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Date issued: June 2023

Review date: June 2025 

Ref: A-579/KFA/Ophthalmology/High Volume Cataract Service Pathway

PDF:  High Volume Cataract Service final June 2023.pdf[pdf] 193KB

Introduction

The Plymouth Royal Eye Infirmary has an over 200 year history of providing the highest quality ophthalmic care to the population of Plymouth, West Devon and East Cornwall. We provide a broad range of ophthalmic services for our community and were the first to carry out cataract surgery in Plymouth.

We have the capability, facilities and specialist surgeons to operate on all forms of cataract, from standard to the most complex, unlike our local competitors.

In this our 202^nd year we are moving to a brand new purpose built ophthalmology facility. The new Royal Eye Infirmary building will allow us to expand our surgical capabilities by providing a 3^rd operating theatre which will be dedicated to carrying out high volume cataract surgery. The high volume service will allow us to operate on more patients, more rapidly, and thus allow us to have very short waiting lists. In this way we hope to provide an improved service for our community.

Referral

Most patients will have received a diagnosis of cataracts from their optician as a result of a sight test necessitated by the onset of symptoms such a blurred vision and / or excess glare.

Cataracts may also be picked up during routine sight tests.

Furthermore, there may be pre-existing patients of the REI who whilst under our care for other eye conditions may develop symptomatic cataracts. These patients would also be eligible to be considered for cataract surgery.

Having a cataract is not necessarily an indication for surgery. There is a “Devon cataract commissioning policy” which determines when opticians or GPs can refer cataracts to any hospital eye service or independent sector treatment centre within Devon. Please see page 5 for the “Devon cataract commissioning policy”.

If a patient fulfills the Devon cataract referral policy their optician or GP will refer them via the Devon Referral Support Service (DRSS). The DRSS is the single point of referral to all the cataract surgery providers in Devon including the REI. The DRSS web address is: https://myhealth-devon.nhs.uk/my- referral/about-devon-referral-support-service.

The DRSS will make contact with the patient, take note of relevant patients details, discuss the referral options and together with the patient will agree where the patient will be referred. The REI accepts all complexities of cataract referrals i.e., we accept:

1. Patients suitable for high volume cataract surgery.

2. Patients requiring complex cataract surgery.

Devon Cataract Commissioning Policy

Before a referral is made, the referrer must confirm that:

1. The patient understands that the purpose of referral is for assessment for surgery.

2. The patient wishes to have surgery if it is offered.

3. The patient meets the criteria for cataract surgery.

Cataract surgery will be routinely commissioned only in the following circumstances: 

There is sufficient cataract in the eye proposed for surgery to account for the patient’s visual symptoms AND one or more of the following criteria apply:

• Best corrected visual acuity of 6/12 or worse in the affected eye AND the patient experiences one or more of the following due to subjective loss of visual performance:

  • Difficulty in accomplishing everyday tasks.

  • Reduced mobility, visual problems when driving or experiencing difficulty with steps or uneven ground.

• Ability to work, act as a carer or live independently is affected.

• Patients who experience disabling problems with glare and a reduction in acuity in daylight or bright conditions or reduced contrast sensitivity.

• The patient has a best corrected visual acuity of better than 6/12 in the affected eye but they are working in an occupation in which visual acuity better than 6/12 is essential to their ability to continue to work.

• Where there is anisometropia following cataract surgery with a refractive difference between the two eyes of at least +/- 2.0 dioptres resulting in poor binocular vision or diplopia.

• Patients with rapidly progressive myopia.

Cataract surgery is also routinely commissioned under the following circumstances:

• Patients with glaucoma who require cataract surgery to control intra-ocular pressure.

• Patients with glaucoma who have undergone a trabeculectomy.

• Patients who have undergone a vitrectomy.

• Patients with diabetes in whom removal of the cataract is necessary to facilitate effective screening for diabetic retinopathy.

Referral criteria for high volume cataract surgery

Age:

• Patients must be 55-90

Communication:

• Additional comms support not typically provided

• Therefore must speak English.

• No severe dementia.

• No severe learning difficulties.

Movement & Mobility:

• Patient must be able to lie still during the procedure.

• Lots of walking to get to pre-op room and theatres and not much space, so patient must be ambulatory

• No hoists available and possible weight limitations on couches, so BMI must be ≤40

Fitness & Complexity:

• GA not available at Hubs/ISPs, patient will know if they

• absolutely must have a GA.

• An implanted defibrillator (which is not ok) is different to a pacemaker (which is ok)

• Patients with other ocular conditions (glaucoma, vitreoretinal surgery, corneal grafts etc.) may be more complex and their usual consultant may have advised their cataract surgery takes place at the acute site. This will supercede patient choice on safety grounds.

