lysosomal storage disorder leads to abnormal glycolipid
into lens fibers creating opacity Lowe’s syndrome Total cataract due to serious X-linked disorder
leading to a small lens + metaplastic EP Alport’s syndrome Congenital/postnatal cortical cataract with
anterior or posterior Lenticonus and Microspherophakia Dystrophia Myotonica Inherited disease
where multilamellar disease causes opacity

44. d) Dermatologic disorders Similarity between skin and eye Skin disorders are: Atopy, ichthyosis,
Rothmund- Thompson syndrome, Werner’s syndrome, Incontinentia pigmenti and Cockayne’s
syndrome. e) Central Nervous System disorders• Neurofibromatosis type II : development of
symmetric, non-malignant brain tumors in the region of the cranial nerve VIII • Zellweger syndrome:
characterized by the reduction/absence of functional peroxisomes in cells . • Norries’s disease:
mutation of the NDP gene on the X chromosome, abnormal retina.

45. f) Local Ocular diseases Glaucoma the use of antiglaucoma drugs increases the chance of cataracts
Uveitis Inflammation resulting in cortical opacities Retinitis Pigmentosa Gyrate Atrophy Degenerative
myopia Retinal detachment and surgery Tumors Tumor of the ciliary body results cataracts Infections
Herpes zoster or Rubella virus

46. Other Risk factors for cataract formation Severe diarrhea Malnutrition and scarcity of antioxidants
intake (vitamin A,C and E) during meals Smoking and alcohol Inferior education Gender: women are
more prone to cataracts than men Genetics: linkage between specific genes and cataract occurrence

47. Biochemical alterations during cataract In cortical cataracts: Soluble proteins content decrease
while insoluble proteins increase, leading to a decrease in the protein content In nuclear cataracts:
insoluble protein increase. Chromophores accumulate in cells resulting in brown color in nucleus due
to Protein + ascorbate combination or protein + glucose combination Proteins may be denatured by
free radicals (UV rays) consequently will be unfolded formation of light scattering aggregates.

48. Diagnosis of the cataract: With the use of a slit lamp biomicroscope.

49. Treatment of cataracts: 1.Couching: A cataract surgery from the 18th century Extracapsular
cataract extraction

50. 2. Old Extracapsular cataract extraction (ECCE): An 8 mm to 10 mm incision is made in the eye at
sclera-cornea junction Another small incision is made into the front portion of the lens capsule.
(capsulorrhexis) The lens is removed, along with any remaining lens material. An IOL is then placed
inside the lens capsule. And the incision is closed.
51. 3. Intracapsular cataract extraction (ICCE): Entire lens removed with capsule Large incision Capsule
removed by traction side-to-side motion to break the zonular fibers Later on, an enzyme
alphachymotrypsin that dissolves the zonular fibers has been attributed to the success and ease of
the lens removal

52. Disadvantages of ICCE Advantages of ICCE Delayed healing Removal of the entire lens so no
residues remain Delayed visual rehabilitation, aphakic eye Less sophisticated equipment Significant
astigmatism Iris confinement Postoperative wound leaks with inadvertent filtration Vitreous
imprisonment in the wound might cause retinal detachment or macular edema Corneal edema
commonly occurs and endothelial cell loss is greater than that of ECCE

53. ECCE vs ICCE ECCE ICCE Small incision: 5-6 mm Large incision: 10-12 mm Posterior lens is
conserved Removal of entire lens No stitches required, self healing Required Stitches, long
rehabilitation time IOL implant aphakic eye Post op complications are minimal Added risk of retinal
detachment, corneal edema and vitreous loss

54. ECCE: Phacoemulsification Procedure for ultrasonically emulsifying the lens nucleus by making
small incisions. 1 • Cycloplegic/mydratic drops to dilate the pupil 2 • Small incision is made at the
edge of the cornea 3 • Capsulorrhexis 4 • Small ultrasonic probe is entered 5 • Artificial intraocular
lens is implanted 6 • Viscoelastic replace aqueous humor

55. Anesthesia during cataract surgery Old surgeries were done without anesthesia Topical cocaine
and retrobulbar anesthesia

56. •pupil dilatators •prophylactic antibiotics, antiseptics Pre op •Antibiotics during the irrigation
process •BSS Inter op •antibiotics •corticosteroids /nonsteroidal anti- inflammatory drugs Post op
Medications during cataract surgery

57. Viscoelastics Hyaluronic acid or hydroxyl methylcellulose Used in low concentration with
supercohesive, cohesive, or dispersive properties that aid the process of IOL implantation.

58. Kinds of IOL

59. Generation I of IOL Biconvex polymethylmethacrylate (PMMA) Implanted after ECCE Lens used to
get dislocated and caused troubles in the eye Generation II of IOL Implanted in the anterior chamber
after ICCE or ECCE (angle) Epithelial atrophy, corneal decompensation, and uveitis-glaucoma-
hyphema. Generation III of IOL Iris-supported IOL dislocation, papillary deformity and erosion, iris
atrophy Generation IV of IOL Intermediate anterior chamber IOL Improved lens design Improved
manufacturing techniques. Kinds of IOL Today’s IOL Made up of PMMA, silicone or acrylic. Silicone
and acrylic are foldable and can be implanted by a small incision. Filters wavelength below 400nm

60. Secondary cataract Posterior capsule opacification: Develops in 50% of patients Cells of the
original cataract can grow and migrate to the center of the posterior capsule

61. Types of secondary cataract Type Description Fibrosis-type posterior capsule opacification • The
anterior epithelial cells form spindle-shaped fibroblast and migrate to the posterior capsule •
Appearance of white opacities leaving fine folds and wrinkles in the posterior capsule. Pearl-type
posterior capsule opacification • Residues of equatorial epithelial cells form pearl like structure on the
posterior capsule • Due to mass cells loosely connected and piled on top of each other

62. Other Causes of PCO Soemmerring’s ring Increase in volume of lens fibers between the anterior
and posterior chamber

63. Other Causes of PCO Breakdown of the blood-aqueous humor: Inflammatory cells released
Inflammatory response to the foreign IOL Fibrils are deposited on the IOL and capsule causing
opacities Bacteria may also enter `
64. Prevention of PCO: Removal of epithelial cells and cortical remnants Infusion of saline water under
the capsule killing epithelial cell residues Implanting IOL reduces the migration of epithelial cells
Cleaning the anterior chamber with an ultrasound irrigating scratcher Freezing posterior capsule to
form intracellular ice crystals Minimizing the breakdown of blood‐aqueous barrier Pharmacological
agents to stop the proliferation of epithelial cells

65. Treatment of PCO: The eye is dilated with dilating eye drops. A laser removes the hazy posterior
capsule without an incision anti-inflammatory eye drops following the procedure. A YAG laser can
treat posterior capsule opacity safely, effectively and painlessly. YAG laser capsulotomy involves just a
few simple steps:.

ANATOMY OF THE LENS Gross Anatomy The lens is an intraocular avascular biconvex disc of
gelatinous transparent substance: contained within an elastic transparent capsule. It alters its shape
according to theI requirements of the accommodative process. It is suspended between the iris
anteriorly and the vitreous body posteriorly. The space between the iris and the lens is called the
posterioer chamber. Posteriorly, the lens is separated from the vitreous face by a narrow retro-lental
fluid space. The lens is maintained in position within the eye by a special suspensory ligament called
the zonule, which is attached to the ciliary body and to the lens capsule. The suspensory ligament
forms a delicate membrane covering the inner surface of the ciliary body and its processes. It then
passes on to the lens dividing into three layers which are attached to the anterior capsule, the
equator and the posterior capsule of the lens.

2. ANATOMY

3. The lens measures about 9 mm. diameter and 3 - 4 mm. in thickness. At birth, the lens weighs
about 60 mg which increases slowly in a linear progression to a weight of approximate 250 mg at the
age of 70 years. Its anterior surface is less convex than the posterior. The radius of curvature of the
anterior surface is10 mm. while that of the posterior surface is 6 mm. The refractive index of the lens
cortex is 1.38 and that the nucleus is 1.40. The refractive (coverging) power of the lens is
approximaely 16 - 22 dioptres when inside the eye but is approximately 60 - 70 dioptres when in air.
Microscopic Anatomy Histologically, the lens consists essentially of a mass of transparent cells, called
the lens fibres, enclosed in an elastic membrane, called the lens capsule. The lens is composed of
three distint portions :

5. The Lens Capsule . —This is a very elastic transparent non-cellular membrane which completely
surrounds the lens. Its thickness is not uniform, being thickest near the equator and thinnest at the
anterior and posterior poles of the lens. The Lens Epithelium . —The anterior epithelium consists of a
single layer of cubical cells covering the anterior surface of the lens substance and lying between the
latter and the capsule. There is no corresponding posterior epithelium.

6. The Lens Fibres and Cement Substance . —The bulk of the lens is composed of successive laminae
of fibres, but between these there is some kind of cement substance having the same refractive index
as the fibres and gluing them together. The lens substance comprises a cortex and a nucleus. The lens
cortex consists of concentric lamellae of long hexagonal transparent fibres which are arranged in
structure of an onion. The nucleus consists of the compressed central portions of lens cortex which
gradually undergoes a process of sclerosis and becomes optically denser and harder than the cortical
fibres.

7. The Suspensory Ligament of the Lens (the Zonule). —The zonule is a band-shaped gel-structure
stretching from the ciliary body to the periphery of the lens. The zonule is inserted into the zonular
lamellae in a belt running concentrically round the equator of the lens. Its anterior surface runs
straight from the lens to meet the ciliary processes just behind their apices. Its posterior surface is
bow-shaped curving along the inner surface of the body
8. Functions of the Lens Static Dioptric Function . —Together with the cornea, the lens forms the eye's
dioptric system, which to converge parallel light rays from a distant object to a focus on the
photoreceptor layer of the retina. Dynamic Dioptric Function .— The refractive power of the lens
varies with the distance of the object of regard so that a perfect image is formed on the retina at all
distances. This dynamic alteration in the refractive power of the lens to see clearly at all distances,
known as accommodation, is achieved by a change in the curvature of the lens, mainly its anterior
surface.

9. Protective Function .— The lens also protects the retina by absorbing the ultra violet rays.
CHEMISTRY OF THE LENS The adult lens contains approximately 65% water and 34% proteins. The
remaining 1 % is made up of inorganic compounds. Lens dehydration is maintained by an active
sodium pump in the epithelium.

10. METABOLISM OF THE LENS The lens, although avascular, is a living structure with definite
metabolic needs. It requires very little energy. This is because its energy requirements are limited to
the following metabolic needs : 1. The maintenance of its transparency. 2. The maintenance of the
elasticity of its capsule. 3. The development and growth of new lens fibres. Glucose seems to be the
only substrate for the lens energy requirements. With restricted oxygen supply, most of the
metabolism of glucose is through anaerobic glycolysis. Pyruvic acid is the end point of glycolysis and is
further converted anaerobically to lactic acid, which diffuses out to the aqueous.

11. As the lens is avascular, the transport of nutrient materials and waste products to and away from
the lens takes place by exchange between the lens susbtance and the aqueous humour. Therefore, it
is important for the normal metabolism of the lens to have a normal aqueous humour and a normal
permeability of the lens capsule, the capsule acts as an inert, non-selective, semi-permeable
membrane, freely permeable to water and electrolytes but impermeable to large complex molecules.

12. LENS OPTICS <ul><li>A schematic 3-D computer-assisted drawing showing tracks of laser beams
transmitted through a lens. The beams are brought to a sharp focus in a single plane </li></ul>

13. ACCOMMODATION Accommodation is the act of altering the dioptric power of the lens in order to
keep the image in sharp focus on the retina when the gaze is directed from far to near objects. This is
accomplished by means of increasing the curvature of the lens surfaces particularly the anterior
surface, and thus changing its refractive power. The degree of accommodation varies with the
distance of the object of regard. Accommodation is most active in children and decreases gradually
throughout life. This is probably due to the fact that as age advances the ciliary muscle atrophies aod
lens becomes less elastic, and thus changes its shape with difficulty. Mechanism of Accommodation
Accommodation comprises two mechanisms, namely, an active contraction of the ciliary muscle,
followed by passive change of the shape of the lens.

15. CATARACT General Considerations A cataract means cloudiness or opacity of the lens substance or
its capsule. This definition includes vacuoles, water clefts, dense areas reflecting or refracting light,
and punctuate microscopic spots in the lens substance. Cataracts most commonly develop as part of
the normal aging process and are called senile cataracts, but sometimes they are developmental.
Cataracts may also be acquired as a result of ocular pathology, metabolic defects, systemic disease,
toxins or trauma. Depending on the location and the extent of lenticular opacity, light rays passing
through the lens may be blocked or scattered, resulting in a blurred retinal image or a bothersome
glare.

16. Pathology of Cataract Formation The exact cause of cataractogenesis is obscure, the loss of
transparency is due to a disturbance of the structure of the lens. The disturbance may be of two
types : Hydration Opacity. — Biochemical, electrolytic and permeability factors produce abnormal
osmotic gradiant leading to an influx of water and sodium ions and an egress of potassium ions.
Coagulative Opacity. —An irreversible chemical change whereby the proteins become coagulated and
insoluble. Denaturization of the lens proteins may initiate or potentiate the process of water influx
and cellular fragmentation. Several factors may be responsible for loss of transparency of the lens
such as :

17. Diagnostic Methods for Catarac t Examination of the Visual Acuity. —Distant and near vision with
the appropriate glasses would be tested. Nuclear cataracts affect vision more than peripheral cortical
cataracts. Examination of the Pupillary Responses . —The direct and consensual pupillary responses
are usually affected to a slight extent by the lens opacities. Examination of the Lens by Direct Focal
Illumination. —Lens opacities appear in the pupillary area as grey or white areas against a black
background. Slit-lamp Biomicroscopy .—The extent, density, type and location of the cataract can
accurately determined by slit-lamp biomicroscopy. Examination of the Red Reflex. Examination of the
Iris Shadow by Oblique Focal Illumination. —

18. Refraction and Retinoscopy. —Retinoscopy often confirms that lens opacities are the cause of a
patient's poor vision. A-Scan and B-Scan Ultrasonography.

