Download Cataract Surgery

Cataract Surgery
Policy
NHS North West London CCGs will fund cataract surgery for either or both eyes if either of the following
criteria thresholds are met: 1 (a & b) or 2 (a or b)
1.
a. Cataract surgery to be considered for patients with a best corrected visual acuity of 6/9 (LogMAR
0.18) or worse in the affected eye(s).
AND
b. Have impairment in lifestyle such as significant effect on activities of daily living, leisure activities,
and risk of falls
2.
a. Surgery is indicated for management of ocular comorbidities e g management of glaucoma OR in
diabetes where the view of the retina is obscured in retina screening
OR
b. Significant optical imbalance (anisometropia or anisekonia) following cataract surgery on the first
eye
Revision cataract surgery is not in scope of this policy
Where the criteria are not met, funding may be considered via the IFR route if there are exceptional reasons
present.
Note: Patients who smoke should have attempted to stop smoking 8 to 12 weeks before referral to reduce
the risk of surgery and the risk of post-surgery complications. Patients should be routinely offered
referral to smoking cessation services to reduce these surgical risks.
These polices have been approved by the eight Clinical Commissioning Groups in North West London (NHS Brent CCG, NHS Central
London CCG, NHS Ealing CCG, NHS Hammersmith and Fulham CCG, NHS Harrow CCG, NHS Hillingdon CCG, NHS Hounslow CCG and
NHS West London CCG).
Background
Cataracts are cloudy patches or areas in the eye lens that are very common in the elderly population and cataract
surgery is a fast, safe and effective treatment.1 Referral depends on reduced visual acuity, impairment of activities of
daily living and a willingness to have surgery. Impairment of activities of daily living may include the following:



The patient is at significant risk of falls
The patient’s vision is substantially affecting their ability to work
The patient’s vision is substantially affecting their ability to undertake leisure activities such as reading,
recognising faces or watching television
Although there is significant improvement in vision from mono- to binocular vision (35% o cataract operations are
1
in the second eye), there is debate around whether second cataract surgery is cost effective. There is also debate
around whether cataract surgery in both eyes should occur simultaneously. The risk of bilateral intra-ocular
complications is generally perceived to be too important to warrant simultaneous treatment and if second surgery
1
occurs it is usually delayed after the first opera ion.
As such, there is no agreed guidance for second eye cataract operations – is i cost-effective and should it be carried
out simultaneously? This document summarises the risks, benefits and cost-effectiveness for first and second eye
cataract surgery, including immediately sequential cataract surgery (ISCS), and offers guidelines for clinicians and
commissioners.
Latest version of the policy is available at:
http://www.hounslowccg.nhs.uk/what-we-do/individual-funding-requests.aspx
Version 4 (April 2016)
Background (continued)
First Eye Cataract Surgery
First eye cataract surgery is recommended by NICE and the Department of Health2 Surgery can involve
either accommodating or non-accommodating intraocular lenses as they both improve visual acuity.
Compared with monofocal lenses, multifocal lenses reduce dependence on spectacles (OR 0.17 – 0.12,
0.24) but do increase the risk of halos and glares (OR 3.55 – 2.11, 5.96). Key efficacy outcomes from
surgery are spectacle independence, uncorrected near and distance vision, pos operative refractive
error, contrast sensitivity and quality of life. Referral should not be based only on the presence of the
cataract but also on the presence of reduced visual acuity impairment of lifestyle and willingness to
have surgery.
Second Eye Cataract Surgery
The Royal College of Ophthalmologists released guidance on cataract surgery in 2004 stating that second
eye surgery is warranted given the significant gains in visual function and quality of life compared with
single surgery alone.3,4 Multiple randomised studies have shown improved clinical and functional benefit
from surgery in he second eye, in terms of visual acuity, contrast sensitivity, stereoacuity, and visual
disability however second surgery does not improve the risk of falling in the elderly.4,5,6,14
At the population level, maximum utility is obtained from increasing access to irst eye surgery in the
first instance. However where first surgery rates are high then second-eye surgeries should be
performed to maximise quality of life to as many as possible.7,8
Cost-benefit of Second Cataract Surgery
Modelled cos -benefit analysis has shown that second eye surgery yields an additional 0.92 QALYs over
a 12 year life expectancy, with each additional QALY gained costing between $2045 to $3649 2001).
