A cataract is a clouding or opacity of the lens that leads to gradual painless blurring of vision

and eventual loss of sight. Worldwide cataract is the primary cause of reduced vision and
blindness.
EPIDEMIOLOGY
Age-related cataract is responsible for 48% of world blindness, which represents about 18 million
people, according to the World Health Organization. In many countries surgical services are
inadequate, and cataracts remain the leading cause of blindness. As populations age, the
number of people with cataracts is growing. Cataracts are also an important cause of low vision
in both developed and developing countries. A person with a normal life span is more likely to
undergo a cataract operation than any other major surgical operation.

CLASSIFICATION OF CATARACT
The most common cataract is the age related or senile type. Senile cataracts usually begin
around the age of 50 yrs & by 80 yrs of age, about 85%of persons have some clouding of the
lens.

They are of 3 types:

1) SUBCAPSULAR
2) NUCLEAR
3) CORTICAL

Cataract Classification
1) Subcapsular: These cataracts may be anterior or posterior.
i) Anterior: Anterior type lies directly under the lens capsule and is associated with fibrous
metaplasia of the anterior epithelium of the lens.
ii) Posterior: Posterior type lies just in front of the posterior capsule and is associated with
posterior migration of the epithelial cells of the lens.
2) Nuclear: This cataract is an exaggeration of the normal ageing change involving the lens
nucleus.
3) Cortical: This cataract is one in which the opacification involves the anterior, posterior, or
equatorial cortex. The opacities frequently assume a radial spoke-like or shield-like
configuration, and eventually the entire cortex becomes opacified.

ETIOLOGY
Cataracts may develop as a result of many other systemic, ocular and congenital disorders.
Systemic Disorders include Diabetes, Tetany, Myotonic Dystrophy, Neurodermatitis,
Galactosemia, Lowe’s syndrome, Werner’s Syndrome and down syndrome.
Intraocular Disorders include iridocyclitis, retinitis, retinal detachment and onchocerciasis.
Congenital Disorders: Infections like German measles, Mumps, Hepatitis, Polio mylitis,
Chicken pox, Infectious mononucleosis during the first trimester of pregnancy may cause
congenital cataract.
Blunt trauma, Lacerations, Foreign bodies, Radiation, exposure to infra-red light and chronic
use of corticosteroids may also result in cataracts.

RISK FACTORS
The cumulative exposure to ultra-violet light over a person’s life span is the single most
important risk factor in cataract development. People who live at high altitudes or who work
in bright sunlight, such as, commercial fishermen, appear to experience cataract formation
earlier in life. Glassblowers and welders who do not wear eye-protection are also at higher risk.

PATHOPHYSIOLOGY
1) Any injury i.e. Etiological factors or risk factors leading to Reduction in oxygen uptake and
initial increase in water content in lens resulting in Dehydration of the lens. So, Sodium and
calcium contents are increased: Potassium, ascorbic acid, and protein contents are decreased.
2) The protein in the lens undergoes numerous age-related changes, including yellowing from
formation of fluorescent compounds and molecular changes.
3) These changes along with the photoabsorption of ultra-violet radiation throughout life
result in cataract formation by a photo-chemical process.
Cataract progress in a predictable pattern. They begin as immature cataracts that are not
completely opaque and some light is transmitted through them, allowing useful vision. Mature
cataracts are completely opaque. Vision is significantly reduced. Hypermature
cataracts are those in which the lens proteins break down into short chain polypeptides that
leak out through the lens capsule. The pieces of protein are engulfed by macrophages, which
may obstruct the trabecular meshwork, causing phacolytic glaucoma.

CLINICAL MANIFESTATIONS
 Blurred vision
 Monocular diplopia (double vision)
 Photophobia (light sensitivity)
 Glare because the opacity of the lens obstructs the reception of light and images by the retina.
 Better vision in low or dim light because pupil is dilated and allows for vision around central
opacity.
 Painless
 Cloudy lens can be observed.
 Halo around lights especially street lights at night.