19. CLASSIFICATION OF CATARACT DEVELOPMENTAL SENILE ACQUIRED : Traumatic Complicating

Ocular Pathology Associating Systemic Disease

20. Classification of Cataracts <ul><li>By Etiology </li></ul><ul><li>Senile or age-related Congenital

and juvenile Traumatic. </li></ul>

21. Classification of Cataracts. (Cataract defined as any lens opacity) <ul><li>By Anatomic Location
</li></ul><ul><li>Cortical </li></ul><ul><li>Nuclear </li></ul><ul><li>Posterior sub capsular
</li></ul><ul><li>Mixed </li></ul>

22. classification of cataract according to morphology 1. Sub capsular <ul><li>Anterior

</li></ul><ul><li>Posterior </li></ul>2. Nuclear 3. Cortical 4. Christmas tree

23. Classification of Cataracts <ul><li>By Etiology </li></ul><ul><li>Senile or age-related Congenital

and juvenile Traumatic. </li></ul>

24. Classification of Cataracts <ul><li>Associated with intraocular diseases : </li></ul><ul><li>uveitis

/inflammation </li></ul><ul><li>glaucoma </li></ul><ul><li>retinal detachment retinal degeneration
(retinitis pigmentosa, gyrate atrophy) </li></ul><ul><li>persistent hyperplasic primary vitreous,
aniridia, Peters' anomaly, sclerocornea. </li></ul><ul><li>micro-ophthalmus, Norris's disease,
</li></ul><ul><li>retinoblastoma, </li></ul><ul><li>retrolental fibroplasias, high myopia,
</li></ul><ul><li>retinal anoxia (Burger's disease, Takayasu's arthritis), </li></ul><ul><li>anterior
segment necrosis </li></ul>

25. Classification of Cataracts <ul><li>Associated with systemic diseases:

</li></ul><ul><ul><li>Metabolic disorders: diabetes; galactosemia ;
hypoparathyroidism/hypocalcemia; Lowe's, Albright's, Wilson's, Fabry's, and Refsum's diseases;
homocystinuria </li></ul></ul><ul><ul><li>Renal disease: Lowe's and Alport's diseases
</li></ul></ul><ul><ul><li>Skin disease : congenital ectodermal dysplasia;Werner's and
Rothmund-Thomson syndromes; a topic dermatitis </li></ul></ul><ul><ul><li>Connective
tissue/skeletal disorders : myotonic dystrophy; Conradi's and Marfan's syndromes; bone dysplasias;
dislocated lenses </li></ul></ul><ul><ul><li>Central nervous system : Marinesco-Sjögren's syndrome,
bilateral acoustic neuroma (neurofibromatosis type 2) </li></ul></ul>

26. Classification of Cataracts <ul><li>Caused by noxious agents : </li></ul><ul><ul><li>Ionizing

radiation: x-ray, ultraviolet rays, infrared rays, microwaves
</li></ul></ul><ul><ul><li>Pharmaceuticals: steroids, naphthalene, triparanol, lovastatin, ouabain,
ergot, chlorpromazine, thallium (acetate and sulfate), dinitrophenol, dimethyl sulfoxide, psoralens,
miotics, paradichlorobenzene, sodium selenite </li></ul></ul>

27. Classification according to maturity Immature Mature Hypermature Morgagnian

29. Mature cataract

30. DEVELOPMENTAL CATARACT Congenital cataracts are present at birth or within 3 months after
birth. Developmental cataracts are not evident at birth but may form during infancy or adolescence.
They normally remain stationary throughout life. Etiology. —The cause may be either one of the
following : 1. A hereditary defect, usually of the dominant type, which is transmitted by the father or
mother. It is due to an anomaly in the chromosomal pattern. 2. A maternal nutritional deficiency
during the process of development leading to a lowered blood calcium. It may be accompanied by
signs of rickets. 3. A maternal infection during the early months of pregnancy, e.g. rubella. 4. A
deficient oxygenation, e.g. due to repeated placental haemorrhages. 5. A familial incidence, which is
dependent upon a genetic influence or some maternal abnormality. Symptoms .—The child is usually
brought for examination because the parents may notice that the pupil is white or that the child holds
things too close to his eyes.

31. S ENILE CATARACT Senile cataract denotes an age-related bilateral progressive opacification of the
lens affecting elderly people not suffering from local or systemic disease. It commonly affects persons
over 50 years of age and is due to a process of aging and degeneration. Sometimes, there appears to
be a familial tendency to cataract formation in which case the lens opacity may occur at an earlier age
in successive generations. It is controversial whether the cataract is genetically determined or
environmentally influenced.Ccataract is usually bilateral, but often one side is more advanced than
the other.

32. Clinical Picture Symptoms. — The patients may complain of one or more of the following symptc
Gradual Diminution of Vision without Pain or Discharge. Uniocular Diplopia or Polyopia. Myopia.
Positive Scotomata. Glare. Altered Colour Perception Signs. —Senile cataract is essentially a process in
which the transparency of is impaired by changes either in the cortex or in the nucleus. The principal
sign is a whitish opacity within the pupillary area, the eye appearing otherwise quiti A white pupil
(leucocoria) is usually seen as a late manifestation of cataract.

34. Intumescent Cataract .— Sometimes, during the immature stage of cataract formation, the lens
absorbs an increasing amount of fluid from the aqueous and becomes swollen, it intumescent. The
swollen lens pushes the iris forwards, reduces the depth of the anterior chamber and may block the
angle, hence there is a tendency to secondary glaucoma. The Mature Stage. —A cataract is called
mature, when complete opacification of the fibres extends to the capsule.

35. Complications of hypermature cataract: <ul><li>1 ) Secondary glaucoma :

</li></ul><ul><ul><li>phakomorphic glaucoma : The swollen cataract may cause a pupillary block and
give rise to glaucoma </li></ul></ul><ul><ul><li>Phakolytic glaucoma: The lens matter might leak out
into the AC. Here it gets engulfed by macrophages which then go and block the trabecular meshwork.
</li></ul></ul><ul><li>2) Uveitis ; </li></ul><ul><ul><li>Phakoanaphylactic uveitis: The lens matter
leaks out and sensitises the uveal tissue. phakoanaphylactic uveitis occurs. </li></ul></ul><ul><li>3)
Subluxation and dislocation of lens : Along with the hyper maturity , there is associated degeneration
of the zonules. This may give rise to subluxation and dislocation of lens. </li></ul><ul><li>4) Rapture
of lens : A swollen Morgagnian cataract may burst releasing milky fluid into the AC. This will produce
glaucoma and uveitis. </li></ul><ul><li>Therefore lens extraction should be done in the immature or
mature stage not only to improve vision but to prevent complications of hypermature cataract.
</li></ul>

36. TREATMENT OF SENILE CATARACT Th e only treatment of senile cataract is by surgical removal of
the opaque lens. The action should be undertaken on the worse eye as soon as the vision in the
better eye less than 6/18, or when the patient's ability to work is threatened. It is no longer necessary
to wait until the cataract is mature. With modern surgical techniques, an immature presents no
difficulty in its removal. However, if the cataract shows signs of maturity, it should be extracted even
if the vision in the better eye is still perfect.
37. COMPLICATED CATARACTS ASSOCIATED WITH SYSTEMIC DISEASE: Cataracts Associated with
Metabolic Disturbances (Metabolic Cataracts): (a) Diabetic cataract. (b) Galactosemic cataract. (c)
Hypocalccemic cataract. (d) Hypothyroidic cataract. (e) Myotonic cataract. (f) Deficiency cataract.
Cataracts Associated with Skin Diseases: Atopic dermatitis (Eczema). Poikiloderma atrophicans
(Rothmund Syndrome). Sclero-Poikiloderma (Werner Syndrome). Anhidrotic ectodermal dysplasia.

38. Extracapsular cataract extraction 1. Anterior capsulotomy 2. Completion of incision 3. Expression

of nucleus 4. Cortical cleanup 6. Polishing of posterior capsule, if appropriate 5. Care not to aspirate
posterior capsule accidentally

39. 8. Grasping of IOL and coating with viscoelastic substance Extracapsular cataract extraction ( cont. )
7. Injection of viscoelastic substance 9. Insertion of inferior haptic and optic 11. Placement of haptics
into capsular bag 10. Insertion of superior haptic 12. Dialling of IOL into horizontal position and not
into ciliary sulcus

40. Phacoemulsification <ul><li>During phacoemulsification, phaco for short, the surgeon makes a
small incision, where the cornea meets the conjunctiva </li></ul><ul><li>The surgeon then uses the
probe, which vibrates with ultrasound waves, to break up (emulsify) the cataract and suction out the
fragments </li></ul>

41. <ul><li>Two things happen during cataract surgery: </li></ul><ul><ul><li>the clouded lens is
removed </li></ul></ul><ul><ul><li>a clear artificial lens is implanted to replace the original clouded
lens </li></ul></ul><ul><ul><li>This lens implant is made of PMMA,plastic, acrylic or silicone and
becomes a permanent part of the eye </li></ul></ul>

42. Reference: <ul><li>1. Clinical ophthalmology </li></ul><ul><li>By </li></ul><ul><li>Jack Kanski

</li></ul><ul><li>2. Lecture notes in ophthalmology </li></ul><ul><li>3. Parson’s diseases of the eye
</li></ul>
R

Cataract associated with systemic diseases andmanagement of Cataract

2. Complicated CataractCataract associated with ocular diseases:Complicated Cataract : is due to

disturbance of the nutrition of lens due to inflammatory or degenerative disease of anterior and /or
posterior segment of the eye like iridocyclitis, cilitis, pars planitis, choroiditis, myopic degeneration,
retinitis pigmentosa, retinal detachment, other retinal pigmentory dystrophies etc.

3. Complicated Cataract Cataract has characteristic breadcrumb appearance and rainbow display of
colours (polychromatic lustre). Vision is usually affected even in early stages as opacity is near the
nodal point of the eye.

4. Complicated Cataract Prognosis depends on the causative condition. All cases of cataract without
obvious cause should be carefully looked for keratic precipitates or evidences of pars planitis.

5. Cataract associated with systemic disease Diabetic Cataract: Early onset of senile cataract and
cataract develops rapidly. True diabetic cataract is rare condition, occurring typically in young people
with acute diabetes (with gross imbalance of water balance of the body). Fluid droplets (vacuoles)
appear under the anterior and posterior subcapsular cortex, manifesting as myopia, producing diffuse
opacity. These changes are reversible.

6. Diabetic Cataract The lens rapidly becomes cataractous with dense, white anterior and posterior
subcapsular cortical cataract resembling snowstorm “snowflake Cataract”. If diabetes is controlled
appropriately, the rapid progression to mature cataract may be arrested.

7. Cataract associated with systemic disease Parathyroid Tetany Myotonic Dystrophy

Galactosaemia Down Syndrome Atopic Cataract

8. Objective Examination The state of the nucleus (grading of nuclear sclerosis) The state of the
cortex The presence or absence of signs of inflammation Pupillary glow by transillumination B-
Scan ultrasonography

9. Functional Tests Pupillary reaction Projection of light Macular function test – two pinholes test
and Maddox rod test Entoptic view of the retina : Auto- ophthalmoscopy Electro-retinographic
record, particularly of macula.

10. Pre-operative evaluation Thorough ocular examination to exclude any ocular disease like
abnormalities of lids, lacrimal sac, conjunctiva (including conjunctival infections), cornea, uveal
inflammation, glaucoma, posterior segment inflammatory/ degenerative condition etc.

11. Pre-operative evaluation Systemic examination to exclude hypertension, cardiovascular disorder,

cerebro-vascular disease, chronic obstructive air way disorder etc. If any disorder is present, it should
be adequately controlled before surgery ENT and Dental checkup to exclude septic focus

12. Treatment of cataract Medical treatment: No medical treatment is effective once the lens
opacity has developed.

13. Treatment of cataract Surgical Treatment:Indication for surgery: 1. Cataract – when routine work
becomes difficult due to reduced vision (attributable to cataract) 2. Subluxated or dislocated lens 3.
Lens induced complications like phacolytic uveitis / glaucoma, phacoanaphylactic endophthalmitis,
phacomorphic glaucoma.

14. Treatment of cataract Surgical Treatment: Options I. Intracapsular lens extraction (ICCE): Method
of intracapsular cataract extraction (ICCE), now becoming obsolete, by which the entire lens including
the capsule is removed by rupturing zonular ligaments.

15. Surgical Treatment of CataractII. Extracapsular Cataract Extraction (ECCE): Methods –1.
Conventional ECCE2. ECCE by small incision cataract surgery(SICS)3. Lensectomy4.
Phacoemulsification

16. Steps of ECCE1. Anaesthesia a. General Anaesthesia : In children, psychiatric patients, senile
dementia b. Local anaesthesia: Retrobulbar block, peribulbar block, along with or without facial block ,
topical anaesthesia

17. Steps of ECCE2. Cleaning of lids with 5% betadine solution and instillation of betadine solution in
conjunctival sac3. Draping4. Superior Rectus suture in case of conventional ECCE and SICS5.
Conjunctival flap in case of SICS

18. Steps of ECCE6. Scleral tunnel incision or Corneo-scleral section or corneal or corneal tunnel
incision7. Anterior chamber entry8. Injection of ocular viscosurgical device (OVD) in anterior chamber
(HPMC or Sodium Hyaluronate)9. Capsulotomy ( can opener or continuous curvilinear capsulorrhexis,
CCC)

19. Steps of ECCE10. Hydrodissection and Hydrodelineation11. Nucleus delivery (in conventional ECCE
and SICS) / Phacoemulsification of nucleus (in phacoemulsification, machine , through titanium needle
provides energy for emulsification of nucleus, needle vibrates at an speed of 20,000 Hz and pulverizes
the nucleus)

20. Steps of ECCE12. Cortical clean up by aspiration and irrigation (BSS or Ringer lactate is used as
irrigating fluid)13. Filling of lens capsule (capsular bag) with OVD14. Insertion of posterior chamber
IOL (in the bag, in case of complications in the ciliary sulcus)

21. Steps of ECCE15. Removal of OVD from anterior chamber16. Closure of wound of entry
(corneoscleral wound requires sutures 10-0 silk or nylon), phaco and SICS incisions are self sealing.

22. Complications of Cataract SurgeryI. Due to local anesthesia: Retrobulbar haemorrhage, globe
perforataion, oculocardiac reflex etc.II. Intra-operative complications : detachment of descemet’s
membrane, damage to corneal endothelium, zonular dialysis, posterior capsular rupture

23. Complications of cataract SurgeryIII. Early post-operative complications: wound leak and
complications related to it (iris prolapse, flat anterior chamber), secondary glaucoma, postoperative
infection, lens matter induced uveitis etc.

24. Complications of Cataract SurgeryIV. Late post-operative complications: cystoid macular edema,
posterior capsular opacification, corneal endothelial decompensation causing corneal edema, retinal
detachment, displacement of IOL etc.

Cataract associated with systemic diseases andmanagement of Cataract

2. Complicated CataractCataract associated with ocular diseases:Complicated Cataract : is due to

disturbance of the nutrition of lens due to inflammatory or degenerative disease of anterior and /or
posterior segment of the eye like iridocyclitis, cilitis, pars planitis, choroiditis, myopic degeneration,
retinitis pigmentosa, retinal detachment, other retinal pigmentory dystrophies etc.

3. Complicated Cataract Cataract has characteristic breadcrumb appearance and rainbow display of
colours (polychromatic lustre). Vision is usually affected even in early stages as opacity is near the
nodal point of the eye.

4. Complicated Cataract Prognosis depends on the causative condition. All cases of cataract without
obvious cause should be carefully looked for keratic precipitates or evidences of pars planitis.

5. Cataract associated with systemic disease Diabetic Cataract: Early onset of senile cataract and
cataract develops rapidly. True diabetic cataract is rare condition, occurring typically in young people
with acute diabetes (with gross imbalance of water balance of the body). Fluid droplets (vacuoles)
appear under the anterior and posterior subcapsular cortex, manifesting as myopia, producing diffuse
opacity. These changes are reversible.

6. Diabetic Cataract The lens rapidly becomes cataractous with dense, white anterior and posterior
subcapsular cortical cataract resembling snowstorm “snowflake Cataract”. If diabetes is controlled
appropriately, the rapid progression to mature cataract may be arrested.

7. Cataract associated with systemic disease Parathyroid Tetany Myotonic Dystrophy

Galactosaemia Down Syndrome Atopic Cataract

8. Objective Examination The state of the nucleus (grading of nuclear sclerosis) The state of the
cortex The presence or absence of signs of inflammation Pupillary glow by transillumination B-
Scan ultrasonography

9. Functional Tests Pupillary reaction Projection of light Macular function test – two pinholes test
and Maddox rod test Entoptic view of the retina : Auto- ophthalmoscopy Electro-retinographic
record, particularly of macula.
10. Pre-operative evaluation Thorough ocular examination to exclude any ocular disease like
abnormalities of lids, lacrimal sac, conjunctiva (including conjunctival infections), cornea, uveal
inflammation, glaucoma, posterior segment inflammatory/ degenerative condition etc.

11. Pre-operative evaluation Systemic examination to exclude hypertension, cardiovascular disorder,

cerebro-vascular disease, chronic obstructive air way disorder etc. If any disorder is present, it should
be adequately controlled before surgery ENT and Dental checkup to exclude septic focus

12. Treatment of cataract Medical treatment: No medical treatment is effective once the lens
opacity has developed.

13. Treatment of cataract Surgical Treatment:Indication for surgery: 1. Cataract – when routine work
becomes difficult due to reduced vision (attributable to cataract) 2. Subluxated or dislocated lens 3.
Lens induced complications like phacolytic uveitis / glaucoma, phacoanaphylactic endophthalmitis,
phacomorphic glaucoma.

