Like buses, you wait the best part of 10 years for a NICE Guideline then two arrive almost at once. First cataract (October 26), then glaucoma (November 1). Forever tainted in the optical world, first for recommending antiVEGf treatment only if one eye left policy of its first ARMD guideline followed by naively failing to anticipate the referral consequences of the first glaucoma guideline, what’s the latest?
With a positive approach, what do the new Guidelines say, who are they aimed at and what do our professional bodies say? Are they consolidating or a catalyst for change?
First cataract. In all practical terms not much has been added since Action on Cataracts came out in 2000. This led to some of the first clear initiatives to use optometrists in pre-op and post-op care, largely bypassing the GPs who add little value to the process.
To my mind the most positive thing is reiterating the advice aimed at CCGs and commissioners that VA is not to be used as a criteria for making a decision on suitability for cataract surgery.
Unfortunately, CCG’s love thresholds and numbers, but there is no mention of an alternative method of visual function. Given the nature of the NICE process this indicates a very clear need for research looking to place contrast sensitivity and disability glare measures at the top of the agenda. This is ignored in favour of more research for Quality of Life assessments.
Fundamentally, cataract is a defect of ocular media and it is 50 years since the research papers of Campbell et al demonstrated the primacy of raised contrast thresholds. We are no closer to recognition of contrast sensitivity in ophthalmology or its use in HES clinics outside of low vision.
How many optometrists have referred patients with significant symptomatic disability glare, then being turned down in the HES? This problem doesn’t usually trouble experienced surgeons but junior doctors do not seem to be taught about contrast sensitivity.
It was interesting to see a recommendation against multifocal lenses which is understandable in the NHS but less so is the absence of recommendation regarding toric lenses. There is little mention of how important it is to manage post-operative anisometropia through prior planning. In particular the NHS seems incapable of planning closely timed sequential surgery in such cases (you could always cancel the second one if needed).
No mention is made of one of the biggest problems that optometrists have to handle. The low myope made emmetropic. Rarely happy and just not figuring in any post-op QoL studies the concept of leaving people with a low level of myopia never seems to figure in ophthalmology circles. To my mind leaving myopes overcorrected into low hypermetropia is a sin.
An anecdotal issue that has begun to surface in the literature is the concept of the wellness of the optical surface. There appears to be good evidence that cataract surgery on an eye with frank ocular surface disease leads to errors in algorithm, delayed recovery and patient dissatisfaction.
Perhaps by the next NICE Guideline there will be more evidence of this. Remember NICE Guidelines have a pretty long half-life (time taken to when 50% of CCG’s continue to ignore them) and research of high quality carries on being published regardless.
As far as the College is concerned the most important political point is that pre- and post-operative cataract care should be commissioned separately to the GOS. The systematic disregard of anything like a workable national GOS contract is the political scandal that underpins our sector.
Thus the College opinion is a clear red flag warning to those CCG’s who do not have a pre-op scheme (or those that do, seeking to downgrade it and pay nothing) that GOS should not be used to go beyond ‘the detection of signs’ and stray into criteria assessment, investigation and diagnosis. Similarly, far too many HES departments jealously hang onto post-op follow-up for no better reason than political control.
With regard to glaucoma it is a relief to see the guidance has extended to referral and case finding, a fundamental flaw that devalued the first glaucoma guideline. It remains important to note that the guidance is only with regard to COAG and does not include ACG, a point which can cause confusion. There is clear guidance that optometrists should not refer solely on IOP measures (except there are some cases, such as ACG, where the gathering of additional data is illogical and unnecessary).
However, this does not help the optometrist who has only GOS, cross-subsidy or a private fee to fall back on. Basic case finding via enhanced referral for glaucoma (and many other conditions) should be nationally contracted in England and not left to a patchwork of commissioned services.
It would have been nice for NICE to say this. All potential COAG referrals should surely include a full data set (including repeat measures). Optometrists working without a commissioned scheme should not be directly or indirectly criticised for a fictitious high false positive rate not as a result of their competence but of contractual failure not of their making.