Page 58 - NAME OF CONDITION: REFRACTIVE ERRORS

*Situation 1: At Secondary Hospital/ Non-Metro situation: Optimal
Standards of Treatment in Situations where technology and resources

are limited

a) Clinical Diagnosis:
History:

Cataracts is an extremely common occurrence in the elderly. However, the key is to
determine whether the cataract is the cause of functional disability for an individual.
Careful history taking is important for assessing the quality of the visual impairment due to
this disability. Occupational and functional needs of the patients should be taken into
consideration before planning for surgical intervention.

History should also include ocular and systemic medications currently and previously used.
Medical history about systemic diseases is important. Patients should be asked about any
allergy to any food or medicine.

Ocular examination:

i. Presenting Visual acuity with and without present correction (if spectacle is available,
the power of the present correction should be recorded) is determined
In advanced and mature cataract, perception and projection of light should be tested
in all the four quadrants to rule out gross retinal problems.
ii. Measurement of best-corrected visual acuity (with refraction when indicated).
iii. External examination (lids, lashes, lacrimal apparatus, orbit).
Pressure should be applied over the sac to look for any regurgitation. If regurgitation is

positive or dacryocystitis is suspected syringing of naso-lacrimal duct should be carried
out. If duct is not free, with mucus or purulent discharge, dacryocystectomy or
dacryocystorhinostomy is done and cataract surgery is done after one month.
iv. Examination of ocular alignment and motility.
v. Assessment of pupillary shape, size and reaction: This is a very important step and
should be done very carefully, since it will help in determining the prognosis.
vi. Slit-lamp biomicroscopy of the anterior segment : Special emphasis should be made to
examine the corneal endothelium for any guttata, pupil for pseudoexfoliation and the
lens for any preoperative compromises on stability.

vii. Dilated Examination of the lens opacity may reveal the extent of visual impairment. For
example, opacity in the visual axis may cause more functional visual deficit than a
peripheral cataract posterior sub-capsular opacity may cause more symptoms of glare
than a nuclear cataract. It helps in grading nuclear sclerosis and reveals any
subluxation. Measuring amount of maximal dilation helps in planning the surgery.

58