ost Operative Care

General instructions for post operative patients after eye surgery

01. Eye shield: Please use eye shield for protection when you sleep. You may use dark glasses during daytime. Please wash
the eye shield and glasses with soap and water each day and dry the same before use.

02. Washing the face: Cleaning of the operated eye will be as per the instructions given by the doctor/ nurse. The rest of the
face can be mopped with a clean and wet cloth. Avoid splashing water into the operated eye.

03. Shaving: Shaving is permitted. But avoid splashing water after shaving. Instead, clean with a wet cloth.

04. Bathing: You can bathe below neck from the first postoperative day itself. But avoid head bath for a period of 3-4 weeks.

05. Use of facial cosmetics: Avoid cosmetics to the eye such as mascara, eye liners etc for at least 4 weeks.

06. Physical activity: Activities such as walking, talking, TV viewing can be resumed immediately after surgery. However,
Jogging, swimming, gardening, contact sports, etc may have to be avoided until 4-6 weeks after surgery.

07. Driving: Avoid driving till your surgeon gives you permission.

08. Joining back duties: Usually you will be allowed to join your duties by 4-6 weeks after surgery depending upon the
surgery. You may have to check with your doctor regards to the exact date of joining duty.

09. You may resume your sexual life a week or two after the surgery.

10. The following symptoms may be expected after most surgeries: Some amount of redness, watering, foreign body
sensation, and glare are common. The severity varies with the type of surgery. These symptoms will reduce with time and
usually disappear by 4-6 weeks.

11. If you have any worsening of the symptoms and specifically if there is increasing redness, pain or decreased vision please
report as emergency to the Sankara Nethralaya premises at 18, college Road, Nungambakkam.

Emergency Services are Available Round The Clock

12. Procedure for cleaning the eye:

A. The operated eye needs to be cleaned at least twice a day.

B. The attendant performing this task should wash the hands with soap and water and dry them with a clean towel.

C. You may use the disposable tissue supplied at the hospital for this purpose.

D. Cleaning the lower lid is done by asking the patient to look up and wiping all the secretions sticking to the lower lid
margin.

E. Cleaning the upper lid is done by asking the patient to look down and doing similar procedure.

F. Similarly the outer and inner corners of the eye are cleaned.

G. Once the margins and corners are cleaned, the eye drops can be instilled and then the surrounding areas can also
be cleaned.

13. Instillation of the eye drops:

A. The attendant should wash his/ her hands with soap and water.

B. The cap of the eyedropper bottle is opened carefully without contaminating the tip of the nozzle.

C. Pull the lower lid and place the drop between the eyeball and the lid by squeezing the bottle or cap as the case may
be.

D. Wipe away excess medicine that may trickle out.

E. The eyes should be kept closed for a period of 5 minutes after the drop is instilled.
14. Procedure for instilling eye ointment:

A. Washing hands as for instilling drops

B. Lower lid is pulled down

C. The tube containing the ointment is squeezed gently so that a small thread of the ointment falls in the space between
the eyeball and the lid. This should be not more than half a centimeter.

D. By letting the eyelid close, the ointment thread will break.

15. General instructions for instilling medicines in the eye:

A. Always instill drops before ointment.

B. Leave a gap of 5 minutes between two medications.

C. Keep the eye closed for 5 minutes after applying the medication.

D. Once opened the eye drops are discarded after 1 month.

E. Replace the cap of the bottle immediately after use.

F. Make sure that the right drops are being used for the right number of times.

G. If similar medication is advised for both eyes, it is advisable to have separate bottles for the two eyes.

H. Unused eye medication, once opened is discarded and never used for other persons.
16. General instructions:

A. Do not rub the eyes

B. Do not lift heavy weights

C. Do not allow the eye to get injured- the eye shield is meant to protect the eye from physical hurt.

D. Avoid too many visitors for fear of contacting infection- especially avoids visitors with conjunctivitis, cold etc.

E. Do not play with children since there is possibility of getting hurt in the eye.

F. Do not strain at toilet. If needed please take laxative.

G. Avoid use of snuff.

H. Cigarette smoking should be avoided.

I. Alcoholic beverages are best avoided.

J. Avoid using handkerchief to mop the eye. Use sterile tissue only.

K. Climbing steps is allowed

L. There is no specific diet restriction to be complied post eye surgery

M. If gas has been injected into your eyes as part of the treatment process, you should avoid air travel for minimum of
2 months or as instructed by your surgeon.
 N. You should maintain head down/prone position after retinal detachment surgery, if silicon oil or gas bubble has been
placed inside the operated eye.