Cataract clinic

Having decided to have your cataract surgery via the REI high volume cataract service the DRSS will inform the REI of your referral. The REI will contact you via your telephone to start gathering your clinical information. This will help to speed up the process when we see you face-to-face in the cataract clinic. You will then be sent an appointment for the cataract clinic.

Please bring your spectacle prescription with you. If you are a contact lens wearer, please do not use them for the 2 weeks leading up to the appointment if they are soft, and for 4 weeks if they are a hard or gas permeable. At the cataract clinic your visual acuity will be measured, your pupils will be dilated, your medical details taken, and your blood pressure, (blood sugar), eye pressure, eye biometry will be taken by the nursing staff.

The eye doctor will examine your eye, confirm the cataract diagnosis, and will if you should wish put you on the waiting list for surgery. The eye doctor will also discuss and agree with you the desired level of focusing to aim for with the lens implant.

The nursing staff will then carry out the consenting for surgery process with you, and issue you with instruction on:

1. Eyelid hygiene.

2. Important reasons to contact the REI

Pre-Operative clinic

The Pre-operative clinic is important in preparing the patient for surgery and will only be required for patients who have not been seen in the “cataract clinic”. At the Pre-operative clinic the nurses will carry out the assessments carried out by them in the cataract clinic (as indicated in the paragraph above) with the exception of dilating the pupils.

Pre-Operative eyelid hygiene

It is important to clean your eyelids before your operation to ensure they are free from crusts and inflammation to reduce the risk of you developing an operative infection. Please follow the following instructions:

• Boil some water and let it cool, put a small amount into a  small clean container.

• Add 1-2 drops of no tears baby shampoo.

• Using a cotton bud dipped in the solution gently clean along the lower eyelid from the inner corner outwards.

• Then close your eyes and do the same to the upper eyelid.

• Using a clean cotton bud repeat the same procedure with the other eye.

• This should be performed once a day two weeks prior to surgery or twice a day one week before surgery.

• If the eyelids become red or sore omit the baby shampoo and use plain cooled boiled water only. 

Day of surgery

A few days prior to your day of surgery you will be contacted by the REI Admissions department to confirm your attendance and transport plans. You may be appointed as the “Golden patient” i.e., a patient who can be relied upon to arrive on time and is scheduled to be the first patient of the operating list.

On the day of surgery you will arrive at the REI via its front entrance where the reception staff will direct you to the Day Case Unit. You will then be welcomed into the Day Case Unit, where the nursing staff will carry out a short admission process and instill eye drops to dilate your pupil. You will also meet the surgical team. Feel free to ask our staff any questions that you may have about your surgery.

When it is your turn for surgery you will be escorted to the high volume cataract surgery theatre anaesthetic room where you will have anaesthetic drops instilled to numb your eye.

You will then proceed to the operating room where you will be positioned comfortably on the operating table. There is no need to worry, there will be a staff member available to hold your hand throughout the procedure. It is important to stay still and look straight ahead during the 10-45 minutes duration of the operation. At the end of the operation a pad and / or clear plastic shield will be placed over your operated eye, following which you will be escorted to the recovery area where the nursing staff will make sure that you have recovered satisfactorily from the operation and that you are provided with the appropriate post- operative eyedrops, advice and instruction leaflet.

The usual post-operative eye drop is Maxitrol, 1 drop to the operated eye, 4x daily for 2 weeks, then 2x daily for 2 weeks. We additionally dispense Bromfenac eye drops 2x daily for 2 weeks to diabetic patients.

Post-Operative follow up

You will require an eye check in the weeks following your cataract operation.

• 1st eye with plan to undergo 2nd eye surgery, a follow up appointment will be arranged with a Nurse Practitioner within 6 weeks at the REI. The Nurse Practitioner will also arrange for your next operation and consent you.

• 1st eye with no plan to undergo 2nd eye surgery, a follow up appointment will be arranged with an optician in the community within 6 weeks.

• 2nd eye surgery, a follow up appointment will be arranged with an optician in the community within 6 weeks.

• Complex surgery, a follow up appointment will be arranged with a doctor at the REI in a timescale recommended by the surgeon.

Where can I find more information about cataract surgery?

   You will be able to obtain further information about cataracts and cataract surgery at the following websites:

    NHS.net: https://www.nhs.uk/conditions/cataract-surgery/

    RNIB: https://www.rnib.org.uk/your-eyes/eye-conditions-az/cataracts/