DIAGNOSTICS
 Physical examination: On physical examination, it can be observed directly.
 Ophthalmoscope examination: A cataract should be suspected when the red reflex seen with
the direct ophthalmoscope is distorted or absent. Although cataracts can usually be easily
identified with the direct ophthalmoscope, an accurate determination of the type and extent
of the lens change requires a slit-lamp examination.

MANAGEMENT
There is no known treatment other than surgery that prevents or reduces cataract formation.

SURGICAL MANAGEMENT
Cataract surgery is painless and is performed on an outpatient basis. Cataracts are usually
removed under local anaesthesia.
Extracapsular Cataract Extraction (ECCE): In this method, only the anterior portion of the
lens capsule plus the capsule contents are removed and intraocular lens (IOL) is placed.
Intracapsular Cataract Extraction (ICCE): Cataracts can also be removed within their
capsule. In this method, a freezing (cryo) probe that adheres to the surface of lens is used to
extract the cataract.
Modern cataract surgery technique has changed significantly over the last 30 years from ICCE
to ECCE with IOL in the late 1970s, to small incision phacoemulsification during the late 1980s,
followed by the adoption of sutureless phacoemulsification with foldable IOL in the 1990s.
Sutureless Phacoemulsification: The cataract is removed by making the small incision in the
cornea. The cataract is broken into microscopic particles using an ultrasonic probe. The use of
high energy sound waves is called phacoemulsification. Then a folded intraocular lens (IOL) is
inserted through the micro-incision, then unfolded and locked into permanent position. The
small incision is self-sealing and usually requires no stitches. It remains tightly closed by the
natural outward pressure within the eye. This type of incision heals fast and provides a much
more comfortable recovery.

Sutureless Phacoemulsification
PREOPERATIVE CARE
Preparation of the eye includes instillation of eyedrops, such as a mydriatic/cycloplegic and a
local anesthetic on the day of surgery. A tranquilizer or mild sedative may also be prescribed. If
topical anesthetic is given, eye should be protected by an eye-pad or glasses.
INTRAOPERATIVE CARE
Most eye surgery is now being performed as ambulatory surgery except when complications are
present preoperatively. Local anesthesia is used for most of the procedures in adults. As the pupil
is widely dilated during surgery, the patient can see only the light but not the surgeon’s actions.
The patient’s head is positioned so as to avoid movement during surgery.
POSTOPERATIVE CARE
The goals of postoperative care are to prevent:
1) Increased intraocular pressure.
2) Stress on the suture line.
3) Hemorrhage into the anterior chamber.
4) Infection.
When intraocular pressure (IOP) is increased, pressure is placed on the suture line and bleeding
may occur. Anterior flexion of the head not only increases IOP but also may cause anterior
synechia (adhesion of the iris to the cornea) because of decreased fluid in the anterior chamber
and inflammation from the trauma of surgery. Thus activities that increase IOP such as straining
and leaning over, are contraindicated after surgery because a sudden increase in pressure places
stress on the suture line. Protection of the eye with eye-shield or glasses prevents injury. Infection
is prevented by the correct use of eyedrops and eye pads, topical antibiotics may be given
prophylactically.
Special instructions regarding activities to avoid, eyedrops to be instilled and symptoms to be
reported are provided to the patient.
Care after cataract removal
1) Leave the eye patch in place.
2) For 24 hours, limit your activity to sitting in a chair, resting in bed, and walking to the
bathroom.
3) Do not rub your eye.
4) You can wear your glasses.
5) Do not lift more than 5 pounds (the weight of a gallon of milk).
6) Do not strain (or bear down).
7) Do not sleep on the operative side of your body.
8) Take your eyedrops.
9) Take acetaminophen (e.g., Tylenol) as needed for pain or itching.
10)Do not take aspirin or drugs containing aspirin.
11)Report any pain that is unrelieved, redness around the eye, nausea and vomiting.
12)Wear an eye shield to protect your eye.
COMPLICATIONS
Postoperative infection, bleeding, macular edema and wound leaks are possible. However, side-
effects after cataract surgery are rare. But the incidence of retinal detachment is higher in the
first 12 months after cataract surgery. Other complications are dropped nucleus , wound
dehiscence, pseudophakic corneal edema, IOL dislocation, and postoperative endophthalmitis.

