Dr. Shanu Subbiah Registrar Ophthalmology Royal Victoria HospitalBelfast Trust

Clouding of the natural lens Causes include trauma, genetic,

systemic and inflammatory diseases Commonest cause is age related Approximately 300,000 cataract

extractions carried out in UK per year Belfast Trust surgery carried out at

two sites 6000 cataract procedures RVH 64% (2008 - 2009) MIH 36% (2008 – 2009)

Clouding of the natural lens Causes include trauma, genetic,

systemic and inflammatory diseases Commonest cause is age related Approximately 300,000 cataract

extractions carried out in UK per year Belfast Trust surgery carried out at

two sites 6000 cataract procedures RVH 64% (2008 - 2009) MIH 36% (2008 – 2009)

Surgery carried out by Consultants and trainees 17 “career grade” trainees in NI Audit (2008-2009) has confirmed that

quality of surgery meets “Gold Standard” of 1997-1998 UK National Cataract Survey

87% procedures performed by consultants 13% junior grade

Annual Audit

Common As with any condition almost definate

under-reporting (Chris Grayling)▪ North London Eye Study. Estimated 2.4

million people in England and Wales aged >65 have visually impairing cataract in one or both eyes1

▪ Equates to approx 75,000 people in Northern Ireland over >65 years with visually impairing cataract in one or both eyes2

▪ 16% 65-69 year age group1

▪ 59% 80 to 84 year age group

Somerset and Avon Eye Study suggests the backlog figure for England is closer to 350,000 in over 55 years of age (used best corrected acuity – a good pair of glasses)3

▪ Equates to approx 12,000 in Northern Ireland MRC suggests in >75 years in UK visual

impairment due to cataract is 12% (VA <6/18)4

Over 30% of patients over 70 yrs with cataract also have other pathology Diabetic retinopathy, Age related

macular degenerationSurgery is not “simple”

Complications include blindness, further surgery, worse vision after surgery

Long training schemeLife changing event for patients

13 weeks

13 weeks4 weeks

1 day

2 weeks

Multi-professional patient centred process involving ophthalmologists, optometrists, GPs and nurses

Ultimate responsibility for diagnosis and management lies with ophthalmologist in charge.

Decision to proceed with surgery is made by the patient in discussion with the ophthalmologist

Referral initiated by GP or optometrist5

Whatever the method of referral The patient should have sufficient cataract to

account for the visual symptoms The cataract should affect the patients lifestyle Risk/ benefits should be discussed The patient should wish to undergo cataract surgery This information together with a report from a recent

sight test should form the minimum data on the referral

Rates of surgery slightly higher with optometric referall7 Referral information varied depending on whether GP or

Optometrist referral (better operative counselling)

Purpose of out-patient appointment Confirm the diagnosis is visually significant cataract Ensure that cataract is cause of visual symptoms Determine if there is co-existing pathology and if

patient is fit for surgery Ensure patient wishes to have surgery and

understands risks Formulate surgical and care management plan –

This is refractive surgery and there are potentially large gains in QALY

20 minutes

Remember the responsibility for patient management lies with the ophthalmologist

Carried out by Nurse Specialists▪ Detailed documented health evaluation▪ Hearing assessment▪ Language ▪ Ability to co-operate/ lie flat▪ Social circumstances▪ Eye drop instillation technique▪ Further explanation and opportunity to ask

questions

High volume surgery 6-7 patients on theatre list, teaching lists

Clinical information rechecked, changes noted and management altered accordingly

Patient re-identified up to 4 times prior to surgery

Surgical site marked Patient discharged when

Comfortable and pain free Post-op instructions, contact details etc

Day 1 review Contentious ? Only eye, complicated surgery,

coexisting disease Final review 2-4 weeks

Review progress and medication Discuss second eye surgery Arrange follow up for co-existing disease Answer questions Collect data

An efficient process Adheres to many of the points from Action

on cataracts: good practice guidelines (2000 DOH), updated RCOphth guidelines cataract surgery 2007 and Good Medical Practice

Further streamlining possible – system in evolution

Surgery meets national standards whilst also training the next generation of ophthalmologists

1Reidy A et al. Prevalence of serious eye disease and visual impairment in a north London population: population-based, cross sectional study. BMJ 1998;316:1643-1646

2Office for National Statistics – mid population 2008

3Frost A et al. The population requirement for cataract extraction: a cross-sectional study. Eye;15:745-52

4Evans et al. Causes of visual impairment in people aged 75 years and older in Britain:an add-on study to the MRC Trial of Assessment and Management of Older People in the Community. Br J Ophthamol 2004;88:365-70

5Department of Health National Eye Plan. May 2004

6Desai et al. Gains from cataract surgery: Visual function and quality of life. Br J Ophthalmol 1996;80:868-873

7Park JC et al. Evaluation of a new cataract surgery referral pathway. Eye 2009;23:309-313