12 Nursing Times 22.04.15 / Vol 111 No 17 / www.nursingtimes.

net 

By looking for early signs of cataracts when conducting holistic patient assessments, 
nurses can help affected patients manage any loss of vision until surgery is appropriate 
Nurses’ role in early detection of cataracts 
In this article... 
Prevalence rates of cataract Predisposing factors and early warning signs and symptoms Cataract 
symptoms and differential diagnoses 
Author Craig S (2015) Nurses’ role in early detection of cataracts. Nursing Times; 111: 17, 12-14. Abstract Cataracts are a 
common problem but can have a significant negative impact on an person’s functional abilities and emotional wellbeing. This 
article provides nurses with an insight into how age-related cataracts develop and clarifies which symptoms to look out for when 
conducting holistic patient assessments. Many symptoms go unnoticed for years but early detection could help patients learn to 
manage gradual loss of vision, thereby maintaining a good quality of life for C 
as long ataracts impact patients’ quality as possible. 
of on life. have independence NHS Despite a resources significant their high and and 
incidence, however, their impact is rarely considered outside ophthalmology. 
Minassian  et  al  (2000)  stated that in the UK adult population there were 225,000 new cases of visually impairing cataracts per 
year.  The  NHS  performed  345,038  proce-  dures to treat cataracts in 2012-13 (Health and Social Care Information Centre, 2014), 
with  a  further  20,800  performed  in  the  inde- pendent sector (HSCIC, 2012); the number of procedures rose the following year to 
371,240  (HSCIC,  2015).  Worldwide  it  is  estimated  that  18  million  people  are  “cataract  blind”,  representing  half  of  all cases of 
blindness (Lansingh, 2011). This article focuses on age- related cataracts and nurses’ role in their early detection. 
Pathophysiology of cataracts The lens is an asymmetric spheroid located 
Patients should be referred to an 
ophthalmic behind the iris in the anterior segment of 
unit in cases of suspected cataracts 

Nursing Practice Review Ophthalmology 

the eye that possesses no nerves, blood ves- sels or connective tissue. It has three parts: » An elastic capsule, made up of collagen 
fibrils that envelop the whole lens; » Lens epithelium, which is confined to 
the anterior surface; » Lens fibres, which make up the main 
mass of the lens. Over time, some lens fibres lose their nucli and start to produce crystallins; these water-soluble proteins are 
thought to increase the refractive index and transpar- ency of the lens (Yanoff and Duker, 2008). These crystallins concentrate 
over time in the central portion of the lens, increasing its density, making it less pliable. 
Impact of cataracts There are several cataract types (Table 1); with some, patients may have “normal” vision in certain light 
conditions despite having cataracts. However, visual impair- ment due to cataracts can reduce functional status and wellbeing to a 
degree comparable to those with a major medical condition (Chia et al, 2004). The decline in visual acuity is insidious and 
patients may not notice for some time; although it is likely to have been deteriorating for several years, they often report a sudden 
loss in visual acuity. 
Diminishing visual function can cause a range of problems. Patients may find it difficult to: » Recognise faces; » Watch 
television; » Read; » Drive. 
As  a  result,  leisure,  employment, activi- ties of daily living, socialisation and safety can be negatively affected. A diminishing 
appreciation of colours may also hinder contrast and affect employment. 
Keywords: Cataracts, Vision, Driving standards, Visual assessment 
#This article has been peer reviewed 
5 key points 1 Half of all cases of blindness in the world are attributable to cataracts 2 Women are much more likely than 
men to develop cataracts 3Cataracts can reduce a person’s ability to perform everyday tasks and negatively affect their 
quality of life 4As vision 
deteriorates gradually, many people have cataracts for years before they notice any loss of vision 5 Nurses in all 
settings can look for early warning signs and symptoms of cataracts 
 
Nursing 
For more articles on dementia, go to Times.net 
nursingtimes.net/cataracts 

