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Over the last decade, the Hospital Eye Service (HES) has undergone dramatic changes. In some cases these changes have been so rapid that individuals not directly involved with the HES may have unwittingly lost touch with current patient pathways and procedures.

If we are to have patients' best interests at heart then, as optometrists, we must be able to give appropriate advice and explanation as to what they might experience in the HES. It is imperative we keep up to date with patient suitability for referral and the actual surgical procedures, and also understand what the patient pathway is likely to be for individual procedures.

This article reviews the most common procedure carried out in the whole of NHS cataract surgery, and compares how the patient pathway has changed on Teesside over the past 10 years.

The South Tees experience

The South Tees Hospital Trust is based in Middlesbrough on Teesside and is the largest hospital trust in Europe. The following information is specific for the South Tees trust but it is not unreasonable to assume that the majority of hospital eye departments throughout the country have undergone similar changes in the last decade.

There have been a multitude of factors behind the changes in the patient pathway for cataract surgery. The major factor was government-set targets for a variety of issues, such as the number of operations carried out in one year and the drive for more day case surgery as opposed to overnight stays in hospital. This, in turn, promoted a greater call for local anaesthetic procedures as opposed to general anaesthesia. The incentive for the HES to meet these government targets was purely financial. Put very simply, if these targets had not been met the hospital trust involved would receive a considerable financial penalty. In addition to government targets, over the last decade there has obviously been substantial developments in the equipment and instrumentation used in hospital out-patient departments, ophthalmic theatres and patient wards which has influenced the changes in the patient pathway for cataract surgery. Surgical techniques have also developed and much more advanced surgical procedures and anaesthetics have emerged which, in turn, have led to safer and quicker surgery. In Middlesbrough, written patient surveys and discussions with patients have also influenced changes to the cataract pathway.

A decade ago, the majority of patients referred for cataract surgery did so either directly from their GP or from their optometrist via their GP. The waiting time 10 years ago between GP referral and the first HES appointment was often up to a year. The patient also had at least three different HES appointments - one to be assessed by the ophthalmologist and listed for surgery if appropriate, one to be assessed by the nursing staff for 'pre-assessment' (PAC clinic, Figure 1) and another to have A-scan biometry carried out. The waiting time between being listed for surgery and the actual operation could be up to 18 months. A few years ago the 'direct cataract referral scheme' was set up nationwide and this has gone some way to help refine patient referral into the HES. Patients are now being referred more appropriately for consideration for cataract surgery. Nowadays, if the referral letter for a patient states or implies that cataract is the sole cause of visual problem these patients are given an appointment for a 'one-stop cataract clinic'. These clinics are multi-disciplinary and are consultant-led. The patient is first seen by an ophthalmic nurse who measures visual acuity, carries out intraocular pressure measurements and, if appropriate, dilates the patient. The patient is then examined by an ophthalmologist, and in some HES units by an optometrist, and the patient is assessed to determine if surgery would be appropriate. If cataract surgery is felt to be appropriate the patient is made aware of the procedures involved and the risks and benefits. Also at this point a discussion is held between the patient and the staff member listing for surgery regarding a proposed planned post-operative refractive error. This is stated in the patient notes as to the power to 'aim for'. If the patient wishes to go ahead they are formally listed and sign a consent form. At the same appointment the patient undergoes 'pre-assessment' (PAC) where the patient's general health, medications and previous medical history are overviewed by nursing staff and any appropriate additional investigations such as blood pressure and ECGs are measured.

A-scan biometry is also carried out for both eyes and the intraocular lens type and power is calculated and noted for that particular patient and for the eye requiring surgery. There are a few occasions where the patient does not fall into a routine case for cataract surgery. For example, they may be highly myopic or hypermetropic and the intraocular lens power required may lie outside the usual dimensions for lenses in the standard IOL stocks. As such, calculating the IOL power required at this appointment allows enough time for any unusual IOL design to be ordered well before the date of surgery. At the end of this appointment the patient is usually given written information to re-emphasise the discussions during their visit and an appointment to come back for the surgery itself which is usually carried out within the following five weeks. Ten years ago there were three nurses staffing the PAC clinic for 18 patients, now there is one nurse and up to 20 patients per clinic. As is often the case in modern medicine, there has been a significant increase in the amount of paperwork required for each patient. For example, in addition to the usual consent forms and information leaflets other forms have recently been introduced which require each patient to be 'interviewed' regarding their and their family's past medical history with respect to CJD. This informs the medical staff and the infection control department within the trust if special precautions need to be taken with individual patients and equipment during and after surgery. One other modern data processing procedure that is viewed as vital by hospital trusts is the 'coding' of patient information. This must be diligently completed so that the hospital trust can get paid for the cataract operation by the correct PCT for each individual patient.

The direct cataract referral scheme has improved patient referral, but it is certainly true on Teesside that there is further room for refinement. Some patients referred by optometrists to the HES with cataract as the only cause of their reduced acuity are being found to have co-existing ocular disease which can make cataract surgery inappropriate.

