Cataract Case Study

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is 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. Early in the development of age-related cataract the power of the lens may be increased, causing nearsightedness (myopia), and the gradual yellowing and opacification of the lens may reduce the perception of blue colours. Cataracts typically progress slowly to cause vision loss and are potentially blinding if untreated. The condition usually affects both eyes, but almost always one eye is affected earlier than the other. A  
 
, occurring in the elderly, is characterized by an initial opacity in the lens, subsequent swelling of the lens and final shrinkage with complete loss of transparency. Moreover, with time the cataract cortex liquefies to form a milky white fluid in a     
 
, which can cause severe inflammation if the lens capsule ruptures and leaks. Untreated, the cataract can cause phacomorphic glaucoma. Very advanced cataracts with weak zonules are liable to dislocation anteriorly or posteriorly. Such spontaneous posterior dislocations (akin to the historical surgical procedure ofcouching) in ancient times were regarded as a blessing from the heavens, because some perception of light was restored in the cataractous patients.

The lens lies behind the iris and the pupil (see diagram). It works much like a camera lens. It focuses light onto the retina at the back of the eye, where an image is recorded. The lens also adjusts the eye's focus, letting us see things clearly both up close and far away. The lens is made of mostly water and protein. The proteins are arranged in a precise way that keeps the lens clear and let¶s 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. Over time, the cataract may grow larger and cloud more of the lens, making it harder to see. 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. 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. Even where surgical services are available, low vision associated with cataracts may still be prevalent, as a result of long waits for operations and barriers to surgical uptake, such as cost, lack of information and transportation problems. Researchers suspect that there are several causes of cataract, such as smoking and diabetes. Or, it may be that the protein in the lens just changes from the wear and tear it takes over the years.

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Cloudy or foggy vision



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Blurry or distorted vision



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Changes in color vision


   

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•requent increases in eyeglass or contact lens prescriptions

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coor night vision (especially affected by headlights)

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crogressive loss of vision

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Halos or glare around lights

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Pouble vision

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A white or "milky" spot over the pupil of the eye

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Îoss of contrast

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Îoss of coordination

     

J ôo specific clinical symptoms related to cataract


 

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The Snellen Visual Acuity Test

J Each eye is tested separately, with and w/o glasses. J Îetters and objects are of a size that can be seen by normal eye at the distance of 6 m (20ft) from the chart.

Slit-Lamp Biomicroscopic Examination (Opthalmoscopy) † An instrument equipped with a special lighting systems and a binocular microscope. † Allows visualizing in details the anterior segment of the eye, which includes the eyelids, eyelashes, conjunctiva, sclera, cornea, tear film, anterior chamber, iris, lens and anterior portion of vitreous humor. † crovides magnification and confirms diagnosis of opacity.

J The pt. sits with the chin and forehead resting against equipment supports. J The room is generally darkened, and the pupils are dilated. J If the patient is wearing contact lenses, have him remove them before the test, unless the test is being performed to evaluate the fit of the contact lenses. J When instilling dilating drops, tell the patient that his near vision will be blurred for 40 mins-2 hrs. Advise him to wear dark glasses in bright sunlight until his pupils return to normal diameter. J Pon¶t administer dilating eyedrops to the patient who has angle-closure glaucoma, is hypersensitive to mydriatics, or has an intraocular lens implants. 

Refraction † Pefined as the bending of light rays by the cornea, aqueous humor, lens, and vitreous humor in the eye, refraction enables images to focus in the retina and directly affects visual acuity. † This test is done routinely during a complete eye examination or whenever a patient complains of a change in vision. † It defines the degree of impairment (refractive error) and determines the degree of correction required to improve visual acuity with glasses or contact lenses.

  J Explain to the patient the test is painless and safe and that it takes about 30 mins. J Tell patient he shouldn¶t use any eye drops, including prescription eye drops, at least 24 hours before the test. J Explain that eye drops may be instilled to dilate the pupils and inhibit accommodation by the lens. 

  

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Sclerotic is the outer coating of the eye which is white in colour that protects the interior of the eye and provides the shape to the eye.

