6.1.6: Manages pxs presenting with cataract

Question 1

What is cataract?

Answer 1

Caused by protein fibrils denaturation due to oxidative stress, Increasing age and metabolic disturbance

Question 2

What are the main symptoms of cataract?

Answer 2

Reduced VA
Reduced CS
Increased Glare

Question 3

Describe nuclear sclerotic cataract - sxs, RFs, signs?

Answer 3

light scattering associated with Brunescence.
* Poorer Diet
* Low socio-economic status
* Age
* Smoking
* Larger Lens
* Higher Ambient Temperature
Signs:
* Yellowish hue
* Myopic Shift

Question 4

Describe cortical cataract - RFs, signs?

Answer 4

Appearance of spokes, wedge shaped usually peripheral
* Sunlight (UVB)
* Lens size
* Age
* Diabetes
* Smoking
* Female
* Non-Caucasian
Signs:
* Increased astigmatism
* Monocular Diplopia

Question 5

Describe posterior sub-capsular cataract - RFs, signs?

Answer 5

abnormal epithelial cells and material at posterior pole
abnormal epithelial cells and granular material at posterior pole due to swelling and breakdown of lens fibres
* Diabetes
* High Myopia
* Steroids
* Age
* Male
* Thyroid Hormone Use
Signs:
Rapidly progressing loss of visual acuity.

Question 6

What is the referral criteria for someone with cataract? What type of referral?

Answer 6

– no clear cut off, when sufficient cataract present to limit:
* The quality of life (mobility, glare)
* ability to work
* ability to drive
* willingness to have surgery
ALWAYS ROUTINE REFERRAL - as per ForthValley guidance

Question 7

Describe cataract surgery procedure?

Answer 7

• Day procedure, ~15/20mins procedure
• Local anaesthetic drops
  o Clear self-sealing corneal incision (2.8 – 4mm)
  o Viscoelastic injected into the anterior chamber
  o Capsulorhexis - circular (no point of weakness) opening in anterior capsular bag
  o Hydrodissection – freeing the cataractous lens from the capsule with balanced salt solution
  o Phacoemulsification – nucleus and epinucleus removal, grooving and splitting the cataract into smaller pieces
  o Irrigate and aspirate, especially epithelial cells from the anterior capsule - to prevent bag collapse when nucleus removed
  o Implantation of IOL into capsular bag
  o Usually no sutures as keyhole surgery
  o Cefuroxime (antibiotic) injected into anterior chamber (intracameral) at end of surgery to prevent endophthalmitis and other infections

Question 8

What are the post-op drops a patient is on following cataract surgery?

Answer 8

Antibiotic - 1 wk
Steroid - 4 wks - no taper
See optom - 4-6wks after surgery

Question 9

Describe operative complications of cataract surgery?

Answer 9

➢ Rupture of the posterior capsule
➢ Loss of lens fragment into vitreous
➢ Suprachoroidal haemorrhage

Question 10

Describe 48hrs post-surgery complications of cataract surgery?

Answer 10

➢ Corneal oedema
➢ Raised IOP
➢ Uveitis
➢ Cystoid macular oedema
➢ Periocular Bruising
➢ Wound leak
➢ Wound burn
➢ Hyphaema

Question 11

Describe post-operative (>48hrs later) complications of cataract surgery?

Answer 11

➢ Iris prolapse
➢ Bacterial endophthalmitis (intraocular infection)
➢ Posterior capsular opacification (Requiring YAG Laser capsulotomy)
➢ Retinal detachment

Question 12

Describe posterior capsular opacification (PCO)?

Answer 12

• Common complication (in 20% of people)
• Usually 2-5 years after the cataract operation
• The posterior part of the lens capsule (the bag which holds the lens in place) becomes hazy due to residual cataract cells growing onto it
• Younger patients have an increased likelihood of developing PCO
• Routine referral
• Treatment is via YAG laser to get rid of the residual cells in the central area to allow clear vision

Question 13

Describe the impact of cataract on a px’s lifestyle?

Answer 13

• Poor night vision due to decreased VA and CS
• Lights seem too bright/glaring
• Eyesight becomes misty
• Driving is not legal if <6/12 VA and cataracts haven’t been removed
• Decrease in stereopsis, especially if one eye is significantly worse than the other.
• Double vision

Question 14

Describe non-surgical management of cataract?

Answer 14

• Tints on glasses/increased sunglass use to help with glare
• UV protection and a wide-brim hat & glasses to prevent further cataract development
• Magnifiers can be used in addition to reading glasses.

Question 15

What advice would you give someone with cataract?

Answer 15

• UV protection.
• Night driving more difficult
• Normal change, likely to progress with time: inform of Sx – glare, VA and CS reduction.
• Advise px to return if they see significant change in VA or it begins to effect their lifestyle.