Nuclear: Nuclear cataracts are the most common type in the aging lens
and involve the central part of the lens.

Cortical: Cortical cataracts involve the outer layer of the lens and are
often associated with childhood cataracts.

Capsular: Capsular cataracts result in clouding of the lens capsule,

which is the bag that surrounds the lens of the eye.

Posterior subcapsular: Posterior subcapsular cataracts result in clouding

of the back part of the lens.

Level of maturity/progression

The level of maturity or progression is also used to classify cataracts.

Within this classification are the following types:

Immature: In an immature cataract, the lens has developed some opacities,

but these are still separated by areas of normal, clear lens.

Mature: Mature cataracts have progressed from immature, so that the

entire lens is completely opaque and cloudy.

Intumescent: In an intumescent cataract, the lens has become swollen and

enlarged due to water being taken into the lens.

Hypermature: Hypermature cataracts result when the lens and capsule

become smaller and wrinkled due to the leakage of fluid out of the lens.

Morgagnian: Morgagnian cataracts are hypermature cataracts in which

the lens’ central portion sinks and becomes liquefied.
 Surgery

Phacoemulsification surgery is now the standard method. This involves a small cut made in the front
part of the eye. Through this hole a fine instrument is used to dissolve the hard lens and the dissolved
lens is suctioned out. This whole process is called phacoemulsfication. A folded, artificial lens implant
is then placed within the empty lens bag and allowed to unfold. Careful washing of the lens is
undertaken in order to remove any left over lens matter. Often stitches are not required as the cut is
so small and is therefore self-healing.

Extracapsular surgery used to be the most widely practiced method of surgery, prior to the
phacoemulsification technique. It involves a larger cut and the entire cloudy lens is removed from the
eye. A non-folding artificial lens is inserted and the cut is closed with stitches. This procedure is
sometimes associated with problems in the wound closure.

Intracapsular surgery is now only used in special situations. It involves removal of the entire lens as
well as the surrounding lens capsule.

Complications of surgery

CataractsAlthough modern techniques make cataract surgery very safe, complications can still occur.
While not common, there are certain risks including:

Infection

Bleeding

Eye perforation

Retinal detachment

Decreased vision post-operatively

Rupture of the posterior capsule

Cystoid macular oedema

Glaucoma

Posterior capsular opacification,

os

1. Apply the eye drops as per the schedule provided by the ophthalmologist. In any case, you
have to strictly adhere to the routine provided by the doctor. Eye drop needs to be applied daily for a
few weeks after the surgery.
2. You may resume light day-to-day activities such as watching TV, reading, writing and
walking. Always keep your physical activities light.
3. Wear your protective eye cover always, even when you are sleeping. And always sleep on
the side that hasn’t been operated on.
4. When taking a shower, keep your eyes closed. Make sure that water or soap doesn’t enter
your eyes.
5. On the day of surgery, as well as the next day after the surgery, it is important that you rest
and relax properly. This promotes healing.
6. After the surgery, the doctor will provide you with a protective shield, and you have to wear
it on your operated eye until the doctor says that your eyes are fit enough to go without the shield.
The doctor will also give you special eye shades in case you have to go out.

Don’ts

1. Never rub your eye or apply anything to your eyes, even water. This will increase the
chance of infection.
2. Immediately after the surgery, avoid bending. This prevents putting extra pressure on your
eye.
3. Never swim or use a hot tub, at least for two weeks after the surgery. Even a small drop of
water makes your eyes vulnerable to infection.
4. Do not drive for 24 hours after cataract surgery.
5. Do not indulge in any strenuous activity, such as strenuous exercise, lifting weights etc. This
should be followed for at least the first week following the surgery. Your eyes need about a month to
fully recover. So it’s safe to avoid strenuous activity during this time.
6. Do not wear any eye makeup until your ophthalmologist allows.
7. Avoid any activity that exposes your eyes to dirt or dust. Patients who stay in dry and dusty
environment should avoid going outdoors. When going out, you must wear a special protective
eyewear provided by the doctor. Dust and sand particles may scratch your eye surface making the
eye prone to infection.
8. Be careful when walking around after surgery. Try not to bump into doors or any other
objects.

