The Royal College of Ophthalmologists (RCOphth) and The College of Optometrists are issuing interim recommendations on routine cataract care to help rapidly increase hospital capacity to see patients with urgent, complex or sight-threatening disease. The combination of pre-existing capacity constraints and the effect of the COVID-19 pandemic has led to record numbers of patients, whose ophthalmology outpatient appointments and surgery are delayed, putting large numbers of patients at real risk of avoidable sight loss. Ophthalmology departments are taking numerous steps to minimise this risk, including validation and prioritisation of surgical and clinic waiting lists, increasing capacity through high volume diagnostic / surgical pathways and optimising the use of hospital non-medical clinical staff and primary care optometrists.
However, there is a pressing need to create additional capacity within existing resources as soon as possible. One potential solution is to manage certain groups of low-risk patients outside of traditional hospital-based pathways, where this can be delivered without compromising safety and quality of care. This includes patients who have had routine, uncomplicated cataract surgery.
These interim recommendations are supported by data from the National Ophthalmology Database Audit for Cataract Surgery (NOD) as well as by existing practice in some eye units. They are also compliant with the recommendations of the NICE Cataract Surgery: Adults guideline (NG 77, 2017), the RCOphth’s NICE accredited Commissioning Guide: Cataract Surgery (2018) and the RCOphth / GIRFT Cataract Hubs and High Flow Cataract Lists (2021).
It is important to note that these recommendations from the RCOphth and The College of Optometrists are not mandated and eye departments can adapt them depending on local circumstances. Cataract surgery outcomes must continue to be audited prospectively, particularly where there is any change in care pathways.
The Recommendations
1. Patients who have had routine, uncomplicated cataract surgery should be discharged from the hospital cataract service as follows:
all patients who have had surgery in their second eyes.
- all patients who have had surgery on one eye where the fellow eye has no significant cataract or expected anisometropia (the need for second eye surgery should be identified earlier e.g. at the initial cataract assessment)
Individual eye clinics must agree to protocols to identify post-operative patients who require ongoing hospital care due to co-existing eye conditions and ensure that they have separate, appropriate and timely subspecialty clinical review
Where patients will benefit from surgery on both eyes, patients should be listed for both eyes to be done, either separately or by immediate sequential bilateral cataract surgery (ISBCS) following NICE, RCOphth and Getting it Right First Time (GIRFT) guidance. Data on first eye outcomes to inform the second eye operation lens choice can be obtained through auto-refraction on the day of second eye surgery or through a recent sight test with their local optometrist.
2. Post-operative care plans must be clearly communicated to patients at the initial appointment. Patients must have a clear route for advice and assessment for unexpected issues and emergencies such as endophthalmitis.
3. Low risk, uncomplicated patients who are discharged can be offered Patient Initiated Follow-up (PIFU). The current evidence indicates that 3-7% of these patients are likely to need some level of post-operative care, which may be patient-initiated or identified by an optometrist on follow-up.
4. All patients should be advised to visit an optometrist for a routine sight test approximately four weeks after uncomplicated surgery, which includes assessment of the patient’s final refractive status and measurement of visual acuity.
5. No NHS patient who has received cataract surgery should have to pay for any aspect of follow up care, i.e. their sight test or because they need additional tests to investigate a possible complication. Commissioning arrangements should be in place to fund the sight test if the patient is not eligible for General Ophthalmic Service (GOS), and for any further investigations, the optometrist judges to be clinically necessary, in line with locally agreed protocols.
6. The patient’s refractive status and final visual acuity should form the basis of the data submission back to the operating centre for local and national audit. Return of post-operative outcomes data continues to be crucial, particularly where there are pathway changes, to confirm that patients continue to benefit from the current high-quality outcomes. A suitable data return mechanism should be agreed with primary care and fully commissioned.
We recognise that in Scotland, Wales, Northern Ireland and parts of England, pathways for routine uncomplicated post-cataract follow-up in primary care are already in place or are about to be commissioned. The provision of existing and effective pathways do not need to change. Where these pathways have not yet been commissioned, we anticipate that approximately 80% of post-operative cataract surgery patients can be managed safely through the recommendations outlined in this statement and will release outpatient resources to see and treat patients at high risk of permanent visual loss because of delayed appointments.
