Eye: Cataract- Diagnosis and Management

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Diagnosis
Clinical examination-
  • The Snellen visual acuity test
  • Ophthalmoscopy
  • Direct ophthalmoscope — red reflex is seen
  • Slit lamp biomicroscopic examination are - to establish the degree of cataract formation.

Management
No nonsurgical treatment cures cataracts.
 Non surgical
  • In the early stages of cataract development, glasses, contact lenses, strong bifocals, or magnifying lenses may improve vision.
  • Reducing glare with proper light and appropriate lighting can facilitate reading.
  • Mydriatics - as short-term treatment to dilate the pupil and allow more light to reach the retina, although this increases glare.
  • Lifestyle adjustment (e.g.: driving during daylight)  
  • Reassurance
 Surgical management
Goal:
 Restoration of visual function through a safe and minimally invasive procedure
 Preoperative care
l. Any anticoagulation therapy that the patient is receiving is withheld, if medically appropriate -To reduce the risk for retro bulbar hemorrhage (after retro bulbar injection)
2. Aspirin should be withheld for 5 to 7 days, nonsteroidal anti-inflammatory medications (NSAIDs) for 3 to 5 days, and warfarin (Coumadin) until the prothrombin time of 1.5 is almost reached.
3.Dilating(mydriatic) drops are administered every 10 minutes for four doses at least 1 hour before surgery. Additional dilating drops may be administered in the operating room (immediately before surgery) if the affected eye is not fully dilated. E.g. phenylephrine HCL
4.Antibiotic, corticosteroid, and NSAID drops may be administered prophylactically to prevent postoperative infection and inflammation.
5.Cycloplegic agents, anticholinergic agent that produces paralysis of accommodation by blocking the effect of ACh on the iris muscle
E.g.: Tropicamide, Cyclopentolate HCL
6.Anti anxiety drugs


Surgery
1. Intra-capsular cataract extraction (ICCE)
Entire lens is removed with the capsule intact. Anterior capsule is opened & lens nucleus & cortex are removed leaving the remaining capsular bag intact.
Fine sutures close the incision.
ICCE is infrequently performed today; however, it is indicated when there is a need to remove the entire lens, such as with a subluxated cataract (ie, partially or completely dislocated lens).
2.Extracapsular cataract cxtraction (ECCE)
In ECCE, a portion of the anterior capsule is removed, allowing extraction of the lens nucleus and cortex.
The posterior capsule and zonular support are left intact.
An intact zonular-capsular diaphragm provides the needed safe anchor for the posterior chamber intraocular lens (IOL).
 After the pupil has been dilated,the surgeon makes a small incision on the upper edge of the cornea, a viscoelastic substance (clear gel) is injected into the space between the cornea and the lens. This prevents the space from collapsing and facilitates insertion of the IOL.
ECCE achieves the intactness of smaller incisional wounds (less trauma to the eye) and maintenance of the posterior capsule of the lens, reducing postoperative complications, particularly aphakic retinal detachment and cystoid macular edema.
3.Phacoemulsification
This method of extra capsular surgery uses an ultrasonic device that liquefies the   nucleus and cortex which are then suctioned out through a tube.
The posterior capsule is left intact. Because the incision is even smaller than the standard.
ECCE, the wound heals more rapidly, and there is early stabilization of refractive error and less astigmatism.
4. Lens Replacement
After removal of the crystalline lens, the patient is referred to as aphakic (i.e., without lens).
There are three lens replacement options:
a.Aphakic eyeglasses
b.Contact lenses
c.IOL implants
Aphakic glasses
Effective but heavy
Objects are magnified by 25%, making them appear closer  than they actually are.
Objects are magnified unequally-, creating distortion.
Peripheral vision is also limited, and binocular vision (i.e., ability of both eyes to  focus on one object and fuse-the two images into one ) is impossible if the other eye is phakic (normal).
Contact lenses
Provide patients with almost normal vision, but because contact lenses need to be removed occasionally, the patient also needs a pair of aphakic glasses-
Contact lenses are not advised for patients who have difficulty inserting, removing, and cleaning them.
Frequent handling and improper disinfection increase the risk for infection.
IOL implants
Insertion of IOLs during cataract surgery is the usual approach to lens replacement.


POSTOPERATIVE CARE
  • Topical antibiotic
  • Topical corticosteroid or other anti inflammatory agent   
  • Mild analgesia
  • Eye shield & activity as preferred by patient's surgeon.
  • After recovery from anesthesia, the patient receives verbal and written instruction regarding how to prolect thc eye, administer medications, recognize signs of complications, and obtain emergency care.

POST-OPERATIVE INSTRUCTIONS
Rest
For the first week after surgery, place the eye-shield over the operated eye at night.
Do not perform any strenuous activities, and avoid bending, lifting, or straining.
Sleep on back, or on the side opposite operated eye.
Avoid washing hair for 48 hours to keep water out of the operated eye.   Resume normal diet and medication
Nursing diagnosis
  • Disturbed sensory perception: visual related to lens extraction & replacement & use of eye patch.
  • Self care deficit related to visual deficit
  • Anxiety related to lack of knowledge about the surgical & postoperative experience

POTENTIAL COMPLICATIONS OF CATARACT SURGERY
Immediate Preoperative
 Retrobulbar hemorrhage: can result from retrobulbar infiltration of anesthetic agents if the short ciliary artery is located by the injectia

Intraoperative Complications
Rupture of the posterior capsule
Suprachoroidal (expulsive) hemorrhage: profuse bleeding into the suprachoroidal space

Early Postoperative Complications  
Acute bacterial endophthalmitis: devastating complication that occurs in about 1 in
1000 cases; the most common causative organisms are Staphylococcus epidermitus, S. aureus, Pseudomonas and Proteus species

Late Postoperative Complications
Suture-related problems
Malposition of the IOL
Chronic endophthalmitis
Opacification of the posterior capsule (most common late complication of extracapsular cataract extraction)



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notes.nursium.com: Eye: Cataract- Diagnosis and Management
Eye: Cataract- Diagnosis and Management
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