Usually, after a cataract surgery, you should be able to perform these activities within a few hours:

 Working on a computer
 Watching TV (not for long hours)
 Showering

In ICCE, the entire lens is removed, most commonly with a

cryoprobe. However, this technique isn’t widely used today. In
ECCE, the patient’s anterior capsule, cortex, and nucleus are
removed, leaving the posterior capsule intact. This is the
primary treatment for congenital and traumatic cataracts.

Eye disorders: In with the implant

Focus topic: Eye disorders

Immediately after removal of the natural lens, many
patients receive an intraocular lens implant. An implant
works especially well for elderly patients who can’t use
eyeglasses or contact lenses (because of arthritis or tremors,
for example).

Eye disorders: Patient preparation

Focus topic: Eye disorders

Tell the patient he’ll need to:

 temporarily wear an eye patch after surgery to

prevent traumatic injury and infection

 get help when getting out of bed

 sleep on the unaffected side to reduce IOP.

Eye disorders: Monitoring and aftercare

Focus topic: Eye disorders

After the patient returns from surgery, follow these

important steps:

 Notify the practitioner if the patient has severe pain.

Also, report increased IOP.

 Because of the change in the patient’s depth perception,

assist him with ambulation and observe other safety
precautions.
  Make sure the patient wears the eye patch for 24
hours, except when instilling eye drops as ordered,
and have him wear an eye shield, especially when
sleeping.

 Instruct the patient to continue wearing the shield at

night or whenever he sleeps for several weeks, as
ordered.

Eye disorders: Home care instructions

Focus topic: Eye disorders

Before discharge, teach the patient:

 how to administer eyedrops or ointments

 to contact the practitioner immediately if sudden eye

pain, red or watery eyes, photophobia, or sudden
vision changes occur
  to avoid activities that raise IOP, including heavy lifting,
straining during defecation, and vigorous coughing
and sneezing

 not to exercise strenuously for 6 to 10 weeks

 to wear dark glasses to relieve glare

 that changes in his vision can present safety hazards if

he wears eyeglasses

 how to use up-and-down head movements to judge

distances to help compensate for loss of depth
perception

 how to insert, remove, and care for contact lenses, if

appropriate, or how to arrange to visit a practitioner
routinely for removal, cleaning, and reinsertion of
extended-wear lenses

 when to remove the eye patch and when to begin using

his eyedrops.

Iridectomy

Performed by laser or standard surgery, an iridectomy

reduces IOP by easing the drainage of aqueous humor. This
procedure makes a hole in the iris, creating an opening
through which the aqueous humor can flow to bypass the
pupil. An iridectomy is commonly performed to treat acute
angle-closure glaucoma.

Eye disorders: Another angle

Focus topic: Eye disorders

Because glaucoma usually affects both eyes eventually,

patients commonly undergo preventive iridectomy on the
unaffected eye. It may also be indicated for a patient with an
anatomically narrow angle between the cornea and iris. An
iridectomy is also used for chronic angle- closure glaucoma,
with excision of tissue for biopsy or treatment, and
sometimes with other eye surgeries, such as cataract removal,
keratoplasty, and glaucoma-filtering procedures.

Eye disorders: Patient preparation

Focus topic: Eye disorders

Make it clear to the patient that an iridectomy doesn’t

restore vision loss caused by glaucoma but that it may
prevent further loss.

Eye disorders: Monitoring and aftercare

Focus topic: Eye disorders

After an iridectomy, take the following steps:

 Watch for hyphema (hemorrhaging into the anterior

chamber of the eye) with sudden, sharp eye pain or
the presence of a small half-moon-shape blood speck
in the anterior chamber when checked with a
flashlight. If either occurs, have the patient rest
 quietly in bed, with his head elevated, and notify the
practitioner.

