Cataract Removal and Intraocular Lens Implant - Assignment Example

Case Study: Cataract (right) removal and intraocular lens implant. Case history Lila Rainey is an 80 year old widow who lives alone in the family home. She has worn glasses for myopia since she was a young girl. Four years ago she was diagnosed with chronic simple glaucoma. Mrs. Rainey is now being admitted to the day surgery unit for a cataract removal and intraocular implant in her right eye. Discussion 1. What are the signs and symptoms of a cataract? Symptoms of cataract develop gradually due to its slow progression. During the initial stages there may not be any symptoms at all. Gradually, over a period of time, Blurring vision, dim vision or blurred vision may occur. Other symptoms include difficult night vision, increased sensitivity to light and glare, halos around lights and fading of colors. The patient may need brighter light to read or may go in for frequent changes in glasses. In advanced stages there may be double vision in a single eye. Cataract does not cause pain. Only a hyper mature cataract may cause pain, redness and inflammation and this is rare. 2. Describe the anatomy involved in the formation of a cataract. Cataract affects lens in the eyes which is located just behind the iris and the pupil. It may or may not affect the entire lens. The lens consists of three layers. The outer layer which is the capsule is a thin, clear membrane. It surrounds a soft, clear material called cortex. The hard center of the lens is the nucleus. A cataract can form in any part of the lens. In most cases, cataract develops in both the eyes. However, cataract occurring as a consequence of injury or trauma can occur in single eyes. In normal eyes, the lens focuses light, producing clear, sharp images on the retina. Due to cataract, the lens becomes clouded, which scatters the light and prevents a sharply defined image from reaching your retina, causing blurred vision. There are 3 types of cataract: Nuclear cataract: This type of cataract occurs in the nucleus of the lens. There may be a temporary improvement in the reading vision in the initial stages due to the way it focuses light. However, as the lens gets clouded, vision gradually diminishes. Dim light vision and driving at night may be especially troublesome. Advanced discoloration can lead to difficulty distinguishing between shades of blue and purple. Cortical cataract: This type of cataract occurs in the cortex and begins as whitish, wedge-shaped opacities or streaks on the outer edge of the lens cortex and gradually encroach the centre. Both the distance and near vision can be impaired. Focusing and glare problems along with distortion and loss of contrast are also common. Subcapsular cataract: A subcapsular cataract starts as a small, opaque area just under the capsule of the lens, near the back of the lens. This type of cataract may occur in both eyes but tends to be more advanced in one eye than the other. It interferes with reading vision, reduces vision in bright light and causes glare or halos around lights at night. The most common cause of cataract is aging. This is because, aging causes change in the composition of the lens. The structure of the protein fibers breaks down. Some of the fibers begin to clump together, clouding small areas of the lens. As the cataract continues to develop, the clouding becomes denser and involves a greater part of the lens. Changes due to aging occur due to smoking, exposure to UV light and wear and tear. Other causes of cataract are congenital cataract (due to intra uterine rubella), metabolic disorders, etc (Comer, 2004). 3. What diagnostic tests would confirm the diagnosis? Diagnosis of cataract is done by examination of the eye and performing the following tests. Visual acuity test: Acuity of vision is tested using Snellen’s chart which has progressively smaller letters from top to bottom. In this test, the patient reads letters from across the room. Each eye is tested at a time, while the other eye is covered. This test determines whether the patient has 20/20 vision or less acute vision. Slit-lamp examination. A slit lamp allows the ophthalmologist to see the structures at the front of the eye under magnification Cornea, iris, lens and the space between your iris and cornea can be visualised. Retinal examination. This test is done after dilating the pupils with mydriatic drops. After dilatation of the pupils, the lens and retina can be visualized using a slit lamp or ophthalmoscope. The lens can be examined for signs of a cataract and, if needed, determine how dense the clouding is. It is also important to determine other causes of decreased vision, such as macular degeneration or advanced glaucoma. 4. What would be the surgical intervention for this condition and why? The treatment of choice for a cataract is surgery where the clouded lens is removed. The lens is replaced with a clear lens implant. Sometimes cataracts are removed without reinserting implant lenses. In such cases, vision is corrected with eyeglasses or contact lenses. Medications, dietary supplements, exercise or optical devices can not cure cataract. Although in early stages, a good understanding of the condition and a willingness to adjust lifestyle can help. There are 3 types of cataract extraction: Intracapsular cataract extraction: This consists of removing the lens with the capsule intact. It involves the breakage of the zonules mainly by cryoprobe.  