NURSING CARE PLANS

Treatment of cataract consists of surgical extraction of the cataractous lens opacity and
intraoperative correction of visual deficits. The current trend is to perform the surgery as a same-
day procedure. Nursing care revolves around patient education before and after surgery and
providing safety.

Here are two (2) nursing care plans (NCP) for patients with cataracts:

1. Disturbed Sensory Perception: Visual

2. Risk for Injury

Disturbed Sensory Perception: Visual

Disturbed Sensory Perception: Change in the amount or patterning of incoming stimuli

accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli.

Related to

 Cataracts
 Poor visual acuity
 Changes in the eyes due to aging

Possibly evidenced by

 Visual distortions
 Loss of vision
 Diminished visual acuity
 Photophobia
 Night blindness
 Myopia
 Presbyopia
 Accommodation changes
  Changes in usual response to stimuli
 Presence of cataract

Desired Outcomes

 Patient will regain optimal vision possible and will adapt to permanent visual changes
 Patient will be able to verbalize understanding of visual loss and diseases of eyes.
 Patient will be able to regain vision to the maximum possible extent with surgical
procedure.
 Patient will be able to deal with potential for permanent visual loss.
 Patient will maintain a safe environment with no injury noted.
 Patient will be able to use adaptive devices to compensate for visual loss.
 Patient will be compliant with instructions given, and will be able to notify physician for
emergency symptoms.

Nursing Interventions Rationale

Assess patient’s ability to see and Provides baseline for determination of changes affecting the
perform activities. patient’s visual acuity.

Can monitor progressive visual loss or complications.

Encourage patient to
Decreases in visual acuity can increase confusion in the
see ophthalmologist at least yearly.
elderly patient.

Provide sufficient lighting for patient to

Elderly patients need twice as much light as younger people.
carry out activities.

Provide lighting that avoids glare on Elderly patient’s eyes are more sensitive to glare and
surfaces of walls, reading materials, and cataracts diffuse and glare so that patient has more
so forth. difficulty with vision.

Provide night light for patient’s room Patient’s eyes may require longer accommodation time to
and ensure lighting is adequate for changes in lighting levels. Provision of adequate lighting
patient’s needs. helps to prevent injury.

Prepare patient for cataract surgery as Provides knowledge, and facilitates compliance with
warranted. regimen.

Helps increase the patient’s understanding of visual changes

Instruct patient regarding normal age-
related visual changes, cataracts, and
methods of dealing with visual acuity
changes.
and to make informed choices about options as the patient
ages, the lens becomes denser and has less elasticity thus
accommodation is decreased.
Presbyopia is an age related change that begins in people
who are in their 40s and progresses. Visual acuity changes
 occur as the eye becomes more hyperopic as a result of
neurologic changes in the visual pathways of the brain. The
ability to distinguish fine details decreases because of loss
of neurons in the visual pathways in the brain.

Vitreous humor changes related to aging occur and consist

of haziness, vertical flashing lights, line spots, or clusters of
moving dots. The ability to differentiate colors also decreases
with age because the cones that are responsible for color
vision decline in sensitivity. In patients over 60, the lens may
become yellowed from age, which results in blue objects
appearing gray. Visual field decreases by approximately 1-3
inches per decade after 50.

Provide large print objects and visual Assists patient to see larger print, and promotes sense of
aids for teaching. independence.
If surgery is planned, instruct patient
and/or family regarding procedure,
post-procedure care, and the need for
follow-up with physician.
Instruct about complications and
emergency signs and symptoms Prepares patient for what to expect, facilitate compliance,
and provides instruction about potential problems to
(flashing lights with loss of vision, seeing lessen anxiety.
a “veil” falling over visual field, loss of
vision in a specific portion of the visual
field, etc.) of which to notify physician.
Risk for Injury

Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the
individual’s adaptive and defensive resources, which may compromise health.

May be related to

 Cataracts
 Decreased vision
 Night blindness
 Age

Desired Outcomes

 Patient will be free of injury and will be able to perform activities within parameters of
sensory limitation.
 Patient will be able to be free of injury.
 Patient and/or family will be able to modify environment to ensure patient safety.