14. Treatment of cataract Surgical Treatment: Options I. Intracapsular lens extraction (ICCE): Method
of intracapsular cataract extraction (ICCE), now becoming obsolete, by which the entire lens including
the capsule is removed by rupturing zonular ligaments.

15. Surgical Treatment of CataractII. Extracapsular Cataract Extraction (ECCE): Methods –1.
Conventional ECCE2. ECCE by small incision cataract surgery(SICS)3. Lensectomy4.
Phacoemulsification

16. Steps of ECCE1. Anaesthesia a. General Anaesthesia : In children, psychiatric patients, senile
dementia b. Local anaesthesia: Retrobulbar block, peribulbar block, along with or without facial block ,
topical anaesthesia

17. Steps of ECCE2. Cleaning of lids with 5% betadine solution and instillation of betadine solution in
conjunctival sac3. Draping4. Superior Rectus suture in case of conventional ECCE and SICS5.
Conjunctival flap in case of SICS

18. Steps of ECCE6. Scleral tunnel incision or Corneo-scleral section or corneal or corneal tunnel
incision7. Anterior chamber entry8. Injection of ocular viscosurgical device (OVD) in anterior chamber
(HPMC or Sodium Hyaluronate)9. Capsulotomy ( can opener or continuous curvilinear capsulorrhexis,
CCC)

19. Steps of ECCE10. Hydrodissection and Hydrodelineation11. Nucleus delivery (in conventional ECCE
and SICS) / Phacoemulsification of nucleus (in phacoemulsification, machine , through titanium needle
provides energy for emulsification of nucleus, needle vibrates at an speed of 20,000 Hz and pulverizes
the nucleus)

20. Steps of ECCE12. Cortical clean up by aspiration and irrigation (BSS or Ringer lactate is used as
irrigating fluid)13. Filling of lens capsule (capsular bag) with OVD14. Insertion of posterior chamber
IOL (in the bag, in case of complications in the ciliary sulcus)

21. Steps of ECCE15. Removal of OVD from anterior chamber16. Closure of wound of entry
(corneoscleral wound requires sutures 10-0 silk or nylon), phaco and SICS incisions are self sealing.

22. Complications of Cataract SurgeryI. Due to local anesthesia: Retrobulbar haemorrhage, globe
perforataion, oculocardiac reflex etc.II. Intra-operative complications : detachment of descemet’s
membrane, damage to corneal endothelium, zonular dialysis, posterior capsular rupture

23. Complications of cataract SurgeryIII. Early post-operative complications: wound leak and
complications related to it (iris prolapse, flat anterior chamber), secondary glaucoma, postoperative
infection, lens matter induced uveitis etc.
24. Complications of Cataract SurgeryIV. Late post-operative complications: cystoid macular edema,
posterior capsular opacification, corneal endothelial decompensation causing corneal edema, retinal
detachment, displacement of IOL etc.

Crystalline lens • Anatomy o Transparent o Biconvex o Flat on ant. surface more than posterior o
Avascular • Approx. 18 diopters • Refractive index o Cortex: 1.38 o Nucleus: 1.42 • Functions o
Refracts light and focuses it on retina by alteration of shape (accommodation) o Retinal protection
from UV rays o Neutralizes spherical and chromatic aberrations of cornea

3. Structure and zones • Made up of o Capsule o Lens epithelium (anterior only) o Lens fibers • Zones
o Cortex • Anterior cortex • Equatorial cortex • Posterior cortex o Nucleus • Embryonic • Foetal •
Infantile • Adult • Metabolism: facilitated diffusion of glucose from across capsule

4. Cataract (opacity of crystalline lens) Congenital/developmental Acquired

5. Congenital/ developmental cataract • Fairly common 1:2000 live births • Unilateral or bilateral •
May be non-progressive and visually insignificant • May have a marked visual impairment • Classified
either by o Morphology o Aetiology o Specific metabolic disorders o Associated ocular abnormalities o
Systemic findings

6. Aetiology • Gestational disturbance o Intrauterine infections o Maternal drug intake o Irradiation o

Nutritional • Metabolic disorders o DM o Galactosemia o Hypoglycaemia o Hypoparathyroidism •
Trauma o Mechanical o Electric shock • Ocular anomalies o Aniridia o Ectopia lentis o Persistent
hyperplastic primary vitreous o Remnants of tunica vasculosa lentis o Congenital anomalies of lens •
Idiopathic • Inheritance (recessive)

7. Morphological classification Polar Lamellar (zonular) Complete (total/diffuse) Coronary Blue dot
Nuclear Sutural (stellate) Membranous

8. Polar cataract • Opacities involve Lens capsule and subcapsular cortex • Subtypes o Anterior polar
• Small • Symmetric • Non progressive • Doesn’t impair vision • May project into AC – pyramidal
cataract o Posterior polar • Larger • Closer to NP • More visual impairment

9. Lamellar (zonular) • Most common type • Bilateral • Opacification of specific layers/zones • Slit
lamp examination o Layer of opacification involving foetal nucleus surrounding clearer center and
surrounded in turn by layer of clear cortex o Front view: disc shaped configuration o Arcuate opacities
straddle equator (riders) • Aetiology o transient toxic influence during embryogenesis o Calcium and
vit D deficiency during pregnancy

10. Complete (total/diffuse) • May start as subtotal at birth then progress • Profound visual
impairment • Requires urgent surgery

11. Coronary cataract • Developmenta • Manifested usually at puberty • Club shaped opacities near
periphery of lens with broad ends towards center

12. Blue dot cataract • Multiple small bluish dots • Scattered all over lens • Cause no visual
disturbance

13. Nuclear cataract • Rubella cataract o Aetiology: maternal infection with rubella virus during first
trimester of pregnancy o Characterized by pearly white nuclear opacification o Can progress to
complete cataract and occasional cortical liquification o Systemic manifestations include • Cardiac
defects • Deafness • Mental retardation • Cardiac conduction o Ocular manifestations • Diffuse
pigmentary retinopathy • Microphthalmia • glaucoma • Bilateral • May involve embryonic nucleus
alone or both embryonic and foetal
14. Membranous cataract • Lens proteins resorbed • Only anterior and posterior lens capsules remain
and fuse into dense white membrane

15. Acquired cataract Senile (age-related) Traumatic Complicated

16. Senile cataract • Old people • Not due to local or general disease • Bilateral with one eye affected
before the other • Incidence o Between 65-74 years 50% o 75 years and above 70% • Pathogenesis:
multifactorial

17. Types Cortical Cuneiform Cupuliform Nuclear

18. Cortical cuneiform cataract • Stages: o Precataractous changes o Incipient stage o Immature stage
o Mature stage o Hypermature stage • Shrunken type • Morgagnian o Intumescent

19. Cortical cupuliform cataract • Posterior subcapsular • Central • Causes glare and poor vision
under bright lightening conditions • Near vision reduced more than distant

20. Nuclear cataract • Due to excessive amount of nuclear sclerosis and yellowing which causes
central opacity • Slow progression • Interferes more with distant vision than near • Causes myopic
shift (presbyopia) • Grades: o N1-N4: cataracta brunesecence o N5: cataracta nigra • Red reflex seen
peripherally around central disc of opacity appears which appears black by retro-illumination

21. Traumatic cataract • Perforating injury • Concussion (contusion) injury o Vossius ring o
Rosette-Shaped opacity o Subluxation and dislocation • Radiation injury o Ionizing radiation (X-ray) o
Infra-red radiation (glass blower’s cataract) o UV radiation • Chemical injury o Alkali (caustic) burn o
Chalcosis (sunflower cataract) o Siderosis • Electrical injury

22. Complicated cataract • Due to local eye disease or general (systematic) disease • Local eye
disease o Perforated corneal ulcer o Iridocyclitis o Chronic glaucoma o Retina and choroid disease •
General disease o Metabolic • DM • Galactosemia o Endocrinal • Hyperparathyroidism •
Hypothyroidism o Severe anaemia o Hypertension o Idiopathic: systemic steroids in genetically prone
patients

23. Diabetes mellitus and the lens Increased blood sugar Increased aqueous content of lens Increased
glucose content of lens sorbitol Water influx into lens Lens swelling + myopic change
Changeinrefractive index • Reverse to hypermetropic change if there is hypoglycemia • Decreased
amplitude of accommodation o With early presbyopia • Cataract (two types) o True-diabetic
(snow-flake cataract) o Senile and pre-senile cataract

24. Management • Congenital o Irrigation aspiration o Lensectomy o Correction of aphakia • Contact

lens • Glasses • Two pairs of glasses • Intraocular lens implantation o Foldable soft acrylic lens o
Iris-claw (artisan) lens

25. Management • Adults o Indications for surgery • Improve vision • Manage complications •
Manage underlying retinal disease o Preoperative evaluation • Systemic evaluation • Local
ophthalmic evaluation o Pertinent ocular history o Visual acuity testing o External examination o Slit
lamp-examination o Fundus examination o Retinal function tests • Surgery o Under local or general
anaesthesia o Operations • ICCE • ECCE • phacoemulsification

What is a cataract? <ul><li>Opacification of human crystalline lens </li></ul><ul><li>Functionally, it

includes the cases which interferes with vision </li></ul>
3. Morphological classification <ul><li>Subcapsular cataract </li></ul><ul><ul><li>Anterior
subcapsular cataract </li></ul></ul><ul><ul><li>Posterior subcapsular cataract
</li></ul></ul><ul><li>Nuclear cataract involves the nucleus of lens. </li></ul><ul><ul><li>Yellow to
brown voloration </li></ul></ul><ul><li>Cortical cataract </li></ul><ul><ul><li>wedge shaped or
radial spoke-like opacities. </li></ul></ul><ul><li>Polar cataract </li></ul>

4. Classification according to maturity <ul><li>An immature cataract </li></ul><ul><li>A mature

cataract </li></ul><ul><li>A hypermature cataract </li></ul><ul><ul><li>A morgagnian cataract
</li></ul></ul>

5. Etiological classification <ul><li>Congenital and developmental cataract </li></ul><ul><li>Acquired

cataract </li></ul><ul><ul><li>Senile cataract </li></ul></ul><ul><ul><li>Traumatic cataract
</li></ul></ul><ul><ul><li>Complicated (secondary) cataract . eg, uveitis, pathological myopia,
glaucoma, retinal detachment, retinitis pigmentosa etc, </li></ul></ul><ul><ul><li>Metabolic
cataract . Eg, Diabetes, hypocalcaemia, Wilson’s disease, Lowe’s syndrome </li></ul></ul>

6. Etiological classification <ul><li>Acquired cataract </li></ul><ul><ul><li>Electric cataract

</li></ul></ul><ul><ul><li>Radiational cataract </li></ul></ul><ul><ul><li>Drug induced cataract eg,
corticosteroid, copper, iron, Chlorpromazine, Busulphan, Allopurinol, Amiodarone, etc,
</li></ul></ul><ul><ul><li>Cataract associated with skin diseases . Eg, atopic dermatitis, scleroderma,
etc, </li></ul></ul><ul><ul><li>Cataract with miscellaneous syndromes . Eg, Dystrophica myotonica,
Down’s syndrome etc, </li></ul></ul>

7. CONGENITAL AND DEVELOPMENTAL CATARACT <ul><li>Congenital cataract develops from some

disturbance to normal development of lens . </li></ul><ul><ul><li>The disturbance occurs before the
birth </li></ul></ul><ul><ul><li>The opacity may limit to embryonic or foetal nucleus.
</li></ul></ul><ul><li>Developmental cataract occurs from infancy to adolescence.
</li></ul><ul><ul><li>The opacity involves infantile or adult nucleus. </li></ul></ul><ul><li>3 children
out of 10,000 live births. </li></ul><ul><ul><li>Two third of the cases are bilateral. </li></ul></ul>

8. Etiology <ul><li>Hereditary. </li></ul><ul><ul><li>1/3 rd hereditary, common mode: autosomal

dominant inheritance </li></ul></ul><ul><li>Maternal factors. </li></ul><ul><ul><li>Malnutrition
during pregnancy . </li></ul></ul><ul><ul><li>Maternal infection . Eg, rubella, toxoplasmosis,
cytomegalo-inclusion disease. </li></ul></ul><ul><ul><li>Drug intake during pregnancy. Eg,
thalidomide, corticosteroids. </li></ul></ul><ul><ul><li>Radiation exposure during pregnancy. Eg,
X-rays, other ionizing radiations. </li></ul></ul>

9. Etiology <ul><li>Foetal or infantile factors. </li></ul><ul><ul><li>Deficient oxygenation owing to

placental haemorrhage . </li></ul></ul><ul><ul><li>Metabolich disorders. Eg, galactokinase
deficiency, neonatal hypoglycemia, galactosaemia, </li></ul></ul><ul><ul><li>Chromosomal
abnormality. Eg, down syndrome </li></ul></ul><ul><ul><li>Skeletal syndromes. Eg,
Hallermann-streiff-Francois syndrome, Nance-Horan syndrome </li></ul></ul>

10. Etiology <ul><li>Foetal or infantile factors. </li></ul><ul><ul><li>Birth trauma

</li></ul></ul><ul><ul><li>Malnutrition early in infancy . </li></ul></ul><ul><ul><li>Prenatal
infection. Eg, congenital rubella, toxoplasmosis, cytomegalovirus, herpes simplex and varicella.
</li></ul></ul>

11. NURSING ASSESSMENT <ul><li>General </li></ul><ul><ul><li>History of white pupil, squint,

spontaneous movement of eyes, loss of visual attention. </li></ul></ul><ul><ul><li>Assess density of
cataract </li></ul></ul><ul><ul><li>Observe the red fundus reflex on ophthalmoscope. Absence of
red fundus reflex indicates cataract is visually significant. </li></ul></ul><ul><ul><li>Perform fundus
examination under dilatation . </li></ul></ul><ul><ul><li>Examine other associated ocular anomalies .
Eg, absence of central fixation, nystagmus, strabismus, corneal clouding, microphthalmos, glaucoma,
retinoblastoma, retinal disorders </li></ul></ul>
12. NURSING ASSESSMENT <ul><li>Investigation </li></ul><ul><ul><li>Serological test for intrauterine
infections (TORCH= toxoplasmosis, rubella, cytomegalovirus, and herpes simplex).
</li></ul></ul><ul><ul><li>A history of maternal rash during pregnancy for varicella zoster antibody
titres. </li></ul></ul><ul><ul><li>Urinalysis for galactosaemia and chromatography for aminoacids.
</li></ul></ul><ul><ul><li>Refer to pediatrician to rule out systemic diseases. </li></ul></ul>

13. AGE RELATED (SENILE) CATARACT <ul><li>Common and bilateral above the age of 50 years.
</li></ul><ul><li>Male: Female::1:1 </li></ul><ul><li>Etiology </li></ul><ul><ul><li>Hereditary :
Incidence, age of onset and maturation </li></ul></ul><ul><ul><li>Ultravoilet radiation : More
exposure to UV-rays = early maturation. </li></ul></ul><ul><ul><li>Dietary factors : Poor diatery
factors eg, lack of certain aminoacids, Vitamines (Vitamin E, Vitamin C, riboflavin) and essential
minerals. </li></ul></ul><ul><ul><li>Dehydrational crisis : Prior episode of severe dehydration due to
diarrhea and cholera. </li></ul></ul>

14. Mechanism of loss of transparency <ul><li>Cortical cataract </li></ul><ul><ul><li>Denaturation

and coagulation of lens proteins. </li></ul></ul><ul><ul><li>Decrease level of aminoacids and protein
systhesis </li></ul></ul><ul><ul><li>Increased hydration brought by decrease in potassium due to
reversal of Na/K pump mechanism. </li></ul></ul><ul><li>Nuclear cataract:
</li></ul><ul><ul><li>Degenerative changes occurring as nuclear sclerosis
</li></ul></ul><ul><ul><li>Increase in water insoluble proteins,
</li></ul></ul><ul><ul><li>compaction of nucleus resulting in a hard cataract.
</li></ul></ul><ul><ul><li>Disturbance of lamellar arrangement in fibres </li></ul></ul>