 

The front part of sclerotic is transparent to light and is termed as cornea. The light coming from an object enters the eye through cornea

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Iris is just at the back of cornea. This controls the size of the pupil. It acts like a shutter of a photographic camer and allows the regulated amount of light to enter the eye.

 

Eye lens is a double convex lens with the help of which image is formed at retina by refraction of light.

  

The eye lens is held by ciliary muscles. Ciliary muscles help the eye lens to change its focal length.



At the centre of the iris there is a hole through which light falls on the lens, which is called pupil.

   

The space between cornea and eye lens is filled with a transparent fluid called aqueous humour.


   

The space between eye lens and retina is filled with a jelly like transparent fluid called vitreous humour.




Retina serves the purpose of a screen in the eye, wherethe images of the objects are formed. Retina is at the back of the eye lens. Retins is made of light sensitive cells, which are connected to the optical nerve.





Optic nerve carries the information to brain.

  


The region of eye containing the optic nerve is not at all sensitive to light and is called blind spot. If the image of an object is formed in the blind spot, it is not visible.

  


The central part of retina lying on the optic axis of eye is most sensitive to light and is called yellow spot Eye lids are provided to control the amount of light falling on the eye. They also protect the eye from dust particles etc

  

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High risk for injury related to poor vision and reduced extremity-eyes coordination.

After the nursing interventions given,



the patient will be able to:


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† Express understanding of the

³I can¶t see clearly, I sometimes fall and outbalanced´ as verbalized by the client.

factors

involved

in

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possibility of injury;

† Modify


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environment

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† Be free of trauma/injury 

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To prevent injury in home/community setting.

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To promote safe physical environment and individual safety.

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To have further assessment and interventions regarding health conditions.



Monitor environment for potentially unsafe conditions and modify as needed 

indicated to enhance safety;

A white or "milky" spot over the pupil of the eye. 

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clace assistive devices (walker, crane);

  




Ascertain knowledge of safety needs/injury prevention and motivation Instruct SO to:  Maintain client¶s bed/chair in lowest position;

 
 

   


 

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Refer the patient for an eye care specialist.



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Pisturbed Visual Sensory cerception r/t changes in sensory acuity.

After the nursing interventions given,


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the patient will be able to:  



 
 ³I see dots everywhere, especially around lights´ as verbalized by the patient.

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carticipate

in

Maintain

current

field/acuity without




visual further

 


loss. J



A white or "milky" spot over the pupil of the eye.

Recommend measures to assist client to manage visual limitation

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therapeutic

regimen



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Ascertain type/degree of visual loss. Encourage expression of feelings about loss/possibility of loss of vision

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Pemonstrate/have client to administer eye drops using correct procedure

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crepare for surgical intervention as indicated like cataract extraction.

Affects choice and client¶s future expectations Although early interventions can prevent blindness, the client may have already experienced partial or complete blindness. Reduces safety hazards related to changes in visual fields









 
 

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Eyedrop treatment is needed to control IOc and prevent further loss of vision     Removing the lens through surgery improves visual acuity.



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Anxiety related to threat of permanent loss of vision and independence.

After the nursing interventions given,


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the patient will be able to:

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crovide accurate, honest information. Piscuss probability that careful monitoring and treatment can prevent additional visual loss

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Encourage client to acknowledge concerns and express feelings 

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Identify helpful resources/people.

 

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Appear relaxed and report




anxiety

³ôobody wants to be blind!´ as verbalized by the patient.

manageable level; J



is

reduced

to

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Use resources effectively


 

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A white or "milky" spot over the pupil of the eye. Apprehensive 



These factors affect client¶s perception of threat to self potentiating the cycle of anxiety.









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Assess anxiety level, suddenness of symptoms and current knowledge of condition

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Reduces anxiety related to unknown/future expectations and provides factual basis for making informed choices about treatment. crovides opportunity of the client to deal with reality of situation, clarify misconceptions and problem solve concerns crovides reassurance that client is not alone in dealing with problems.



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 There is no medical treatment for cataracts, although use of vitamin C and E and betacarotene is being investigated. Glasses or contact, bifocal, or magnifying lenses may improve vision. Mydriatics can be used short term, but glare is increased. But there are take home medications following a cataract extraction which usually includes an anti-inflammatory drop containing antibiotic and cyclopegic to prevent ciliary spasm. 