Nursing Interventions Rationale

Increases awareness of problem, and

Assess patient for degree of visual impairment. identifies severity to allow for establishment
of a plan of care.

Ensure room environment is safe with adequate lighting

Provides a safe environment to reduce
and furniture moved toward the walls. Remove all rugs,
potential for injury.
and objects that could be potentially hazardous.

Provides for assistance for patient and for

Keep patient’s glasses and call bell within easy reach.
optimal visual acuity.

Instruct patient and/or family regarding need for Reduced visual acuity puts patient at risk
maintain safe environment. for injury.
Instruct patient and/or family regarding safe lighting.
These techniques helps to enhance visual
Patient should wear sunglasses to reduce glare. Advise
discrimination and reduce potential for
family to use contrasting bright colors in household
injury.
furnishings.

After surgery to extract a cataract:

Because the patient will be discharged after

Remind patient to attend checkup the following day he recovers from anesthesia post-op. Warn
after surgery. him to avoid activities that increase
intraocular pressure.

Instruct patient to wear a plastic or metal shield over

the eye with perforations; a shield or glasses should be To protect the eye from accidental injury.
worn for protection during the day.

Teach the patient how to

administer antibiotic ointment or drops; including To prevent infection and inflammation.
steroids.

Instruct patient to watch out for development of

complications, such as sharp pain in the eye This may indicate infection and should be
uncontrolled by analgesics, or clouding in the anterior reported immediately.
chamber.
 A pterygium is an elevated, wedged-shaped bump on the eyeball that starts on
the white of the eye (sclera) and can invade the cornea. If you have more than one of these eye
growths, the plural form of the word is pterygia.

Though it's commonly called "surfer's eye," you don't have to be a surfer or ever see the ocean
to get a pterygium. But being in bright sunlight for long hours — especially when you are on
water, which reflects the sun's harmful UV rays — increases your risk.
Pterygia are benign (non-cancerous) growths, but they can permanently disfigure the eye. They
also can cause discomfort and blurry vision.

Causes

Although ultraviolet radiation from the sun appears to be the primary cause for the
development and growth of pterygia, dust and wind are sometimes implicated too, as is dry
eye disease.
Pterygia usually develop in 30- to 50-year-olds, and these bumps on the eyeball rarely are seen
in children. Having light skin and light eyes may put you at increased risk of getting a pterygium.

If a pterygium becomes inflamed and affects the cornea, excision (pterygium surgery) may be
necessary.
Signs and Symptoms

A pterygium starts as redness and thickening in the corner of the eye – usually the corner
closest to the nose. The growth can extend across the surface of the eye towards the iris (the
coloured part of the eye). Often a person may notice the formation of a pterygium but may
not experience any other symptoms. If other symptoms are experienced, they may include:

 Eye redness and inflammation

 A gritty feeling in the eye
 A feeling that there is a foreign object in the eye
 Dryness of the eye due to reduced tear production
 Blurring of vision if the corneal surface is altered or “warped”
 Obscuring of vision if growth encroaches across the pupil.

Pterygium Treatment

Treatment of surfer's eye depends on the size of the pterygium, whether it is growing and the
symptoms it causes. Regardless of severity, pterygia should be monitored to prevent scarring
that could lead to vision loss.

If a pterygium is small, your eye doctor may prescribe lubricants or a mild steroid eye drop to
reduce swelling and redness. Contact lenses are sometimes used to cover the growth, protecting
it from some of the effects of dryness or potentially from further UV exposure. Topical
cyclosporine also may be prescribed for dry eye.
If pterygium surgery is required, several surgical techniques are available.
Your opthalmologist who performs the procedure will determine the best technique for your
specific needs.

Pterygium excision may be performed either in a room at the doctor's office or in an operating
room. It's important to note that pterygium removal can induce astigmatism, especially in
people who already have astigmatism.

Surgery for pterygium removal usually lasts no longer than 30 minutes, after which you likely
will need to wear an eye patch for protection for a day or two. You should be able to return to
work or normal activities the next day.