15. Symptoms <ul><li>Painless progressive visual loss </li></ul><ul><li>Glare

</li></ul><ul><li>Reduced color perception </li></ul><ul><li>Color haloes </li></ul><ul><li>Uniocular
diplopia </li></ul><ul><li>Based on the location and density </li></ul>

16. Sign <ul><li>Opacification of the normally clear lens seen through the pupil
</li></ul><ul><li>Indistinct on retina examination </li></ul><ul><li>Red reflex may be dim
</li></ul><ul><li>No afferent pupillary defect </li></ul><ul><li>Myopic shift </li></ul>

17. NURSING ASSESSMENT <ul><li>Assess visual acuity and review report on refraction.
</li></ul><ul><ul><li>Surgery is indicated when cataract develops to a degree sufficient to cause
difficulty in performing daily essential activities. </li></ul></ul><ul><li>Assess a complete morphology
of opacity (size, site, shape, color, and pattern) under slit lamp examination.
</li></ul><ul><li>Perform cover test </li></ul>

18. NURSING ASSESSMENT <ul><li>Test papillary response. </li></ul><ul><li>Examine cornea to rule

out any opacities </li></ul><ul><li>Examine ocular adnexa </li></ul><ul><li>Performed dilated
fundus examination </li></ul><ul><li>Perform USG B-scan </li></ul><ul><li>Measure intraocular
pressure </li></ul><ul><li>Perform potential acuity measurement </li></ul><ul><li>Perform biometry
</li></ul>

19. Nursing Assessment <ul><li>Specular Microscopy (endothelium cells) </li></ul><ul><ul><li>A

normal cell count > 2400 cells/mm 2 </li></ul></ul><ul><ul><li>If a cell count fewer than 1000
cells/mm 2 is risk of postoperative corneal decompensation </li></ul></ul>

20. Laboratory investigation <ul><li>Complete blood counts </li></ul><ul><li>Blood sugar

</li></ul><ul><li>Urine analysis </li></ul><ul><li>Chest X-ray </li></ul><ul><li>Conjunctival swab for
C/S </li></ul>

26. Type of cataract surgery <ul><li>Extracapsular cataract extraction (ECCE).

</li></ul><ul><ul><li>Requires a relatively large circumferential limbal incision (8-10mm) through
which the lens nucleus is extracted and the cortical matter aspirated, leaving behind an intact
posterior capsule. </li></ul></ul><ul><ul><li>The IOL is then inserted. </li></ul></ul><ul><ul><li>It is
the universal procedure of operation in cataract. </li></ul></ul><ul><ul><li>Posterior IOL can be
transplanted after ECCE. </li></ul></ul>

27. Type of cataract surgery <ul><li>Intracapsular cataract extraction (ICCE) .

</li></ul><ul><ul><li>The entire cataractous lens along with the intact capsule is removed in this
procedure. </li></ul></ul><ul><ul><li>Weak and degenerated zonules are a pre-requisite for this
method. </li></ul></ul><ul><ul><li>This is the surgery of choice only in markedly subluxated and
dislocated lens. </li></ul></ul><ul><ul><li>This technique of surgery has been largely replaced by
ECCE nowadays. </li></ul></ul>

28. Type of cataract surgery <ul><li>Phacoemulsification: </li></ul><ul><ul><li>A small hollow needle

containing a piezo-electric crystal vibrates longitudinally at ultrasonic frequencies
</li></ul></ul><ul><ul><li>The tip is applied to the lens nucleus; cavitation occurs at the tip as the
nucleus is emulsified; </li></ul></ul><ul><ul><li>an irrigation and aspiration system removes this
emulsified material from the eye. </li></ul></ul><ul><ul><li>The IOL is then injected through a much
smaller incision than in ECCE. </li></ul></ul><ul><ul><li>Safe: avoid compression of eye, results in
little postoperative astigmatism and early stabilization of refraction, and eliminate post-operative
wound related problem </li></ul></ul>

29. Type of cataract surgery <ul><li>Lensectomy: </li></ul><ul><ul><li>Most of the lens including

anterior and posterior capsule along with anterior vitreous are removed with the help of a vitreous
cutter, infusion and suction machine. </li></ul></ul><ul><ul><li>Congenital as well as developmental
cataract being soft are easily dealt with this procedure. </li></ul></ul>

30. NURSING DIAGNOSIS <ul><li>Gradual painless diminution of vision </li></ul>

31. EXPECTED OUTCOME <ul><li>Immediate. </li></ul><ul><ul><li>Optimal vision will be restored

with periodic refractive correction with glasses. </li></ul></ul><ul><ul><li>Patient will be reassured
and informed with progression and option of surgery. </li></ul></ul><ul><ul><li>Make patient
educate and aware about possibility of fall due to visual impairment. </li></ul></ul>

32. EXPECTED OUTCOME <ul><li>Preoperative </li></ul><ul><ul><li>Comfort and safety will be

maintained. </li></ul></ul><ul><ul><li>Any infection will be treated and prophylaxis treatment will
be initiated. </li></ul></ul><ul><ul><li>Surgical procedure and postoperative care will be explained.
</li></ul></ul><ul><ul><li>Patient’s anxiety will be eliminated. </li></ul></ul><ul><ul><li>Secondary
development of glaucoma will be prevented. </li></ul></ul>

33. EXPECTED OUTCOME <ul><li>Postoperative </li></ul><ul><ul><li>Pain is relieved, comfort is

ensured. </li></ul></ul><ul><ul><li>Haemorrhage and loss of vitreous humour will be prevented.
</li></ul></ul><ul><ul><li>Intraocular pressure will be prevented to rise.
</li></ul></ul><ul><ul><li>Infection will be prevented. </li></ul></ul><ul><ul><li>Ensure restoration
of vision </li></ul></ul>

34. Implementation: Prepare patient for cataract operation <ul><li>Topical antibiotics tobramycin,
gentamycin or ciprofloxacin qid for 3 days. </li></ul><ul><li>Trim or cut upper lid eyelashes
</li></ul><ul><li>Obtain written and detailed consent from the patient or first degree relatives.
</li></ul><ul><li>Ensure each patient take scrub bath including face and hair. Males must get their
beard cleaned. </li></ul><ul><li>Acetazolamide 500mg stat 2 hours before surgery.
</li></ul><ul><li>Instill cycloplegic/mydriatic eye drops every ten minutes one hour before surgery
</li></ul>

35. Implementation <ul><li>Relieve patient from anxiety with proper counseling.

</li></ul><ul><li>Make sure patient does not develop nausea or gastritis due to anxiety or
preoperative medicines. </li></ul><ul><li>Instruct patient not to touch eyes.
</li></ul><ul><li>Cataract operation can be performed by ophthalmic surgeon under general or local
anaesthesia. </li></ul>
36. PREOPERATIVE CHECKLIST <ul><li>History and physical examination </li></ul><ul><li>Name of
procedure on surgical consent </li></ul><ul><li>Signed surgical consent </li></ul><ul><li>Laboratory
results </li></ul><ul><li>Allergies have been identified </li></ul><ul><li>Vital signs assessed
</li></ul><ul><li>Jewelry removed </li></ul><ul><li>Client is wearing a hospital gown and hair cover
</li></ul><ul><li>Client has urinated </li></ul><ul><li>The prescribed preoperative medication has
been given </li></ul>

37. Implementation: Immediate postoperative care <ul><li>The patient is asked to lie quietly upon
the back for about three hours and advised not to take food. </li></ul><ul><li>Instruct patient avoid
coughing, sneezing and avoid bending from the waist. </li></ul><ul><li>Give analgesics.
</li></ul><ul><li>Provide quite and safe environment. </li></ul><ul><li>Notify physician of sudden
pain occurs </li></ul><ul><li>Treat nausea or vomiting immediately if present </li></ul>

38. DISCHARGE INSTRUCTIONS <ul><li>Care of the incision </li></ul><ul><li>Signs of complications

</li></ul><ul><li>Drugs for pain management </li></ul><ul><li>How to self administer prescribed
medications </li></ul><ul><li>Amount of weight that can be lifted </li></ul><ul><li>Diet
</li></ul><ul><li>Return for a medical appointment </li></ul>

39. Implementation: Subsequent post-operative care <ul><li>Remove bandage next morning.

</li></ul><ul><li>Inspect eye for any postoperative complication. </li></ul><ul><li>Instruct patient
and family to instill antibiotic and steroid eye drops prescribed for 2 to 4 weeks.
</li></ul><ul><li>Antibiotic ointment at bed time for a week. </li></ul><ul><li>Oral analgesic (sos)
</li></ul><ul><li>Provide eye shield. </li></ul><ul><li>Then patient can be instructed to wear
sunglasses. </li></ul><ul><li>Ensure patient got prescribed spectacle after 6-8 weeks of operation.
</li></ul>

40. EVALUATION <ul><li>Outcome criteria </li></ul><ul><ul><li>Pain is relieved and infection is

prevented. </li></ul></ul><ul><ul><li>Cataract is removed and sight is restored with or without
corrective glasses. </li></ul></ul><ul><ul><li>Patient successfully adapts to vision change with
planned rehabilitation. </li></ul></ul>

41. THANK YOU !

‘CATARACTA’(LATIN) = MEANING ‘WATERFALL’ Cataract:

5. Cataract: progressive, painless clouding of the natural, internal lens

of the eye. Opacification and degeneration of lens fibers The formation
of aberrant lens fibers or deposition of other materials in their place.

6. Normal eye Infected eye Cataract Vs. normal eye:

7. Cataract Symptoms: blurred vision due to scattering of light on the

retina

8. Cataract Symptoms: glared view i.e.(trouble driving at night)

9. Cataract Symptoms: change in color vision dimness

10. age of onset CONGENITAL senile SUB CAPSULAR CATARACT CAPSULAR CATARACT
morphology IMMATURE CATARCT MATURE CATARACT maturity Cataract Cataract
classification:

11. PATHOPHYSIOLOGY: • Cataracts can develop in one or both eyes at any

age • Three most common type of senile(aged-related) cataracts are defined
by the location in the lens
12. PATHOPHYSIOLOGY: 1.Nuclear: Central opacity in lens Associated
with myopia Worsen on progression Genetic cause = 48% Environmental
cause = 14%

13. 2.Cortical: Involve the interior and posterior equatorial cortex

of the lens Worst in very bright light Genetic cause = 37-58 %
Environmental cause= 11-37% cataracts PATHOPHYSIOLOGY:

14. 3.Posterior sub capsular : occurs in front of posterior capsule

Mostly occurs in youngers Associated with prolonged use of
corticosteroids, diabetes, ocular trauma Near vision is diminished
PATHOPHYSIOLOGY:

15. Causes and risk factors: Smoking Obesity Eye injuries UV

Malnutrition Family history. Metabolic problems, such as diabetes.
Aging (most common). cataracts

16. Genetics of cataract: Most common mode of inheritance is autosomal

dominant cataract. Autosomal recessive and X-linked forms are also seen
but are uncommon. Half of congenital cataract are inherited while
age-related cataracts tend to be multifactorial, with both multiple genes
and environmental factors influencing the phenotype.

17. 1. Autosomal dominant inheritance: manifests in the heterozygous

state In this male and female both are affected. Mutation in one allele
is enough to express the disease. This is vertical transmission. The
offspring's have 50% chances to have the disease.

18. 1. Autosomal dominant inheritance:

19. 2. Autosomal recessive inheritance: only manifest when mutant

allele is present in homozygosity. Individuals heterozygous for such
mutant alleles show no features of the disorder and are healthy, i.e. they
are carriers.

20. 3. X-linked inheritance: When a gene for particular disease/trait

lies on the X chromosome it is X-linked Males = XY (X from mother, Y
from father) Females = XX (1 X from mother, 1 X from father) X-linked
genes are NEVER passed from father to son In an affected family affected
females must have an affected father Males are hemizygous for x-linked
traits Males are never carriers A single dose of mutant allele in
a male will produce a mutant phenotype regardless of whether it is dominant
or recessive

21. X linked dominant X linked recessive 3. X-linked inheritance:

22. Genes & Loci For Cataract: currently about 45 genetic loci to which
cataracts have been mapped with specific genes identified is 38, although
the number is constantly increasing. The genes linked to cataract will
be considered under the following headings: a)Those linked to the genes
coding for connexin proteins b)Those linked to the crystallins of the lens
c) Those linked to currently unidentified genes

23. Connexins: Transmembrane proteins Pulverulent cataract and

nuclear Pulverulent cataract are linked to gene locations at 1q22-30 and
13q11-12 respectively, sites of the genes that code for the connexin
proteins of the lens. Connexin 50 (Cx50) and connexin 46 (Cx46), are
present in lens fibers and form the intercellular channels of the lens.
Cx46 is concerned primarily with lens clarity, and Cx50 with lens growth.
Deletion of Cx46 will lead to severe cataract and deletion of Cx50 will
lead to reduce lens growth. PAX6 (Paired Box 6) gene and mutation in
this gene causes Cataract

24. Crystallins: Long-lived proteins located inside lens fibers,

maintenance of transparency and refractive power. Approximately 90%
of the lens proteins are crystallins. Three basic types of crystallin
in the vertebrate lens – α, β, γ presence of cataract is associated
with gene locations at sites involving the crystallin genes.

25. Crystallins: Locus 2q33-35 is the site of the γ-crystallin cluster

of genes (γA, γB, γC, γD, γE, γF, γG). Of this cluster, mutations
in γD and γE have been associated with progressive nuclear cataract and
pulverulent cataract respectively. mutation of the βB2 gene on 22q is
associated with progressive nuclear cataract and mutations within the
α-crystallin cluster on 17q with nuclear cataract. HSF4, which
regulates transcription of heat-shock proteins, including lens
αB-crystallin. HSF4 mutations are associated with both
autosomal-dominant and recessive cataracts.

26. Locus Inheritance Candidate Genes Cataract Type 1q22-30 AD Connexin

50 Pulverulent 2q33-35 AD γ-crystallin cluster Pulverulent, nuclear
13q11-12 AD Connexin 46 Nuclear pulverulent 17q AD α-crystallin cluster
Lamellar, zonular nuclear 22q AD β-crystallin cluster Caerulean,
pulverulent 6p24 AR ? Congenital Xp22.3-21.1 X ? Congenital Gene locations
and candidate genes linked to various types of cataract Genetics of
cataract Richard A. Armstrong BSc, Dphil Cataract Special 2005.

27. Three metabolic pathways and one single problem: cataracts There
are three metabolic pathways which convert glucose in energy (ATP) and
other relevant metabolic molecules. These are: 1. Glycolysis 2. The
Pentose Phosphate Shunt, and 3. The Polyol Route

28. Aging Decrease in Hexokinase Concentration Poor control of

electrolyte balance Drop in ATP level Massive influx of water into the
lens Disorganization of structured proteins in the lens Aggregation and
precipitation of proteins Glycolysis pathway: Cataracts

29. Metabolization of 14% glucose NADPH + H+ synthesis by

glucose-6-phosphate Pentose phosphate shunt pathway:

30. Saturation of Hexokinase at high glucose level in blood(Km = 100μM

Glucose Polyol Pathway Sorbitol Accumulation of sorbitol in lens Hyper
osmotic effect- Polyol pathway: Influx of excess water through aquaporin
channels (Aldose Reductase) (Polyol dehydrogenase has low Km for
sorbitol)

31. Polyol pathway:

32. Tests and diagnosis for cataract: • Visual acuity test: • Slit lamp
examination • Retinal examination
nlm.nih.gov/medlineplusnlm.nih.gov/medlineplus Home remedies: Use
magnifying glass to read Use better lamps Wear
sunglasses/broad-brimmed hat to reduce glare Limit your night driving

33. Treatment for cataract: • Only effective treatment is surgery.

Procedure: It involves removing the clouded lens and replacing it with
a clear artificial lens. Artificial lens= intraocular lens Positioned
in same place of natural lens and it becomes a permanent part of eye.