Table 1. CommoN TyPes of CATArACTs 

and more densely than other types, with colour, contrast and acuity failing more 
Cataract type Main symptoms 
Nuclear sclerotic cataract 
rapidly. Jobling and Augustyen (2002) sug- 
Near vision can improve to begin with, patients can manage without reading glasses for a while. Distance vision worsens 
gested steroids do not directly act on the lens but affect the balance of ocular cytokines and growth factors, but the Cortical Light 
is scattered quickly throughout the lens, causing blurring of 
mechanisms are not fully understood. vision. Associated 
with glare, loss of contrast and depth perception 
Nurses should be mindful of the risk 
Posterior subcapsular 
of  corticosteroid-induced  cataracts  when  caring  for  patients  with  conditions  requiring  long-term  steroid  treatment  (Wang  et  al, 
2013), such as long-standing respiratory problems and inflammatory disorders like systemic lupus erythematosus. 
Smoking, alcohol and obesity There is conflicting evidence on whether there is an absolute link between cataract formation and 
smoking, alcohol con- sumption or high body mass index. Cum- ming and Mitchell (1997) demonstrated an increased link in the 
development of cata- racts in people who both smoke and drink alcohol. Kelly et al (2005) found a fourfold increase in the 
development of nuclear cat- aracts in smokers, but no link between passive smoking and cataract formation. 
Cumming and Mitchell (1997) reported that drinking alcohol in itself was not thought to cause cataracts; this was sup- ported by 
Klein et al (2003). However, Hiratsuka and Li (2001) noted that long- term habitual alcohol consumption, par- ticularly of spirits 
and wine, could be asso- ciated with cortical cataract formation. People with a high BMI are at increased risk of developing 
posterior subcapsular, cor- tical and nuclear cataracts (Hiller et al, 1998). The other conditions associated with smoking, alcohol 
and obesity may mean nurses are less likely to recognise if patients have poor visual acuity. Asking patients whether they have 
experienced any loss of vision while conducting the nurse assessment could help to identify those with cataracts at an earlier 
stage. 
Diagnosis Symptoms of cataracts develop gradually and painlessly, but can vary depending on the location, size and whether the 
patient has unilateral or bilateral cataracts (National Institute for Health and Care Excellence, 2010). Table 2 lists the main 
symptoms and diagnoses. 
Assessing visual function Assessment of visual function and confir- mation of cataracts to the exclusion of a differential 
diagnosis must be performed by a qualified professional. However, rec- ognising patients with a visual impair- ment is the first 
step to diagnosis; all More common in the younger age range. Haloes and glare common during dusk, dawn or night-time, 
especially when driving 
Post capsular Visual acuity is worse when the pupil is constricted, such as in 
daytime and when reading 
Axial An opacity on the visual axis in the lens 
Source: National Institute for Health and Care Excellence (2010) 
Patients’ safety can be compromised if 
 Gender they cannot see to avoid potential hazards, 
The prevalence of cataracts is higher in even in familiar environments. Davey et 
al 
women, with a female:male ratio of 1.22:1 (2011) noted that patients with 
cataracts 
(Royal College of Ophthalmology, 2010). who have had a procedure experienced 
fewer falls at home (18% compared with 
Diabetes 25% of those who have not had a proce- 
Diabetes is linked to a fivefold higher preva- dure), and fewer bone fractures (3% 
com- 
lence of cataracts (Obrosova et al, 2010). The pared with 12%); this clearly 
shows that 
risk of cataracts increases with the length of rehabilitation of vision from cataract 
sur- 
time patients have had diabetes and the gery has wider benefits for patients. 
severity of hyperglycaemia (Negahban and Some cataracts are associated with 
Chern, 2002). Transient loss or blurring of visual glare at dusk or dawn; this can 
make 
vision in patients with diabetes could result driving difficult or dangerous, putting 
from poor glycaemic control. Those with patients at risk of committing an 
offence if 
bilateral blurring of vision not known to they are unable to comply with the eye- 
have diabetes should have serum glucose sight requirements of the Road Traffic 
Act 
levels checked. 1988. They may lose mobility and inde- pendence by giving up 
driving. 
Sunlight In the UK, the only test of visual ability to 
A meta-analysis by Zigman (1993) found a be able to drive is the registration 
mark or 
link between excessive exposure to sunlight number plate test – drivers must be 
able to 
and cataracts, concluding that UVB radia- read a registration plate with letters 
and fig- 
tion is more likely to cause cataracts. Sev- ures measuring 79mm high and 57mm 
wide 
eral studies have confirmed this, including at a distance of 20.5m. This forms part 
of the 
Roberts (2011), who suggested people over practical driving test but a driver 
arrested on 
the age of 50 should wear UV protective eye- suspicion of driving without the 
required 
wear. The eyes should be protected when visual acuity may be required to take it 
– 
outdoors, especially on sunny days, by refusal to do so is an offence. Drivers with 
peaked or brimmed hats and/or sunglasses cataracts may not meet this legal 
standard, 
that meet British and European standard and any practitioner who suspects that a 
code BS EN ISO 12312-1:2013. This standard patient cannot do so should advise 
them to 
has a 0-7 category range, with 0 being no or have an ophthalmic assessment of 
their 
insufficient protection and 7 being full pro- visual fitness to drive via an 
optometrist or, 
tection. Lens tints are on a 1-4 range; 4 is the if in hospital, the hospital eye 
service. 
darkest and is not suitable for driving. 
Patients who have spent long periods in Predisposing factors 
hot, arid countries should, when com- Although age is a primary cause, aetiolog- 
plaining of gradual loss of vision, be ical epidemiological studies have identi- 
assessed for cataracts. fied a number of risk factors for cataracts. 
Prolonged steroid use Age 
The prolonged use of topical, inhaled and In the UK the average age of patients 
under- 
systemic steroids (usually in patients with going cataract procedures is 74 years 
(Health 
long-term conditions such as rheumatoid and Social Care Information Centre, 
2015). 
arthritis and chronic obstructive pulmo- Hammond et al (2000) estimated the 
herita- 
nary disease) is associated with axial cata- bility of age-related cataracts to be 
48-59%. 
racts, which tend to develop more quickly 
www.nursingtimes.net / Vol 111 No 17 / Nursing Times 22.04.15 13 
 
