CATARACT

CATARACT
A. CONCEPT CATARACT1. Definition Cataract is a cloudiness in the lens without the pain gradually Gradually, blurred vision eventually not be able to receive light (Barbara, 2001). Cataract is the turbidity [opacity] of the lens can not describe objects clearly in the retina. (Doengoes, 2001).
2. Etiology § age, usually found senile cataract. § Trauma, due to blow a blunt instrument / sharp exposed by X-rays or radioactive objects. § eye diseases such as Uveitis § systemic diseases such as diabetes mellitus. § congenital defects.
3. Physiology of Eye Lens The function of the lens focus the rays on the retina. At that time refractive power of the lens changes as needed so that beam can be focused on the retina. Change retraction force called accommodation. 2 (two) factors that determine the accommodation that is: a) The ability of the lens to change shape (becoming more convex) b) Strength of muskulus siliaris. When muskulus siliaris relaxed, zonula Zinn became tense, the diameter between the posterior lens becomes shorter and the power of refraction reduced. Conversely, if the muscular contraction siliaris Zinn zonula tension is reduced, so that the shape of the lens becomes more convex and the power of refraction increases.
4. Pathophysiology Under normal circumstances due to lens transfaransi equilibrium between a soluble protein with a protein can not dissolve in sesemi permeable membrane. In the event of increase in the number of proteins that can not be absorbed, resulting in amount of protein in the lens exceeds the amount of protein in other parts ataubbintik transparent so as to form a small mass around lens, forming a capsule, known as cataracts. The occurrence of fluid accumulation / degenasi and disintegration in these fibers causes the light path blocked and lead to impaired vision.

5. Distribution of cataract 1) Congenital Cataract In general, bilateral. Many are caused by the rubella virus in First trimester of pregnancy when the positive examination rubella, then surgery should be postponed until the age of 2 years because the virus is still active in the lens. If the operation will occur endoftalmitis and the eyes will be damaged. When turbidity bilateral immediately do one eye had surgery less than 6 months to form a visual acuity normal. While the eye may be operated only after age 2 years. 2) Cataract Jevenil Cataracts that occur in children after birth. This Cataracts included in cataract development, the lens opacities occurs during fiber development are still happening - fibers lens so usually mushy consistency like porridge and is called soft cataract. Usually, juvenile cataracts are part of a incidence of other hereditary diseases. 3) Cataracts Senil Senile cataracts have anything to do with increasing age and associated with the aging process that occurs in the lens. Changes visible is the increasing thickness of the nucleus with the development of cortical layers of the lens. The clinic / aging process of the lens is seen in the reduction strength due to the occurrence of lens accommodation skelerosa lens resulting in a 4 decade dimanifestasi in the form of presbyopia. a. Cataract insipien Cataracts are not like the patches that form the serrations with peripheral base and clear areas between them. Turbidity usually located in the cortex or posterior nterior. This turbidity at the beginning only visible when the pupil dilated. At this stage there are complaints because polidiopia by index refraction is not the same in all parts of the lens. When done testing shadow iris (shadow test) will be negative. b. Immature cataract At a more advanced stage there will be a turbidity thicker. But do not or are not familiar with all the lenses so that there are still parts that are clear on the lens. At the stadium It happened that resulted in the lens cortex hydras become increasing convex. Pencembungan this lens will give a change refractive index where the eye will become myopia. This convexity will result in pushing the iris forward so that chamber front and anterior chamber angle is more narrow. At this stage glaucoma would easily occur as complications. Immature stages which occur due to lens curvature of the earth to absorb water intumesen called staging. Shadow positive test in these circumstances. c. Mature cataract If the degeneration process goes on there will be expenditure water along the disintegration through the capsule. Lens loss liquid so that the shrink again and the camera becomes the anterior okuli back to normal. Turbidity of the lens is gray-white color thoroughly gray. On the negative shadow iris examination and fundus reflex negative. At this stage a good time to surgery with intra technique capsular (Old Engineering). d. Cataract hipermatur It is a further degeneration process lens so the lens cortex melt and can exit through the lens capsule. Can occur are 2 possibilities: · Lenses continue to be lost fluid SHRUNKEN shrank and thinned called cataracts. · Soften and melt the lens cortex, whereas the nucleus is not subject to change, consequently the nucleus fall called MORGANIAN Cataracts. Operations at this time is less profitable because more simple case of complications. Senile cataract: o Most often found o Usually more than 50 years of age, but sometimes starting at the age of 40 years o Almost always on both eyes with a stage different. Turbidity can be started from the peripheral cortex or around nucleus. o The main symptoms are increasingly blurred vision. Since the onset of turbidity occurred until the mature takes time few years. o The pupil reaction to light normal.
6. Examination 1) decreased visual acuity depends on: 2) No signs of inflammation (hyperemia did not exist) 3) Illumination oblique look grayish turbidity or white with black shadow is called the iris shadow. 4) examination with ophthalmoscope appear black on orange base is called the fundus reflexes. 5) At a more advanced cataract, increased turbidity so that the shadow iris and fundus reflexes disappear into a black only (Negative). 7. Eye treatment If the patient can still be corrected glasses, then given first glasses. But the size of the glasses the patient usually very easy / quick change. The best treatment and appropriate is currently operating. Indications of surgery are: 1) decreased visual acuity that can not be corrected with glasses and disrupt the activity. 2) Formerly operated patients when visusnya 1 / 300 s / d no infinity (LP +). However, with advances in technology today can cataract surgery at any stage, if the patient has been disrupted activities.
Kinds of operations: 1) Intra-capsular: Intra capsular Catarax Extraction (ICCE) issued by the lens intact. 2) Extra capsular: Extra capsular extraction Catarax (Ecce) issued a lens with tore the anterior capsule and leave the capsule parts posterior. At this time where technological progress is already high, the technique Ecce preferred because its complications are smaller and can be accompanied the installation of intra-ocular lens implant (IOL = Intra-ocular Lens). So the result after the operation the better.
Afakia: o The eyes are the lens does not exist (surgery or other reasons). o visual acuity 1 / 60 o Being hipermetrop (about 10:00 + D) o Loss of power of accommodation o To read requires additional + 3:00 D
Pseudofkia: Eyes that had been taken and the mounted lens IOL Better visual acuity, can be up to 6 / 6 Loss of accommodation resources To read requires an additional + 3:00 D

