Ophthalmology
cataracts:
a quicker cure Professor Charles Claoué
Cataract is opacification of the crystalline lens of the eye causing visual failure, and cataract surgery is the most common procedure in developed countries. Although the surgical technique has changed significantly over the past 20 years, the mode of delivery has not been examined, and most patients have two visits before surgery, one cataract surgery, one or two post-operative visits, second eye surgery and at least one more visit: so that’s seven trips to hospital in total! Cataract is normally a bilateral disease – hence the “CataractS” plural in the title. It is common for both eyes to be equally effected, or for one eye to be worse than the other. However, in most patients bilateral surgery is needed and there is excellent peer-reviewed evidence for additional benefit from second eye surgery. Many patients find the delivery of cataract care drawn-out, confusing and cumbersome. They often ask why both eyes cannot have surgery on the same day; if given free choice 80% of patients would choose this. What are the advantages? If pre-operative assessment and biometry (measurements for the intraocular lens) occur at the first visit, the pathway changes to: one pre-operative visit, surgery, one post-operative visit. The saving of patient time and trouble is three or four hospital visits, and depending on the delay for second eye
“They often ask why both eyes cannot have surgery on the same day: if given free choice 80% of patients would choose this.” surgery, at least four weeks before full visual rehabilitation. Where waiting lists approach six months, it can take over a year to complete the pathway using the conventional “one eye at a time” model. The healthcare economists note a saving of about £350 per eye if both eyes have surgery on the same day.
less than 1 person would get BSE. Even better, with improved treatment comes better visual outcomes, with about 1 in 3 eyes regaining driving vision. What this means is that if the entire population having cataract surgery in the USA had ISBCS every year, it would be once every 50 years that 1 American would not have good enough vision to drive from BSE…
So why don’t we do more ISBCS (Immediate Sequential Bilateral Cataract Surgery) – “both eyes same day”? The main answer is the perceived risk of infection, specifically bilateral simultaneous endophthalmitis (BSE). Endophthalmitis is a dreaded complication and is too frequently associated in ophthalmologists’ minds with blindness. Is this evidence-based logical thinking? The answer is undoubtedly “no”. Thirty years ago, the risk of endophthalmitis was perhaps 1 in 300, and most current consultants remember eye wards with at least one patient with an eye full of pus. However, in the 21st century the incidence has fallen to at least 1 in 3,000 and probably 1 in 5,000. With these figures it can easily be computed that the risk of BSE is 1 in 9-25 million! Put another way, if every single person in Greater London had ISBCS,
I have been a champion of ISBCS for over 10 years and I am certain that it is a better way to deliver care for most patients. “Nothing is more powerful than an idea whose time has come.” To find out more about Professor Charles Claoué please visit www.dbcg.co.uk
www.practicemattersmag.co.uk PRACTICE MATTERs AUTUMN/WINTER 2015 • 19