Cataract is defined as opacity within the clear natural crystalline lens of the eye.12 The word derives from the Greek ‘cataractis’ which means ‘waterfall’, due to its resemblance to the turbulent water of a waterfall. The WHO (2017) estimated cataract accounts for 25% of moderate to severe vision impairment and 35% of blindness worldwide.11
Impact of cataract
Risk factors for cataract include increasing age, diabetes, corticosteroid use, female gender, socio-economic status, ethnicity, smoking and alcohol.1 The pathophysiology of cataract varies by type although it is thought to be related to oxidative stress and metabolic changes which affect the structure of lens crystallins.12
Although some antioxidants might delay cataract formation,12 surgery remains the only method of treatment. Cataract surgery is the commonest operation performed in the UK and Europe13 with approximately 400,000 procedures performed each year in the UK.2 It is one of the most cost-efficient surgeries in the NHS,5,9 (current NHS tariff is £789 17) and demand is likely to increase by around 50% over the next 20 years due to an aging population.10
Cataracts can cause a range of symptoms including blurred vision, reduced contrast sensitivity, diplopia and disabling glare.5 This can stop patients from working or driving5 (despite meeting the DVLA’s visual acuity standards4) and can limit the ability to lead an independent life and care for others,2 thus increasing levels of depression and anxiety.2,10 Cataract has also been shown to double a patient’s risk of having a fall.2,5
Following the economic downturn in 2008 and the financial constraints placed on the NHS, many CCGs restricted access to treatments which were deemed to be of ‘limited value’ and visual acuity (VA) thresholds were introduced for cataract surgery.1 Visual acuity thresholds can be used by a range of health care providers and offer several advantages such as aiding clinical decision making, allowing for easier patient counselling and reducing unnecessary referrals.
Nevertheless, many clinicians, researchers and professional bodies objected to restricted access to cataract surgery on the basis of visual acuity13 since VA in isolation can underestimate visual disability1 (as described above) and because such policies will increase health inequalities of access8 (which commissioners have a duty to reduce) and create long-term financial and resource impact on primary, social and community care systems.2,5,10
In the absence of NICE guidance, commissioners make funding decisions based on an assessment of the available evidence; this resulted in a wide variety of CCG commissioning policies across the country.1 In a 2017 survey, cataract policies in England were found to range between no restriction and VA thresholds of 6/18 or worse; restrictions for second eye surgery were even stricter with some thresholds of 6/24 or worse.2
The benefit of second eye cataract surgery may be limited24 but in some cases it may be nearly as beneficial as surgery on the first eye6 with improved stereopsis1 and a reduced risk of falls or other accidents.5 Several symptoms and clinical indications (table 1) were accepted in approximately 50% of cases which did not meet the VA threshold but often required an application for funding, as described below.2
Table 1: Examples where cataract surgery might be indicated despite good visual acuity
To manage other co-existing ophthalmic conditions
- Glaucoma – to control IOP
- Medical retina eg diabetes, CRVO, AMD – to aid investigation and management
- Neuro-ophthalmology eg field defect – to aid investigation and management
- Corneal disease eg Fuchs/post keratoplasty – to reduce the chance of losing corneal clarity
- Corneal/conjunctival disease eg cicatrising – to reduce the risk of complications caused by delays
- Oculoplastics – if the ‘good’ eye requires surgical closure
- To manage symptoms/impaired QOL
- Significant risk of falls
- Significantly impaired ability to work
- Significantly impaired ability to drive
- Significantly impaired ability to undertake leisure activities (eg read, watch TV or recognise faces)
- Significant glare and dazzle in daylight or having difficulties with night vision
- Significant anisometropia causing BV problems/marked refractive non-tolerance
Studies have consistently shown that decisions on the need for cataract surgery should be based on levels of visual functioning and quality of life, not just visual acuity,6 so that patients are given the best and most appropriate care9 for their clinical situation.2 Best practice is to offer treatment for cataract if it is affecting sight and having a negative impact on quality of life.2,7 Also the patient must understand the risks2/benefits of surgery, agree to surgery and be fit enough for it.7 Few of these factors were considered in many CCG policies.
NICE Guidance 2017
In October 2017 NICE published NG77 ‘Cataracts in adults: management’;14 this was conveniently summarised in the College of Optometrists’ member briefing.15 Much of NG77 is beyond the scope of this article since it discusses the pre, intra and post-operative appointment, however, it is clear that access to cataract surgery should not be restricted on the basis of visual acuity.
Referrers are now advised to discuss how the cataract affects the person’s vision and quality of life, whether one or both eyes are affected, possible risks and benefits of surgery (providing appropriate literature) and whether the person wants to have cataract surgery. These factors are consistent with best practice (described above) and should therefore be recorded in the clinical notes and referral.