 Prugs

Prug

Mechanism of

Classification

Action



   Corticosteroid

  

 Cycloplegic Mydriatics

Betamethasone is a corticosteroid with mainly glucocorticoid activity. It prevents and controls inflammation by controlling the rate of protein synthesis, depressing the migration of polymorphonuclear leukocytes and fibroblasts, and reversing capillary permeability and lysosomal stabilisation.

Side Effects

Nursing Responsibilities

Sodium and fluid retention, potassium and calcium depletion. Muscle wasting, weakness, osteoporosis. GI disturbances and bleeding

By blocking J fast or muscarinic receptors, uneven cyclopentolate heart produces dilatation rate; of the pupil J warmth, (mydriasis) and redness, prevents the eye from or tingly accommodating for feeling near vision under the (cycloplegia). skin; J severe skin rash; J slow or shallow breathing ;

J Assess involved systems periodically J Assess patient for signs of adrenal insufficiency J Monitor intake and output ratios and daily weight J If dose is ordered daily, administer in the morning to coincide with the body¶s normal secretion of cortisol. J use cautiously in patients with history of glaucoma; systemic absorption may cause anticholinergi c effects such as confusion, unusual behavior, flushing and hallucinations

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????       ± Withhold any ± Instruct patient to wear ? Cataract The entire lens is anticoagulants the a protective eye patch Extraction: removed and fine patient is for 24 hours after receiving, if surgery to prevent 1. Intracapsular sutures are used to medically accidental rubbing or 2. Extracapsular close the incision appropriate. poking of the eye. After Aspirin should be 24 hours, eyeglasses  Involves smaller withheld for 5 to 7 should be worn during incisional wounds days, nonsteroidal the day and a metal (fewer traumas to the anti-inflammatory shield worn at night for eye) & maintains the drugs (ôSAIPs) 1 to 4 weeks. posterior capsule of for 3 to 5 days,  the lens, reducing and warfarin ± crovide postoperative post-operative (Coumadin) until discharge teaching complications. the prothrombin concerning eye time of 1.5 is medications, cleansing   almost reached. and protection, activity    Uses an ultrasonic level and restrictions,  device that device that 
  diet, pain control, liquefies the nucleus ± Administer dilating drops positioning, office and cortex which are every 10 minutes appointments, expected then suctioned out for four doses at postoperative course, through a tube. least 1 hour before and symptoms to report   surgery. immediately to the The lens, which  Antibiotic, surgeon. focuses light on the  
 corticosteroid, and  retina, must be ôSAIP drops ± Instruct patient to replaced for the may be restrict bending and patient to see clearly. administered lifting heavy objects. 3 lens replacement prophylactically  options: to prevent ± Caution patient that 1. Aphakic postoperative vision may blur for Eyeglasses infection and several days to weeks. 2. Contact Îenses inflammation.  3. IOÎ implants ± Inform patient that  vision gradually improves as the eye heals; IOÎ implants improve vision faster than glasses or contact lenses.  ± Reinforce that vision correction is usually needed for remaining visual acuity deficit.

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 © Anti-inflammatory drop containing an antibiotic ex: 





   (a corticosteroid) combined with antibiotic  
 

neomycin. © A cycloplegic may also be prescribed to prevent ciliary spasm:     

 twice daily and should be stored in a refrigerator between uses. 



© Modified or structured environment to ensure patient¶s safety


 


because vision may be blurry for several weeks after the surgery. 



© crotective eye patch to avoid accidental rubbing or poking of



 

the eye. © Continuation of prescribed medications. 



© Wearing of eye patch 24 hours after surgery.



© Sunglasses should be worn while outdoors during the day


  

because the eye is sensitive to light. © Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days. © Because cataract surgery increases the risk for retinal detachment, the patient must know to notify the surgeon if new floaters (dots) in vision, flashing lights, decrease in vision, pain or increase in redness occurs.






  

© The patient needs to have a scheduled check up to see the progress of vision or detection of any complications. 



© There are no dietary restrictions. However, the restrictions as




per pre-existing medical problems, if any, are to continue.  © The patient must avoid constipation by taking high fiber diet and plenty of fluids. 







© Spiritual practices according to one¶s faith and religion.

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