34. Chromosome/Genes/Loci Cataract Type Chromosome 19q13 Autosomal

Recessive Congenital Nuclear Cataracts Exon 11 of HSF4 Autosomal
Recessive Cataract Chromosome 7q21.11-q31.1 Autosomal Recessive
Congenital Cataract FYCO1 Autosomal Recessive cataract EPHA2 Autosomal
Recessive Congenital Cataracts LCA5 Cataracts Chromosome 2p12 Autosomal
Dominant Nuclear Cataract βB3-Crystallin Autosomal Recessive Cataract
Prevalence of Cataract In Pakistan: Genetics of cataract Richard A.
Armstrong BSc, Dphil Cataract Special 2005.

35. http://mmhpk.org/publications.html Breakdown of Cataract In

Pakistan:

36. References: Suddarth and Bruner text book Medical Surgical Nursing
(Edi: 12th, 2010) published by Wolter Kluwer health І Lipponcott Williams
& wilkins South Asia Advisory Penal
http://www.world-federation.org/Health/Aeinullah+Eye+Clinics/Mianwali
+-
+Pakistan/Articles/115_Patients_screened_39_cataract_surgeries_perfor
med_Aeinullah_Eye_Clinic_P akistan_month_March_2013.htm Dineen B,
Bourne RR, Jadoon Z,Shah SP, Khan MA, Foster A, et al, Causes of Blindness
and visual impairment in Pakistan: the Pakistan national blindness and
visual impairment survey. Br J Ophthalmology 2007; 91:1005-10. Genetics
of cataract Richard A. Armstrong BSc, Dphil Cataract Special 2005. Klopp
N, Heon E, Billingsley G, et al. Further genetic heterogeneity for
autosomal dominant human sutural cataracts. Ophthalmic Res. 2003;35:71–
77. Kaul H, Riazuddin SA, Yasmeen A, et al. A new locus for autosomal
recessive congenital cataract identified in a Pakistani family. Mol
Vis.2010;16:240–245. Valleix S, Niel F, Nedelec B, et al. Homozygous
nonsense mutation in the FOXE3 gene as a cause of congenital primary
aphakia in humans.Am J Hum Genet.2006;79:358–364.

etiology Acquired Congenital Age- related (90%) Metabolic disease: DM

Traumatic Toxin: steroid, chlorpromazine Secondary to ocular disease:
uveitis, acute angle glaucoma. Genetic and metabolic disease: down’s
syndrome, galactosemia. Intrauterine infection: rubella. Ocular
anomalies: aniridia. Hereditary . ?? Smoking, alcohol, and exposure to
UV radiation as factor causing cataract progression, especially nuclear
sclerosing cataract

5. Pathophysiology • Changes in the lens proteins. • Chemical modification

of these lens proteins leads to the change in lens colour. affect how the
lens refracts light and reduce its clarity, therefore decreasing visual
acuity

6. Nuclear sclerotic cataract • New cortical fibres are produced

concentrically and lead to thickening and hardening of the lens. • appears
yellow. • can increase the focusing power of the natural lens (myopia,
second sight). Patient may read without previously needed reading glasses

7. Cortical cataracts • Defragment of electrolyte and water balance. •

most often seen as whitish spokes peripherally in the lens, separated by
fluid.

8. Posterior sub-capsular cataracts • due to the migration and enlargement

of lens epithelial cells (Wedl cells) posteriorly. • DM is a major factor
in the formation of this type of cataract.
9. Diabetic cataract • Osmotic stress due to sorbitol accumulation has
been linked with sudden worsening in patients with uncontrolled
hyperglycaemia.

10. Classification By age onset Acquired Congenital Lamellar or zonular

cataracts are the most commonly seen form of congenital cataracts. Usually
bi-lateral and symmetrical. May be due to transient toxic influences
during lens development, or may be inherited in an autosomal-dominant
pattern By etiology

11. Classification By clinical features Nuclear sclerotic: generally

age-related opacification, primarily involving the nucleus of the lens
Cortical: primarily opacification of the cortex of the lens Posterior
sub-capsular: opacification of the posterior sub-capsular cortex, seen
frequently in drugrelated (e.g., with topical corticosteroids) or
metabolic cataracts Anterior sub-capsular: opacification of the anterior
sub-capsular cortex, frequently seen in blunt traumatic injuries Cerulean:
small bluish opacity seen in the lens cortex (often also referred to as
blue-dot cataracts) Snowflake: grey-white sub-capsular opacities that
can be seen in cataracts in uncontrolled diabetes mellitus Sunflower:
yellow or brown pigmentation of the lens capsule in a petal-shaped
distribution, seen in patients with an intra-ocular copper-containing
foreign body or Wilson's disease Christmas tree: polychromatic iridescent
crystals, seen in the lens cortex of patients with myotonic dystrophy Oil
droplet: on retro-illumination, seen in patients with galactosaemia. An
accumulation of galactose and galactitol in lens cells causes an increase
in osmotic pressure due to fluid influx.

12. Classification By stage Immature Partially opaque mature whole lens

is opaque and no clear cortex is visible with a slit lamp. The mature
cataract appears white, No iris shadow is seen on oblique illumination
Hypermature, (Morgagnian ) Rare. the cortex may liquefy and the nucleus
becomes free-floating within the capsule. If the liquefied cortex leaks
through the intact capsule, wrinkling of the lens capsule may be seen and
phacolytic glaucoma may develop

13. Prevention Primary prevention •UV protection (UV filtration in

spectacles and sunglasses) or antioxidants may slow the progression. (??)
•no established way to prevent cataract formation. Brimmed hats and
UVB-blocking sunglasses are reasonable precautions to recommend.

14. Secondary prevention many implanted intra-ocular lenses have UV

chromophores in them, certain models have fewer than others. This may mean
that UV filters could be placed in postoperative glasses to help protect
the retina from continued exposure

15. Diagnosis History: C/O: blurring or cloudy of vision. glary vision

especially when driving at night. inadequate glasses prescription.
(nuclear sclerosis) Gradual over years ( problem reading words from TV)
Relatively sudden (DM) ☟ in color richness (blue) Risk of cataract
formation?. Trauma? Ocular disease? Systemic Disease? Medication? .
Intraoperative Floppy Iris Syndrome (alpha 1 blocker)

16. Physical exam Complete ocular examination: •VA, pupillary examination,

IOP •A dilated slit-lamp examination using both direct and
retroillumination techniques •Refraction Fundus examination Glare stress
test

17. Examination Nuclear sclerosis: Yallow to brown discoloration of

center. Cortical: Radial or spoke opacity. Posterior subcapsular

18. DDx

19. Treatment • effective and safe. • Surgical Indication: Functional

imairment To aid management of other ocular exam surgical therapy
for ocular disease (e.g., lens-related glaucoma or uveitis) Congenital
or traumatic cataract. trial of mydriasis (e.g., scopolamine 0.25% q.d.)
may be used successfully in some patients if the patient desires
nonsurgical treatment. The benefits of this therapy are only temporary.

20. Rx • preoperative treatments—e.g., topical antibiotics for

blepharitis, or atropine for poor dilation. • Type of surgery: • ICCE •
ECCE • Phaco

21. On day of surgery • • • • • • • • Consent. Ensure mydriasis. Topical

antibiotic. ? Any ophthalmic problem , or infection. Mark side of
operation. Confirm type of IOL and power. Positioning for operation.
Scraping and draping.

22. Biometry/IOL selection • • • • Usually aiming for emmetropia. Check

power as discussed with the patient. check the keratometry and axial
length Use appropriate formula • ?Refractive surgery before.

23. Follow up/ post-op • 1 day, 1 week, 1 month: postoperative complication,

spectacle change. What to examine? prognosis: excellent if not
complicated by other ocular disease. Patient education. When to come back,
eye shield. Will need reading glasses.

24. Complication • Intra-op • Early post-op • Late post-op

25. Complication • During surgery, the patient starts to cough. What
complications can result from this? • Shallow chamber, iris prolapse,
choroidal effusion / hemorrhage.

Other types of cataracts <ul><li>Secondary (can form after surgery, or

with other health problems) </li></ul><ul><li>Traumatic (develop after
injury) </li></ul><ul><li>Congenital (can occur at birth)
</li></ul><ul><li>Radiation cataract (after exposure to radiation)
</li></ul>

5. How does it look with cataracts?

6. What causes cataracts? http://www.nei.nih.gov/ <ul><li>Lens: Works

like camera lens. Focuses light on retina, where image recorded. Also
adjusts focus, letting us see close and far. Lens made up of protein and
water. </li></ul><ul><li>With aging, protein may clump together and start
to cloud. </li></ul><ul><li>Researchers believe smoking/diabetes MAY
contribute, or it can be wear and tear. </li></ul>

7. How it affects vision? <ul><li>Clumps of protein reduce sharpness of

image </li></ul><ul><li>Clear lens may change to yellowish/brownish
color </li></ul>

8. Who is at risk for cataracts? <ul><li>Diseases such as diabetes

</li></ul><ul><li>Previous eye injury or surgery
</li></ul><ul><li>Prolonged use of corticosteriods
</li></ul><ul><li>Behavior such as smoking & alcohol
</li></ul><ul><li>Environment such as prolonged exposure to sun
</li></ul>

9. How can I protect my eyes? <ul><li>Wear sunglasses and a brimmed hat

</li></ul><ul><li>Stop smoking </li></ul><ul><li>Nutrition (eat green
leafy vegetables, fruit, etc.) </li></ul><ul><li>Comprehensive dilated
eye exam at least once/every 2 years. </li></ul><ul><li>Early treatment
may save your sight. </li></ul>

10. Symptoms & Detection <ul><li>Cloudy, blurred vision

</li></ul><ul><li>Faded colors </li></ul><ul><li>Glare from
headlights/lamps </li></ul><ul><li>Poor night vision
</li></ul><ul><li>Double vision </li></ul><ul><li>Frequent
prescription changes </li></ul>
11. How is it detected? <ul><li>Visual acuity test (Eye test for distances)
</li></ul><ul><li>Dilated eye exam </li></ul><ul><li>Tonometry
(instrument to measure pressure in eye) </li></ul>

12. How is it treated? <ul><li>Can be improved with new eyeglasses,

brighter lighting, anti glare sunglasses or magnifying glasses
</li></ul><ul><li>Surgery (remove cloudy lens and replace with
artificial lens) </li></ul><ul><li>Cataract surgery will include only
one eye at a time, is one of the safest and most effective types of surgery.
</li></ul>

13. What research is being done? <ul><li>Effect of sunlight exposure (may

be related) </li></ul><ul><li>Vitamin supplements which may slow
progression </li></ul><ul><li>Genetic studies, to better understand
cataract development </li></ul>

14. Interactive eye <ul><li>Click on link below for an interactive look

at the eye </li></ul><ul><li>http://www.nei.nih.gov/health/eyediagram/
</li></ul>

15. More information <ul><li>Tutorial on cataracts from Medline Plus:

</li></ul><ul><li>http://www.nlm.nih.gov/medlineplus/tutorials/catara
cts/htm/_yes_50_no_0.htm </li></ul>

What is a Cataract? <ul><li>An ocular opacity, partial or complete, of

one or both eyes, on or in the lens or capsule, especially an opacity
impairing vision or causing blindness. </li></ul><ul><li>The subsequent
cloudy appearance of the eye resulted in the origin of the name cataract
</li></ul>Katarak adalah sejenis kerosakan mata yang menyebabkan kanta
mata berselaput dan rabun. Kanta mata menjadi keruh dan cahaya tidak dapat
menembusinya. Keadaan ini menjejaskan penglihatan seseorang dan akan
menjadi buta sekiranya lewat, atau tidak dirawat. Masalah katarak berbeza
dengan Glaukoma yang merupakan sejenis kerosakan mata yang disebabkan
oleh tekanan cecair yang terlalu tinggi di dalam bebola mata.

3. <ul><li>The lens is made mostly of water and protein. The protein is

normally arranged to let light pass through and focus on the retina.
</li></ul><ul><li>Protein clumps together
</li></ul><ul><ul><ul><li>Small areas of lens begin to cloud
</li></ul></ul></ul><ul><ul><ul><li>Light is blocked from reaching the
retina and vision is impaired </li></ul></ul></ul>Cataract Development
<ul><ul><li>An advanced stage cataract would be something like putting
sheets of wax paper over your glasses </li></ul></ul><ul><ul><li>You
would be able to see light and dark and maybe distinguish large objects
and see movement. </li></ul></ul>

4. Cataract Formation <ul><li>1. Early Stages – change prescription

</li></ul><ul><li>2. Late Stages – surgical removal
</li></ul><ul><ul><li>It is 90% effective for age-related cataracts
</li></ul></ul><ul><ul><ul><ul><li>For secondary, traumatic and
congenital cataracts surgery is not always an option
</li></ul></ul></ul></ul><ul><li>Once a cataract begins to develop there
is nothing that can be done to prevent its growth. </li></ul>

5. Types of Cataracts <ul><li>There are four different types of cataracts

</li></ul><ul><ul><li>1. Age-related cataract: Most cataracts are
related to aging </li></ul></ul><ul><ul><li>2. Congenital cataracts:
Some babies are born with cataracts or develop them in childhood , often
in both eyes. These can lead to blindness or may not affect vision at all
</li></ul></ul><ul><ul><li>3. Secondary cataract: Development in people
who have certain other health issues, such as diabetes or things such as
steroid use </li></ul></ul><ul><ul><li>4. Traumatic cataract: cataracts
which develop after an eye injury </li></ul></ul>

6. Golongan berisiko <ul><li>1) Pesakit kencing manis yang gagal mengawal

penyakitnya. </li></ul><ul><ul><li>Kandungan gula dalam darah
menjadikan kanta kurang kenyal dan membentuk katarak.
</li></ul></ul><ul><li>2) Orang dewasa yang berusia 60 tahun keatas.
</li></ul><ul><ul><li>Katarak merupakan suatu proses akibat usia yang
lanjut. </li></ul></ul><ul><li>3) Kanak-kanak dan bayi yang baru lahir
dengan komplikasi </li></ul><ul><ul><li>Katarak boleh berlaku pada bayi
atau kanak-kanak sekiranya si ibu mengidap jangkitan seperti penyakit
Rubella semasa mengandung. </li></ul></ul>

7. What causes a Cataract? <ul><li>This is a somewhat complicated subject

</li></ul><ul><ul><li>Aging of the lens is caused by oxidation (the
formation of free radicals) </li></ul></ul><ul><ul><li>b) Free Radicals :
A molecule which has lost an electron and will do anything to get it back
</li></ul></ul><ul><ul><ul><li>They attack the protein of the lens,
steal a hydrogen and cause oxidative damage. This leads to a snowball
effect </li></ul></ul></ul><ul><ul><ul><li>The protein then clumps
together and the lens begins to cloud, blocking some light from reaching
the retina and clouding vision </li></ul></ul></ul><ul><li>Speed of
oxidation is increased by: </li></ul><ul><ul><ul><li>1. Smoking /Alcohol
use </li></ul></ul></ul><ul><ul><ul><li>2. Diabetes
</li></ul></ul></ul><ul><ul><ul><li>3. Excessive exposure to
ultraviolet sunlight </li></ul></ul></ul>

8. What does a mid-stage cataract look like? The type of cataract you have
will

9. What does a late-stage cataract look like?

10. How an early stage cataract effects vision

11. Symptoms <ul><li>Cloudy, fuzzy, foggy or filmy vision

</li></ul><ul><li>Changes in the way you see colors
</li></ul><ul><li>Problems driving at night because headlights seem too
bright </li></ul><ul><li>Problems with glare from lamps or the sun
</li></ul><ul><li>Frequent changes in your eyeglass prescription
</li></ul><ul><li>Double vision </li></ul><ul><li>Better near vision in
those who are farsighted </li></ul><ul><ul><li>As the lens becomes
cloudier the optics of the eye change this may actually allow people who
once needed glasses to be able to read without them </li></ul></ul>