 Administer a topical corticosteroid to decrease

inflammation and medication to dilate the pupil.

 Administer a stool softener to prevent constipation

and straining during bowel movements, which
increases venous pressure in the head, neck, and eyes.
This increased pressure can led to increased IOP or
strain on the suture line or blood vessels in the
affected area.

Eye disorders: Home care instructions

Focus topic: Eye disorders

Before discharge, teach the patient to:

 report sudden, sharp eye pain immediately, because it

may indicate increased IOP

 refrain from strenuous activity for 3 weeks

 refrain from coughing, sneezing, and vigorous nose

blowing, which raise venous pressure

 move slowly, keep his head raised, and sleep with two
pillows under his head.

Laser surgery

The treatment of choice for many ophthalmic disorders is

laser surgery because it’s relatively painless and especially
useful for elderly patients, who may be poor surgical risks.
Depending on the type of laser, the finely focused,
high-energy beam shines at a specific wavelength and color
to produce various effects. Laser surgery can be used to treat
retinal tears, diabetic retinopathy, macular degeneration,
and glaucoma.

Eye disorders: Patient preparation

Focus topic: Eye disorders

Before the procedure, take these steps:

 Tell the patient he’ll be awake and seated at a slit

lamp–like instrument for the procedure.

 Explain that his chin will be supported and that he’ll

wear a special contact lens that will prevent him from
closing his eye.

 Explain that laser use requires safety precautions,

including eye
protection for everyone in the room.

Eye disorders: Monitoring and aftercare

Focus topic: Eye disorders

After the procedure, the patient may occasionally have eye

pain. Apply ice packs as needed to help decrease the pain.
The patient may be discharged after this office procedure.
Eye disorders: Home care instructions

Focus topic: Eye disorders

Instruct the patient to receive follow-up care as scheduled.

Tell him that ice packs may ease eye discomfort.

Scleral buckling

Used to repair retinal detachment, scleral buckling involves

applying external pressure to the separated retinal layers to
bring the choroid into contact with the retina. Indenting (or
buckling) brings the layers together so that an adhesion can
form. It also prevents vitreous fluid from seeping between the
detached layers of the retina, which could lead to further
detachment and possible blindness.
cataracts

-Visual aids
-Changing eyewear prescription
-Reading glasses
-Magnifiers
-Increased lighting
-No driving at night
-Psychosocial help
-Occupational and lifestyle adjustments

