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Cataract Clinical Care Standard. Consultation draft. February 2019. 1

TRIM: D18-38682

Cataract Clinical Care Standard Consultation draft

February 2019


Published by the Australian Commission on Safety and Quality in Health Care Level 5, 255 Elizabeth Street, Sydney NSW 2000

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ISBN: TBC

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Contents

Cataract Clinical Care Standard ................................................................................. 4 1

About the clinical care standards .............................................................................. 5 2

Introduction ................................................................................................................. 6 3

General principles of care in relation to this clinical care standard ....................... 9 4

Using the clinical care standard .............................................................................. 10 5

Quality Statement 1: Primary care assessment and referral ................................. 14 6

Quality Statement 2: Patient information and shared decision making ............... 18 7

Quality Statement 3: Access to ophthalmology assessment ................................ 19 8

Quality Statement 4: Indications for cataract surgery ........................................... 22 9

Quality Statement 5: Prioritisation for cataract surgery ........................................ 24 10

Quality Statement 6: Second-eye surgery .............................................................. 27 11

Quality Statement 7: Preventive eye medicines ..................................................... 29 12

Quality Statement 8: Postoperative care ................................................................. 31 13

Glossary ..................................................................................................................... 33 14

References ................................................................................................................. 36 15


Cataract Clinical Care Standard 1

Quality Statement 1: Primary care assessment and referral 2

A patient with visual problems and suspected cataract has an initial assessment in primary 3 care of their visual impairment, vision-related activity limitations, comorbidities and 4 willingness to have surgery. When referral is appropriate based on these criteria, the patient 5 is referred for consideration for cataract surgery and this information is included in the 6 referral form. 7

Quality Statement 2: Patient information and shared decision making 8

A patient with suspected or confirmed cataract receives information to support shared 9 decision making. Information is provided in a way that meets the patient’s needs and is easy 10 to use and understand. The patient is given the opportunity to discuss the likely benefits and 11 potential harms of the available options, as well as their needs and preferences. 12

Quality Statement 3: Access to ophthalmology assessment 13

A patient who has been referred for consideration for cataract surgery is prioritised for 14 ophthalmology assessment according to clinical need, based on a locally approved protocol 15 and following receipt of a detailed referral. 16

Quality Statement 4: Indications for cataract surgery 17

A patient is offered cataract surgery when they have a lens opacity that limits their vision-18 related activities and causes clinically significant visual impairment involving reduced visual 19 acuity of 6/12 or worse, or disabling glare or contrast sensitivity. 20

Quality Statement 5: Prioritisation for cataract surgery 21

A patient is prioritised for cataract surgery according to clinical need. Prioritisation protocols 22 take into account the severity of the patient’s visual impairment and vision-related activity 23 limitations, the potential harms of delayed surgery, any relevant comorbidity and the 24 expected benefits of surgery. 25

Quality Statement 6: Second-eye surgery 26

Options for a patient with bilateral cataract are discussed when the decision about first-eye 27 surgery is being made. Second-eye surgery is offered using similar criteria as for the first 28 eye, but the potential benefits and harms of a delay in second-eye surgery are also 29 considered, leading to a shared decision about second-eye surgery and its timing. 30

Quality Statement 7: Preventive eye medicines 31

A patient receives an intracameral antibiotic injection at the time of cataract surgery, 32 according to evidence-based guidelines. After surgery, a patient receives antibiotics or anti-33 inflammatory eye drops only when indicated. 34

Quality Statement 8: Postoperative care 35

A patient receives postoperative care that ensures the early detection and treatment of 36 complications of cataract surgery and the patient’s complete visual rehabilitation. 37 Postoperative care is provided by the operating ophthalmologist or a designated team 38 member. The patient is informed of the arrangements for postoperative care. 39


About the clinical care standards 1

Clinical care standards aim to support the delivery of appropriate evidence-based clinical 2 care and promote shared decision making between patients, carers and clinicians. 3

A clinical care standard contains a small number of quality statements that describe the 4 clinical care that a patient should be offered for a specific clinical condition. Many of the 5 quality statements are linked to indicators that can be used by health service organisations 6 to monitor how well they are implementing the care recommended in the clinical care 7 standard. 8