Advances in anaesthetics have allowed the number of patients requiring general anaesthetic (GA) to be reduced considerably over the last 10 years. For example, during 1998 there were approximately 20 patients each month undergoing a GA for cataract surgery in South Tees Trust, today there are approximately six patients per month requiring a GA. Nowadays, patients are only listed for a GA if they are claustrophobic, if they cough when they lie down, have absolute fear of surgery, if they are confused or have learning difficulties or they are a child. Ten years ago all cataract patients undergoing a GA were kept in the hospital overnight for observation. Now no cataract patient regardless of the type of anaesthetic used is kept in the hospital overnight unless there is an exceptional clinical reason or the patient has had a GA and has nobody at home to be with them overnight.

In 1998 all the patients for the morning theatre session arrived at 8am and at 1pm for the afternoon session. This caused the patients at the end of the theatre list to have to wait for up to five hours in the eye ward before their operation. Again, following patient satisfaction surveys, this has changed and patients now have staggered arrival times for their operations. This has reduced the amount of time that a patient needs to wait in the day unit prior to surgery. Assuming an uncomplicated extraction, patients are in the hospital for between two and three hours on the day of surgery and are given tea, coffee and biscuits following the surgery. Ten years ago all the patients arrived at once, there was a five or six hour wait and they needed to be given sandwiches and drinks to help them achieve their wait.

Patient attire has also changed considerably during the last decade. In 1998 all cataract patients were required to undress and wear a theatre gown for surgery. Now patients are asked to arrive wearing a short-sleeved shirt or blouse which is buttoned at the front. This allows access to the patient chest should ECG leads be required and access to the arms to measure blood pressure or give intravenous injections if complications occur. The patient does not need to remove shoes in theatre, instead they simply wear overshoes, and they also wear a paper theatre hat. Patients are also asked not to wear necklaces or earrings as these can catch on the theatre drapes.

Ten years ago an ophthalmic surgeon in the South Tees Trust would have a typical operating list (for a whole morning or afternoon session) consisting of three cataract operations plus one other small procedure such as a straightforward eyelid operation. Currently, an ophthalmic surgeon can operate on nine cataracts per theatre list. During February 1998 there were a total number of 119 cataract operations carried out in South Tees Trust as opposed to 320 during February 2008.

Disposable instruments

As mentioned previously, the work carried out in the anaesthetic room has undergone transformation during the last decade. Ten years ago there were no disposable instruments, all surgical instruments and anaesthetic devices were multi-patient use and all sterile instruments were laid covered on shelves in a cupboard ready for use. The well documented concerns about cross patient infection and the particular issue of CJD has led to the development of disposable instruments in ophthalmic theatres. A large number of surgical instruments and anaesthetic devices are now disposable and are incinerated following use on one patient, but some instruments cannot be made in a disposable form. These items are kept sterile wrapped in a sterile tray in the eye theatre and each individual instrument is colour and number coded to allow tracing if required following any surgical procedure. For each cataract operation the individual code number of all instruments used is written down in the patient notes. Following the surgery the instruments are wrapped and sent to the hospital sterile services division for full sterilisation. Once this is complete they are returned for sterile storage. Supplementaries used in a cataract operation, such as cannulas, pads, gauze, syringes etc, are sealed in separate packs and opened just prior to the surgery. All manufacturers' stickers on these packs which include lot numbers and type of item in the pack are put in the patient notes and kept for tracing purposes.

For a GA case 10 years ago an endotracheal tube was used and this was fed into the patient's mouth and into the trachea. In some cases this caused patients to have a sore throat following surgery in addition to a sore eye. Nowadays, a laryngeal mask is placed into the patient's mouth and it sits over the top part of the larynx. This causes very little postoperative discomfort. The recovery time of a patient following a GA 10 years ago was commonly 25 minutes. Nowadays, due to the development of quick acting and reversing drugs, the patient recovery time is about 15 minutes. In addition, the number of anaesthetic nurses in theatre has now doubled to two for each operating list and this has significantly speeded things up in theatre.

A modern introduction to cataract surgery under local anaesthesia (LA) is the use of povidene iodine. This is dropped onto the cornea while the patient is in the anaesthetic room prior to any anaesthetic block. Povidene iodine has been shown to significantly reduce the risk of intraocular infection. LA cases 10 years ago involved sharp needle blocks such as peribulbar and retrobulbar injections. These were potentially dangerous procedures because the depth of the injection required with the sharp needle could cause damage to ocular structures. Now all LAs involve subtenons injections which are blunt needle blocks, these are much safer because the needle is not sharp and is much shorter than required for peribulbar and retrobulbar injections. Some surgeons now prefer to carry out cataract surgery under topical anaesthesia only. In these cases proxymetacaine and tetracaine are used in the form of eye drops only - no injections are required. This technique has obvious benefits for all involved. The patient has no injections or general anaesthetics in their system and they have no postoperative diplopia or eyelid dysfunction which are common after LAs so their procedure and recovery is more straightforward. The hospital and patient also benefit because the anaesthetic risk is much reduced using topical eye drops and more operations can be carried out in the same time interval compared to other types of anaesthesia. However, the patients chosen for topical anaesthesia must be carefully selected as they must be relied upon to be cooperative throughout surgery, any sudden physical moves could be disastrous. Figure 2 shows retrobulbar and subtenon's needles and the topical medication used in cataract surgery.

