Ophthalmology Complications Quiz

Cataract Overview

• Cataract is a cloudy area in the eye's lens, obstructing light focus.

Objectives

• Cataract definition and incidence: Defining cataract and its prevalence.
• Pathophysiology: Understanding the causes of cataract formation (traumatic, congenital, senile).
• Risk factors: Identifying factors that increase cataract risk.
• Clinical manifestations: Recognizing noticeable symptoms.
• Assessment and diagnostic tests: Techniques used to diagnose cataract.
• Medical management: Non-surgical treatment options.
• Surgical management: Surgical approaches to cataract removal.
• Surgical complications: Potential issues arising from surgery.
• Nursing management: Care of patients undergoing cataract surgery.
• Health education: Information provided to patients about cataract.

Incidence

• Cataracts cause visual impairment in 18 million globally.
• Over half of Americans aged 80 have cataracts.
• Cataracts are a leading cause of blindness worldwide.
• In Bahrain, up to 60 cataract cases are diagnosed daily.
• Doctors often refer to it as a condition rather than a disease.

Pathophysiology

• Traumatic: Eye injuries disrupt lens structure, causing protein denaturation, swelling, and opacification.
• Congenital: Genetic mutations or infections during pregnancy disrupt lens protein structure, leading to clouding.
• Senile: Aging lens proteins degrade, aggregate, and oxidize, leading to clouding.

Risk Factors: Aging

• Accumulation of yellow-brown pigment due to lens protein breakdown.
• Clumping/aggregation of lens proteins leading to light scattering.
• Decreased oxygen uptake.
• Decreased vitamin C, protein, and glutathione (antioxidant).
• Increased sodium and calcium.
• Loss of lens transparency.

Risk Factors: Toxic Factors

• Alkaline chemical eye burns and poisoning.
• Aspirin use.
• Calcium, copper, iron, gold, silver, and mercury deposits in pupillary lens areas.
• Cigarette smoking.
• High-dose/long-term corticosteroid use.
• Ionizing radiation.

Risk Factors: Physical Factors

• Blunt trauma, perforation with sharp objects or foreign body, electric shock.
• Dehydration related to chronic diarrhea, purgative use, or hyperbaric oxygenation.
• Ultraviolet radiation (sunlight and x-rays).

Risk Factors: Associated Ocular Conditions

• Infections (e.g., herpes zoster, uveitis).
• Myopia (nearsightedness).
• Retinal detachment and retinal surgery.
• Retinitis pigmentosa.

Risk Factors: Nutritional Factors

• Obesity.
• Poor nutrition.
• Reduced antioxidant levels.

Risk Factors: Systemic Disease and Syndromes

• Diabetes.
• Lipid metabolism disorders.
• Down syndrome.
• Musculoskeletal disorders.
• Renal disorders.

Clinical Manifestations

• Reduced contrast sensitivity.
• Painless & blurry vision.
• Dim surroundings.
• Sensitivity to glare.
• Light scattering.
• Reduced visual acuity.
• Monocular diplopia (double vision in one eye).
• Color changes.
• Myopic shift.
• Astigmatism.

Assessment & Diagnostic Findings

• Decreased visual acuity is directly proportional to cataract density.
• Snellen visual acuity test.
• Ophthalmoscopy.
• Slit-lamp biomicroscopic examination.

Medical Management

• Medications.
• Eye drops.
• Eyeglasses.
• Cures/prevents age-related cataracts.

Risk Reduction Strategies

• Patient education: On smoking cessation, weight reduction, and optimal blood glucose control (for DM patients).

Surgical Management

• Surgery not needed if reduced vision doesn't impact daily life.
• Surgery based on patient's functional and visual status.
• Outpatient surgery typically under 1 hour, discharge within 30 minutes.
• Goal: Visual function restoration via a minimally invasive technique.
• Advances in topical anesthesia, smaller wound incisions, and lens design used.

Cataract Surgery Timing

• One eye treated first, with interval of weeks/months between surgeries.
• Opportunity to assess prior surgery outcome before treating the other eye.
• Flexibility allows possible alternative surgical approaches if necessary.

Injection-Free Topical & Intraocular Anesthesia

• Lidocaine gel ideal for anticoagulant patients.
• Patient communication/cooperation during surgery.
• IV sedation for anxiety/discomfort reduction.
• Minimizes regional anesthesia risks (perforation, hemorrhage, optic injury, diplopia, ptosis).