12. Eye examination <ul><li>Visual acuity test : This eye chart test
measures how well you see at various distances </li></ul><ul><li>Pupil
dilation : the pupil is widened with eye drops to allow your eye doctor
to see more of the lens and retina and look for other eye problems
</li></ul><ul><li>Tonometry : This is a standard test to measure fluid
pressure inside the eye </li></ul>Cataract Detection

13. How are cataracts treated? <ul><li>For early cataracts

</li></ul><ul><ul><li>Vision may be improved by:
</li></ul></ul><ul><ul><ul><li>Using different eyeglasses
</li></ul></ul></ul><ul><ul><ul><li>Magnifying lenses
</li></ul></ul></ul><ul><ul><ul><li>Stronger lighting
</li></ul></ul></ul><ul><ul><li>If these measures do not improve quality
of life, surgery is the only option
</li></ul></ul><ul><ul><ul><ul><li>Involves the removal of the cloudy
lens and replacing it with a substitute lens
</li></ul></ul></ul></ul><ul><ul><li>A cataract needs to be removed only
when vision loss interferes with everyday activities such as driving,
reading or watching TV </li></ul></ul>

14. How is a cataract removed? <ul><li>Phacoemulsification : The most

common method of removal. Phaco involves a small incision on the side of
the cornea. A tiny probe is inserted which emits ultrasound waves that
soften and break up the cloudy center of the lens so it can be removed
with suction </li></ul>
15. Intraocular Lens <ul><li>After the lens is removed a clear, artificial
lens called an Intraocular lens (IOL) is required. The IOL becomes a
permanent part of the eye and must last the rest of the patients life
</li></ul>

16. Benefits of Cataract Surgery <ul><li>Improvements in activities

</li></ul><ul><ul><li>Driving </li></ul></ul><ul><ul><li>Watching TV
</li></ul></ul><ul><ul><li>Reading </li></ul></ul><ul><ul><li>Working
</li></ul></ul><ul><ul><li>Moving around
</li></ul></ul><ul><ul><li>Social activities
</li></ul></ul><ul><ul><li>Hobbies </li></ul></ul><ul><ul><li>Safety
</li></ul></ul><ul><ul><li>Self-confidence
</li></ul></ul><ul><ul><li>Independence </li></ul></ul>

17. BUT….

18. Risks of Cataract Surgery <ul><li>Possible complications:

</li></ul><ul><ul><li>High pressure in the eye
</li></ul></ul><ul><ul><li>Blood collection inside the eye
</li></ul></ul><ul><ul><li>Infection inside the eye
</li></ul></ul><ul><ul><li>Artificial lens damage
</li></ul></ul><ul><ul><li>Drooping eyelids
</li></ul></ul><ul><ul><li>Retinal detachment
</li></ul></ul><ul><ul><li>Severe bleeding inside the eye
</li></ul></ul><ul><ul><li>Swelling or clouding of the cornea
</li></ul></ul><ul><ul><li>Blindness </li></ul></ul><ul><ul><li>LOSS
OF EYE </li></ul></ul>

19. Epidemiology of Cataracts <ul><li>According to the World Health

Organization cataracts are the number one cause of blindness worldwide
</li></ul><ul><ul><li>50 million persons in the world are BLIND from
cataracts </li></ul></ul><ul><ul><ul><li>More then half of people over
65 have cataracts </li></ul></ul></ul><ul><ul><ul><li>60% of people over
the age of 75 have cataracts </li></ul></ul></ul><ul><ul><ul><li>If you
live long enough you are virtually GUARANTEED to develop a cataract
</li></ul></ul></ul>

20. Primary Prevention <ul><li>Intake of dietary antioxidants prevent

cataract formation by blocking the oxidative modification of the lens
</li></ul><ul><ul><ul><ul><li>Vitamins A, C and E
</li></ul></ul></ul></ul>People who had regular daily doses of the
antioxidants Vitamin C and E were 32% less likely to have developed
cataracts
21. VITAMIN A

22. VITAMIN C

23. VITAMIN E

24. What can I do to protect my vision? <ul><li>Wearing sunglasses and

a hat with a brim to block ultraviolet sunlight may help to delay cataract.
</li></ul><ul><li>If you smoke, stop . Researchers also believe good
nutrition can help reduce the risk of age-related cataract.
</li></ul><ul><li>They recommend eat ing green leafy vegetables, fruit,
and other foods with antioxidants </li></ul>

25. <ul><li>If you are age 60 or older, you should have a comprehensive
dilated eye exam at least once every two years. </li></ul><ul><li>In
addition to cataract, your eye care professional can check for signs of
age-related macular degeneration, glaucoma, and other vision disorders.
</li></ul><ul><li>Early treatment for many eye diseases may save your
sight. </li></ul>What can I do to protect my vision? Cont…
AR DISORDERS DISORDERS OF THE EYELID DISORDERS OF THE GLOBE OF THE EYE

REFRACTIVE ERRORS : 14 REFRACTIVE ERRORS HYPEROPIA MYOPIA ASTIGMATISM PRESBYOPIA

HYPEROPIA (FAR SIGHTEDNESS): 15 HYPEROPIA (FAR SIGHTEDNESS ) MECHANISM * object focuses

behind the retina * able to see only far objects ETIOLOGY * genetic link
PowerPoint Presentation: 16 SYMPTOMS AND SIGNS * blurred vision * squinting * eye rubbing *
headaches DIAGNOSIS * Snellen visual acuity test * ophthalmoscope TREATMENT * Convex lens

PowerPoint Presentation: 11/1/2011 17

MYOPIA (NEAR SIGHTEDNESS): 18 MYOPIA (NEAR SIGHTEDNESS) MECHANISM * object focuses in

front of the retina * able to see only close objects ETIOLOGY * genetic link SYMPTOMS AND SIGNS
* blurred vision * squinting * eye rubbing * headaches

PowerPoint Presentation: 19 DIAGNOSIS * Snellen visual acuity test * opthalmoscope TREATMENT

* concave lens * radical keratotomy - shallow incision in the cornea causing it to flatten in
desired area (could have significant complications)

ASTIGMATISM: 20 ASTIGMATISM MECHANISM * Abnormal shaped cornea (egg shape instead of

spherical) * object is partially clear & other blurred ETIOLOGY * genetic link

PowerPoint Presentation: 21

PowerPoint Presentation: 22 SYMPTOMS AND SIGNS * blurred vision * squinting * eye rubbing *
headaches DIAGNOSIS * Snellen visual acuity test * opthalmoscope TREATMENT * artificial
lens transplant * radial keratotomy

PRESBYOPIA: 23 PRESBYOPIA MECHANISM * Rigidity of the lens (old age) * unable to focus
ETIOLOGY * genetic link Old age (< 40 year) SYMPTOMS AND SIGNS * blurred vision * squinting *
eye rubbing * headaches

PowerPoint Presentation: 24 DIAGNOSIS * Snellen visual acuity test * opthalmoscope TREATMENT

* lens transplant

MUSCULAR DISORDERS: 25 MUSCULAR DISORDERS NYSTAGMUS STRABISMUS (CROSS EYED)

NYSTAGMUS: 26 NYSTAGMUS MECHANISM * repetitive involuntary movements of one or both

eyes ETIOLOGY * Congenital * Brain tumors * CV lesions * Ear lesions * Alcohol/drug abuse

PowerPoint Presentation: 27 SYMPTOMS AND SIGNS * Eye Movements *Horizontal, vertical,

circular, or combination * blurred vision DIAGNOSIS * viewing of the eyes - involuntary
movement * complete neurological tests TREATMENT * Treat the underlying condition * Congenital
stays for life
STRABISMUS (CROSS EYED): 28 STRABISMUS (CROSS EYED) MECHANISM* Failure of eyes to look in
the same direction at the same time * Weakness of muscles of one eye (superior oblique, interior
oblique, lateral) ETIOLOGY in childhood : associated with amblyopia (decreased vision in one eye)
(reversible after 7 years of age) in adults: Usually caused by disease: i.e. diabetes, high blood pressure,
brain trauma

PowerPoint Presentation: 29 SYMPTOMS AND SIGNS * TYPES: 1. Esotropia (convergent-cross eye

of one eye) 2. Exotropia (divergent- one eye turns outward) 3. Diplopia (adults strabismus) 4.
Congenital (no strabismus exists)

PowerPoint Presentation: 30 DIAGNOSIS * complete ophthalmic examination * Diagnose underlying

disease TREATMENT * Treat early * Corrective glasses * orthoptic training * surgery to restore eye
muscle balance * treat underlying disorder

DISORDERS OF THE EYE LID : 31 DISORDERS OF THE EYE LID HORDEOLUM (STYE) CHALAZION
(MEIBOMIAN CYST) BLEPHARITIS ENTROPION ECTROPON CONJUNCTIVITIS (PINK EYE)

HORDEOLUM (STYE): 32 HORDEOLUM (STYE) MECHANISM Inflammatory infection of the hair

follicle of the eye lid ETIOLOGY staphylococcal infection usually associated with Blepharitis
SYMPTOMS AND SIGNS occurs on the outside Pain/swelling/redness/pus patient feels something in
the eye

PowerPoint Presentation: 33 DIAGNOSIS * Visual exam * culture if needed TREATMENT * Hot

compress to alleviate pain * Topical or systemic antibiotics

CHALAZION (MEIBOMIAN CYST): 34 CHALAZION (MEIBOMIAN CYST) MECHANISM Collection of fluid

or soft mass cyst ETIOLOGY Blockage of meibomian gland SYMPTOMS AND SIGNS Pea size cyst
painless slow swelling of the inner part of eye lid Could become infected

PowerPoint Presentation: 35 DIAGNOSIS * Visual Examination TREATMENT * small ones usually

disappear spontaneously after a month or two * large ones usually need surgical removal

PowerPoint Presentation: 36

BLEPHARITIS: 37 BLEPHARITIS MECHANISM * Inflammation of the margins of the eye lids ETIOLOGY
* Ulcerative: staphy infection * nonulcerative: allergies, smoke, dust, chemicals, seborrhea, stye,
chalazions SYMPTOMS AND SIGNS * Persistent redness & crusting on eyelids * itching / burning
sensation * feeling something in the eye * Ulcers can cause eye lashes to fall out * Scales can get into
eye causing conjunctivitis
PowerPoint Presentation: 38 DIAGNOSIS * visual examination * Culture (confirm staphy infection)
TREATMENT Salt & water cleansing for 2 weeks If unsuccessful - local antibiotics or sulfonamide

PowerPoint Presentation: 39

ENTROPION: 40 ENTROPION MECHANISM * Inversion of eye lid into eye ETIOLOGY * aging (course
fibrous tissue) SYMPTOMS AND SIGNS * Foreign body sensation * Tearing / itching / redness *
Continuous rubbing causes conjunctivitis or corneal ulcers Decreased visual acuity if not corrected

PowerPoint Presentation: 41 DIAGNOSIS * visual examination TREATMENT * clean up on its own *

if not, minor surgery

PowerPoint Presentation: 42

ECTROPON: 43 ECTROPON MECHANISM * Outurned eye lids ETIOLOGY * elderly (weakness of eye lid
muscles) SYMPTOMS AND SIGNS * dryness of the exposed part of the eye * tears run down the
cheeks * if not treated can cause ulcers and permanent damage to cornea

PowerPoint Presentation: 44 DIAGNOSIS * visual examination TREATMENT * minor surgery if

doesn’t disappear

PowerPoint Presentation: 45

BLEPHAROPTOSIS (PTOSIS): 46 BLEPHAROPTOSIS (PTOSIS) MECHANISM * weakness of eye muscle

that raises eyelid (superior rectus, superior oblique) ETIOLOGY * familial * trauma * diabetes mellitus
* muscular dystrophy * myasthenia gravis * brain tumors

PowerPoint Presentation: 47 SYMPTOMS AND SIGNS * “drooping eye” * Blocks vision

DIAGNOSIS * ophthalmic examination * blood work to rule out underlying disease
TREATMENT * Surgery (strengthen muscles) * eye glasses with raised eyelid support * treat
underlying disease

Conjunctivitis : Conjunctivitis ANATOMY: It is the mucous membrane covering the under surface of
the lids and anterior part of the eyeball up to the cornea. 48

PowerPoint Presentation: Palpebral ; covering the lids—firmly adherent. Forniceal ; covering the
fornices—loose—thrown into folds. Bulbar ; covering the eyeball—loosely attached except at limbus.
Also marginal and limbal parts and plica semilunaris. 49
PowerPoint Presentation: Nerve supply – Sensory: Ophthalmic division of trigeminal Blood supply:
Posterior conjunctival arteries derived from arterial arcade of lids which is formed by palpebral
branches of nasal and lacrimal arteries of the lids. Anterior conjunctival arteries derived from the
anterior ciliary arteries – muscular br. of ophthalmic artery to rectus muscles. Venous drainage;
Palpebral and Ophthalmic veins. 50

Physiology physiology : : Physiology physiology : Smooth surface. Secretes mucin and aqueous
component of tear film. Highly vascular: supplies nutrition to the peripheral cornea. Aqueous veins
drains from anterior chamber maintenance of IOP. Lymphoid tissue helps in combating infections.
Basic secretion—reflex secretion. 51

PowerPoint Presentation: 52

ye Trauma

Eye trauma occurs from accidents and from debris in the air. Not using safety goggles or glasses when
sanding or operating weed trimmers and various types of power equipment accounts for most
incidents of foreign bodies landing in the eyes.
Removal of Foreign Bodies from the Eye

If the foreign body is not deeply embedded in the tissues of the eye, it can easily be removed by
irrigation. Irrigation with clear, lukewarm water or sterile water or saline is used to remove a foreign
body sticking to the cornea. Continuous irrigation can be done with small tubing, and a bottle of
solution or an irrigating syringe or bottle can be used. The nurse must be very careful not to touch the
eye with the tip of the irrigating device. Sometimes a speck of foreign matter on the cornea can be
removed with a moistened, sterile cotton swab. Have the patient tilt the head back. Hold the eyelids
open to prevent blinking.

If a foreign body is sticking out of the eye, no attempt to remove it should be made. Both eyes should
be patched to prevent further eye movement, and the patient should be transported to the
emergency department or to an ophthalmologist. If the patient continues to complain of a sensation
that a foreign body is still in the eye after it appears to have been removed by irrigation, or complains
of continuing pain, refer to a physician immediately, as there may be a corneal abrasion.

The physician will apply a stain to the eye to assess whether the cornea is abraded. If there is an
abrasion, medicated ointment will be prescribed, and the eye will be patched. The patient must be
given instructions on how to instill the ointment (see Box 26-1). A thin line of eye ointment is applied
from the inner canthus to the outer canthus along the lower eyelid inside the conjunctival sac (Figure
27-4). The patient closes the eyelid and moves the eyeball around in the socket to distribute the
ointment. Excess medication is gently wiped away with a tissue, moving from the inner to the outer
canthus. If an eye patch is not applied, the patient is warned that the ointment may blur vision for a
while. A corneal abrasion is painful; a nonsteroidal anti-inflammatory drug may be used for
discomfort.

Chemical burns should be treated by lengthy, continuous irrigation. An IV bag of normal saline is the
preferred solution; otherwise, tap water will do. Place the patient supine with his head turned to the
affected side. With gloves on, direct the stream of fluid to the inner canthus so that the stream flows
across the cornea to the outer canthus, holding the lids apart with your thumb and index finger. At
intervals, stop and have the patient close his eyes to move secretions and particles from the upper
eye to the lower conjunctival sac; then begin again. The patient should be seen by a physician as soon
as possible. All commercial businesses where exposure to chemicals is a possibility must comply with
Occupational Safety and Health Administration (OSHA) standards and have an eyewash station within
the facility as close as possible to the area where chemicals are likely to be used.