Preop care for cataract surgery

-H and P
-Eye drops (NSAIDS, dilating)
-Antianxiety meds
-Local anesthesia

Dilating drugs for cataract surgery

-Mydriatic drug: alpha agonist to promote pupillary dilation

-Cycloplegic drug: anticholinergic

ntraoperative care for cataract surgery

-Corneoscleral incision
-Cataract extracted and sutured
-Cortex irrigated and aspirated
-Steroid and abx ointment applied with protective shield or patch over eye
-Often new intraocular lens implanted
Postop care cataract surgery
-Outpatient unless complications occur
-Abx and steroid eyedrops
-Limiting activities
-Follow-up visits
-Eye shield at night
Activity avoidance postop cataract surgery
Limit activities that increase IOP:
-Bending
-Stooping
-Coughing
-Lifting
Considerations for postop cataract surgery**
Visual acuity may decrease initially, but usually gets better; may still need glasses
Nursing assessment / management for cataracts
-Visual acuity
-Psychosocial impact of visual disability
-Level of knowledge of disease
-Comfort
-Ability to comply with post op tx
Nursing diagnosis for cataracts
-Self care deficit
-Anxiety r/t lack of knowledge about surgery and postop experience
Post op goals cataract surgery
-Understand and comply with postop therapy
-Maintain level of comfort
-Remain free of infection or complications
Health promotion to avoid cataracts
-Wear sunglasses
-Avoid radiation
-Ensure adequate antioxidants
-Ensure good nutrition and vitamins C and E
-Avoid steroids
-Prevent DM
Acute nursing intervention with cataracts
-Teach about disease process and tx options
-Administer meds
-Inform about patch (depth perception)
-Teach s/s of infection
-Decrease room lighting
Important education about an eye patch (post op)**
No depth perception!! Take consideration to avoid falls and injuries
Why is it important to decrease room lighting in cataract surgery?
Often given dilating drugs that may cause photophobia
How long may it take for visual acuity to return or restore after cataract operation?
1-2 weeks
Is cataract surgery associated with pain?
No, not usually! May need little analgesics. Sometimes slight itchiness
What should the pt do if pain is intense post cataract surgery?
Notify surgeon immediately because it may indicate hemorrhage, infection, or
increased IOP
When should the surgeon be informed?
-Intense pain
-Purulent drainage
-Increased redness
-Decrease in visual acuity for a long time
Ambulatory and home care postop cataract surgery
-Activity restrictions (anything that increases IOP)
-Meds
-Follow ups
-S/S of complications
-Safety
-Perform return demonstrations of self-care activities
-Teach about postop visual acuity
-Modify activities and environment
Home care environment modification postop cataract surgery if significant visual
impairment
-Remove area rugs
-Prepare frozen meals
-Provide audio books for diversion
Outcomes for cataract surgery
-Improved vision
-Self care abilities
-Minimal to no pain
-Optimistic expectations
Gerontologic considerations for cataracts
-More common
-Sensitive to self-esteem
-Promote independence
-Provide support and encouragement
-Address safety issues
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Medical
Nuclear cataracts: These cataracts develop in the middle portion of the
lens, causing a yellowish / brownish discolouration in the centre (a
nucleus). This type can also result in near-sightedness. The denser the
discolouration, the blurrier vision becomes over time, along with
increased difficulty in distinguishing between colours.

Cortical cataracts: These form around the edges of the nucleus (lens),
creating a wedge shape or the development of streaks along the outer lens
cortex. The cataract begins as a whitish tint and slowly progresses with
streaks edging closer to the centre of the nucleus. This then progressively
interferes with the ability of light to pass through the lens centre.

Posterior subcapsular cataracts: This type of cataract affects the back of

the lens and generally forms quicker than a nuclear or cortical cataract
type. The cataract initially forms as a small opaque area at or near the
back of lens of the eye, but normally directly in the path of where light
would normally enter. This type disrupts vision relating to reading ability,
causes halos and glare (especially around lit up areas at night) and may
reduce visual ability in bright light.

Congenital cataracts: A baby is born with cataracts (in one or both eyes)
due to infectious causes, injury or impaired development in the uterus
during pregnancy (intrauterine infection or trauma). A baby may also be
born with a susceptibility for developing cataracts within his or her first
year of life.

Secondary cataracts: These types of cataracts normally occur as a result

of other existing problems such as medical conditions, exposure to toxic
substances, radiation or UV light, as well as long-term use of diuretics or
corticosteroid medications used to treat various health concerns.

Traumatic cataracts: This type refers to cataracts which develop as a

result of penetrative or blunt injury to the eye. The development of
cataracts, however, may not occur directly following injury and can take
a few years to develop.

Radiation cataracts: Radiation based treatments, such as those used for

cancer, may sometimes cause the development of this type of cataracts.
hacoemulsification + IOL Implantation

Anesthesia (topical, local, general)

Incision

Capsulorhexis

Hydrodissection

Phacoemulsification

Irrigation –aspiration

IOL Implantation,

Removal of viscoelastic substance

Hydration of the incisions

56 Complications of Cataract Surgery

MAJOR- EARLY

Endophthalmitis!!

Blurred vision- loss of vision

Severe ocular pain

Photophobia

Periorbital edema

Ciliary injection

Chemosis (conjunctival edema)

Corneal edema
Hypopyon - Collected white material in the anterior chamber

Treatment: URGENT!!

