EXTRACAPSULAR CATARACT EXTRACTION

____________________

A Report Presented to

The Faculty of Nursing Department

San Pedro College, Davao City

Erein Therese Acero, RN, MN

____________________

In Partial Fulfillment to

The Requirements in NCM 216

PC/OR NURSING ROTATION

By:

Khesler Bernie Bacalla

Kristel Marie R. Boteros

Fiona L. Sotito

BSN 3D

April 14, 2021

Definition

Extracapsular cataract extraction (ECCE) is a category of eye surgery in which the eye's
lens is removed. In contrast, the elastic capsule covering the lens is left partially intact to
allow implantation of an intraocular lens (IOL). This approach is contrasted with
intracapsular cataract extraction (ICCE), an older procedure in which the surgeon
removed the wide lens within its capsule and left the eye aphakic (without a lens). The
patient's vision was corrected after intracapsular extraction by extremely thick
eyeglasses or by contact lenses.

Indication
● Extracapsular cataract extraction is a method for surgically removing a cataract,
which is a clouding of the eye’s naturally clear lens. A cloudy lens interferes with
light passing through to the retina, the light-sensing layer of cells at the back of
the eye. Having a cataract can be compared to looking at the world through a
foggy window.

Contraindication
● Subluxation
● Dislocation of lens
● Sclera thinning disorders, such as scleritis and ectasia
● Increased potential of suprachoroidal hemorrhage, or poor patient cooperation

Preoperative Management

Intervention Rationale

Procedure Orientation Proper explanation of the procedure

helps to ensure their cooperation and
understanding.

Instruct client do not to eat or drink after This is because when the anaesthetic is
midnight before surgery, including gum or used, your body's reflexes are temporarily
candy. stopped. If your stomach has food and
drink in it, there's a risk of vomiting or
bringing up food into your throat.

Informed consent The client must sign a surgical consent

form or operative permit. Clients must
sign a consent form for any procedure
that requires anesthesia and has risks of
 complications.

Leave all jewelry, purse and other To prevent the patient from receiving a
valuable possible burn from the current that comes
from the electrocautery unit, it is good
practice and safe practice to have jewelry
removed before surgery. The reason to
remove all piercings before surgery is
because metal can lead to skin burns
from any use of medical equipment or
electric cauterize used to stop any
bleeding.

Client is wearing a hospital gown and hair The surgical cap minimizes the risk of hair
cover. falling into the sterile area during surgery.

Patient’s medical history The nurse assesses the patient’s medical

history to determine the preoperative
tests to be required.

Preoperative tests The standard battery of preoperative tests

such as complete blood count,
electrocardiogram, and urinalysis are
prescribed only if they are indicated by
the patient’s medical history.

Recent medication intake It is a common practice to withhold any

anticoagulant therapy to reduce the risk of
retrobulbar hemorrhage.

Visual acuity test results Test results from Snellen’s and other
visual acuity tests are assessed.

Vital signs Stable vital signs are needed before the

patient is subjected to surgery.

Verifies surgical site Identify the site in a way that is

appropriate for the particular procedure to
be performed.

Administers medications if prescribed is intended to reduce these stresses

through anxiolytic and sedative
effects.Ensuring that medications are
given safely and accurately is a
cornerstone of safe medical care.

Takes measures to ensure patient’s It is characterized by the satisfaction of

comfort one's needs, by the client feeling strong,
 safe, supported and cared for.

INTRA-OPERATIVE

Surgical position Rationale

Upright seated position or Face-to-face seated positioning made cataract surgery

the face-to-face position feasible for patients who were unable to lie flat or face
the ceiling. The technique is suitable for many patients
with orthopedic, neurological, cardiac, respiratory or
psychological conditions.

Reverse- Trendelenburg This technique is used for morbidly obese patients. This
position position may help lower posterior venous pressure by
reducing central venous pressure.

Anesthesia Rationale

Topical anesthesia Eye numbing drops are used by medical professionals

to block the nerves in your eye from feeling pain or
discomfort. These drops are considered a topical
anesthetic. They're used during eye exams and for
surgical procedures involving your eyes.

