NICE update: support for some cataract removal earlier in pathway

Cataract management usually involves a multidisciplinary team of ophthalmologists, optometrists, nurses and technicians. Cataract surgery is the most commonly performed elective surgery in the UK, with over 370,000 operations in England in 2015/16. The demand for cataract surgery is increasing because of the ageing population.

The clinical threshold used to access cataract surgery is commonly based on visual acuity and, in many areas, priority is given to first-eye surgery. Variation in commissioning policies has resulted in differences in access to cataract surgery. A study by the Royal National Institute of Blind People (RNIB) found noticeable variation in first- and second-eye operation rates, large variations in time to treatment, and a consistent reduction in the number of cataract operations in some areas. 

Wrong lens implant errors are the most common ‘never events’ for implants in England, with 19 incidents in 2016/17. Never events are serious, largely preventable patient safety incidents that should not occur if national guidance has been implemented. 

The guideline recommended access to cataract surgery is not restricted on the basis of visual acuity. Providing additional cataract operations for people previously denied access because of visual acuity, or because it is a second eye, may result in additional costs in the shorter term. 

These operations are likely to be carried out anyway, but it is now recommended they happen sooner in the pathway. This could prevent further development of the cataract and reduce the need for a more complex operation later. It may also greatly improve quality of life for patients.

Commissioners and providers should ensure processes are in place to identify complications after surgery and ensure there is prompt access to specialist ophthalmology services. It also recommends in-person first-day reviews are not offered to people after uncomplicated surgery. 

The large majority of patients with no postoperative complications can receive an assessment in a community setting, provided the outcome is communicated back to the secondary care unit. The cost of an outpatient ophthalmology appointment is £139; the cost of community optometry assessments will vary according to local commissioning contracts. 

Having well defined processes to identify post-cataract surgery complications may generate offsetting savings from the avoidance of unnecessary post-op referrals.

Nicola Bodey is a senior business analyst at NICE