Compared with first eye surgery ($2023 per QALY) this is only slightly less cost-efficient and represents
good cost-effectiveness when compared with o her procedures. However, these estimates may not be
generalisable to the UK because they are based on US studies where healthcare costs and systems are
different from the NHS
Immediate Sequential Cataract Surgery (ISCS)
Simultaneous surgery in both eyes results in improved visual function9 compared to single eye surgery,
however this is not a long-lasting effect and its value is mostly to avoid suboptimal vision while waiting
for second-eye surgery. Simultaneous bilateral surgery minimises the use of local and general
anaesthesia, ensures only one-s ep visual rehabilitation is required, leads to fewer hospital visits, and a
more efficient use of hospital time, shorter waiting lists and less demand on hospital services. Including
all surgical costs, delayed second-eye surgery is 14% more expensive than ISCS. ISCS leads to 15-30%
greater efficiency in the numbers of eyes that can be operated on per day, given that the second
operation adds only 12 minutes on average to the operating time compared to delayed surgery.
3,10,11,12
Theoretically, there is no risk arising from ISCS additional to that from monocular cataract surgery
itself. The perceived threat of binocular complications occurring simultaneously underpins the concern
around simultaneous bilateral surgery. However, evidence suggests that the risk of bilateral
complications in ISCS (which includes catastrophic and non-catastrophic complications) compares
favourably to unilateral surgery complica ion rates Smith and Liu (2001). In general, the risk of a
complication in the second eye is he same as in the first eye. The chance of complications occurring in
both eyes is the same as in the unilateral operations of two consecutive patients. The principal
exclusion criteria or ISCS should be for patients that have specific underlying co-morbidities or
experiences with previous cataract surgery that indicate an increased risk of post-operative
complications.
Latest version of the policy is available at:
http://www.hounslowccg.nhs.uk/what-we-do/individual-funding-requests.aspx
Version 4 (April 2016)
References
Patient information leaf et
http://www.nhs.uk/conditions/Cataract-surgery/Pages/Introduction.aspx
References
1.
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8.
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11.
12.
13.
14.
NHS Executive. Action on Cataracts Good Practice Guidance. 2000
NICE 2007 Interventional Procedure Guidance: implantation of multifocal (non- accommodative)
intra-ocular lenses during cataract surgery
Smith GT and Liu CSC 2001 – Is it time for a new attitude to ‘simultaneous’ bilateral cataract
surgery British Journal of Ophthalmology 85:1489-1496
Royal College of Ophthalmologists 2004 - Cataract surgery guidelines.
Foss AJ, Harwood RH, Osborn F 2006 – Falls and health status in elderly women following second
eye cataract surgery: a randomised controlled trial. Age and Aging 3591):66-71
Castells X, Cornas M, Alonso J et al 2006 – In a randomised trial, cataract surgery in both eyes
increased benefits compared to surgery in one eye only. Journal of Clinical Epidemiology
59(2):201-7
Lundstrom M and Wendel E 2004 – Modelling utility of second-eye cataract surgery. International
Journal of Technology Assessment in Health Care. 20(3):361-7
Busbee BG, Brown MM, Brown GC et al 2003 – Cost-utility analysis of cataract surgery in the
second eye. Ophthalmology 110(12):2310-7
Laidlaw DA, Harrad RA, Hopper CD et al 1998 – Randomised trial of effectiveness of second eye
cataract surgery. Lancet 352(9132):925-9
Javitt JC, Steinberg EP, Sharkey P et al 1995 – Cataract surgery in one eye or both: a billion dollar
per year issue. Ophthalmology 102(11):1583-93
Nassiri N, Nassiri N and Sadeghi Yarandi SH et al 2009 – Immediate vs delayed sequential
cataract surgery: a comparative study. Eye 23(1):89-95
Lunstrom M, Albrecht S, Nilsson M 2006 – Benefit to patients of bilateral same-day cataract
extraction: randomised clinical study. Journal of Cataract and Refractive Surgery. 32(5):826-30
Lundstrom M, Albrecht S and Roos P 2009 – Immediate vs delayed sequential bilateral cataract
surgery: an analysis of costs and patient value. Acta Opthalmologica 87(1):33-8
Javitt JC, Bremner HM, Curbow B et al 1993 – Outcomes of cataract surgery: improvement in
visual acuity and subjective visual function after surgery in the first, scond and both eyes. Archives
of Ophthalmology 111: 686-91
Latest version of the policy is available at:
http://www.hounslowccg.nhs.uk/what-we-do/individual-funding-requests.aspx
Version 4 (April 2016)