Cataract Finals

8/8/2019 Cataract Finals

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CATARACT


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CATARACT

a clouding that develops in the crystalline lens of the eye

or in its envelope, varying in degree from slight to

complete opacity and obstructing the passage of light.

The condition usually affects both the eyes, but almostalways one eye is affected earlier than the other.

derives from the Latin cataracta meaning "waterfall" and

the Greek kataraktes and katarrhaktes, from katarassein

meaning "to dash down" (kata-, "down"; arassein, "to

strike, dash")

In dialect English a cataract is called apearl, as in "pearl

eye" and "pearl-eyed".


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Epidemiology

Age-related cataract is responsible for 48% of world

blindness, which represents about 18 million people,

according to the World Health Organization (WHO).

In many countries surgical services are inadequate,and cataracts remain the leading cause of blindness

The increase in ultraviolet radiation resulting from

depletion of the ozone layeris expected to increasethe incidence of cataracts.


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History

The earliest records are from the Bible as well as earlyHindu records.

Early cataract surgery was developed by the Indian

surgeon, Sushruta (6th century BCE).

The Indian tradition of cataract surgery was performed

with a special tool called the Jabamukhi Salaka, a

curved needle used to loosen the lens and push the

cataract out of the field of vision. The eye would later be

soaked with warm butter and then bandaged.

The Muslim ophthalmologist Ammar ibn Ali ofMosulperformed the first extraction of cataracts through

suction. He invented a hollow metallic syringe

hypodermic needle, which he applied through the

sclerotic and extracted the cataracts using suction.


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Classification

Classified by etiology

Age-related cataract

Cortical Senile Cataract

Immature senile cataract (IMSC):

partially opaque lens, disc view hazy

Mature senile cataract (MSC):

Completely opaque lens, no disc viewHypermature senile cataract (HMSC):

Liquefied cortical matter


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Classification

Congenital cataract

Secondary cataract

Drug-induced cataract (e.g. corticosteroids), DM

Traumatic cataract

Blunt trauma (capsule usually intact) Penetrating trauma (capsular rupture & leakage of

lens materialcalls for an emergency surgery for

extraction of lens and leaked material to minimize

further damage)

Bilateral cataracts in an infant due to

Congenital rubella syndrome


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Causes

AgeLong term exposure to UV light

Cigarette smoking

Heavy alcohol use

Eye injury or inflammation

Congenital defect

DM

Medications


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What does a mid-stage cataractlook like?


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What does a late-stage cataractlook like?


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pathophysiology

The lens is a clear part of the eye that helps to focus

light, or an image, on the retina

The lens is made mostly of water and protein.

The protein is normally arranged to let light pass throughand focus on the retina.

Protein clumps together (aging process= degeneration)

Small areas of lens begin to cloud

Light is blocked from reaching the retina and vision isimpaired

Over time, the cloudy area in the lens may get larger


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Signs and symptoms

Cloudy or blurry vision.

Colors seem faded (Decreased color perception)

Glare. Headlights, lamps, or sunlight may appear too

bright. A halo may appear around lights. Poor night vision.

Double vision or multiple images in one eye. (This

symptom may clear as the cataract gets larger.)

Absence of red reflex Better near vision in those who are farsighted 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


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Cataract Detection/diagnosis

Eye examination

Visual acuity test: This eye chart test

measures how well you see at various distances

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 Tonometry: This is a standard test to measure

fluid pressure inside the eye


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TREATMENT

The symptoms of earlycataract may be improved

with:

new eyeglasses

brighter lighting

anti-glare sunglasses

magnifying lenses


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TREATMENTCONT.

If these measures do not help:

surgery is the onlyeffective treatment.

Surgery involves

removing the cloudy lensand replacing it with an

artificial lens.


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different types of

cataract surgery

Phacoemulsification, or phaco.

extra-capsular (extracapsular

cataract extraction, or ECCE)

intra-capsular (intracapsular cataractextraction, or ICCE).


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1. Phacoemulsification,

orphaco.

A small incision is made on the

side of the cornea, the clear,

dome-shaped surface that covers

the front of the eye. Your doctorinserts a tiny probe into the eye.

This device emits ultrasound

waves that soften and break up

the lens so that it can be removedby suction. Most cataract surgery

today is done by

phacoemulsification, also called

"small incision cataract surgery."


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Extra-capsular (ECCE)

surgery consists ofremoving the lens but

leaving the majority of the

lens capsule intact.Intra-capsular (ICCE) surgery

involves removing the

entire lens of the eye,including the lens capsule,

but it is rarely performed in

modern practice.


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After the natural lens has been

removed, it often is replaced

by an artificial lens, called an

intraocular lens (IOL).