Retrobulbar anesthesia retrobulbar anesthesia (RBA) was the gold standard for
anesthesia of the eye and orbit.This injection provides
akinesia of the extraocular muscles by blocking cranial
nerves II, III, and VI, which prevents movement of the
globe. Retrobulbar block also provides sensory
anesthesia of the cornea, uvea, and conjunctiva by
blocking the ciliary nerves
Incision Rationale

Phacoemulsification, or A small incision is made on the side of the cornea, the

phaco clear, dome-shaped surface that covers the front of the
eye. The doctor inserts a tiny probe into the eye. This
device emits ultrasound waves that soften and break up
the lens so that it can be removed by suction. Most
cataract surgery today is done by phacoemulsification,
also called “small incision cataract surgery.”

Extracapsular surgery The doctor makes a longer incision on the side of the
cornea and removes the cloudy core of the lens in one
piece. The rest of the lens is removed by suction.

limbal incision Traditionally been used with an intracapsular or

extracapsular cataract extraction. The technique usually
involves the creation of a conjunctival flap exposing
underlying bare sclera.

scleral tunnel incision Created in response to the rapid advancements in

phacoemulsification, and offered cataract surgeons the
option of a surgical entry site that was more
astigmatically neutral and self-sealing

corneal incision The clear corneal incision is started immediately

anterior to the limbal arcades, and a shelved incision is
created until the anterior chamber is entered. The
incision can be created in a uniplanar, biplanar, or
triplanar incision; the formation is dependent on the
creation of an initial groove. These clear corneal
wounds usually are self-sealing, and do not induce
astigmatism as they heal.

Sutures Rationale

Interrupted Sutures The simplest and most common form of wound closure
is achieved with a single interrupted suture. The suture
is usually placed in a radial fashion perpendicular to the
cataract wound. While allowing for adequate closure of
today’s small incision cataract wounds, the major
disadvantage of this suture is the risk of inducing large
amounts of astigmatism given its perpendicular
orientation to the wound.

Corneal suture Corneal suture in cataract surgery is known as a

 significant factor for reducing post-operative
endophtalmitis but may induce a transitional corneal
astigmatism

Running sutures Most commonly used with large cataract incisions, as

seen in intracapsular or extracapsular cataract
extractions. These incisions are rarely seen in
phacoemulsification, but there remains the occasional
need for the closure of a large cataract wound, and the
running suture is ideal for this situation

infinity suture and horizontal each use suture placement in a horizontal fashion to
mattress technique provide wound apposition and theoretically less
induced astigmatism

Instruments Characteristics and Pictures

uses
Barraquer wire It is a universal
speculum speculum as can be
used for both eyes. It
is used to separate
eye lids for intraocular
surgery. Self retaining.
Light weight
USES- Intraocular
surgery-cataract
& glaucoma
surgery. Extraocular
surgery- squint &
pterygium surgery.
Superior rectus It is a forcep with a
holding forceps double curve at the
end(S shaped) It has
a single big tooth to
hold the superior
rectus muscle It has it
first angle at a
distance of 7.7 mm
Uses- Used to hold
the superior rectus
muscle for passing
bridle suture to rotate
the eyeball downward
in cataract and
glaucoma surgery. To
fix the eyeball during
surgery.
Kelman-
McPherson
forceps

These are fine forceps

with bent blade.
USES- Used to tear
off the anterior
capsule of lens in
cataract surgery. Used
to hold the IOL . Used
to hold the sutures.

Conjunctival It may be straight or

spring scissor curved with sharp or
blunt tip. It is a sleek
longer scissor. The
blade is kept apart by
spring action. USES-
Used to cut
conjunctiva to make
conjunctival flap.
Globe Fixation It has 2-3 or 3-4 teeth
Forcep at its tip. It is used to
hold the conjunctival
tissue and episcleral
tissue together.
USES- To hold the
conjunctiva for making
conjunctival flap with
use of conjunctival
scissor. To fix the
globe while making
tunnel with crescent.

Bard parker It is a handle in which

knife handle 15 number disposable
with blade blade is loaded if
cataract surgery is
done. It has a long
handle with groove at
its extreme end in
which blade is loaded.
USES- To make
corneo-scleral gutter
in cataract surgery.
Used in DCR , ptosis ,
entropion , ectropion
surgeries for incision
of skin.
It is blunt tipped which
Crescent Knife has a cut splittinf
action at the tip and
both the sides. The
blade is curved and is
mounted on plastic
handle. USES- It is
used to make self
sealing sclero corneal
tunnel after making
the scleral gutter in
cataract surgery.