Phacoemulsification

• Posterior capsule and zonular supports remain intact during surgery.
• Lens nucleus and cortex liquefied via ultrasonic device.
• Suctioning removes liquefied contents.
• Zonular-capsular diaphragm secures IOL base.
• Pupil dilated (7mm+) for easier IOL insertion.
• Viscoelastic material (clear gel) used to prevent collapsing and facilitate IOL placement.
• Small incisions promote rapid wound healing.

Lens Replacement

• The patient is referred to as aphakic (without lens) after lens removal.
• Lens must be replaced for clear vision.
• The three options are aphakic eyeglasses, contact lenses, and IOL implants.
• Aphakic eyeglasses are less common but effective.
• Distortion can occur from enlargement.
• Binocular vision (both eyes focusing on same object) is impossible for one eye without a natural lens.

Contact Lenses

• Allows nearly normal vision.
• Must be removed and worn with glasses sometimes.
• Risk of infection increases with frequent handling and inadequate cleaning.
• Patients with issues handling are not suitable.

IOL Implants

• Most common lens replacement method during cataract surgery.
• IOL inserted after phacoemulsification or extraction.
• Potential complications: eye infection, fluid loss, implant slipping.
• Contraindicated for specific conditions: recurrent uveitis, proliferative diabetic retinopathy, neovascular glaucoma, rubeosis iridis.

Surgical Complications

• Immediate Preoperative: Retrobulbar hemorrhage.
• Intraoperative: Rupture of posterior capsule, suprachoroidal (expulsive) hemorrhage.
• Early Postoperative: Acute bacterial endophthalmitis.
• Early Postoperative: Toxic anterior segment syndrome.
• Late Postoperative: Suture-related problems (toxic reactions and mechanical injury from broken sutures).
• Late Postoperative: Malposition of IOL
• Late Postoperative: Chronic endophthalmitis
• Late Postoperative: Opacification of the posterior capsule.

Providing Preoperative Care

• Standard preoperative care for ambulatory eye surgery.
• Preoperative tests (CBC, ECG, urinalysis)
• Patient education on eye medications (antibiotic, corticosteroid, anti-inflammatory).
• Dilating drops administered pre-surgery.
• Nurse to query patient history of alpha-antagonists.

Providing Postoperative Care

• Eye shield recommended at night during first week.
• Minimal discomfort expected.
• Mild analgesics (acetaminophen) as needed.
• Prescribed antibiotic/anti-inflammatory/corticosteroid eye drops/ointments.
• IOP monitored for elevated pressure.

Continuing & Transitional Care

• Eye patch removal after first follow-up appointment (48 hours of surgery).
• Importance of follow-up appointments for monitoring and intervention of complications.
• Vision stabilization typically within 6-12 weeks.
• Potential for continuing visual correction if needed.
• Multifocal IOLs may cause increased night glare and contrast sensitivity.

Post-Cataract Surgery Care at Home

• Recovery requires time. Proper care ensuring healing is crucial.

Caring for Your Eye

• Wear eye glasses and/or shields as advised, particularly at night.
• Clean the eye with a clean tissue, inward to outward.
• Avoid rubbing or poking the eye.
• Damp washcloth for minor morning discharge.

Ensuring Safe Recovery

• Avoid lying on the operated eye side.
• Be cautious on stairs and avoid tripping risks.
• Seek assistance with heavy lifting/washing hair.
• Support resources available for meals and transport.

Activities to Avoid

• No lifting, pushing, pulling objects heavier than 15 lbs.
• No prolonged bending or stooping.
• Avoid driving, sex, strenuous activities until cleared by a doctor.
• Light activities like walking, reading, or watching TV are encouraged.
• Urgent consultation needed if experiencing visual changes, redness, swelling, pain, unusual discharge, or pain not relieved.

Importance of Follow-up

• Schedule a follow-up appointment within 48 hours after surgery.
• Monitor vision stabilization (6 to 12 weeks after surgery).
• Discuss any remaining vision problems with an ophthalmologist.

Stay Connected with your Healthcare Team

• Maintain contact information.
• Communicate concerns, questions, and emergencies to care team.
• Adhere to prescribed medication schedule.