An IOL is a clear, plastic lens

that requires no care andbecomes a permanent part of

your eye. Light is focused

clearly by the IOL onto theretina, improving your vision.

You will not feel or see the

new lens.


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diagnoses

Anxiety

Deficient knowledge (diagnosis

and treatment)

Disturbed sensory perception:Visual

Risk for infection

Risk for injury


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InterventionsPostoperatively, monitor the patient

until he recovers from the effects ofthe anesthetic.

Keep the side rails of the bed up,

monitor vital signs, and assist him with

early ambulation.Apply an eye shield or eye patch

postoperatively as ordered.

Communication enhancement: Visual

deficit; Activity therapy;Cognitive stimulation; Environmental

management; Fall prevention;

Surveillance: Safety


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Nursing Care Plans For

Cataract Home Health:

Caution him to avoid activities that

increase intraocular pressure, such

as straining with coughing, bowelmovements, or lifting

Clients fitted with cataract

eyeglasses need information about

altered spatial perception. The

eyeglasses should be first used

when the patient is seated, until the

patient adjusts to the distortion.


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Instruct the client to look through

the center of the corrective lensesand to turn the head, rather than

only the eyes, when looking to the

side.

Clear vision is possible only

through the center of the lens.

Hand-eye coordination movements

must be practiced with assistanceand relearned because of the

altered spatial perceptions.


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RETINAL DETACHMENTRETINAL DETACHMENT

-- a painless, gradual loss of vision described as a veil,a painless, gradual loss of vision described as a veil,curtain, or cobweb that eliminates a portion of the visualcurtain, or cobweb that eliminates a portion of the visualfield.field.

-- occurs when the layers of the retina separates from theoccurs when the layers of the retina separates from thechoroid, creating achoroid, creating a subretinalsubretinal space where fluidspace where fluidaccumulates.accumulates.

-- a medical emergency where time is of the essence.a medical emergency where time is of the essence.Unless the detached retina is promptly surgicallyUnless the detached retina is promptly surgicallyreattached, it may lead to permanent loss of vision.reattached, it may lead to permanent loss of vision.

CausesCauses -- degenerative changes in the retina or vitreousdegenerative changes in the retina or vitreous -- a tumor e.g.a tumor e.g. retinoblastomasretinoblastomas -- inflammationinflammation -- systemic disease e.g. diabetessystemic disease e.g. diabetes -- high myopiahigh myopia

-- cataract surgerycataract surgery --


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TYPES:TYPES:

PARTIALRETINALDETACHMENTPARTIALRETINALDETACHMENT

-- becomes complete if left untreated

COMPLETERETINALCOMPLETERETINALDETACHMENTDETACHMENT- when detachment is complete,blindness may occur


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Diagnostic testsDiagnostic tests OpthalmoscopyOpthalmoscopy

done by fully dilating the pupil for proper diagnosisdone by fully dilating the pupil for proper diagnosis retina becomes gray and opaque from transparentretina becomes gray and opaque from transparent reveals folds in the retina and a ballooning out of thereveals folds in the retina and a ballooning out of the

areaarea

UltrasonographyUltrasonography performed when lens is opaqueperformed when lens is opaque


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Signs and SymptomsSigns and Symptoms

Flashes of light

Floaters

Increase in blurred vision

Sense of curtain being

drawn

Loss of a portion of the

visual field

IMMEDIATE NURSING CAREIMMEDIATE NURSING CARE

Complete bed rest

Restriction of eye movement to preventfurther detachmentwith eye patches

Speak before approaching

Position t he clients head as prescribed

Protect from injury

No sudden head movements

Minimize eye stress

Prepare for surgical procedure asprescribed


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DIATHERMYDIATHERMY the use of electrode needle & heatthe use of electrode needle & heatthrough the sclera to stimulate anthrough the sclera to stimulate aninflammatory response leading toinflammatory response leading toadhesionsadhesions

LASER THERAPYLASER THERAPY during photocoagulation, a laser beam isduring photocoagulation, a laser beam is

directed through a special contact lens todirected through a special contact lens to

make burns around the retinal tearmake burns around the retinal tearcreating a scar to weld the retina to thecreating a scar to weld the retina to theunderlying tissueunderlying tissue


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Glaucoma


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Glaucomais a disease in which the optic nerve is damaged, leading to

progressive, irreversible loss of vision. It is often, but not

always, associated with increased pressure of the fluid in the

eye

Glaucoma is characterized by high IOP associated with opticdisk cupping and visual field loss

The nerve damage involves loss ofretinal ganglion cells in a

characteristic pattern

has been nicknamed the "silent thief of sight" because the

loss of vision normally occurs gradually over a long period of

time and is often only recognized when the disease is quite

advanced


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Normal outflow through trabecular

meshwork (large arrow) and uveoscleral

routes (small arrow) and related anatomy.