Extracapsular cataract extraction: In this type of surgery, only the lens is removed so that the preserved intact capsular bag with its zonules can be used to hold the intra-ocular lens (as a scaffold). An intact posterior capsule is invaluable in decreasing the risk of retinal detachment and cystoid macular edema, two of the most dreadful complications in cataract surgery. Phacoemulsification: This is an improvement over extracapsular cataract extraction. Here, a smaller incision is done through which fragmentation of the crystalline lens and removal of the fragments is done. This is achieved by hydrodynamic system which produces high frequency mechanical waves out of an electric current, while incorporating irrigation and aspiration all in one setting (“Cataract & Cataract Surgery”). 5. Complete the nursing care plan for this client. a) Nursing Diagnosis: Disturbed Sensory Perception: Visual related to myopia and lens extraction. Nursing Interventions: Assess patient’s ability to see and perform activities. Encourage patient to see ophthalmologist at least yearly. Provide appropriate lighting for patient to carry out activities, to avoid glare on surfaces of walls and reading materials and to enable night vision. The patient should be instructed regarding normal age-related visual changes, cataracts and methods of dealing with visual acuity changes. Large print objects and visual aids must be used for teaching (Comer, 2004). Rationale: Assessing patients ability to see provides a base line for determination of changes affecting the patients visual acuity. Seeing an ophthalmologist regularly monitors for progressive visual loss or complications. Elderly patients over the age 60 may need twice as much light for god vision. Their eyes are more sensitive to glare especially if they have cataract because; cataract diffuses glare. They also need longer accommodation time. Hence providing adequate light prevents injury. Education will help them understand age-related vision problems and help them cope with their disability better (Comer, 2004). b) Nursing Diagnosis: Anxiety: related to anticipated surgery. Nursing Interventions: Instruct patient and family about regarding procedure, post procedure care and need for follow up with physician. Rationale: Prepares patient for what to expect, facilitates compliance and provide instruction about potential problems to lessen anxiety. c) Nursing Diagnosis: Deficient Knowledge: related to a lack of information about post-operative care. Nursing Interventions: The nurse taking care of the patient should advise the following: The operated eye must be protected from dust and smoke. For this an eye shield must be worn. At bed time and during naps, the eye shield must be taped with non-allergic tape with no pad under. The eye must not be rubbed or exerted pressure upon. Sun glasses may be worn. Hair must be washed in such a way that chemicals do not get in to the eye. Advice regarding activity limitations must also be given. While light house work is allowed in the first week, bending below the weight and lifting weights above 10 kgs is discouraged. Sexual relations may be resumed in 3 weeks provided care is taken not to strain excessively for up to 6 weeks. Driving vehicle is resumed only after follow up and ophthalmologist advice. The patient must also be advised to report in case of severe or increasing pain in the eye and decreasing vision, floaters or flashes (Comer, 2004). Rationale: This is because the wound will not be completely healed before the sixth week. Decreased vision, floaters and flashes are signs of complications to surgery like delayed subarachnoid hemorrhage, choroidal detachment, etc. 6. What medications would be administered to Mrs. Rainey while in hospital (group, generic name, route, and usual dosage). Tropical beta-adrenergic receptor antagonists such as timolol will be given in view of chonic simple glaucoma. One drop in each eye twice a day is the dosage. If she is on any other anti-glaucoma medication, she will need to continue them. Oral antibiotics, broad spectrum, like erythromycin will be started pre-op. The usual dosage for the elderly is 250mg twice daily which should be continued for 5 to 7 days post-op. Also, topical broad spectrum antibiotic like tobramycin or ciprofloxacin should be stated on the day prior to surgery. These drops will be continued for 7- 10 days. The dose is 1 drop in each eye four times a day. Topical steroid, dexamethasone also will be given. These are gradually tapered over 4-6 weeks. This may be given in combination with the topical antibiotic or administered separately. The dose is 1 drop four times a day in each eye. Oral acetaminophen 500 mg is given for pain relief sos (“Cataract & Cataract Surgery”). References Cataract and Cataract Surgery. Amarillo Eye Care Center. Retrieved on 26th August 2007 from http://www.amarilloeyecare.com/cataract.htm Comer, S.R., & Jaffe, M.S. (2004). Delmarss Geriatric Nursing Care Plans (3rd edition). London: Thomson Delmar Learning. Read More