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

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% (2008 - 2009) MIH 36% (2008 – 2009)

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% (2008 - 2009) MIH 36% (2008 – 2009)

Cataract Surgery carried out by Consultants and trainees Annual Audit 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

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% 65-69 year age group1 59% 80 to 84 year age group

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

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

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

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

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)

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

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

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

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

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

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;316:1643-1646 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

References 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