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Glaucoma classified according to

etiology

Primary glaucoma

Open-angle glaucoma

Angle-closure glaucoma

Congenital glaucoma

Secondary glaucoma

Chronic angle-closure

Neovascular glaucoma

Trauma

Open-angle, trabecular

abnormality

Siderosis


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Congenital GlaucomaCongenital GlaucomaCongenital GlaucomaCongenital Glaucoma

Onset: antenatally to 2 years oldOnset: antenatally to 2 years old

SymptomsSymptoms

IrritabilityIrritability

PhotophobiaPhotophobia

EpiphoraEpiphora

Poor visionPoor vision

Signs

Elevated IOPBuphthalmos

Haabs striae

Corneal clouding

Glaucomatous cupping

Field loss


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Buphthalmos and cloudy corneasBuphthalmos and cloudy corneas


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Buphthalmos,

glaucomatous

cupping, and

cloudy corneaOD

Normal OS

Haabs striae


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The major risk factor for most glaucomas and focus of

treatment is increased intraocular pressureIn primary open-angle glaucoma, aqueous outflow by these

pathways is diminished

pathophysiology


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In angle-closure glaucoma, the iris isabnormally positioned so as to block

aqueous outflow through the anterior

chamber (iridocorneal) angle.


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Normal optic disc. Note the

distinct optic disc margins, the

well-demarcated cup, and the

healthy pink color of the

neuroretinal rim.

The cup-to-disc ratio of this optic

nerve is 0.6. Clinical correlationwith the patient's history and

examination is required to

decide if this optic nerve is

abnormal.

Glaucomatous optic nerve cupping.

The cup in this optic nerve is

enlarged to 0.8, and there is typical

thinning of the inferior neuroretinal

rim, forming a "notch."


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Causes - Risk Factors

Ocularhypertension (increased pressure within the

eye)

African descent are three times more likely to develop

primary open angle glaucoma.

Elder people have thinner corneal thickness and often

suffer from hypermetropia

family history of glaucoma

"secondary glaucomas

(steroid-induced glaucoma), DM, hypertension,

ocular trauma (angle recession glaucoma); and

uveitis

genetics


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GLAUCOMAGLAUCOMAGLAUCOMAGLAUCOMA

TonometryTonometry

ApplanationApplanation SchiotzSchiotz


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GoldmannGoldmann applanationapplanation

tonometertonometer


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TonopenTonopen


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Goldmann perimeterGoldmann perimeter Glaucoma visual fieldsGlaucoma visual fields


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THE VISUAL FIELDTHE VISUAL FIELD

Humphrey automated perimetry


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Visual fields in glaucomaVisual fields in glaucomaEarlyEarly

LateLate


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NormalNormal

DISKCUPPINGDISKCUPPING

GlaucomaGlaucoma


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Management

The modern goals of glaucoma

management are to avoid glaucomatous

damage, nerve damage, preserve visual

field and total quality of life for patients

with minimal side effects.


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Medication The possible neuroprotective effects of various topical and systemic medications are

also being investigated.

Prostaglandin analogs like latanoprost (Xalatan), bimatoprost (Lumigan) andtravoprost (Travatan) increase uveoscleral outflow of aqueous humor.

Bimatoprost also increases trabecular outflow

Topical beta-adrenergic receptor antagonists such as timolol, levobunolol

(Betagan), and betaxolol decrease aqueous humor production by the ciliary

body.

Alpha2-adrenergic agonists such as brimonidine (

Alphagan) work by a dualmechanism, decreasing aqueous production and increasing trabecular outflow.

Less-selective sympathomimetics such as epinephrine decrease aqueous humor

production through vasoconstriction of ciliary body blood vessels.

Miotic agents (parasympathomimetics) like pilocarpine work by contraction of the

ciliary muscle, tightening the trabecular meshwork and allowing increased

outflow of the aqueous humour. Ecothiopate is used in chronic glaucoma.

Carbonic anhydrase inhibitors like dorzolamide (Trusopt), brinzolamide (Azopt),

acetazolamide (Diamox) lower secretion of aqueous humor by inhibiting carbonic

anhydrase in the ciliary body.

Physostigmine is also used to treat glaucoma and delayed gastric emptying.


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Surgery

Canaloplasty- an incision is made into the

eye to gain access to Schlemm's canal in

a similar fashion to a viscocanalostomy

Laser surgery

Laser trabeculoplasty

Trabeculectomy

Glaucoma drainage implants

Laser assisted non-penetrating deep

sclerectomy

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