A clinical care standard differs from, and therefore is not intended to be, a clinical practice 9 guideline. Rather than describing all the components of care recommended for managing a 10 clinical condition, a clinical care standard addresses priority areas of the patient pathway 11 where the need for quality improvement is greatest. 12

Clinicians are advised to use clinical judgement and consider an individual patient’s 13 circumstances, in consultation with the patient and/or their carer or guardian, when applying 14 the information in the clinical care standard. Health service organisations are also 15 responsible for ensuring that local policies, processes and protocols to guide clinical practice 16 are in place so that clinicians can apply the information described in the clinical care 17 standard and to enable clinicians and health service organisations to monitor the delivery of 18 appropriate care. 19

Clinical care standards intend to support key groups of people in the healthcare system by: 20 Educating the public about the care that should be offered by the healthcare system, 21

and helping them to make informed treatment decisions in partnership with their 22 clinicians 23

Providing clear information to clinicians to assist making decisions about appropriate 24 care 25

Outlining the systems required by health service organisations so that they are better 26 able to examine their performance and make improvements in the care that they 27 provide. 28

This Cataract Clinical Care Standard was developed by the Australian Commission on 29 Safety and Quality in Health Care in collaboration with consumers, clinicians, researchers 30 and health service organisations. It complements existing efforts, including state and 31 territory-based initiatives, which support the provision of cataract care. 32

For more information about the development of this clinical care standard visit 33 www.safetyandquality.gov.au/ccs. 34


Introduction 1

Context 2

Cataract is a condition in which the lens of the eye becomes cloudy and can cause problems 3 with vision. It is more common in older people1 and is a significant issue for Aboriginal and 4 Torres Strait Islander populations.2,3 The impact of cataract on a person’s vision and their 5 ability to carry out their daily activities can vary considerably between people. Cataract 6 usually worsens over time, but how quickly this happens is difficult to predict for an 7 individual.4 8

People with cataract may experience blurriness, poor distance vision, difficulty seeing in 9 strong light (glare sensitivity), or difficulty seeing in low light conditions. The position of the 10 cataract in the lens can affect the type of visual problem - a cataract in the central part of the 11 lens is more likely to impair distance vision, while other types of cataract, for example a 12 posterior subcapsular cataract, can cause significant problems with glare without affecting 13 sharpness (visual acuity).5 14

Cataract that is identified during routine eye examination but is not causing problematic 15 symptoms can be managed with watchful waiting and non-surgical measures, such as 16 prescription glasses, tinted lenses for glare sensitivity and other visual aids.4,6,7 There are 17 some medical indications that may increase the need for surgery including angle closure 18 glaucoma, or to allow monitoring or treatment of other eye problems, but in general, surgery 19 is recommended when visual changes significantly interfere with activities.4,7 20

The procedure itself involves removing the cloudy natural lens and replacing it with a clear 21 synthetic lens, usually under local anaesthetic and performed as day surgery.8 22

Cataract surgery rates 23

Cataract is the most common elective surgery diagnosis in Australia.9 In 2016-17 there were 24 9.3 cataract surgeries per 1000 population, a total of 258,954 hospital separations. 9 Almost 25 70% of cataract surgery is performed in private hospitals10, an option that is not accessible 26 for all Australians. Admission rates to public hospitals for cataract surgery in areas with 27 socioeconomic disadvantage are more than double those in areas with socioeconomic 28 advantage (3.4 and 1.3 per 1000 population respectively).9 29

In Australia, as in other high income countries, rates of cataract surgery have increased 30 markedly in the past 25 years.11,12 This can be attributed to ageing populations coupled with 31 improved surgical methods.13 Interest has therefore increased in identifying: 32

When surgery is clinically warranted and appropriate4,14,15 33 How public health services can provide equitable and efficient access to surgery in a 34

way that takes into account individual patient circumstances and health service 35 resource constraints16-18 36

Whether some patients are more likely to benefit, or be at risk from a delay, than 37 others.14 38