Ten years ago the majority of cataract operations in South Tees were extracapsular, each procedure lasted about an hour and a rigid PMMA intraocular lens was used as an implant. Due to the large diameter of the rigid intraocular lenses this type of surgery necessitated a large incision, and each eye required a minimum of four corneal sutures and sometimes a continuous suture at the end of the operation. These sutures commonly caused large amounts of postoperative astigmatism. To determine whether any sutures needed removing a refraction was carried out by the hospital optometrist three weeks after surgery. The eye shown in Figure 3 has five interrupted sutures following extracapsular cataract surgery. For this particular patient the sutures induced 16 dioptres of astigmatism (plus cylinder axis at 90°). If significant suture-induced astigmatism was found the sutures could be removed at an out patient appointment. However, a continuous suture had to remain in the eye for a minimum of three months following surgery. Obviously, this caused an time delay between surgery and the final postoperative refractive state of the patient. In some cases the patient underwent three months of uncorrectable vision. However, for some eyes even though the sutures had been removed completely, the eye continued to exhibit significant astigmatism which was not present prior to surgery. This could be several dioptres and at an axis different to that preoperatively. These patients were renowned for having better postoperative acuity but were non-tolerant to their postoperative glasses correction. Currently, all routine cataract patients are listed for a phacoemulsification technique which lasts about 15 minutes and a foldable acrylic intraocular lens is used. Because the incision is very small it is rare for sutures to be required. As such, it is very unusual for a patient to have any surgical-induced astigmatism and visual recovery following surgery can be immediate without any non-tolerances.

The cost of surgical equipment for cataract surgery has obviously increased over the last 10 years. Ten years ago a set of instruments required for one cataract operation cost about £100 and all these instruments were reusable. Now the cost of the disposable instruments for each operation is approximately £225 and a set of reusable instruments is about £3,240 (which includes an approximate 20 per cent repair/replacement cost). Additional costs are also involved, such as the cost of drugs used, drapes, swabs, pads, cannulas, staff costs including the surgeon, anaesthetist, nurses and other ophthalmic staff.

Ten years ago each cataract patient was required to re-attend the hospital the day following surgery for post-operative checks. These checks included changing the eye dressing, measuring acuity, carrying out a slit-lamp examination and taking another opportunity to reinforce the use of postoperative eye drops. However, following extensive audits in South Tees it was decided in 2002 that there was no clinical reason for this appointment unless there had been an unusual occurrence during surgery. Patients are now verbally instructed and have written information explaining that should they have any concerns they must telephone the ophthalmic day unit and they will be required to attend the unit if thought appropriate the day following surgery. The patient is also given a bottle of postoperative eye drops (usually betnesol N) with instructions. As a rule of thumb, the patient needs to continue to use these drops until either they have their first postoperative visit to the hospital or they run out of the drops. A decade ago all patients wore an eye pad and shield to leave the hospital and they needed to continue to wear the shield for some days. Nowadays, patients leave the day unit with a clear shield, which they need to wear overnight only for the first week postoperatively.

The patient is given a letter to take to their community optometrist requesting that an eye examination is carried out. If the patient is under 60 years old they are given a standard HES1 form to give to their optometrist. If all goes to plan, the patient arrives at their first out-patient appointment with a copy of the post-operative refraction and acuities. This out-patient appointment is usually at two to three weeks following surgery. The ophthalmologist, or optometrists in some units, examines the eye for any intraocular inflammation, checks that the postoperative acuity is what was expected and either lists the patient for surgery on their second eye or discharges them back to their GP. If the postoperative acuity is less than expected the patient's pupils are re-dilated and further investigation is carried out.

There are obviously some cases that turn out to be technically complicated and there may be an uneventful occurrence during the surgery itself. All these cases and those where it is known prior to the surgery that the patient will have a poor visual outcome (eg those where age-related macular degeneration co-exists) are refracted by the hospital optometrists on the same day as the first postoperative out-patient appointment.

Although this article is based on what happens in the South Tees Hospitals Trust most other eye units follow similar pathways and procedures. However, there are some variations some units do not have one-stop cataract clinics, some have ophthalmic theatres totally dedicated to cataract surgery and some out-patient follow-ups may be slightly different. Nevertheless, it is clear that cataract surgery has made considerable advances over the last decade. The patient wait for surgery is now significantly shorter, the procedures involved are less traumatic and the patient recovery time is much shorter.

There is no doubt that the quality of life of the ageing population has been improved by these advances. This could not have been achieved without all hospital ophthalmic staff being prepared to work as a team and to undergo extensive and additional training to introduce these improvements for patients.

Acknowledgements

The authors would like to thank David Smerdon, consultant ophthalmic surgeon, for providing Figure 3, and the staff in the Department of Ophthalmology at James Cook University Hospital for their co-operation.

● Dr Janet English is principal optometrist, Sue Puckering ophthalmic ward manager, and Eileen Truman ophthalmic theatre manager, at The James Cook University Hospital, Middlesbrough

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