Vitreous tap-biopsy

Systemic antibiotics

Topical antibiotics-fortified

Intravitreal antibiotics

Vitrectomy (pars plana vitrectomy)

57 Complications of Cataract Surgery

MAJOR-LATE

Bullous Keratopathy

IOL Malposition

Cystoid Macular Edema

Retinal Detachment

58 Complications of Cataract Surgery

OTHER - EARLY

OTHER- LATE

Wound gape

Anterior Chamber Hemorrhage

İris Trauma

Zonular Rupture
Posterior Capsular Rupture

Vitreous Loss

Vitreous Hemorrhage

Choroidal Hemorrhage!!

Uveitis

Glaucoma (open angle/closed angle)

Posterior Capsule Opacification

IOL Dislocation
ANATOMY OF THE LENS A biconvex structure attached to the
ciliary process by the zonular fibre, between iris & vitreous humour
Non-vascular, colourless and transparent Index of refraction 1.336
Consists of stiff elongated, prismatic cells known as lens fibre, very
tightly packed together Divided into nucleus, cortex and capsule The
whole lens enclosed within an elastic capsule Helps to refract incoming
light and focus it onto the retina

3. ANATOMY OF THE LENS STRUCTURE OF THE LENS: LENS

CAPSULE ANTERIOR LENS EPITHELIUM LENS FIBER

4. ANATOMY OF THE LENS LENS CAPSULE Thin transparent,

collagen membrane Surrounds lens completely Elastic in nature but
contain no any elastic tissue Anteriorly secreted by lens epithelium and
posteriorly by basal cells of elongating fibers

5. ANATOMY OF THE LENS ANTERIOR LENS EPITHELIUM

Single layer below the lens capsule Formed of cuboidal cells
Become columnar at equatorial region LENS FIBER The epithelial
cells elongated to form lens fibers which have a complicated structural
forms. Mature lens fibers are cells which have lost their nuclei. As
the lens fibers are formed throughout the life, these are arranged
compactly as nucleus & cortex of the lens.

6. ANATOMY OF THE LENS NUCLEUS Its is the central part

containing the oldest fibres. It consists of different zones, which are laid
down successively as the development proceeds. Different zones: I.
Embryonic nucleus II. Fetal nucleus III. Infantile nucleus IV. Adult
nucleus CORTEX Its is the peripheral part which compromises the
youngest lens fibres.

7. LENS TRASPARENCY Its transparency is due to the arrangement

of its fibres, internal structure and the biochemistry of the lens cells and
fibres. A cataractous lens is when the lens become opaque.

CAUSES CONGENITAL AGE METABOLIC Familial

Intrauterine infections Maternal drug ingestions Elderly Diabetes
Hypocalcaemia Wilson’s Disease Galactosemia

12. CAUSES DRUG - INDUCED TRAUMATIC AND

INFLAMMATORY DISEASE ASSOCIATED Corticosteroids
Miotics Amiodarone Phenothiazines Post intra-ocular surgery
Uveitis Down’s Syndrome Dystrophia Myotonica Lowe’s
Syndrome Atopic dermatitis
13. CLASSIFICATION 1. Subcapsular cataract - Anterior subcapsular
cataract - Posterior subcapsular cataract 2. Nuclear cataract - Involves the
nucleus of lens. Yellow to brown coloration 3. Cortical cataract - Wedge
shaped or radial spoke-like opacities. 4. Polar cataract - Central posterior
part of the lens MORPHOLOGICAL CLASSIFICATION

14. CLASSIFICATION MORPHOLOGICAL CLASSIFICATION

15. CLASSIFICATION MORPHOLOGICAL CLASSIFICATION

16. CLASSIFICATION

17. CLASSIFICATION BASED ON DEGREE OF MATURITY

HYPERMATURE MORGAGNIAN Cataract is shrunken and wrinkled
anterior capsule due to leakage of water out of the lens Cataract is a
hypermature cataract in which liquefaction of the cortex has allowed the
nucleus to sink inferiorly MATURE IMMATURE Cataract is one in
which the lens is completely opaque. Cataract is one in which the lens is
partially opaque.