Evaluation after cataract surgery: Day 1 after surgery have been evaluated, namely: 1) Bleeding in the anterior chamber (hifema). 2) Camera okuli anterior clear / cloudy: When the front eye turbid (flares / positive cell) o anterior chamber turbid (flares / positive cell) o Perhaps until there is pus in the deposition chamber front (hipopion). o Iris miossi accompanied sinekia postrior 3) Note pupillary miosis / midriasis / normal: o Miosis: usually used at the time of surgery miotikum so the next day the pupil becomes miosis. This Miosis occur if there is anterior uveitis, and is usually accompanied by sinekia posterior. o Midirasis: can occur when there is increased pressure intra-ocular (glaucoma) o The pupils are not round: occurs when the operating time occur korpukasi (corpus viterius out).
AFTER TREATMENT Cataract Operation: After the surgery can be given: o Glasses, given if signs of irritation is gone (Approximately after 1.5 months post op), there is no change refraction (3 x refraction per week). o Contact Lenses: Better vision than glasses, and used in operations unilateral cataract (one eye). o Intra Okuli Inolan Lens (IOL): - Implant is inserting into the eye during surgery, replace the lens is taken (Ecce). - It's permanent - Does not require treatment. - Visual acuity better than glasses / contact lenses.
Disadvantages: o A foreign object, possibly react / rejected by the body. o The operation technique is more difficult / advanced.
B. The concept of nursing care
Assessment a) Pre Operative Subjective: complaints vision o Blurred in total o Just look good in a dim place o Just to see the light stimulus alone o Double / compound in one eye. Verbal and non verbal indicators of anxiety. An understanding of cataract surgery include: o The nature of the procedure o Risks and benefits o Drug anesthesia o The options for visual rehabilitation after surgery, such as intraocular lens implants, contact lenses and cataract glasses (Glasses afakia). Number of client information sought. Objective: o There were no signs of inflammation, except on Complicated cataract intra okulernya the disease is still active. o On examination lens illumination appear gray or a white turbidity. o In ophthalmoscope examination at a certain distance turbidity obtained with a black background red. o On examination of refraction increases. In patients who was suffering from presbyopia later suffered cataracts, the early stage can be read without using reading glasses. o Observation of the signs of glaucoma because complications of cataract, glaucoma, such as common is a sense of pain because of increased IOP, visual field abnormalities. b) Post Operative Subjective Data § Pain § Nausea § Diaporesis § History of previous falls § Support Systems, the home environment. Objective Data § Changes in vital signs § common response to pain. § The signs of infection 1) Reddish 2) edema 3) Infection kojunctiva (konjunctiva prominent blood vessels). 4) Drainage of the eyelids and eyelashes. 5) Substance purulent 6) Increased temperature 7) The lab, increased leukocytes, changes in leukocyte, abnormal sensitivity of the results of culture examination. § The sharpness of vision of each eye § Readiness and ability to learn and absorb information 2. Nursing Diagnosis a) Pre operarif 1) Impaired visual sensory perception / vision associated with decreased visual acuity, visual double. Objective: The perception of sensory disturbances resolved. Criteria results: o With limited vision client can see environment as closely as possible. o Know the changes in positive and negative stimuli o Identify environmental habits. Intervention Rational 1. Orient the patient towards environmental activities.