Enucleation

If the eye is too damaged by trauma to be salvaged, or is irreparably damaged by disease or tumor,
enucleation (removal of the eye) is performed. An implant is created to maintain the orbital anatomy
while a matching artificial eye is created. The implant is sutured to the muscle structures. When the
artificial eye is placed, the muscle attachments allow for coordinated eye movement.

Postoperatively, observe for signs of complications such as excessive bleeding, swelling, increased
pain, elevated temperature, or displacement of the implant. Losing an eye is a devastating experience
even when there has been a long period of painful blindness preoperatively. Understanding of the
emotional impact and support of the patient are prime nursing responsibilities. The permanent
prosthesis is placed about 6 weeks after the surgery.
Care of an Artificial Eye

The procedure for cleansing and caring for an artificial eye is similar in many ways to the care of
dentures. Both require basic principles of cleanliness, careful handling, and proper storage. An
artificial eye is very expensive and must be handled very carefully.

The artificial eye is cleansed with gentle soap and water, unless the patient, his family, or the
physician directs otherwise. Keep it in a safe place to avoid damage. When the eye is to be reinserted,
it should be cleansed again with soap and water. When inserting or removing the prosthesis, have the
head over a padded surface. The patient’s upper lid is lifted, and the eye is inserted with the notched
end toward the nose. After the prosthesis is placed as far as possible under the upper lid, the lower lid
is depressed, allowing the eye to slip into place.

laucoma

Etiology

The term glaucoma comprises a complex group of disorders that involve many
different pathologic changes and symptoms, but have in common an optic
neuropathy that damages the optic disc, causing atrophy and loss of
peripheral vision. The neuropathy often is caused by increased IOP
(National Eye Institute, 2011). Glaucoma may come on slowly and cause
irreversible visual loss without presenting any other noticeable symptoms,
or it may appear abruptly and produce blindness in a matter of hours.
Glaucoma can be present at birth, or can develop at any age. It can result
from genetic predisposition, trauma, or another disorder of the eye.
Glaucoma frequently is a manifestation of diseases and pathologies in
other body systems. The amount of increased IOP that causes damage differs
from one person’s eye to another. Blindness is preventable if the
disorder is treated early.

YE DISORDERS REFRACTIVE ERRORS MUSCUL

How can you include inquiries about family history or predisposing risk
factors for glaucoma into your patient care?

Pathophysiology

The IOP is determined by the rate of aqueous humor production and the
outflow of the aqueous humor from the eye. Aqueous humor is produced in
the ciliary body and flows out of the eye through the canal of Schlemm
into the venous system (Concept Map 27-1). An imbalance may occur from
overproduction by the ciliary body or by obstruction of outflow. Increased
IOP greater than 22 mm Hg requires thorough evaluation. Increased IOP
restricts the blood flow to the optic nerve and the retina. Ischemia causes
these structures to lose their function gradually. The vision impairment
from damage to the optic nerve or retina is permanent. Glaucoma may be
secondary to eye infection, trauma, eye surgery, or ocular tumor.

CONCEPT MAP 27-1 Pathophysiology of glaucoma.

There are three types of glaucoma: narrow-angle or angle-closure (acute)

glaucoma, open-angle (chronic) glaucoma (Figure 27-6), and associated or
secondary glaucoma. The terms narrow angle (angle closure) and open angle
refer to the angle width between the cornea and the iris. Acute and chronic
refer to either the onset or duration of the problem. These two major types
differ in their clinical signs and symptoms, treatment, and effects on
vision. Associated glaucoma may occur with diabetes mellitus,
hypertension, or extreme myopia, or after retinal detachment.

FIGURE 27-6 Comparison of open-angle (wide, chronic) and narrow-angle

(closed, acute) glaucoma.

Open-Angle Glaucoma

Signs and Symptoms

Open-angle, or chronic, glaucoma, in which there is no angle closure, is

much more insidious and more common, occurring in about 90% of people with
glaucoma. It often is an inherited disorder that causes degenerative
changes in the aqueous humor outflow tracts. It may be caused by a mixture
of factors of overproduction of aqueous humor and anatomical problems
within the eye. It usually is bilateral and can progress to complete
blindness without ever producing an acute attack. Its symptoms are
relatively mild, and many patients are not aware that anything is wrong
until vision has been seriously impaired.

Health Promotion

Danger Signals of Glaucoma

The National Society for the Prevention of Blindness lists the following
symptoms as danger signals of open-angle glaucoma:

• Glasses, even new ones, that do not seem to clarify vision

• Blurred or hazy vision that clears up after a while

• Trouble in getting used to darkened rooms, such as in movie theaters

• Seeing rainbow-colored rings around lights

• Narrowing of vision at the sides of one or both eyes

Encourage a complete eye examination if any of these signs is present.

Diagnosis

People at high risk for glaucoma are:

• Diabetics

• African Americans (at least four times as many African Americans as non–
African Americans have glaucoma-related blindness)

• Individuals with a family history of glaucoma

A commonly used screening technique for early detection of glaucoma is

to measure IOP with an air tonometer. A puff of air is directed at the
cornea, which causes a momentary indentation while a pressure reading is
taken (WebMD, 2010). The test is painless, and nothing but the air touches
the eye. Verification of the diagnosis of glaucoma may require the use
of a more complex instrument called an applanation tonometer (Figure 27-7).
The cornea is flattened and pressure is measured with a slit-lamp
biomicroscope.

Treatment
The initial treatment of choice for chronic (open-angle) glaucoma is
medication rather than surgery. If drugs are not effective, or if they
produce worrisome side effects, surgery is performed.

Drugs prescribed are intended to enhance aqueous humor outflow, decrease

its production, or both (Table 27-1). They do this by constricting the
pupil (miotics) or by inhibiting the formation of aqueous humor. Miotics
cause blurred vision for 1 to 2 hours after use. Adjustment to dark rooms
is difficult because of pupil constriction. Pilocarpine is available in
an eye medication disk that resembles a contact lens. The disk is inserted
into the conjunctival sac in a patient’s lower eyelid, where it can remain
for up to 7 days. The medication is slowly released. Use of the disk does
not prevent the wearing of contact lenses. Diuretics may be prescribed
to reduce the production of aqueous humor fluid. Not all diuretics reduce
IOP, and a substitute should not be used for the specific drug prescribed.

Pharmacologic Management of Eye Disorders

Classification Examples Action/Nursing Implications

Drugs Used for Glaucoma

Miotics Prostaglandin analogs: latanoprost (Xalatan), bimatoprost

(Lumigan), travoprost (Travatan)Unoprostone isopropyl (Rescula)
Increase outflow of aqueous fluid through the ciliary muscle by
relaxation of the muscle.

Cholinergics: pilocarpine HCl (Isopto Carpine), pilocarpine nitrate

(Ocusert Pilo-20, Ocusert Pilo-40), carbachol (Miostat) Constrict the
pupil, promote outflow of aqueous humor, and reduce intraocular pressure.
Reduce visual acuity in dim light; advise patient to avoid driving at night.
Ocusert is placed in conjunctival sac and replaced weekly.

Cholinesterase inhibitors: echothiophate iodide (Phospholine iodide),

demecarium bromide (Humorsol) Produce miosis, increase aqueous humor
outflow, and decrease intraocular pressure. Avoid touching tip of bottle
to eye; moisture may interfere with drug potency.

Beta-adrenergic blockers: timolol maleate (Timoptic), betaxolol

(Betoptic), levobunolol (Betagan), metipranolol (OptiPranolol),
carteolol (Ocupress) Reduce production of aqueous humor, thereby
reducing intraocular pressure. Betoptic reduces intraocular hypertension.
Monitor pulse and blood pressure during initiation of therapy. Blurred
vision decreases with continued use. Use beta blockers cautiously in
patients with a history of asthma.

Carbonic anhydrase inhibitors Acetazolamide (Diamox), dorzolamide

(Trusopt), brinzolamide (Azopt)Interfere with carbonic acid production,
thereby decreasing aqueous humor formation and decreasing intraocular
pressure. Taken orally or as eyedrops (TruSopt). When taken orally, these
drugs have a diuretic action; observe for dehydration and postural
hypotension. Monitor electrolytes. Confusion may occur in the elderly.
Check interaction with other drugs patient is receiving.

Sympathomimetics Epinephrine (Epifrin), dipivefrin (Propine),

apraclonidine (Iopidine) Reduce intraocular pressure by increasing
aqueous outflow. May cause brow headache, headache, eye irritation, and
blurred vision. Used for open-angle glaucoma only. May cause tachycardia
and rise in blood pressure.

Alpha-2 adrenergic agonist Brimonidine tartrate (Alphagan) L Acts

on alpha receptors in the blood vessels, decreasing the production of
aqueous humor. Do not use with soft contact lenses. Contraindicated in
heart disease.

Anti-inflammatories Corticosteroids: Pred Forte, Ocu-Pred,

Ophtho-TateNSAIDs: ketorolac (Acular), flurbiprofen
(Ocufen)Prostaglandin analog: latanoprost (Xalatan) Decrease
inflammation and swelling; reduce miosis. Interact with contact lens
materials.

Drugs Used to Facilitate Diagnosis and Surgery of the Eye

Cycloplegics and mydriatics anticholinergic agents Atropine

(Atropisol), cyclopentolate (Cyclogyl), homatropine (Isopto
Homatropine), scopolamine (Isopto Hyoscine), tropicamide (Mydriacyl)
Dilate the pupils and paralyze the muscles of accommodation, causing
mydriasis and cycloplegia. Mydriasis facilitates observation of the
eye’s interior during an examination. Cycloplegia prevents movement of
the lens during assessment of the eye.

Adrenergic agonist Phenylephrine (Ocu-Phrin) Induces mydriasis by

action on the muscle of the iris. Causes blurred vision. Photophobia may
be eased by using dark glasses.
Staining solution Fluorescein Turns corneal scratches bright green; a
green ring surrounds foreign bodies. Dye will filter through the lacrimal
duct into the nasal secretions.

Topical anesthetics Proparacaine (Alcaine, AK-Taine), tetracaine

(Pontocaine) Anesthetize the eye. Caution patient not to rub the eye
while it is anesthetized. Patch eye when patient leaves the office if
medication is still in effect.

Anti-infective Optic Medications

Antibiotics Gentamicin sulfate (Garamycin ophthalmic), erythromycin

(Ilotycin), polymyxin B sulfate, neomycin sulfate, bacitracin,
sulfonamides (Sodium Sulamyd, Gantrisin), ciprofloxacin (Ciloxan),
chlortetracycline (Aureomycin), ofloxacin (Ocuflox) Used to treat
infection or for prophylaxis. Caution patient to use a clean washcloth
and towel on the face each time to prevent reinfection.

Antifungal Natamycin (Natacyn ophthalmic) To treat Fusarium. Caution as

above.

Antivirals Idoxuridine (IDV, Stoxil, Herplex), trifluridine (Viroptic)

Store in refrigerator. Do not use with boric acid. If no improvement,
discontinue after 1 wk.

Vidarabine (Vira-A ophthalmic) Effective against DNA viruses; used

for keratoconjunctivitis.

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PowerPoint Presentation: 53

CONJUNCTIVITIS (PINK EYE): 54 CONJUNCTIVITIS (PINK EYE) MECHANISM * inflammation of the

conjunctiva. ETIOLOGY * Viral / bacterial * irritants (allergies, chemicals, UV light)

Acute Bacterial Conjunctivitis: Acute Bacterial Conjunctivitis Mucopurulant conjunctivitis Caused by:
Staph epidermidis and Staph aureus –usually. Strep pneumonae, H influensae and Morexella
lucanatae occasionally 55

PowerPoint Presentation: 56 Symptoms: *Acute onset of redness, grittiness, burning and discharge.
*Photophobia may be present (corneal involvement) *Stickiness of the eyelids *Usually bilateral
disease Signs: *Conjunctival hyperaema *Mild papillary reaction *Mucopurulant discharge *Lid
crusting *No lymphadenopathy. *Normal VA

PowerPoint Presentation: Purulant cojunctivitis (Adult gonococcal ) Symptoms: *Hyperacute

condition *Extremely profuse, thick, creamy puss from the eye or eyes 57

PowerPoint Presentation: Signs: *Severe conjunctival chemosis *May be membrane formation

*Periocular edema *Ocular tenderness *Gaze restriction *Lamphadenopathy *Corneal involvement
Treatment Systemic and topical antiboitics 58

VIRAL CONJUNCTIVITIS: VIRAL CONJUNCTIVITIS The leading cause of a red, inflamed eye is viral
infection A number of different viruses can be responsible 59

PowerPoint Presentation: Signs & symptoms: Vary from moderate to severe. Eye redness (hyperemia)
is a common Swollen, red eyelids More tear production in the eyes than usual Make you feel as
though there is something in the eye Creamy white or thick yellow drainage. Sensitivity to light
(photophobia) 60

Allergic Conjunctivitides: Allergic Conjunctivitides Allergy is an altered or exaggerated susceptibility to

various foreign substances or physical agents which are harmless to the great majority of individuals.
It is due to an antigen antibody reaction. Allergens is an agent capable of producing a state or
manifestation of allergy. 61

PowerPoint Presentation: 62 Symptoms: Itching, lacrimation, photophobia, FB sensation, burning.

Signs: Giant papilla, ptosis, hyperemia, mucus, trantas dots, punctate keratopathy, corneal ulcer.

PowerPoint Presentation: 63
PowerPoint Presentation: 64

DIAGNOSIS : 65 DIAGNOSIS Ophthalmic examination Culture discharge Slit lamp examination

TREATMENT Warm compress 3-4 times daily (10-15 min.) If bacterial (antibiotics) If viral- self limiting

Prevention:: Prevention: Highly contagious Spread by direct contact with infected people Proper
washing and disinfecting can help prevent the spread Wash your hands frequently, particularly after
applying medications to the area Avoid touching the eye area Never share towels or hankies Change
bed linen and towels daily if possible Disinfect all surfaces, including worktops, sinks and doorknobs
To reduce pain from conjunctivitis use a cold or warm compress on the eyes 66

Applying Eye Drop Medicine: 67 Applying Eye Drop Medicine STEP ONE: Tilt your head back. Using
your middle finger, gently press the corner of the eye by the side of the nose. STEP TWO: Use your
index finger to pull down the lower lid. Then apply the eye drop medicine. STEP THREE: After applying
the eye drop, let go of your lower lid. Close the eye and keep the middle finger in place for at least
two minutes. If you’re applying more than one type of drop, wait at least 15 minutes for the next
application. Use a facial tissue to wipe away excess drops on eyelids .