18. IMMATURE CATARACT Features: Opacification becomes more

diffuse and irregular. Iris shadow still visible. Lens is not completely
opaque Wedge shaped opacities at periphery of the lens Progress
gradually

19. IMMATURE CATARACT When there is any clear cortex between

the iris and the opacity (greyish white in immature senile cataract), the
shadow of the iris which falls upon the opacity, as light is cast upon the
eye is visible through the clear cortex. This is called the ‘iris shadow’ and
is a common sign in immature senile catarct. IRIS SHADOW IN
IMMATURE CATARACT

20. IMMATURE CATARACT WHAT IS THE IRIS SHADOW?

Black crescent Due to the presence of clear interval between iris and
lens opacity

21. MATURE CATARACT Symptoms - Usually severe decrease in

vision. Features - Complete opacification of the lens capsule, cortex
and the nucleus - Lens appears pearly white in colour. Also known as
ripe cataract. May progress to hypermature cataract May be
complicated with phacolytic glaucoma.
22. MATURE CATARACT

23. MATURE VS IMMATURE HOW TO DIFFERENTIATE MATURE

AND IMMATURE CATARACT? IMMATURE CATARACT
MATURE CATARACT Visual acuity is reduced to counting fingers
Visual acuity is reduced to hand movement or perception of light Lens
is partially opaque Lens in totally opaque Iris shadow is present
No iris shadow is present Fundus may be visible No fundus details

24. HYPERMATURE CATARACT Which is characterized by

wrinkling of the capsule due to liquefied lens cortex and morgagnian
cataract (sinking of lens nucleus inferiorly within the capsule) This can
cause inflammation, eye pain and headache (if complicated by glaucoma)
A hypermature cataract is rare and needs removal

25. HYPERMATURE CATARACT

26. MORGAGNIAN CATARACT Complete cortex is liquefied and

appears milky white in colour. Nucleus settles at the bottom
Calcium deposits may also be seen on the lens capsule.

27. PATHOPHYSIOLOGY OF CATARACT

28. PATHOPHYSIOLOGY The lens is made mostly of water and

protein fibers. Opacity occur when the lens protein (crystallins) clump
together Ability for lens to refract lights reduce which cause reduce
visual acuity. Chemical modification of the lens cause it to be thicken
and harden

29. PATHOPHYSIOLOGY It is not fully understood. 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 3. The Polyol Route

30. 1. GLYCOLYSIS Aging Decrease in Hexokinase concentration Drop

in ATP level Poor control of electrolyte balance Massive influx of water
into the lens Disorganization of structured proteins in the lens
Aggregation and precipitation of protein CATARACT

31. 2. HMP PATHWAY Metabolization of 14% glucose NADPH + H+

synthesis by glucose-6-phosphate
32. 3. POLYOL PATHWAY High glucose level in blood Polyol Pathway
GlucoseSorbitol Accumulation of sorbitol in lens Hyper osmotic effect -
Influx of excess water through aquaporin channels CATARACT Aldose
Reductase Polyol dehydrogenase has low Km for sorbitol

33. DIABETES & CATARACT POLYOL PATHWAY

34. DIABETES & CATARACT Cells use glucose for energy. This
normally occurs by phosphorylation via the enzyme hexokinase.
However, if large amounts of glucose are present (as in diabetes mellitus),
hexokinase becomes saturated and the excess glucose enters the polyol
pathway when aldose reductase reduces it to sorbitol.

35. DIABETES & CATARACT Hexokinase can return the molecule

to the glycolysis pathway by phosphorylating fructose to form fructose-6-
phosphate. However, in uncontrolled diabetics that have high blood
glucose - more than the glycolysis pathway can handle - the reaction's
mass balance ultimately favors the production of sorbitol.

36. POLYOL PATHWAY The retina cells use glucose for energy as
normal, and any glucose not used for energy will enter the polyol
pathway. When blood glucose is normal, this interchange causes no
problems, as aldose reductase has a low affinity for glucose at normal
concentrations. In a hyperglycemic state, the affinity of aldose
reductase for glucose rises, causing much sorbitol to accumulate. This
change of affinity is what is meant by activation of the polyol pathway.

37. POLYOL PATHWAY When sorbitol collects in the lens, it can

affect cells and naturally-occurring proteins, causing the lens to become
less clear and more opaque. This condition eventually leads to cataract
formation.