2. Differentiate the ability of visual field between the two eyes 3. Observation sign of disorientation by staying on the side patients. 4. Encourage clients to perform simple activities such as watching TV, radio, etc. 5. Instruct the patient to use cataract glasses, prevent the field peripheral view and record the occurrence of blind spots. 6. Position open the door must be closed, minimize obstacles. £ Introducing the patient about the dam environmental activities so as to leave the stimulus of sight. £ Determine the ability of visual field of each eye
£ Reducing the fear of patients and increase the stimulus.
£ Improving the sensory input, and maintain a normal feeling, without increasing stress. £ Lowering peripheral vision and movement.


£ Lowering peripheral vision and movement.

2) anxiety associated with surgery to be undertaken and the possibility of failure to gain vision back. Goal: overcome anxiety Criteria results: Expressed concern and fear about the surgery will be lived. Perioperasi routine actions reveal the understanding and treatment. Intervention Rational 1. Create a quiet and relaxed environment, give encouragement to verbalize and listen with rapt attention. 2. Reassure clients that anxiety has a normal response and estimated to occur in cataract surgery to be undertaken. 3. Show misconception that expressed the client, give accurate information. 4. Present the information using the methods and media instructional.
5. Explain to clients that premedication activity required.
6. Discuss pre-operative nursing action expected. 7. Give information about the activities of sight and sound associated with intra-operative period £ Helps identify the source of anxiety.


£ Increase client confidence


£ Increase client confidence

£ Improving the learning process and have written information referral source after coming home. £ Increased knowledge will add cooperative client and reduce anxiety. £ S d a

£ Explaining options allow clients to make decisions true.
b) Post operative 1) Impaired sense of comfort (acute pain) are associated with invasive procedures. Objective: The pain resolved Criteria for outcome: clients reported decreased pain progressive and uncontrollable pain after intervention. Intervention Rational 1. Assist clients in identifying the removal action Effective pain.
2. Explain that pain can occur up to several hours after surgery.



3. Take action to reduce pain by means of: - Position: elevate the head of the bed, dressing and sleep position, change positions and do not sleep on that side be operated - Distraction - Practice relaxation 4. Give appropriate analgesic drugs program 5. Report your doctor if the pain does not disappear after ½ hour administration of drugs, if pain accompanied by nausea. 1. Helping patients find measures that can eliminate or reduce pain effectively. 2. Pain can occur until the local anesthetic out, understand this can help reduce the anxiety associated with are not expected. 3. Exercise pain by using non-action pharmacology allows clients to gain a sense of control to pain.



4. Analgesics can inhibit pain receptors. 5. This sign shows the increase in intra-ocular pressure or another complication.