“You’ve Nursing Practice Review 
made a great choice to be a nurse but that is just the start of the 
journey” Michelle Mello p24 
Table of vIsIoN 
2. DIffereNTIAl DIAgNosIs of PAINless loss 
Symptom Differential diagnosis 
Difficulty reading Uncorrected refractive error 
Difficulty recognising faces Some types of corneal disease, eg Fuchs’ 
endothelial dystrophy 
Difficulty watching television Presbyopia 
Difficulty seeing in bright light Age-related macular degeneration 
Reduction in colour intensity Primary open-angle glaucoma 
Gradual reduction in contrast Chemicals or medication, eg methanol, 
chloroquine, hydroxychloroquine, isoniazid, thioridazine, isotretinoin, tetracycline or ethambutol and statins 
Frequent changes of spectacles 
Pituitary tumour and papilloedema (refractive change) 
(particularly if chronic) 
Double vision in one eye (monocular 
Chronic uveitis diplopia) 
Reduced need for reading glasses: 
Diabetic retinopathy cataract increases the converging power of the lens, making 
patients short-sighted 
Difficulty driving at night or in the day, due to glare 
» Tolerable refractive correction provides 
vision meeting the patient’s needs; » Surgery is not expected to improve 
visual function, and no other indication for lens removal exists; » The patient cannot safely undergo 
surgery due to coexisting medical or ocular conditions; » Appropriate post-operative care cannot 
be arranged; » The patient or surrogate decision 
maker cannot give informed consent for non-emergency surgery; » Indications for second-eye surgery are 
the same for the first eye (with consideration given to needs for binocular function). 
Conclusion Nurses in all settings can help identify patients experiencing loss of visual acuity and refer them to local ophthalmic 
services. This could increase the number of cataracts diagnosed at an early stage, allowing patients to be helped to access and 
develop skills to compensate for their reducing vision until surgery is appropriate. 
NT 
references British Standards Institution (2013) Eye and Face Protection: Sunglasses and Related Eyewear, Sunglasses for 
General Use. London: BSI. 
The The author author has has requested requested enhancement enhancement of of the the downloaded 
downloaded file. file. All All in-text in-text references references underlined underlined in in blue blue are are linked 
linked to to publications publications on on ResearchGate. ResearchGate. 
Diabetic maculopathy (type 2 diabetes may present with chronic visual loss from maculopathy) 
Reduced need for distance spectacles Long-sighted eyes may become focused 
in the distance as a result of myopia 
nurses can contribute to this by consid- ering visual acuity during holistic patient assessments. 
Patients who have difficulty reading, or who avoid reading, should be asked about their ophthalmic history, including: » 
Increasing frequency of changing lens 
prescription; » Changing to large-print books; » Loss of colour appreciation. 
If  visual  assessment  charts  are  unavail-  able,  ask  the  patient  to  read  a  newspaper  article.  If  the  patient could previously read 
text of that size but now cannot their eye- sight should be discussed further. 
If  visual  impairment  is  suspected  to  be  caused by cataracts, patients can be referred to a local ophthalmic unit for assessment; 
community  optometrists  can  also  refer.  Domestic visits from commu- nity optometrists and ophthalmic services are available for 
patients in long-stay set- tings or who find it difficult to leave home. 
Treatment Treatment is by surgical extraction of the cataract and insertion of an artificial intraocular lens. This is done only when 
