Posted: October 8th, 2024

Cataract Formation and Associated Risk Factors in a 71-Year-Old Patient

Cataract Formation and Associated Risk Factors in a 71-Year-Old Patient.

Cataracts are a common ocular condition characterized by the clouding of the lens, leading to impaired vision. This paper examines a case study of a 71-year-old woman with bilateral cataracts, exploring the contributing factors, pharmacotherapy, and related health conditions. The analysis aims to identify risk factors for cataract formation and assess the patient’s overall health management.

Contributing Factors to Cataract Formation
Several factors contribute to the development of cataracts in this patient:

Age: The most significant risk factor for cataracts is age. As individuals age, the proteins in the lens can clump together, leading to cloudiness (Klein et al., 2018).

Hypertension: Chronic high blood pressure can affect ocular health, potentially accelerating cataract formation (Chua et al., 2019).

Diabetes Mellitus: The patient has type 2 diabetes, which is known to increase the risk of cataracts due to changes in lens metabolism (Lindblad et al., 2020).

Chronic Renal Failure: Associated metabolic disturbances can contribute to cataract development (Matsuo et al., 2021).

Steroid Use: Long-term use of prednisone for rheumatoid arthritis can lead to posterior subcapsular cataracts (Urban et al., 2022).

Smoking History: Although the patient quit smoking five years ago, her previous smoking history may have contributed to cataract formation (Kelly et al., 2019).

Hyperlipidemia: Dyslipidemia has been linked to an increased risk of cataracts (Klein et al., 2018).

Among these, age is the single greatest risk factor for cataract development.

Pharmacotherapy and Medical Conditions
The patient’s medications are aligned with her medical conditions:

Diltiazem, Furosemide, Clonidine: These are used to manage hypertension, which is not well-regulated as indicated by her blood pressure readings (170/105 mm Hg) (Chua et al., 2019).

ASA, Nitroglycerin: These medications are prescribed for coronary artery disease, not rheumatoid arthritis.

Nabumetone, Prednisone, Methotrexate, Folic Acid: These are used for rheumatoid arthritis management. Folic acid is taken to mitigate methotrexate’s side effects (Urban et al., 2022).

Atorvastatin: This is used to manage hyperlipidemia.

Laboratory Findings and Sensory Impairment
The laboratory results indicate chronic renal failure, with abnormalities in creatinine (9.1 mg/dL), hemoglobin (9.1 g/dL), hematocrit (27%), and blood urea nitrogen (72 mg/dL). These findings are consistent with her diagnosis of end-stage renal disease (Matsuo et al., 2021).

The “moderately subnormal sensation in the lower legs” is likely due to diabetic neuropathy, a common complication of diabetes mellitus (Lindblad et al., 2020).

Cataract Classification
The cataract in the left eye is likely subcapsular, given the patient’s symptoms of glare and halos around lights. The right eye’s cataract is more likely nuclear, as indicated by the progressive worsening of vision. Both cataracts are likely immature, as the patient still retains some vision (Klein et al., 2018).

Arteriolar Narrowing and Hypertension
The observed arteriolar narrowing during funduscopy is probably caused by chronic hypertension, which can lead to vascular changes in the retina (Chua et al., 2019). The patient’s hypertension is not well-regulated, as evidenced by her elevated blood pressure readings.

Conclusion
This case study highlights the multifactorial nature of cataract formation, emphasizing the importance of managing systemic conditions such as hypertension and diabetes to mitigate ocular complications. Further research and regular monitoring are essential for optimizing the patient’s health outcomes.

References
Chua, J., et al. (2019). The relationship between blood pressure and cataract formation. Journal of Hypertension, 37(3), 456-462.

Klein, B. E., et al. (2018). Age-related eye diseases and cataract formation. Ophthalmology, 125(5), 678-685.

Lindblad, B. E., et al. (2020). Diabetes and cataract risk: A population-based study. Diabetes Care, 43(2), 345-350.

Matsuo, T., et al. (2021). Chronic kidney disease and its impact on ocular health. Nephrology Dialysis Transplantation, 36(4), 789-795.

Urban, R. C., et al. (2022). Steroid-induced cataracts: Mechanisms and management. Clinical Ophthalmology, 16, 123-130.

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PATIENT CASE
Patient’s Chief Complaints
“My vision is getting worse in both eyes. Brighter lamps and the drops that were prescribed three months ago aren’t working anymore, and I think that I am finally going to need eye surgery.”

HPI
Dr. EGB is a 71-year-old white woman who has made an appointment with her ophthalmologist for further evaluation of her cataracts. She has a five-year history of gradual and progressive deterioration of vision in both eyes. The right eye is worse than the left. She reports that, even with a change in prescription for eyeglasses less than five months ago, “objects keep getting fuzzier. Far-vision is still relatively good in my left eye but near-vision has gotten noticeably worse. Near-vision is good in my right eye but far-vision is getting bad. My left eye is also susceptible to glare, and I see halos around lights with it.” The patient has been followed for some time for chronic renal insufficiency related to membranous nephropathy and is being treated with dialysis. She recently reported for her annual physical exam and was found to have gained 23 pounds in the last 12 months. She has a history of refractory hypertension that required multiple medications before BP was adequately regulated. She has a home BP monitor, but often forgets to perform her BP checks. Earlier today, her home BP measurement was 165/96 mm Hg.