Despite commissioners’ responsibility to apply NG7715 and access to a variety of standardised commissioning frameworks and tools,3 providers are still being asked to restrict access to surgery based on visual acuity thresholds.2
As telemedicine triagers, my colleagues and I often see cataract referrals requesting ‘patient to be seen in accordance with NICE guidelines’ which are subsequently rejected because the VA is outside the CCG’s threshold. It is likely to take some time until CCGs revise their cataract threshold policies to align with NG77 and in the interim we must remember that the CCG are funding the surgery therefore we must continue to follow their criteria, so all referrers should be familiar with local threshold policies (CCG’s website).
In an attempt to avoid delayed access to cataract surgery for symptomatic patients who need it,1 clinicians may apply for funding through an Individual Funding Request form (IFR). These are used where a particular treatment that is not routinely offered by the NHS (in this case because the VA criteria are not met) is appropriate for the patient given their individual clinical circumstances.2 It is likely that NG77 will add significant credibility to an IFR although the process does add an administrative burden. It is anticipated that fewer IFR’s will be made when the CCGs update their policies.
In a cataract patient with good preoperative VA the risk of worse visual acuity after surgery increases, so surgery should be considered only where the patient is highly symptomatic.1 In such cases, clinicians might wish to quantify the impairment in visual function with a questionnaire (eg ADVS or VF146) or through other methods which are beyond the scope of this article,18 including devices which measures ocular scatter.16 Some CCGs use a weighted scoring system to establish the effect a cataract has on QOL.20
Direct referral schemes involving accredited optometrists19 have been widely supported by professional bodies7 and often attract an additional fee. Some optometrists might expect additional funding if they are to include the information suggested by NG77 in a conventional (non-direct) referral.
One might argue that including a patient’s symptoms in a referral along with which eye you are referring for and if the fellow eye is pseudophakic constitutes good practice. In order to refer someone for cataract surgery there should be informed consent which would require a discussion of the procedure/risks and it is a waste of resources to refer a patient for surgery who does not want it. Therefore, the only ‘extra’ information suggested in NG77 is the impact of the cataract on quality of life.
Some CCGs require evidence of the patient’s smoking status and will only accept a referral for elective surgery if smokers have attended a smoking cessation service.22 Irrespective of the presence of cataract, optometrists should routinely ascertain a patient’s smoking status and advise them to contact a smoking cessation service.23
There are numerous patient and clinician resources available relating to cataract surgery.1 The decision to refer should involve shared decision-making with patients and their families or carers.2 The NHS has produced a decision aid to help patients decide if they want to proceed with cataract surgery21 and some CCGs require a seven-day ‘cooling off period’ so patients have sufficient time to carefully consider their decision.
A simple pro forma (figure 1) has been provided to assist referrers7 in efficiently meeting the recommendations and to promote the sharing of good practice19 with a view to improving referral and outcome quality. Please note that this does not supersede existing direct referral forms and is not suitable for use where there are co-morbidities which might reduce the degree of improvement following cataract extraction; these are usually assessed prior to referral for cataract surgery.6
Figure 1: A simple cataract referral pro forma
The publication of NG77 has paved the way for a more standardised approach to CCG thresholds for cataract surgery which focus more on symptoms/QOL and less on rigid high-contrast VA measurements. This has the potential to benefit a sizeable cohort of symptomatic patients who might otherwise have been denied access to cataract surgery. Referrers must now demonstrate to commissioners and providers that they can supply the recommended clinical information and continue to practice to evidence-based standards.
Commissioners are in the process of revising their outdated cataract policies so IFRs are still likely, in the short-term, to be required for a proportion of symptomatic cataract patients who do not meet current CCG thresholds. Good quality appropriate referrals will give commissioners confidence in implementing new evidence-based policies for our patients’ benefit.
The cataract referral form can be downloaded from www.evolutio-uk.com/how-to-refer, and is embedded into Evonnect, Evolutio’s secure digital referral management software. Evolutio also provide an ‘ophthalmology referral guidance’ document listing over 120 ophthalmic conditions organised by sub-speciality with proposed referral urgency and suggested clinical investigations.
Christian Dutton and Peter McElduff are clinical optometrists and referral triagers for Evolutio. Lyn Price is clinical lead optometrist and Mr Simon Hardman-Lea is clinical lead ophthalmologist.
