6.1.6. Manages patients presenting with cataract. Flashcards
Symptomatic Cataract Questions (these are the MAIN questions):
- Regarding your eyesight in the past month or so, how are you finding your vision overall when wearing your glasses (both eyes open)?
- How much has your eyesight been interfering with your life in general or with things you like to do?
- How has your eyesight been affecting your reading ability?
- Any issues with glare? Night vision?
- How has this been making you feel?
- DO PINHOLE MONOCULARLY
6.1.6 - Cataract, NO Referral
Advise:
“12/12 recall sooner if any problems/vision worsens & impacts lifestyle, new Rx, vision degrading due to cataracts but normal due to age, if px feels vision affecting daily life/out of driving standards, px has option to be referred. Px declined today, happy for now. Aware of waiting list, risks & benefits of surgery. Advised UV protection to slow cataract onset, reduced smoking, better lighting when reading etc, larger & bolder text. CoO cataract leaflet given”
what type of people are likely to have PSC;
pxs taking steroids. Therefore, pxs with atopic history i.e. taking steroid creams & inhalers will have higher risk!
Nuclear:
- Nuclear: yellowing and hardening of the central portion of the crystalline lens and it occurs slowly over years
- General haziness of distance & near
- Increased myopia
- Lowered ability to discern colour - reduced CS
- Glare & difficulty night driving
- Monocular diplopia
Cortical:
- Cortical: when the portion of lens fibers surrounding the nucleus become opacified. The impact on vision is related to how close the opacities are to the center of the visual axis
- Glare!!
- Decreased vision & CS - relates to how close it is to the central axis
Posterior subcapsular:
- opacities located in the most posterior cortical layer, directly under the lens capsule.
- Very close to central axis so great impact on vision
- Glare
Cataract severity ranges from
- Lamellar separation - demarcation of cortical fibres due to fluid
- Incipient - wedge shaped opacities going toward centre in both ant & post cortex
- Immature - greyish white
- Intumescent -
- Mature - complete cortex involvement, quite ripe, milkier due to calcium formation
- Hypermature -
- Morganian -
Anterior subcapsular
Can be from trauma, iatrogenic, idiopathic
Posterior polar
- Typically congenital and autosomal dominantly inherited.
- Not many sxs but if PSC forms around it, can cause lots of sxs!
Traumatic
- Rosette or Stellate
- Following both blunt and penetrating eye injuries as well as after electrocution, chemical burns, and exposure to radiation
Glassblower’s
IR radiation, cortical changes
Blue dot
Genetic - Discrete punctuate bluish opacities throughout the cortex
Lamellar
Lamellar fibres separated
Criteria (generally speaking): for referral
Px wants to proceed, needs noting on referral letter AND
Their vision worse than 6/12 OR
If vision better than 6/12 but px having sig synmtoms releated to visual problems
Done at time or referral, not on assumption may be worse at further time
Record Keeping & Questioning:
Symptomatic Cataract Questions (these are the MAIN questions):
- Regarding your eyesight in the past month or so, how are you finding your vision overall when wearing your glasses (both eyes open)?
- How much has your eyesight been interfering with your life in general or with things you like to do?
- How has your eyesight been affecting your reading ability?
- Any issues with glare? Night vision?
- How has this been making you feel?
Understand how quickly cataracts progress:
NS (slow, over years) —> Cortical (within a year) —> Posterior subcapsular (within months)
Recordings
- VAs & previous VAs (if possible)
- DO PINHOLE MONOCULARLY
- Tonometry (ideally contact)
- Slit lamp biomicroscopy of the anterior and posterior segments through a dilated pupil noting location and type of cataract
Advise: if refer for surgery
“12/12 recall, no Rx change, told not within driving standards so cannot drive currently, cataracts impacting daily life, VCG for surgery referral for (which eye), aware waiting time, risks & benefits of surgery, private Vs NHS. CoO leaflet given. Wear current spex for now, advised UV protection, smoking less, good lighting, larger & bolder text for reading etc to help until surgery. CoO cataract leaflet given. Any problems, return sooner.”
Referral Letter: (may not be able to fit all onto referral letter!)
Reason for referral and patient’s willingness for surgery
Current and previous visual acuity (with best VA, Rx, and date)
Pinhole visual acuity (if relevant)
Confirmation that cataract is main cause of vision loss
Note any ocular pathology or co-morbidities
Driving issues, if any
Exclusion criteria for cataract
- Px under 18yrs old
- Weight 250kg
- Unable to lie flat for 30mins
- Have uncontrolled airways (sleep apnoea)
- Are on home oxygen
- Require general anaesthetic
Risks of Surgery:
- Posterior capsular opacification (PCO) - can happen anytime after surgery; clouding effect; treated with YAG laser capsulotomy with immediate visual improvement
- Posterior capsule rupture/Vitreous loss - can happen during surgery
- Cystoid macula oedema (CMO) - peak incidence is about 6 to 8 weeks post-operatively
- Endophthalmitis - microorganisms that gain entry into the eye, infecting tissue & fluids within eyeball; treated with intravenous antibiotics
- Vitreous/Suprachoroidal Haemorrhage
- Retinal detachment; risk is increased in patients who have received YAG laser capsulotomy following surgery
- Lens Dislocation - rare