PMH

ESRD (chronic membranous glomerulonephritis)
IV access difficulties
Anemia secondary to CRF
HTN
Hyperlipidemia
Type 2 DM—diet-controlled
AMI ×2; coronary artery angioplasty 9 years ago
Rheumatoid arthritis
S/P appendectomy
CASE STUDY: CATARACTS
For the Disease Summary for this case study, see the CD-ROM.

FH

Father had HTN and died from AMI at age 69; negative for cataracts
No information available for mother
One brother at age 64 is alive with HTN and DM
Has four daughters from previous marriage (all alive and healthy) and one son who committed suicide
SH

Divorced and remarried, lives with husband
Retired university professor and surgical pathologist; still writes textbooks
Smoker, quit 5 years ago, previously 2 ppd
Occasional glass of wine with dinner
No history of illicit drug use
ROS

States that overall she is “doing okay and holding her own, albeit not the best”
Unremarkable, except for vision problems at this time
Meds

Diltiazem CD 120 mg po BID
Atorvastatin 20 mg po QD
Furosemide 160 mg po QD
EC ASA 325 mg po QD
Prochlorperazine 10 mg po TID PRN
Nitroglycerin 0.4 mg SL PRN
Calcium acetate 667 mg 2 gel caps po PC
Nitroglycerin transdermal patch 0.4 mg QD at night with removal in AM
Acetaminophen 650 mg po QID PRN
Clonidine 0.2 mg po TID but not before dialysis
Nabumetone 750 mg 2 tabs Q HS
Prednisone 5 mg ½ tab po Q AM
Methotrexate 2.5 mg 6 tabs po once a week
Folic acid 1 mg po QD
Allergies

IV dye → worsened renal function (4 years ago)
Codeine intolerance → nausea and vomiting
Patient Case Questions

Identify seven contributing factors that have increased susceptibility to cataract formation in this patient.
Which of the seven risk factors that you listed above is the single greatest risk factor for cataracts?
Match the pharmacotherapeutic agents in the left-hand column directly below with the medical conditions in the right-hand column.
a. Diltiazem, furosemide, clonidine → coronary artery disease
b. ASA, nitroglycerin → rheumatoid arthritis
c. Nabumetone, prednisone, methotrexate → hyperlipidemia, folic acid
d. Atorvastatin → hypertension
Why is the patient taking folic acid?
PE and Lab Tests

Snellen Visual Acuity Examination
Right eye: 20/200
Left eye: 20/60
Swinging Flashlight Test
Positive each eye
Slit-Lamp Examination
Lid margins were without inflammation, each eye
Cornea clear and smooth, each eye
Lenses: opacity noted in center of right lens; opacity noted in back of left lens under the capsule
Iris round and without neovascularization or abnormality, each eye
Vitreous examination: clear, each eye
Color vision: WNL, each eye
Lens position: positive for subluxation, each eye
General

Obese white woman who appears her stated age and is in NAD
Vital Signs

BP 170/105 right arm, sitting
BP 165/103 left arm, sitting
P 86
T 98.4°F
WT 194 lbs
Skin

Warm and dry
Good turgor
HEENT

Eyes are negative for pain and redness
PERRLA
EOMI
Arteriolar narrowing on funduscopic exam
Negative for hemorrhages, exudates, or papilledema
Oropharynx clear
Oral mucosa pink and moist
Chest

CTA bilaterally
Cardiac

RRR
S1 and S2 normal
Negative for S3 and S4
Negative for murmurs and rubs
Abdomen

Obese, soft, and non-tender with no guarding
Bowel sounds present
Negative for HSM, masses, and bruits
Genit/Rect

Stool heme negative
MS/Extremities

Negative for CCE
Capillary refill <2 sec Age-appropriate strength and ROM Neuro A & O ×3 Moderately subnormal sensation in lower legs CNs II–XII intact Laboratory Blood Test Results Na: 135 meq/L K: 3.8 meq/L Cl: 102 meq/L HCO3: 23 meq/L BUN: 72 mg/dL Cr: 9.1 mg/dL Glu, fasting: 109 mg/dL Ca: 8.7 mg/dL Hb: 9.1 g/dL Hct: 27% Mg: 2.4 mg/dL Phos: 2.6 mg/dL Plt: 229 × 10³/mm³ Alb: 3.4 g/dL Patient Case Questions 5. Identify four abnormal laboratory blood test results that are consistent with a diagnosis of chronic renal failure. 6. Account for the “moderately subnormal sensation in the lower legs.” 7. Is the cataract in the left eye more likely to be subcapsular, nuclear, or cortical? 8. Is the cataract in the right eye more likely to be subcapsular, nuclear, or cortical? 9. Is the cataract in the left eye more likely to be mature, immature, or incipient? 10. Is the cataract in the right eye more likely to be mature, immature, or incipient? 11. What probably caused the “arteriolar narrowing” that was observed with funduscopy? 12. Is hypertension in this patient well regulated?

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Tags: Cataract Formation and Associated Risk Factors in a 71-Year-Old Patient, Cataracts, Chronic Renal Failure, Diabetes Mellitus, Hypertension