The National Institute of Clinical Excellence (NICE) was originally set up in 1999 as a special health authority with the aim of getting rid of variation in the availability and quality of NHS treatments and care throughout the UK. In April 2013 NICE was established in primary legislation, becoming a Non-Departmental Public Body (NDPB) and placing it on a solid statutory footing as set out in the Health and Social Care Act 2012. The way NICE was established in legislation means the guidance it offers, for example on the management of eye disease, is officially England-only. However, we have agreements to provide certain NICE products and services to Wales, Scotland and Northern Ireland. Decisions on how our guidance applies in these countries are made by the devolved administrations, who are often involved and consulted with in the development of NICE guidance.

From the end of last year, NICE issued updated guidelines on the assessment and management (including referral) of glaucoma, cataract and age-related macular degeneration. Though these guidelines do not over-ride any protocols already established either at local or national level, they have been designed by health professionals to maximise efficiency of management by current professional services available and represent an accepted template upon which any local variations in protocol are adherent.

Cataract

A new NICE cataracts guideline came into effect on October 25, 2017. It is primarily for clinical treatments and surgery at ophthalmology level. There is an excellent summary and interpretation of the new guideline as it applies to optometrists that can be downloaded from the College of Optometrists website or the following link http://fplreflib.findlay.co.uk/images/pdf/optician/NICE-guidelines-cataracts-member-briefing.pdf 

Lens opacification occurs in every eye eventually. Unless other factors speed up the process, such as trauma, injury, radiation exposure or genetic and metabolic influences, the gradual yellowing or brunescence of the lens begins in our forties and opacities of the cortex, the nucleus and elsewhere manifest in subsequent decades. The rate of opacification varies greatly from person to person, as does the impact upon vision. Similarly, the morphology and therefore location within the lens of the opacification has a major influence on vison loss. For example, posterior subcapsular changes, often found in secondary cataract, not only lie on or near the visual axis but also closer to the point behind the lens where incident light crosses the axis to form the inverted image, and so might scatter light even at an early stage of development. Conversely, very dense central cataract, such as a congenital lamellar cataract, may look much more significant but only knocks out light close to the axis and may allow surprisingly good acuity.

Up until the last decade when local heath authorities started reviewing their budgets, practitioners would consider referral of a patient with cataract for possible extraction for the following reasons: if it was stopping them see what they wished to see and they wanted something done.

Referral might also be appropriate to recommend in the following cases:

  • If the reduced vision represented a possible cause of danger to the patient or to others (typically when driving, but also any impact upon some occupations, such as operating
  • machinery).
  • If the cataract prevented adequate view of the retina and such a view was essential, as for example in the case of a diabetic.
  • If a secondary cataract was suspected.
  • If evidence of secondary complications from the maturing cataract itself were found (such as significant angle narrowing and pressure rise).

As budgets tightened, some authorities introduced much stricter requirements for referral, mostly based around the drop in high contrast (Snellen) acuity. Sometimes, there were different acuity levels to be reached for referral of the second eye compared to the first and there was variation between different geographical locations as to what was acceptable to refer. According to NICE, such different local policies led to a reported threefold variation in the number of people having cataract surgery across different areas of England.

Many cataracts have significant impact on vision without a major impact on high contrast letters – for example those with early posterior subcapsular cataract often report disabling glare that prevents safe driving in some conditions while still maintaining reasonable high contrast acuity and so were ineligible for referral under some local guidelines.

The new NICE guideline emphasises that the majority of patients with symptomatic cataract will benefit from surgery, and importantly, delaying surgery until any chosen acuity threshold is reached is not cost effective. This applies to each eye considered for any individual patient.

The College summary states: ‘NICE concludes that, ultimately, decisions for referral and surgery should be via an informed discussion between clinician and patient. Consideration needs to be given to the balance between clinical measures and the personal circumstances of the patient, for example, for driving. The clinical measures to consider should include distance visual acuity and other indicators of visual function, and the clinical need for a clear fundus view (for diabetic retinopathy screening or the management over other ocular comorbidities).’

Points about Referral

The patient is at the heart of the referral decision process. Clinicians need to discuss cataract with each patient and such discussions should include:

  • How the patient is affected by their cataract.
  • Whether one or both eyes are affected.
  • The nature of the treatment after referral.
  • Implications of not being treated – which might be the patient’s choice.

How the referral is then undertaken may still vary from area to area, some via a traditional GP route, others via a dedicated direct referral or a pre-operative cataract assessment pathway. With the patient at the heart of the referral decision process, the NICE guidelines (and, indeed the GOC Standards of Practice guidelines) reinforce the importance of good quality information given in an understandable way to insure informed choice is always the outcome. To this end, patients must receive information about:

  • What cataracts are.
  • How they can affect vision.
  • How they can affect quality of life.
  • Details of cataract surgery: this includes what the surgery involves, post-operative considerations and timescale for recovery, and visual prognosis and future refractive correction.

More than ever, good quality information leaflets are an excellent idea here, such as those produced by bodies such as the College of Optometrists or the RNIB.

A useful discussion to the current changing approach to cataract referral can be found here https://www.opticianonline.net/features/nice-cataract-referrals

Once you have read through the source material, please attempt the 6 multiple choice questions.

Interactive Exercise

An interactive exercise may be completed online related to the NICE guidance revision.

Before you attempt the exercise, there are six multiple choice questions which assess an overall understanding of the NICE guidance. To ensure successful completion, the relevant documentation from NICE along with a summary interpretation of the guidance from the College of Optometrists are to be read first (links are available online).  

  • Remember there is no one single answer, but what is needed is a reflection of your discussion that is sufficient evidence of the various points having been covered.
  • Go to opticianonline.net and click into the CET zone where you can select this exercise.
  • Read the source material available.
  • Complete six multiple choice questions to confirm you have grasped the main concepts.
  • Read the case scenario about which you are to confer with a registered colleague (for at least 10 minutes please).
  • The exercise is designed for both optometrist and dispensing optician so please ensure your discussion is relevant to your own role and responsibility.
  • Confirm with us the name and GOC registration number of the colleague with whom you have discussed the case and also write some short notes on the outcome of your discussion.
  • At the end of the month’s active period we will confirm that your discussion outcome meets the requirement for an interactive point