Keratome
It has a thin diamond
shape blade with a
 sharp apex and two
cutting edge. This is a
curved disposable
keratome . Straight
disposable keratome
are also available.
USES- It is used for
making entry in
anterior chamber after
the tunnel is formed
Lens expressor
It has a flat corrugated
metal handle with
curved limb ending in
a knob which is at 90
degree USES- It is
applied at 6 o clock
position to deliver the
nucleus out.

Irrigation wire It is a modified vectis

vectis in whick loop is made
of hollow wire . It has
three 0.3 mm opening
. Posterior end of loop
is continuous with
hollow handle to which
infusion set is
attached. USES- It is
used to deliver
nucleus by introducing
this vectis from tunnel
and applying counter
pressure at 12 o clock
position.
Lens holding It is a spring action
forcep forcep. It have has
blunt curved blades.
They dont have tooth.
USES- It is used to
hold the non foldable
PMMA IOL during
implantation .

Sinskey hook or It is a pencil like

IOL dialer handle with thin neck .
The neck is bent in
between at 45 degree
. The tip is bent at 90
degree. USES- The tip
is engaged in the hole
present in optics of
PC-IOL and is used to
rotate it .

Vannas These are very fine,

scissors delicate scissors with
small cutting blades
kept apart by spring
action.

Types- 1) Straight 2)
Curved

Uses:

● To cut the
anterior
capsule of lens
in ECCE
● To cut the inner
scleral flap in
trabeculectomy
● To do papillary
sphincterotomy
● To perform
iridectomy
● To cut pupillary
membranes
Video on how this surgery is done : https://www.youtube.com/watch?v=6ItRIhiSg1Q

Post op Management:

1. Give medications prescribed by the doctor after surgery such as Ciprofloxacin

to prevent bacterial infections, Analgesics for pain and Acetazolamide to reduce
the amount of fluid in the eye, which decreases pressure inside the eye.

R: Following correct medications aids client for fast recovery.

2. Protective eye patch.

R: To prevent accidental rubbing or poking of the eye, the patient wears a protective
eye patch for 24 hours after surgery, followed by eyeglasses worn during the day and a
metal shield worn at night for 1 to 4 weeks.

3. Expected side effects.

R: Slight morning discharge, sone redness, and a scratchy feeling may be expected for
a few days, and a clean, damp washcloth may be used to remove slight morning eye
discharge.

4. Notify the physician.

R: Because cataract surgery increases the risk of retinal detachment, the patient must
know to notify the surgeon if new floaters in vision, flashing lights, decrease in vision,
pain, or increase in redness occurs.

Health teachings:
1.Do not lift heavy weights

R: Strenuous activity (like lifting something) can increase your eye pressure levels.

2. Do not stoop or bend over

R: Bending over will place pressure on the eye and this may cause unnecessary
complications to your eye. The main complication will be a delay in the healing
process.

3. Do not touch the operated eye with bare hands

R: Rubbing your eye can lead to bacteria or an infection, and the pressure is also bad
for the healing incision. Your eye may itch sometimes, but rubbing it will only make
things worse— you must resist the urge.

4. Avoid head bath. Bathe below the neck only.

R: It may cause infections.

5. Avoid dusty and crowded places.

R: To prevent accidental injury or contamination to the operated eye.

6. Usual diet may be continued after surgery. Avoid constipation by taking high
fiber diet and plenty of fluids.

R: Constipation causes unnecessary strain which may affect the operated eye.

7. In case of cough or constipation, consult physician for treatment. For any

other systemic problems, seek necessary medical treatment.

R: Because this can cause an increase in eye pressure. Notify your doctor if the
person coughs frequently.

8. You can use previous corrective spectacles. Use dark glasses outdoors. The
dark glasses should have closed sides.
R: To avoid any discomfort caused by the bright light and also to prevent any injury to
the eye.

9. Use an eye shield during sleep.

R: This helps to prevent accidental injury to his eye during sleep. Check with the
surgeon when the use of the shield can be stopped.

10. Have the eye cleaned by your attendant in the manner as shown by the
surgeon. Cleaning should be done twice daily.

R: Proper cleaning aids in fast recovery and prevents further infections.