References
1 Royal College of Ophthalmologists (2018) ‘Cataract Commissioning Guidance’ [online] www.rcophth.ac.uk/wp-content/uploads/2018/02/Catar... (Accessed 20/04/18)
2 Royal College of Ophthalmologists (2017) ‘66% of Clinical Leads surveyed by the RCOphth confirm cataract rationing is restricting access to surgery’ [online] www.rcophth.ac.uk/2017/11/cataract-rationing-surve... (Accessed 20/04/18)
3 Clinical Council for Eye Health Commissioning (2017) ‘System and Assurance Framework for Eye-health (SAFE) – Cataract’ [online] www.college-optometrists.org/asset/34295ADE-8FA3-4... (Accessed 20/04/18)
4 Driver and Vehicle Licensing Agency (2017) ‘A guide to the standards of vision for driving cars and motorcycles (Group 1)’ [online] assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/621557/inf-188X1-standards-of-vision-for-driving-cars-and-motorcycles-group-1.pdf (Accessed 20/04/18)
5 Royal College of Ophthalmologists (2013) ‘Eye health professionals raise alarm over reports of growing number of patients denied cataract surgery’ [online] www.rcophth.ac.uk/2013/01/eye-health-professionals... (Accessed 20/04/18)
6 NHS Centre for Reviews and Dissemination (1996) ‘Management of cataract’ Effective Health Care Bulletin, 2 (3) pp. 1-12
7 Department of Health (2000) ‘Action on Cataracts Good Practice Guidance’ [online] www.rcophth.ac.uk/wp-content/uploads/2015/03/Actio... (Accessed 20/04/18)
8 Royal National Institute Blind and Royal College of Ophthalmologists (2011) ‘Don’t turn back the clock: Cataract surgery – the need for patient-centred care’ [online] www.rcophth.ac.uk/wp-content/uploads/2014/12/2011_... (Accessed 20/04/18)
9 Royal College of Ophthalmologists (2015) ‘RCOphth concerned at the continued restriction of second eye cataract surgery by CCGs’ [online] www.rcophth.ac.uk/2015/12/rcophth-is-concerned-at-... (Accessed 20/04/18)
10 Royal College of Ophthalmologists (2016) ‘Cataract surgery must be determined on clinical need and not rationed due to funding restrictions’ [online] www.rcophth.ac.uk/2016/08/cataract-surgery-must-be... (Accessed 20/04/18)
11 World Health Organisation (2017) ‘The causes of visual impairment’ [online] www.who.int/mediacentre/factsheets/fs282/en/ (Accessed 20/04/18)
12 Nartey, A. (2017) ‘ MedCrave – The Pathophysiology of Cataract and Major Interventions to Retarding Its Progression: A Mini Review’ Advances in Ophthalmology & Visual System, 6 (3)
13 Eurostat (2017) ‘Surgical operations and procedures statistics’ [online] ec.europa.eu/eurostat/statistics-explained/index.php/Surgical_operations_and_procedures_statistics (Accessed 20/04/18)
14 NICE (October 2017) ‘Cataracts in adults: management - NICE guideline [NG77]’ [online] www.nice.org.uk/guidance/ng77 (Accessed 20/04/18)
15 College of Optometrists (2017) ‘NICE guideline Cataracts in adults: management - A briefing for members of the College of Optometrists’ [online] www.college-optometrists.org/asset/7530F77F-0D12-4... (Accessed 20/04/18)
16 Visiometrics (2017) ‘HD Analyzer overview’ [online] www.visiometrics.com/hd-analyzer/#overview (Accessed 20/04/18)
17 Roberts, H. Ni, M. O'Brart, D. (2017) ‘Financial modelling of femtosecond laser-assisted cataract surgery within the National Health Service using a ‘hub and spoke’ model for the delivery of high-volume cataract surgery,’ BMJ Open, 7:e013616. doi:10.1136/bmjopen-2016-013616 (Accessed 20/04/18)
18 Frost, N. (2001) ‘The Role of Vision Tests in Clinical Decision Making about Cataract Extraction’ Optometry in Practice, 2 (2) pp. 71-77
19 Amin, M. Edgar, D. Parkins, D. & Hull, C. (2014) ‘A survey of local optical committees (LOCs) involved in cataract pathways within the London region’ Optometry in Practice 15 (1) pp. 29–38
20 Ipswich and East Suffolk CCG and West Suffolk CCG (2013) ‘T11a Cataract Surgery (Primary Care referral)’ [online] www.westsuffolkccg.nhs.uk/wp-content/uploads/2013/... (Accessed 20/04/18)
21 NHS Choices (2017) ‘Cataract surgery’ [online] www.nhs.uk/conditions/Cataract-surgery/Pages/Intro... (Accessed 20/04/18)
22 North East Essex Clinical Commissioning Group (2017) ‘Clinical Priorities Policy’ [online] www.neessexccg.nhs.uk/uploads/files/Clinical%20Pri... (Accessed 20/04/18)
23 Painter, J. & Crossland, M. (2006) ‘Smoking, Eye Disease and Smoking Cessation Strategies’ Optometry in Practice, 7 (4) pp. 147–154
24 Foss, A. Harwood, R. Osborn, F. Gregson, R. Zaman, A. Masud, T. (2006) ‘Falls and health status in elderly women following second eye cataract surgery: a randomised controlled trial’ Age Ageing, 35 (1) pp. 66-71