38. CLINICAL PRESENTATION Decreased visual acuity is the

commonest complaint. - Progressive and painless - Worse in bright light
There may be complaint of glare and monocular diplopia if the cataract
splits the visual axis A myopic shift in the refraction with progression
of cataract may also be noted Some complain of a white reflex in the
pupil PRESENTING COMPLAINTS AND HISTORY

39. CLINICAL PRESENTATION PAST MEDICAL HISTORY May

reveal risk factors such as - Trauma - Intrauterine infections - Diabetes or
other metabolic disorders Cataract may have occurred in other
members of the family in the hereditary variants. FAMILY HISTORY

40. PE FINDINGS Visual acuity is impaired for both distance and near
and patient may even be blind. Opacity in the lens Ocular adnexia
and intraocular structures when examined may reveal lesions that may
point at - The cause, type and eventual visual prognosis If RAPD
positive, this indicates an optic nerve disease or extensive macular lesions
- Visual prognosis guarded in such cases

41. VISUAL ACUITY Blurred vision due to scattering of light on the

retina

42. VISUAL ACUITY

43. VISUAL ACUITY

44. LENS OPACITY Normal eye – Good red reflex Cataractous eye –
Poor red reflex

45. MANAGEMENT

46. TREATMENT The treatment of cataracts is : 1. Glasses 2. Better

lighting 3. Surgery a. Phacoemulsification b. ECCE c. ICCE (not
performed now) Sometimes a cataract should be removed even if it
doesn't cause major problems with vision, if it is preventing the treatment
of another eye problem, such as age-related macular degeneration,
diabetic retinopathy or retinal detachment

47. TREATMENT The aim of treatment is: 1. Improve vision 2. Increase

mobility and independence 3. Relief from the fear of going blind

48. INDICATIONS 1. Work or lifestyle is affected by vision problems

caused by the cataract. 2. Glare caused by bright lights is a problem. 3.
Cannot pass a vision test 4. Have double vision. 5. Notice a big difference
in vision when you compare one eye to the other. 6. Have another
vision-threatening eye disease, such as diabetic retinopathy or macular
degeneration.

49. SURGERY: ICCE Intracapsular cataract extraction Involves

extraction of the entire lens, including the posterior capsule and zonules
Weak and degenerated zonules are a pre-requisite for this method
This is the surgery of choice if there is markedly subluxated or dislocated
lens This technique of surgery has largely been replaced by ECCE

50. SURGERY: ECCE Extracapsular cataract extraction An 5 mm

to 6 mm incision is made in the eye where the clear front covering of the
eye (cornea) meets the white of the eye (sclera). Another small incision
is made into the front portion of the lens capsule. The lens is removed,
along with any remaining lens material. An IOL may then be placed
inside the lens capsule. And the incision is closed. *it is usually done if
the cataract is too large to be destroyed by ultrasound

51. SURGERY: ECCE

52. COMPLICATIONS 1. Infection in the eye (endophthalmitis). 1.

Swelling and fluid in the center of the nerve layer (cystoid macular
edema). 1. Swelling of the clear covering of the eye (corneal edema). 1.
Bleeding in the front of the eye (hyphema). 1. Detachment of the nerve
layer at the back of the eye (retinal detachment).

53. ICCE VS ECCE ECCE ICCE Small incision 5-6mm Large incision
10-12mm Posterior lens conserved Removal entire lens No stiches
required, self healing Required stiches, long rehabilitation time IOL
implant Aphakic eye Post operative complication minimal Added risk for
retinal detachment, corneal edema and vitreous loss

54. PHARMACOEMULSIFICATION Two small incisions are made

in the eye where the clear front covering (cornea) meets the white of the
eye (sclera). A circular opening is created on the lens surface (capsule)
A small surgical instrument (phaco probe) is inserted into the eye.
Sound waves (ultrasound) are used to break the cataract into small pieces.
Sometimes a laser is used too. The cataract and lens pieces are removed
from the eye using suction. An intraocular lens implant (IOL) may then
be placed inside the lens capsule. Usually, the incisions seal
themselves without stitches.
A cataract usually is defined as an opacification of the lens or its capsule
Congenital

Following factors are generally involved in the development of the congenital cataracts.