11. Use the eye drops as prescribed.

R: They are usually for preventing infection and controlling eye pressure. Note that
some eye drops need to be kept in the refrigerator.

12. In case of persistent pain, sudden marked redness, excessive discharge, lid
swelling, sudden decrease in vision, call on your surgeon immediately.

R: To prevent complications immediately.

Complications

DEFINITION
Posterior capsule opacity One of the most common cataract surgery
(PCO) complications is a posterior capsule opacity (also
called posterior capsule opacification or PCO).

Although some people call PCO a "secondary

cataract," it really is not a cataract. Once a
cataract is removed, it does not come back.

During cataract surgery, your surgeon will remove

the cloudy natural lens of your eye (cataract) and
replace it with a clear intraocular lens (IOL)
implant. Much of the thin clear membrane that
surrounds the natural lens (called the lens
capsule) is left intact during surgery, and the IOL
usually is implanted within it.

When the cataract is removed, your surgeon

makes every attempt to maintain the integrity of
the lens capsule, and normally your vision after
cataract surgery should be very clear.

Intraocular lens dislocation

Another example of cataract surgery
complications is malpositioned or dislocated
intraocular lenses. You may see the edge of the
lens implant, or you may even develop double
vision. If the intraocular lens becomes too badly
dislocated, your visual acuity could decrease
substantially.
Eye inflammation · Endophthalmitis is inflammation of
intraocular contents of the eye. It is one of the
most feared complications of cataract surgery.
Although precautions are taken to prevent this, it
may occur after an uneventful surgery.

Photopsia (perceived
flashes of light) Seeing flashing lights in the eyes (photopsia) is a
symptom of various conditions, some of which
may be hard to diagnose. Photopsia may appear
suddenly and intermittently as flashes, zigzags,
dots or pinpoints of white light in your eyes. You
may also see flashes of light in other shapes or
colors.
Macular edema (swelling of
the central retina) Irvine-Gass syndrome, also known as
postoperative macular edema , is a common
complication of cataract surgery. (13) A prior
history of diabetes, retinal detachment, ocular
inflammation, retinal vein occlusion, epiretinal
membrane, and ocular prostaglandin use have all
been associated with an increased risk of macular
edema after cataract surgery

Ptosis (droopy eyelid)

Ptosis (pronounced “TOE-sis”) is drooping of the
upper eyelid of one or both eyes. The droopy
eyelid(s) may be barely noticeable, or the upper
lid may cover the entire pupil and interfere with a
person’s vision.

Ocular hypertension
(elevated eye pressure) Ocular hypertension means the pressure in your
eyes — your intraocular pressure (IOP) — is
higher than normal. Left untreated, high eye
pressure can cause glaucoma and permanent
vision loss in some individuals.
REFERENCES: (DILI PA FINAL)

Uttely, S.(n.d). Microsurgical Suturing Techniques: Closure of the Cataract Wound. Retrieved
Aril 14, 2021 from
https://www.ophed.com/system/files/2016/09/Macsai%20MST%20Chapter%204%20-
%20Cataract%20Wound.pdf

Oetting, T.(2016). Conversion to Extra-capsular Cataract Extraction (ECCE). Retrieved

April 14, 2021 from https://webeye.ophth.uiowa.edu/eyeforum/tutorials/Cataract-
ECCE/index.htm

https://www.youtube.com/watch?v=6ItRIhiSg1Q

American Academy of Opthalmology, 2017. Cataract Surgery Complications. Retrieved

on April 14, 2021. Retrieved from
https://eyewiki.aao.org/Cataract_Surgery_Complications

Health Net café, 2018. Specific Nurisng Care. Retrieved on April 14, 2021. Retrieved
from: https://www.healthnetcafe.com/content/specific_nursing_care/cataract.html

Rao,R. 2017. Instruments used in Cataract Surgery: Ready Reckoner for the Post
Graduates. Retrieved on April 14, 2021. Retrieved from:
http://www.eophtha.com/posts/instruments-used-in-cataract-surgery-ready-reckoner-for-
the-post-graduates

Medscape. 2021. What is the role of extracapsular cataract extraction in the treatment
of senile cataract (age-related cataract. Retrieved April 14, 2021 from
https://www.medscape.com/answers/1210914-161517/what-is-the-role-of-
extracapsular-cataract-extraction-in-the-treatment-of-senile-cataract-age-related-
cataract