Cataract Nursing Care Management: Study Guide for Nurses

Cataract is a clouding of the lens. Most of your patients are older adults losing vision slowly, and most cases end in outpatient surgery. The work is preoperative prep, protecting the eye after surgery, and teaching the patient to spot the complications that send them back.

What Is a Cataract?

A cataract is a lens opacity or cloudiness, one of the most common eye disorders. On inspection the lens looks gray or milky.

Classification

The three most common senile cataracts are defined by location in the lens. A nuclear cataract comes from central opacity and carries a strong genetic component. A cortical cataract involves the anterior, posterior, or equatorial cortex. A posterior subcapsular cataract sits in front of the posterior capsule.

Pathophysiology

Cataracts can develop in one or both eyes at any age. Risk factors include cigarette smoking, long-term corticosteroid use, sunlight and ionizing radiation, diabetes, obesity, and eye injuries. Recent studies also link cataract risk to lower income and education, smoking for 35 or more pack-years, and high triglyceride levels in men. Nuclear cataract is associated with myopia, which worsens as the cataract progresses. A dense cataract severely blurs vision, while one at the equator or periphery of the cortex does not block light through the center of the lens.

Statistics and Incidences

Cataract ranks behind only arthritis and heart disease as a leading cause of disability in older adults. It affects nearly 20.5 million Americans age 40 or older, about one in six people in that range. By 80 years of age, more than half of all Americans have cataracts. The World Health Organization calls cataract the leading cause of blindness worldwide. Almost one in five people between 65 and 74 develop cataract severe enough to reduce vision.

Causes

Cataracts usually develop without an apparent cause, but can result from several sources. Senile cataracts develop in elderly patients from degenerative changes in lens proteins. Congenital cataracts occur in neonates from genetic defects or as a sequela of maternal infection during the first trimester. Traumatic cataracts follow a foreign body that injures the lens with enough force to let aqueous or vitreous humor enter the lens capsule and dislocate the lens. Complicated cataracts occur secondary to uveitis, glaucoma, or retinitis pigmentosa, or alongside systemic disease such as diabetes, hypoparathyroidism, or atopic dermatitis. Toxic cataracts result from drug or chemical toxicity (prednisone, ergot alkaloids, dinitrophenol, naphthalene, phenothiazines, or pilocarpine) or extended ultraviolet exposure.

Clinical Manifestations

Because all light entering the eye passes through the lens, any clouding worsens vision. Blurred vision is usually the first symptom. Glare is the pain felt looking directly into light. Halos appear as a lingering ring of light after looking away from a bright source. Double vision is another early sign.

Prevention

Teach the patient to quit smoking, one of the largest contributing factors, and to wear sunglasses to shield the eyes from the UV exposure that predisposes to cataract.

Complications

Complications after cataract surgery include retrobulbar hemorrhage (from retrobulbar infiltration of anesthetic if the short ciliary artery is hit by the injection), acute bacterial endophthalmitis (a devastating complication in about 1 in 1000 cases), and toxic anterior segment syndrome (noninfectious inflammation following anterior chamber surgery).

Assessment and Diagnostic Findings

Decreased visual acuity tracks directly with cataract density. The Snellen visual acuity test measures acuity. Ophthalmoscopy shows the extent of the cataract. Slit-lamp biomicroscopic examination establishes the degree of formation.

Medical Management

No nonsurgical treatment cures cataracts or prevents age-related ones.

Pharmacologic Therapy

Dilating drops are given every 10 minutes for 4 doses, starting at least 1 hour before surgery. Antibiotics may be given prophylactically against postoperative infection and inflammation. IV sedation eases anxiety and discomfort before surgery.

Surgical Management

Three procedures remove the cataract. Phacoemulsification removes part of the anterior capsule, then extracts the lens nucleus and cortex while leaving the posterior capsule and zonular support intact. Extracapsular cataract extraction (ECCE) removes the anterior lens and cortex, leaving the posterior capsule intact. Intracapsular cataract extraction removes the entire lens within its intact capsule.

After the lens is removed, three replacement options restore focus. Aphakic glasses magnify objects by 25%, making them appear closer than they are. Contact lenses give nearly normal vision but must be removed periodically, so the patient still needs a pair of aphakic glasses. IOL implants are the most common choice: the single-focus (monofocal) IOL cannot change shape, multifocal IOLs reduce the need for eyeglasses, and accommodative IOLs mimic the accommodation of a youthful, phakic eye.

Nursing Management

The cataract patient gets the usual preoperative care for ambulatory eye surgery.

Nursing Assessment

Assess recent medication intake; anticoagulants are commonly withheld to cut the risk of retrobulbar hemorrhage. Standard preoperative tests (complete blood count, electrocardiogram, urinalysis) are ordered only when the patient's history indicates them. Confirm stable vital signs before surgery. Review Snellen and other visual acuity test results, and use the medical history to determine which preoperative tests are needed.

Nursing Diagnosis

Common diagnoses include disturbed visual sensory perception related to altered sensory reception, risk for trauma related to poor vision and reduced hand-eye coordination, anxiety related to the threat of permanent loss of vision or independence, and deficient knowledge about coping with altered abilities.

Nursing Care Planning and Goals

Major goals: regain the usual level of cognition, recognize sensory needs, stay free of injury, identify environmental risk factors, keep anxiety at a manageable level, verbalize feelings of anxiety, and identify healthy ways to express it.

Nursing Interventions

Preoperatively, withhold anticoagulants to reduce the risk of retrobulbar hemorrhage. Postoperatively and before discharge, give the patient verbal and written instructions on protecting the eye, giving medications, recognizing signs of complications, and getting emergency care.

Evaluation

Confirm the patient meets the planned goals: usual cognition regained, sensory needs recognized, no injury, environmental risk factors identified, anxiety manageable and verbalized, and healthy coping expressed.

Discharge and Home Care Guidelines

Teach self-care before discharge, including activities to avoid. To prevent rubbing or poking the eye, the patient wears a protective eye patch for 24 hours after surgery, then eyeglasses during the day and a metal shield at night for 1 to 4 weeks. Expect slight morning discharge, some redness, and a scratchy feeling for a few days; a clean, damp washcloth can remove the discharge. Because cataract surgery raises the risk of retinal detachment, the patient must notify the surgeon for new floaters, flashing lights, decreased vision, pain, or increased redness.

Documentation Guidelines

Document individual findings (specific deficits, associated symptoms, and client and family perceptions), assistive device needs, use of safety equipment or procedures, environmental and safety concerns, level of anxiety with precipitating and aggravating factors, description and awareness of feelings, the plan of care, the teaching plan, client involvement and response to interventions and teaching, attainment of or progress toward outcomes, modifications to the plan of care, and long-term needs.