Ptregium : Ptregium Definition Of Pterygium: A pterygium is a fleshy growth that invades the cornea.
It is an abnormal process in which the conjunctiva grows into the cornea. Definition Of Pterygium It
is a fibro vascular, triangular and degenerative condition of conjunctiva. 68

PowerPoint Presentation: Types of Pterygium : There are two types: Progressive Pterygium : These
types of pterygium are those which progress day by day. Non Progressive Pterygium : Those which
after limited growth has been occur than stop their generation. 69

PowerPoint Presentation: Etiology: The exact cause is not known. The probable causes are: i.
Commonly occurs in people living in hot & dry climate. ii. Dusty atmosphere. iii. Common in outdoor
workers. iv. Common in males. v. It may occur nasal than temporal side. 70

PowerPoint Presentation: Symptoms: Redness Irritation Dryness Tearing May cause decreased vision
( when it reaches the visual axis of cornea) Sign : Visible triangular fold of conjunctiva. Triangular
shape with the apex, or head, extending onto the cornea. 71

PowerPoint Presentation: Treatment 1. Local: i. Lubricant eye drops. ii. Topical steroids for
inflammation. 2. Surgical: i. Surgical excision when the pterygium progressive towards the cornea . 72

PowerPoint Presentation: Precautions: Use sun glasses. Protect from sunlight Use eye goggles when
working. (laborers, welders) Wash eye with water after work in sunlight. 73
Trachoma:: Trachoma: Trachoma is the world’s leading cause of preventable blindness Trachoma is a
contagious bacterial infection in the eye which causes blindness after multiple reinfections. 74

PowerPoint Presentation: Trachoma is caused by the bacterium Chlamydia trachomatis Chlamydia

trachomatis is spread through direct contact with an infected person. Flies also play a major role in
the spread of the disease. Poor sanitation, dirty water, and lack of hygiene are causes of trachoma. 75

Intervention:: Intervention: S urgery for trichiasis. A ntibiotics . F acial cleanliness to prevent

transmission. E nvironmental change to prevent transmission. 76

DISORDERS OF THE GLOBE OF THE EYE: 77 DISORDERS OF THE GLOBE OF THE EYE KERATITIS CORNEAL
ABRASION OR ULCER SCLERITIS CATARACT GLAUCOMA MACULAR DEGENERATION DIABETIC
RETINOPATHY RETINAL DETACHMENT UVEITIS

Anatomy of cornea:: Anatomy of cornea: 78

PowerPoint Presentation: 79

KERATITIS: 80 KERATITIS MECHANISM * inflammation and ulceration of the cornea ETIOLOGY *

herpes simplex virus (cold sores) * other bacteria & fungi * trauma * dry air or intense light (welding)

PowerPoint Presentation: Bacterial keratitis. Viral keratitis Fungal keratitis 81

PowerPoint Presentation: 82 SYMPTOMS AND SIGNS * pain or numbness of the cornea *

decreased visual acuity * irritation * tearing * photophobia * mild conjunctivitis

PowerPoint Presentation: 83 DIAGNOSIS * examination of cornea using slit lamp * medical history *
previous upper respiratory tract infection TREATMENT * eye patch to protect from photophobia

CORNEAL ABRASION OR ULCER: 84 CORNEAL ABRASION OR ULCER ETIOLOGY * foreign bodies *

trauma (fingernail, contact lenses) SYMPTOMS AND SIGNS * pain / redness & tearing * something
constantly in eye * vision impairment

PowerPoint Presentation: 85 DIAGNOSIS * visual examination * fluorescien (stain) TREATMENT *

remove foreign bodies * eye wear for protection. * eye dressing to reduce movement
SCLERITIS: 86 SCLERITIS MECHANISM * Inflammation of sclera ETIOLOGY * rheumatoid arthritis *
digestive disorders (Crohn’s) SYMPTOMS AND SIGNS * Dull pain * Intense redness * loss of vision
(posterior sclera inflammation) * if untreated can lead to perforation or loss of eye

PowerPoint Presentation: 87 DIAGNOSIS * ophthalmic examination * Blood work to uncover

underlying cause TREATMENT * MILD : eye drops (antibiotics) * SEVERE : immunosupressive drugs *
PERFORATION : surgery

The lens: : The lens: The crystalline lens is the only structure continuously growing throughout the life.
Changeable refractive media. Capsule, epithelium and lens fibers. Congenital anomalies and effect of
systemic diseases. Cataract. 88

Anatomy of lenses:: Anatomy of lenses: Location posterior to iris anterior to vitreous Shape biconvex
Structure lens capsule lens cortex lens nucleus 89

PowerPoint Presentation: 90

PowerPoint Presentation: Equator Anterior capsule Posterior capsule Diameter:9-10mm

Thickness:4-5mm Lens zonule 91

Physiology of lens:: Physiology of lens: No vessel, nerve and transparent. Derive nutrients from the
aqueous humor Significant refractive medium Accommodative function No immediate relation with
adjacent tissues Complex metabolism Simple disorders: transparency and location change 92

CATARACT: 93 CATARACT Definition: * Gradual deterioration of lens. Opacification of the lens

ETIOLOGY Any factors that change the intraocular environment to affect lens metabolism. Such as:
ageing, mechanical, chemical, operation, inflammation, metabolic Malformation Congenital factors

Risk factors:: Risk factors: UV Diarrhea Malnutrition Diabetes Smoking Drinking alcohol 94

PowerPoint Presentation: Mechanism: many factors lens capsular damage osmosis increase, loss of
protective screen,metabolic disorders protein degeneration, cell apoptosis lens opacify cataract 95

PowerPoint Presentation: CLASSIFICATION : by cause : congenital, senile(age-related), complicated,

metabolitic, drug-induced, toxic, traumatic, secondary by age : congenital, acquired by location :
cortical, nuclear, subcapsular by shape : dot-like, coronary, lamellar by degree : immature,
intumescent, mature, hypermature 96
PowerPoint Presentation: 97 SYMPTOMS AND SIGNS * Cloudy / white opaque area of the lens *
reduce visual acuity * Blurring of vision * photosensitivity DIAGNOSIS * Visual examination * pen
light of slit lamp confers the presence of a cataract TREATMENT * Intra-capsular
phacoemulsification (involves breakage of cataract then aspiration) * Extra-capsular
phacoemulsification: (artificial lens replacement)

PowerPoint Presentation: 98

GLAUCOMA: GLAUCOMA What is it? A disease of progressive optic neuropathy with loss of retinal
neurons and their axons (nerve fiber layer) resulting in blindness if left untreated.

GLAUCOMA: GLAUCOMA “Glaucoma describes a group of diseases that kill retinal ganglion cells.”
“High IOP is the strongest known risk factor for glaucoma but it is neither necessary nor sufficient to
induce the neuropathy.”

GLAUCOMA: GLAUCOMA Angle Anatomy

GLAUCOMA: GLAUCOMA How do we measure IOP? Applanation Tonopen Schiotz Air Non-contact

GLAUCOMA: GLAUCOMA Tonometry Applanation Schiotz

Glaucoma: what is happening: Glaucoma: what is happening Either: the drain blocks here Or poor
blood supply here Damages the optic nerve..looks ‘caved in’, called ‘cupped’

PowerPoint Presentation: Characteristic pattern to loss of visual field Rim of optic nerve becomes
thinner as disc caves in and becomes more cupped

Types of glaucoma: Types of glaucoma Congenital Secondary Juvenile Chronic open angle Acute
closed angle Many different types

GLAUCOMA: 107 GLAUCOMA Chronic Open-Angle Glaucoma MECHANISM * Increased intraocular

pressure due to a malfunction in eyes aqueous humor drainage system - can lead to optic nerve
damage ETIOLOGY * trauma * overuse of steriods

PowerPoint Presentation: 108 SYMPTOMS AND SIGNS * Gradual loss of peripheral vision. * If
untreated - eventually complete vision loss DIAGNOSIS * ophthalmic examination * tonometry
(pressure measure) TREATMENT * Medication that helps decrease aqueous humor production or
opens drainage system * laser to open drainage * surgery (bypass)
PowerPoint Presentation: 109 Acute Angle-Closure Glaucoma MECHANISM * complete blockage of
aqueous humor drainage system ETIOLOGY * trauma

PowerPoint Presentation: 110 SYMPTOMS AND SIGNS * Blurred vision * severe eye pain * redness
of the eye * nausea & vomiting * photophobia (sees “halo” around light) * hazy cornea (elevated
pressure) * if untreated --> blindness DIAGNOSIS * goniolens (special lens to view the opening)
TREATMENT * LASER IRIDOTOMY (creation of a hole in the iris between the anterior and posterior
chamber) * medications to reduce pressure

Acute glaucoma: Acute glaucoma Emergency Can be more gradual Red eye Achy, abdominal pain
Misty vision Go from light into dark Small eye, shallow anterior chamber, pupil mid dilated, Iris lens
contact Push the iris forward Eye feels hard

Chronic glaucoma: Chronic glaucoma Painless, common in elderly Don’t notice anything wrong
detected by optometrist Screening vital field, pressure, disc

PowerPoint Presentation: RETINA : light-sensitive layer of tissue sends visual messages through the
optic nerve

Retina :: Retina : 114

Retinal detachment : Retinal detachment Definition: The separation of neurosensory retina (NSR)
from the retinal pigment epithelium (RPE) by subretinal fluid (SRF). 115

PowerPoint Presentation: pulled away from the underlying choroid small areas of the retina torn =>
retinal tears or retinal breaks retinal cells deprived of oxygen if not promptly treated => permanent
vision loss 116

Types of RD: Types of RD Rhegmatogenous RD (RRD) Tractional RD Exudative RD Combined

tractional-rhegmatogenous RD 117

Rhegmatogenous RD (RRD) : Rhegmatogenous RD (RRD) Affect about 1 in 10,000 of the population

each year. Both eyes may eventually involved in about % of cases. Acute PVD (Posterior Vitreous
Detachment): A separation of the cortical vitreous from the internal limiting membrane (ILM) of the
sensory retina posterior to the vitreous base. Myopia: Over 40% of all RDs occur in myopic eyes.
Trauma: Responsible for about 10% of all cases of RD and is most common cause in children. 118

Tractional Retinal detachment : Tractional Retinal detachment 1. PDR ( proliferative diabetic

retinopathy ) 2. ROP ( retinopathy of prematurity ) 3. Penetrating posterior segment trauma 119
Exudative Retinal detachment : Exudative Retinal detachment 1. Choroidal tumor: Melanomas,
metastases 2. Inflammation: Posterior scleritis 120

PowerPoint Presentation: 121

PowerPoint Presentation: SYMPTOMS floaters - bits of debris in field of vision that look like spots,
hairs or strings

PowerPoint Presentation: SYMPTOMS : floaters light flashes shadow or curtain over a portion of visual
field blur in vision

PowerPoint Presentation: C an occur as a result of: t rauma a dvanced diabetes a n inflammatory

disorder, such as sarcoidosis s hrinkage of the jelly-like vitreous that fills the inside of the eye

PowerPoint Presentation: vitreous liquid leaks through retinal tear and accumulates underneath
retina retina can peel away from underlying layer of blood vessels

PowerPoint Presentation: Factors that may increase risk of retinal detachment: aging - more common
in people older than 40 previous retinal detachment in one eye family history of retinal detachment
extreme nearsightedness previous eye surgery previous severe eye injury or trauma

PowerPoint Presentation: TREATMENTS Retinal tears: laser surgery (photocoagulation) freezing

(cryopexy) Retinal detachment: pneumatic retinopexy scleral buckling vitrectomy

PowerPoint Presentation: PHOTOCOAGULATION

PowerPoint Presentation: CRYOPEXY

PowerPoint Presentation: PNEUMATIC RETINOPEXY

PowerPoint Presentation: PNEUMATIC RETINOPEXY

PowerPoint Presentation: SCLERAL BUCKLING

PowerPoint Presentation: VITRECTOMY

PowerPoint Presentation: Nursing care: Asses visual status and functional vision in the unaffected eye
to determine self care needs. Prepare the client for surgery by explaining possible surgical
interventions and technique to alleviate some of the client's anxiety. Discourage straining during
defecation, bending down and hard coughing, sneezing or vomiting to avoid activities that increase
intraocular pressure. Assist with ambulation, as needed, to help the client remain independent.
Approach the clients from the unaffected side to avoid startling him. Provide assistance with activities
of daily living to minimize frustation adn strain. Orient the client to his environment to reduce the risk
of injury. Posoperatively instruct the client to lie on his back or on his unoperated side to reduce
intraocular pressure in the affected area. 135

PowerPoint Presentation: 136

PowerPoint Presentation: Corneal foreign body is foreign material on or in the cornea, usually metal,
glass, or organic material.

PowerPoint Presentation: Symptoms: Foreign body sensation, Tearing, History of

trauma ,photophobia , pain , red eye Signs: Corneal foreign body with or without rust ring, edema of
the lids, conjunctiva, and cornea, foreign body can cause infection and/or tissue necrosis. 138

PowerPoint Presentation: Workup 1.History and document visual acuity. One or two drops of topical
anesthetic may be necessary to control pain. 3.Slit-lamp Examination: If there is no evidence of
perforation, evert the eyelids and inspect for foreign bodies. 4.Dilate the eye and examine the
vitreous and retina 5.Consider a B-scan US, CT of the orbit. 139

PowerPoint Presentation: Treatment 1.Apply topical anesthetic, remove the foreign body with a spud
or forceps at a slit lamp. If multiple superficial foreign bodies, its easier to remove with irrigation.
2.Measure the size of the resultant corneal epithelial defect. 3.Treat as for corneal abrasion. 140

Blindness:: Blindness: DEFINITIONS: blindness : visual acuity of less than 3/60 or its equivalent. low
vision : visual acuity of less than 6/ 18 but ≥ 3/60 or corresponding to visual field loss to less than 20°
in the better eye with best possible correction. avoidable blindness : blindness which could be either
treated or prevented by known cost-effective means. 141

CAUSES OF BLINDNESS:: CAUSES OF BLINDNESS: In Developed Countries : accidents, glaucoma,

diabetes, vascular diseases(hypertension),cataract and degeneration of ocular tissues esp. of the
retina and hereditary conditions. In Developing Countries : cataract-62.6% refractive errors-19.7%
glaucoma-5.8% post. segment disorder-4.7% surgical complication-1.2% 142

PowerPoint Presentation: Causes Of Childhood Blindness : refractive errors, trachoma, conjunctivitis,

xerophthalmia , congenital cataract , retinopathy of prematurity. Causes Of Avoidable Blindness :
cataract, trachoma, childhood blindness, refractive errors, glaucoma, diabetic retinopathy 143
Reheblitation :: Reheblitation : Skills person with blindness or low vision may need Compensatory
skills Visual efficiency skills Literacy and Braille skills Listening skills Orientation and mobility skills
Social interaction skills Independent living skills Recreation and leisure skills Career and transition
skills 144

PowerPoint Presentation: In general, students with blindness and low vision should learn the same
information as general education students although more time and accommodations might be
needed. Counseling to deal with reactions from others Possible teaching of care for prosthetic eye
Adaptations for color or visual discrimination problems Responding to traffic signals, etc. Provide a
copy of teacher’s notes Read aloud Supply audio tapes/CDs of print materials Use hands-on models
and manipulatives 145

PowerPoint Presentation: Assist through touch and sound, more than sight, for those with little or no
functional vision. Use specialized equipment. Provide equal access to the core curriculum. Do not
re-arrange the furniture or leave items in the path. Determine the LRE based on student needs and
strengths, preferences, and related services needs. In general, provide appropriate lighting, tactile
materials, necessary print size, and decrease visual clutter. 146

PowerPoint Presentation: Use programs to magnify computer screens. Scan materials for access.
Provide Braille if the student uses it. Use of a guide dog may be needed. May scan in materials and
use a synthesizer that reads the text to the student Voice recognition software applications 147

PowerPoint Presentation: Request large print materials in advance. Get training on the use of optical
devices and software. Encourage student relationships and interaction. Support emotional and
learning needs. Provide daily cues. Consult with vision specialist regularly. Use tactile materials.
Reduce glare on materials. Speak in normal tones. Tell the student when you are leaving the room.
Maintain high expectations and give regular feedback. 148

BASIC REHABILITATION: BASIC REHABILITATION The activities on the basic rehabilitation are directed
at rehabilitating the person’s social functions with the purpose of optimum accomplishing a
self-dependent life . The following basic rehabilitation activities take place at the NRCB : 149

Training in orientation and mobility this training helps students to move in new conditions - : Training
in orientation and mobility this training helps students to move in new conditions - 150

Visual rehabilitation the better usage of poor sight: Visual rehabilitation the better usage of poor sight
151

Cooking : Cooking 152

Useful skills rehabilitates the previous everyday skills and assists the acquisition of new ones under
the conditions of bad damaged or missing sight: Useful skills rehabilitates the previous everyday skills
and assists the acquisition of new ones under the conditions of bad damaged or missing sight 153

Braille training assists the overcoming of the informational deficit : Braille training assists the
overcoming of the informational deficit 154

Physical education : Physical education 155

Computer training for blind people, operating a computer with synthetic speech or a Braille display
Computer training for visually impaired people, operating a computer with a visual monitor:
Computer training for blind people, operating a computer with synthetic speech or a Braille display
Computer training for visually impaired people, operating a computer with a visual monitor 156

VOCATIONAL TRAINING: VOCATIONAL TRAINING 157