2) High risk of infection associated with invasive procedures (surgical removal). Objective: The infection did not occur Criteria results: § The signs of infection does not occur § timely wound healing § Free purulent drainage, erythema, and fever Intervention Rational 1. Improve wound healing by: - Give encouragement to follow a balanced diet and intake Adequate fluid


- Instruct client to keep a close eye until today first after surgery or until notified.
2. Use aseptic techniques to shed a drop of eye: - Wash hands before starting - Hold the dropper tool little distance from the eye. - When the shed to avoid contact between the eye with drops and dropper tool. 3. Use aseptic technique to clean the eyes of the out with wet wipes / cotton ball for each sweep, replace Wrap and put the lens when using. 4. Emphasize the importance of not touching / scratching the eye surgery. 5. Observation of signs and symptoms of infection such as redness, eyelid swelling, purulent drainage, injection konjunctiva (Prominent veins), the increase in temperature. 6. Suggest to prevent tension on the suture with how to: use protective glasses and protective eye on the night days. 7. Collaboration medications as indicated: - Antibiotics (topical, parental or sub conjunctiva) - Steroids

£ optimal nutrition and hydration that improves their health Overall, improve surgical wound healing. £ Wearing eye protection improving healing and reducing eyelid irritation strength to suture the wound. £ menimalkan aseptic technique and reduce the entry of microorganisms infection.






£ aseptic techniques reduce the risk of spreading infection / .bakteri and cross-contamination.

£ Preventing contamination and damage to the operating side. £ Early detection of infection allows for rapid handling minimize the seriousness of the infection.

£ tension on the sutures can cause interruptions, creating nets go to mirkoorganisme
£ topical preparations used in prophylaxis, where therapy Aggressive required when there is infection £ Reduces inflammation
3) Disturbance of sensory - perceptual: vision related with disorders receiving sensory / sensory organ status, of environmental a therapeutic is limited, is characterized by: § The reduced acuity, visual disturbances. § Changes in respo usually against stimuli. Expected result: § Increasing the sharpness penglihatn within the limits of individual situations § Know the sensory disturbance and compensated against changes. Intervention Rational 1. determine visual acuity, note whether one or both eyes involved

2. patient orientation to the environment, staff / others area

3. Observation of signs and symptoms of disorientation, maintain security of the bed until it is completely recovered from anesthesia. 4. Remind the client uses the objective lens cataract enlarge ± 25%, peripheral vision is lost. £ individual needs and choices of interventions and intervention options varied causes vision loss occurs slowly and progressive. £ Provide increased comfort and kekeluargaaan, lower postoperative anxiety and disorientation. £ Built in an unknown environment and experience limited vision can lead to confusion on the parents. £ Changes in acuity and depth perception can cause confused / increase the risk of injury until the patient learns to compensate.
4) Lack of knowledge about the condition of medical prognosis associated with not knowing the source of information, marked with clients less followed the instructions, frequently asked complications which can be prevented. Objectives: After nursing a given action is expected clients HE understand the condition, prognosis, and treatment. Criteria results: § Able to perform maintenance with the correct procedure § Able to heal back what has been dijelasakan Intervention Rational 1. Review the information about the condition of the individual prognosis of type procedure, procedure type lens. 2. Emphasize the importance of treatment evaluation. Tell to reported cloudy vision. 3. Tell the client to avoid eye drops sold freely. 4. Encourage adequate fluid intake, eating terserat. 5. Encourage clients to avoid reading, blinking, heavy lifting, straining during defecation, bent on pelvis, blowing nose using spray, powder powder, smoke. £ Improving the understanding and cooperation with post-operative course
£ Oversight periodically reduce the risk of serious complications.

£ can cross-react / interfere with the drugs given. £ preserves the consistency of faeces to avoid pushing £ Activities that cause eye fatigue tense, Valsalva maneuver or increase the TID could affect operating results and trigger bleeding. Note: respiratory irritant that causes coughing / net can increasing TID.
REFERENCES
Carpenito, Lynda Juall, (1999), Farm Plan and Documentation Nursing, Edition 6, EGC, Jakarta. Doengoes, Mariyln E., (2000) Nursing Care Plan Guidelines For Planning and Documenting Patient Care, 3rd Edition, EGC, Jakarta. Tamim Radjamin RK, et al, (1993), Eye Pathology, Airlangga University Press, Surabaya.