Recurrence

Unfortunately, pterygia often return after surgical removal, possibly due to oxidative stress
and/or continued UV exposure.

Exposure to ultraviolet light from the sun is a

suspected cause of pterygia; wrap sunglasses will
protect your eyes from all angles. These Zyon sailing
sunglasses by Rudy Project come with removable
side wings for even more eye protection.
Some studies show recurrence rates up to 40 percent, while others have reported recurrence
rates as low as 5 percent. Some research even shows higher rates of recurrence in those who have
pterygia removed during the summer months, potentially because of their increased exposure
to sunlight.

To prevent regrowth after a pterygium is surgically removed, your eye surgeon may suture or
glue a piece of surface eye tissue onto the affected area. This method, called autologous
 conjunctival autografting, has been shown to safely and effectively reduce the risk of pterygium
recurrence.

A drug that can help limit abnormal tissue growth and scarring during wound healing, such as
mitomycin C, also may be applied topically at the time of surgery and/or afterward to reduce
the risk of pterygium recurrence.

After removal of the pterygium, the doctor will likely prescribe steroid eye drops for several
weeks to decrease swelling and prevent regrowth. In addition to using your drops, it's very
important to protect your eyes from the sun with UV-blocking sunglasses or photochromic
lenses after surgery, since exposure to ultraviolet radiation may be a key factor in pterygium
recurrence.

Prevention
To prevent pterygia forming, or to reduce the risk of a pterygium recurring, the following
measures are recommended:

 Use sunglasses that block out ultra-violet light (close-fitting, wrap around styles are best)
 Wear sunglasses and a hat with a wide brim when outdoors
 Avoid exposure to environmental irritants eg: smoke, dust, wind and chemical pollutants
 Use appropriate eye safety equipment in work environments.

Nursing Management/ Post-Operative Instructions

The pterygium has been removed from the surface of the eye. Generally, a conjunctival
graft is sutured in place. A pad is over the eye and should remain in place until
tomorrow. A contact lens may be in the eye. It is normal to experience significant pain in
the first 24-48 hours. Please take Panadeine Forte if required. The cornea is a very
sensitive area. The pain settles as the cornea heals. Please take your other medications as
usual.

The eye pad is removed the next day. The eye is cleaned with cool boiled water or
saline. Antibiotic drops are used initially, then steroid drops are added as the cornea
heals. The sutures can be scratchy. Please do not rub the eye.

To put in eye drops, wash hands, then, with chin up, look up, pull the lower lid down and
allow a drop to fall inside the lower lid. Close the eye for 30 seconds. Gently dab away
any excess. Wait 5 minutes before using the next drop.

Keep the eye dry and closed in the shower for the first few days. Do not lift heavy things,
garden, play sport, or wet your face swimming for 2-4 weeks. Please wear sunglasses
outside. The post-operative drops will be gradually reduced over 4-8 weeks. It is
recommended to use lubricating drops / gel and sunglasses long term, but particularly in
the first 6 months to reduce the risk of recurrence of the pterygium.

If pain persist or sudden change in your vision, report this to the doctor
immediately.

Nursing Diagnosis:

OPTICAL:
-
Alteration in visual perception as a result of refractive error
-
Knowledge deficit related to treatment of refractive error
-
Altered comfort as a result of refractive error manifested by asthenopia (Eye
strain, also known as asthenopia, is an eye condition that manifests through nonspecific
symptoms such as fatigue, pain in or around the eyes, blurred vision, headache, and
occasional double vision)
MEDICAL CARE:
- Altered comfort related to pain of the eye structure
- Altered tissue integrity of the eye
- Knowledge deficit on the possibility of secondary infection
- Knowledge deficit about the risk of transmission
- Knowledge deficit about treatment
- Altered visual perception
- Anxiety
- Altered body image
- Self-care deficit
- Low self esteem
- Potential for loss of vision and/or vision impairment
 OR Exposure Requirement
(Phacoemulsification & Pterygium
Extraction)

Submitted by: Silao, Nerlyn L.

BSN - IV

Submitted to: Decosto, Michelle N.

TPMC Clinical Instructor