vision loss affects the patient’s ability to function normally. The Royal College of Ophthalmology (2010) recommends sur- gery 
is not performed if: 
14 Nursing Times 22.04.15 / Vol 111 No 17 / www.nursingtimes.net 
Chia EM et al (2004) Impact of bilateral visual impairment on health-related quality of life: the Blue Mountains Eye Study. 
Investigative Ophthalmology and Visual Science; 45: 1, 71-76. Cumming RG, Mitchell P (1997) Alcohol, smoking and cataracts: 
the Blue Mountains Eye Study. Archives of Ophthalmology; 115: 10, 1296-1303. Davey CJ et al (2011) Assessment of referrals 
to eye hospital service by optometrists and GPs in Bradford and Airedale. Ophthalmic Physiology and Optometry; 31: 1, 23-28. 
Hammond CJ et al (2000) Genetic and environmental factors in age-related nuclear cataracts in monozygotic and dizygotic twins. 
New England Journal of Medicine; 342: 24, 1786-1790. Health and Social Care Information Centre (2015) Hospital Episode 
Statistics: Main Procedures and Interventions: 2013-2014. Leeds: HSCIC. Bit.ly/ HSCICProcedures13-14 Health and Social Care 
Information Centre (2014) Hospital Episode Statistics: Main Procedures and Interventions: 2012-2013. Leeds: HSCIC. Bit.ly/ 
HSCICProcedures12-13 Health and Social Care Information Centre (2012) NHS Hospitals: New Figures Suggest 11 per cent 
Increase in Procedures Carried out by Private Sector in a Year. Bit.ly/HSCICHospProcedures Hiller R et al (1998) A longitudinal 
study of body mass index and lens opacities: The Framingham studies. Ophthalmology; 105: 7, 1244-1250. Hiratsuka Y, Li G 
(2001) Alcohol and eye diseases: a review of epidemiologic studies. Journal of Studies on Alcohol; 62: 3, 397-402. Jobling Al, 
Augusteyn RC (2002) What causes steroid cataracts? A review of steroid-induced posterior subcapsular cataracts. Clinical and 
Experimental Optometry; 85: 2, 61-75. Kelly SP et al (2005) Smoking and cataract; review of causal association. Journal of 
Cataract and Refractive Surgery; 31: 12, 2395-2404. Klein BE et al (2003) Socioeconomic and lifestyle factors and the 10-year 
incidence of age-related cataracts. American Journal of Ophthalmology; 136: 3, 506-512. Lansingh VC (2011) Public Health and 
Cataract Blindness. San Francisco, CA: International Council of Ophthalmology. Bit.ly/ICOPHCataractPubHealth] Minassian 
DC et al (2000) The deficit in cataract surgery in England and Wales and the escalating problem of visual impairment: 
epidemiological modelling of the population dynamics of cataract. British Journal of Ophthalmology; 84: 1, 4-8. National 
Institute for Health and Care Excellence (2010) Cataracts. Bit.ly/NICECataracts Negahban K, Chern K (2002) Cataracts 
associated with systemic disorders and syndromes. Current Opinion in Ophthalmology; 13: 6, 419-422. Obrosova IG et al (2010) 
Diabetic cataracts: mechanisms and management. Diabetes/ Metabolism Research and Reviews; 26: 3, 172-180. Roberts JE 
(2011) Ultraviolet radiation as a risk factor for cataract and macular degeneration. Eye and Contact Lens; 37: 4, 246-249. Royal 
College of Ophthalmology (2010) Cataract Surgery Guidelines. London: RCOphth. Bit.ly/ RCOphthCataractGuide Wang C et al 
(2013) Dexamethasone influences FGF-induced responses in lens epithelial explants and promotes the posterior capsule coverage 
that is a feature of glucocortacoid-induced cataract. Experimental Eye Research; 111: 79-87. Yanoff M, Duker JS (2008) 
Ophthalmology. London: Mosby Elsevier. Zigman S (1993) Ocular light damage. Photochemistry and Photobiology; 57: 6, 
1060-1068. 
For more on this topic go online... Patient support to reduce risk of diabetic retinopathy Bit.ly/NTCataractrole