1. Dr. Shanu Subbiah
Registrar Ophthalmology
Royal Victoria Hospital
Belfast Trust
The Future Direction of Primary Eyecare in Northern Ireland - Cataract Services

2. Cataract 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% ( )
MIH 36% (2008 – 2009)

5. Cataract 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% ( )
MIH 36% (2008 – 2009)

6. Cataract Surgery carried out by Consultants and trainees Annual Audit
17 “career grade” trainees in NI
Audit ( ) has confirmed that quality of surgery meets “Gold Standard” of UK National Cataract Survey
87% procedures performed by consultants
13% junior grade
Annual Audit

7. The problem with cataracts
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% year age group1
59% 80 to 84 year age group

8. The problem with cataracts
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

9. The problem with cataracts
Over 30% of patients over 70 yrs with cataract also have other pathology
Diabetic retinopathy, Age related macular degeneration
Surgery is not “simple”
Complications include blindness, further surgery, worse vision after surgery
Long training scheme
Life changing event for patients

10. Present Patient Pathway
Reduced Vision
General Practitioner or Optometrist
Hospital Outpatients
Pre-operative assessment + biometry
Surgery
Day 1 review (site specific)
Post-op visit +/- listing for fellow eye
Post-op refraction (community)
13 weeks
1 day
13 weeks
4 weeks
2 weeks

11. Present Patient Pathway – Clinical Responsibility
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

12. Present Patient Pathway - Referral
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)

13. Present Patient Pathway – Hospital Outpatients
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

14. Present Patient Pathway – Pre-operative assessment
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

15. Present Patient Pathway – Surgery
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

16. Present Patient Pathway – Reviews
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

17. Conclusions 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

18. References
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: Office for National Statistics – mid population Frost A et al. The population requirement for cataract extraction: a cross-sectional study. Eye;15: Evans 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

19. References
5Department of Health National Eye Plan. May Desai et al. Gains from cataract surgery: Visual function and quality of life. Br J Ophthalmol 1996;80: Park JC et al. Evaluation of a new cataract surgery referral pathway. Eye 2009;23: