Pilot ‘one-stop’cataract surgery facility

Objectives: To determine the feasibility of a) direct optometrist referral of patients with cataract, and b) combined assessment with same day cataract surgery (‘one stop’ cataract surgery). Methods: Evaluation of 169 patients referred directly by optometrists into a pilot ‘one stop’ cataract surgery facility. Results: Of 169 referrals, 160 patients (94.7%) were given confirmed appointments for the ‘one stop’cataract service and 9 patients (5.3%) were appointed conventionally. Of 160 patients attending the ‘one stop’ cataract service, 154 patients (96.3%) underwent cataract surgery at the same visit, in 4 patients (2.5%) cataract surgery was indicated but deferred and in 2 patients (1.3%) cataract surgery was not indicated. The referral was supplemented with information regarding the patient’s medical history forwarded by the general practitioner for 3 patients (1.8%). There were no systemic or sight-threatening complications. 151 patients (98.1%) achieved a visual acuity of 6/12 or better at a mean of 31 days post-operatively. Conclusion: Optometrists can accurately predict the need for cataract surgery and refer directly into a pilot ‘one stop’ cataract surgery facility, without the need for general practitioner involvement. ‘One stop’cataract surgery is feasible; benefits to the patient include the abolition of the need to visit the general practitioner for consultation and referral, and the hospital for pre-assessment.

Keywords: Cataract extraction, day care, family practice, optometry, outpatient clinics, referral and consultation, waiting lists

The majority of patients referred to ophthalmologists for assessment of cataracts are initially diagnosed by their optometrist. Traditionally, the optometrist refers the patient to the general practitioner who then refers to the hospital for an ophthalmologist’s assessment and consideration for cataract surgery. In the 1997-98 UK national survey of patients who had undergone cataract surgery, 50% were referred via this route, 38% were referred solely by general practitioners, 3% were directly referred by optometrists and 9% were referred from other sources.¹ Following an ophthalmologist’s assessment and the decision to proceed with cataract surgery, patients are conventionally either placed on a waiting list or given a date for surgery. Pre-operative assessment may be undertaken at a separate visit or in combination with the initial hospital assessment at a ‘one stop’cataract assessment clinic.

Direct referral into a ‘one stop’surgery facility, thus abolishing the waiting list process, has been suggested for various conditions in the fields of paediatric surgery, oral surgery, general surgery and otolaryngology.^2-5 With the approval of the area general practitioner sub-committee and the area optometrists, a pilot service was introduced involving direct optometrist referral of patients with cataract into a ‘one stop’ cataract surgery facility (as distinct from a ‘one stop’ cataract assessment clinic). This study aims to evaluate the feasibility of a) direct optometrist referral of patients with cataract, and b) combined assessment and same day cataract surgery.

All area optometrists were invited to attend seminars detailing the proposed guidelines for referral, the referral process, hospital assessment and review procedure for the pilot ‘one stop’ cataract service. Guidelines for referral to the pilot service (Table 1), exclusion criteria (Table 2), referral forms and patient information booklets were then circulated to all area optometrists and a telephone cataract appointments system was introduced. No financial incentives were given to the optometrists during the study but all were made aware that it was likely that a fee would subsequently be negotiated for the increased demands on the optometrists associated with the assessment and referral.

Cataract sufficiently dense to produce subjective impairment of vision manifesting as: - generally dim vision - glare in sunlight or driving at night - difficulty reading or performing specific tasks - difficulty with kerbs or steps
The patient wishes to be considered for surgery
Visual acuity of 6/12 or worse
Visual acuity of 6/9 or worse if lifestyle is affected
The intraocular pressures should be recorded and the fundus assessed

Table 2: Exclusion criteria for referral to pilot ‘one stop’ cataract service

Ophthalmic conditions
- blepharitis - lacrimal disease
- ocular inflammation
- previous eye surgery
- traumatic cataract
- significant macular degeneration (exudative maculopathy or dry degenerative changes judged to be more responsible for the visual impairment than the cataract ) - visual acuity of 6/60 or less in fellow eye
Medical conditions
- significant cardiac or respiratory disease
- possible infection source
- diabetes
- dementia
- deafness
- head tremor
Social exclusions
- no telephone
- age under 40

Adhering to referral guidelines (Table 1) and exclusion criteria (Table 2), the optometrist performed a refraction, a slit-lamp biomicroscopy examination of the external eye and anterior segment, and examined the fundi following pupil dilatation where possible. The refraction, distance and near visual acuities, intraocular pressures and type of cataract were recorded on a dedicated referral form together with any corneal, anterior segment or fundal abnormalities. The optometrist also documented specific visual requirements, such as the need to drive, and listed the patient’s general medical conditions.

Having established that the patient wished to be considered for cataract surgery the optometrist telephoned the hospital for a ‘one stop’ cataract service appointment, provided the patient with an information booklet together with appointment details and forwarded a referral form to the hospital and a duplicate form to the general practitioner. This provided the general practitioner with the opportunity to intervene in the referral process or to forward information regarding the patient’s medical history. The referral form was screened by the ophthalmologist and the patient’s hospital file was then reviewed by a cataract nurse.

Two weeks prior to the appointment a telephone assessment of the patient’s medical, social and ophthalmic history was undertaken by a cataract nurse.

On the day of the appointment the patient’s blood pressure, pulse, temperature and urinalysis were recorded by the cataract nurse. The visual acuity was then assessed, biometry performed (estimation of intraocular lens implant power), intraocular pressures recorded and, after checking pupil reactions, both pupils dilated by the cataract nurse. Thereafter, the ophthalmologist assessed the patient and, following discussion detailing potential risks of sight-threatening complications, then offered cataract surgery, if deemed appropriate. Informed consent was obtained if the patient expressed a desire to proceed with surgery on the same day.

There was no deviation from the ophthalmologist’s standard procedure for cataract surgery. Surgery involved removal of cataract under local anaesthesia by phacoemulsification combined with insertion of a foldable intraocular lens implant into the capsular bag via a 3.5 mm self sealing temporal corneal incision. A subconjunctival injection of cefuroxime 125 mg/ml was given at the end of surgery.

The eye was examined by slit-lamp biomicroscopy one hour post-operatively by a cataract nurse. The patient was discharged having been given a post-operative information booklet, instruction on drop instillation (steroid/antibiotic) and a 3-4 week review appointment, either at the hospital cataract clinic or, if post-operative review training had been completed, with the referring optometrist in the community. The patient was assessed by telephone one day postoperatively by a cataract nurse, who was also available to give telephone advice at any stage pre-operatively or postoperatively to patients or optometrists.

At the 3-4 week post-operative review, the refracted visual acuity was recorded and slit-lamp biomicroscopy examination performed. The patient was then discharged to the optometrist for spectacle prescription, listed for cataract surgery to the other eye or kept under review for management of postoperative complications or coexisting ophthalmic conditions.

Of 67 optometrists invited to seminars detailing the ‘one stop’ cataract service 45 attended. Forty optometrists participated in the study; 169 direct optometrist referrals to the pilot ‘one stop’ cataract service were received between 22nd February 1999 and 20th August 1999. The referral was supplemented with information regarding the patient’s medical history forwarded voluntarily by the general practitioner for three patients (1.8%). Upon receipt of the referral letters it was decided that nine patients (5.3%) would be appointed conventionally for various reasons (known macular degeneration, macular hole, previous corneal graft, corneal scarring), these patients thus being excluded from the pilot service. Following conventional assessment, cataract surgery was deemed appropriate in 6 of these patients.

One-hundred and sixty patient appointments for the pilot ‘one stop’cataract service were confirmed and all patients attended. Following assessment and discussion of the risks and benefits, 154 patients (96.3%) were offered cataract surgery and all accepted and agreed to proceed with surgery on the same day. Cataract surgery was indicated but deferred in four patients (2.5%), two pending investigation and management of glycosuria first detected on the day of the appointment, one requiring surgical correction of lower lid entropion and one pending investigation and observation of a pigmented iris lesion. Two patients (1.3%) were judged to have insufficient cataract to justify surgery.

Data for 154 patients who underwent ‘one stop’cataract surgery between 22nd March 1999 and 13th September 1999 is presented. The median age was 75 years (range 40 to 92). There were 103 females (66.9%) and 51 males (33.1%). Thirty-eight patients (24.7%) had hypertension, 26 patients (16.9%) had chronic obstructive airways disease/asthma, 20 patients (12.9%) had ischaemic heart disease and 12 patients (7.8%) had cerebrovascular disease. The pre-operative visual acuities of the eyes having surgery are detailed in Table 3. Coexisting ocular conditions are detailed in Table 4. Eleven patients (7.1%) had previously undergone cataract surgery to the other eye.

Visual acuity	Number(%)
6/9-6/12	46 (29.9)
6/18-6/24	75 (48.7)
6/36-6/60	27 (17.5)
Less than 6/60	6 (3.9)
Total	154

Co-exisiting ocular conditions	Number(%)
Dry age related macular degenerative changes	43 (27.9)
Corneal endothelial dystrophy	5 (3.2)
Corneal scar	3 (1.9)
Mild ectropion	2 (1.3)
Previous branch retinal vein occlusion	1 (0.6)
Macular branch vein occlusion in fellow eye	1 (0.6)
Low tension glaucoma	1 (0.6)
Fuchs’heterochromic iridocyclitis	1 (0.6)
Pseudo-exfoliation of lens capsule	1 (0.6)
Ocular hypertension	1 (0.6)
Total	59

There were no systemic, intra-operative or subsequent sight-threatening complications. At the 3-4 week post-operative review appointment, seven patients (4.5%) were found to have cystoid macular oedema, which resolved with treatment, and all subsequently achieved a visual acuity of 6/9 or better. Two patients (1.3%) required intraocular lens implant exchange, one as a result of inaccurate implant power prediction and one due to implant related optical aberrations. One patient (0.6%) developed lower lid entropion requiring lid surgery, one patient (0.6%) sustained a corneal abrasion, one patient (0.6%) developed a subconjunctival haemorrhage and one patient (0.6%) developed an allergy to eye drops.

All patients were examined one hour post-operatively and were assessed by telephone one day post-operatively by a cataract nurse. Three to four weeks post-operatively, 143 patients (92.9%) were reviewed at the hospital cataract clinic and 11 patients (7.1%) were reviewed by their referring optometrist in the community. One hundred and thirty-nine patients (90.3%) attended for a single 3-4 week post-operative review, four patients (2.6%) attended for an additional earlier assessment and 11 patients (7.1%) attended for further assessment or management of complications after the scheduled 3-4 week post-operative review appointment. Six patients (3.9%) were referred to other clinics for further assessment or management of pre-existing ophthalmic conditions. Eighty-four patients (54.5%) were listed for cataract surgery to the other eye.

One hundred and fifty-one patients (98.1%) achieved a best corrected visual acuity of 6/12 or better at a mean of 31 days post-operatively (range 11-183 days). In three patients (1.9%), the visual acuity was restricted to 6/18 secondary to pre-existing macular disease (two with macular degeneration, one with a macular hole).

In the UK, the vast majority of patients referred to ophthalmologists to be considered for cataract surgery are referred by their general practitioner either solely, or more frequently, following an initial referral from an optometrist to the general practitioner. Following an ophthalmologist’s assessment and the decision to proceed with cataract surgery, patients are then conventionally either placed on a waiting list or given a date for surgery.

It has been suggested that there is a strong case for allowing access to specialist services through channels of referral other than the conventional general practitioner to specialist referral and that “barriers at the hospital / community frontier will have to come down”.⁶ To our knowledge, direct optometrist referral of patients with cataract to hospital ophthalmologists has not previously been evaluated in the UK although this is one of the recommendations made in the NHS Executive publication “Action on Cataracts, Good Practice Guidance” (February 2000).⁷ A previous study concluded that listing patients for cataract surgery on the basis of referral letters from general practitioners or optometrists would have been inappropriate for 26% of patients.⁸ In this study, with 96.3% of patients appointed to the ‘one stop’ cataract service proceeding to same day cataract surgery, it can be considered that appointing for same day cataract surgery on the basis of optometrist referrals was inappropriate for 3.7% of patients. We attribute this low level of inappropriate referrals to the development of guidelines for direct optometrist referral, optometrist training and screening of referral letters. The low inappropriate referral rate, together with the observation that the general practitioner voluntarily supplemented the optometrist referral with further information in only 1.8% of referrals, confirms the feasibility of direct optometrist referral, without the need for general practitioner involvement, in this pilot service.

The high proportion of patients (96.3%) proceeding to same day surgery following assessment in this study confirms the feasibility of ‘one stop’ cataract surgery. Endophthalmitis, choroidal haemorrhage and retinal detachment/tear are the most serious complications of cataract surgery as they are potentially sight-threatening. With an incidence of 0.1% for each of these complications reported in the 1997-98 UK national cataract survey it is recognised that several thousand procedures would be required to make a valid comparison between ‘one stop’ cataract surgery and conventional pre-assessed cataract surgery.9 It may be considered that performing biometry just before cataract surgery risks traumatising the cornea or increasing the potential for endophthalmitis, as biometry involves placing a probe onto the cornea. During this study, however, no patient suffered corneal trauma attributable to biometry and there were no cases of endophthalmitis. The theoretical potential for introducing micro-organisms to the corneal epithelium or conjunctival sac is minimised by sterilising the biometry probe prior to use. In agreement with other authors’ experience that the exact cause of cystoid macular oedema has remained elusive, we were unable to identify a cause in the seven cases of cystoid macular oedema in this study as the assessment, surgery and post-operative treatment were routine and uncomplicated in all cases.¹⁰ All cases subsequently resolved, however, with good visual outcomes. The lack of systemic, operative and subsequent sight-threatening post-operative complications in this study suggests that ‘one stop’cataract surgery is safe and as there is no difference in surgical technique or procedure, it is not expected that there would be an alteration in the incidence of complications.

The General Medical Council, in the document ‘Seeking patients’ consent: the ethical considerations,’ advises that the patient should be allowed “sufficient time to reflect before and after making a decision.”¹¹ After discussion of the risks and benefits, of those patients offered cataract surgery, no patient opted to defer the decision, all deciding to proceed with cataract surgery at the same visit. It was our experience that patients were able to reach a decision shortly after considering the risks and benefits and that no patient gave the impression that more time was required to reflect on the information before or after making the decision. This may be due to the relatively low risk of serious complications of cataract surgery compared with procedures in other specialties. However, consideration could be given to detailing risks and benefits of surgery in the information booklet given to the patient by their optometrist if the pilot ‘one stop’cataract service were to be fully implemented.

We agree with the suggestions of others, that an early post-operative examination may not be necessary or justified, following routine uncomplicated phacoemulsification cataract surgery, as only 2.6% of patients in this study required an early review.^12-14 Serious postoperative complications are symptomatic, and a postoperative telephone assessment, patient education and a ‘helpline’, facilitate early presentation of significant problems.

The benefits to patients of direct optometrist referral ‘one stop’cataract surgery include the abolition of the need to visit the general practitioner for consultation and referral, and the hospital for pre-assessment. This is particularly beneficial to elderly patients, who may have poor mobility, in addition to poor vision and who may thus be dependent on others for transport. We reiterate the value of nursing telephone assessments in reducing the need for the patient to attend the general practitioner or hospital.¹⁵ ‘One stop’ cataract surgery also reduces the administration and workload associated with the waiting list procedure.

Optometrists can accurately predict the need for cataract surgery and refer directly into a pilot ‘one stop’ cataract surgery facility, thus, reducing the workload of the general practitioner. ‘One stop’ cataract surgery is feasible; benefits to the patient include the abolition of the need to visit the general practitioner for consultation and referral, and the hospital for pre-assessment.

It is clear that there is a need to significantly improve access to treatment for people who need cataract surgery and that more cataract surgery needs to be undertaken to meet the demand.^7,16

It is important, therefore, that the efficiency of the service is maximised while maintaining or improving quality. We believe that direct referral ‘one stop’ cataract surgery is an attempt to achieve these aims and merits further appraisal.

We thank all area optometrists and Dr Alan White for assistance and feedback during the development of the pilot service; Anne Jeffreys, Anne Campbell and Kathleen Urquhart for facilitating development and implementation; Anne Kennedy, Mary McGinn, Susan Pye, Elaine Smart, Anne Thompson and Carole Wall for assistance with data retrieval and Diane Graham for assistance with data analysis.

Designed Healthcare Initiative funded by the Scottish Office, Ayrshire and Arran Health Board and Ayrshire and Arran Acute Hospitals NHS Trust.

Correspondence: Mr Alan Gaskell FRCSEd, FRCOphth, Consultant Ophthalmologist, Department of Ophthalmology, The Ayr Hospital, Dalmellington Road, Ayr KA6 6DX, UK

ORIGINAL ARTICLES

Direct optometrist referral of cataract patients into a pilot ‘one-stop’cataract surgery facility