Improving access to care 39

Tools and systems have been developed in New Zealand, Spain, Sweden and Canada 40 which aim to provide surgery according to clinical need and to improve the equity and 41 timeliness of access.19 Studies of these prioritisation systems suggest that they can achieve 42 these aims more effectively than ‘first-in first-out systems’.18,20-25 43


Each tool was developed with clinical input and validated in terms of how well it 1 approximates clinical decision-making, and some were further improved based on 2 experience and evaluation.18,21,25,26 Broadly speaking, appropriateness and priority for 3 surgery are determined based on similar components – the degree of visual impairment and 4 the impact of poor vision on daily activities and social function (including the ability to work 5 and live independently). However the weight given to each parameter and the way it is 6 measured differs.21 7

Most tools include visual acuity as a useful objective measure, but it is not recommended as 8 the only criteria for determining visual impairment.4,5,7,8,13 Even with good visual acuity some 9 people can have disabling visual impairment due to cataract-related glare or contrast 10 sensitivity. Since the impact of visual deficits can vary according to individual needs and a 11 person’s reliance on their vision for work or to maintain independence or quality of life, 12 vision-related activity limitations – as reported by patients – are an important aspect of the 13 likely benefit from surgery.4,7 14

Improving referral and initial assessment 15

A study of referral practices in NSW found that almost half of patients assessed by 16 ophthalmologists in two public hospitals did not proceed to surgery because of insignificant 17 cataract, minimal functional loss or being unwilling to undergo the procedure. Similar 18 patterns are reported elsewhere 13,23,27 suggesting considerable scope to improve both the 19 appropriateness and management of referrals, and hence the use of health resources. 20

This is important because while 90% of public hospital patients in Australia have surgery 21 performed within 334 days28, these statistics underestimate the true waiting time, as the time 22 waited for a first specialist assessment is not routinely reported. Waiting times vary between 23 states and territories. Awareness of the relative priority of referrals when determining 24 appointments could help clinicians and health service organisations to identify patients at 25 high risk while waiting. 26

Why this clinical care standard is needed 27

This clinical care standard aims to support clinicians and health service organisations to 28 improve their pathways of care and provide equity of access for people with clinically 29 significant cataract. It articulates some key elements for an improved pathway of care 30 including referral, assessment and surgery. These include: 31

Using consistent, clinically sound criteria for determining when cataract surgery may 32 be appropriate 33

Referral of patients from primary care that is informed by these criteria 34 Allocating ophthalmic assessments prior to surgery according to clinical need, using 35

essential information provided in the referral 36 Prioritising patients for surgery according to clinical need and based on transparent 37

criteria. 38

Other aspects of quality care included in the standard are considerations about second-eye 39 surgery and post-operative care including the appropriate use of post-operative eye drops. 40


Evidence sources that underpin this clinical care standard 1

Key evidence sources for the Cataract Clinical Care Standard include: 2

Royal Australian and New Zealand College of Ophthalmologists (RANZCO) - Preferred 3 practice patterns: cataract and intraocular lens surgery 8 4

NICE (UK) guideline - Cataracts in adults: management 4 5

Evidence-based guidelines for cataract surgery: guidelines based on data in the 6 European Registry of Quality Outcomes for cataract and Refractive Surgery database 29 7

American Academy of Ophthalmology - Cataract in the adult eye preferred practice 8 pattern 6 9

Canadian Ophthalmological Society evidence-based clinical practice guidelines for 10 cataract surgery in the adult eye. 7 11

Goal of this clinical care standard 12

To ensure that patients with cataract are offered cataract surgery or non-surgical 13 alternatives, according to their clinical needs. Patients have the opportunity to make an 14 informed choice suitable to their individual situation. 15

Scope 16

This clinical care standard relates to the care of patients with cataract aged 18 years and 17 over. It covers the assessment of patients with suspected cataract, decisions about cataract 18 surgery and postoperative care. This clinical care standard applies to all healthcare settings 19 where care is provided to patients with cataract including primary care, hospitals, Aboriginal 20 Health Services and privately operated eye clinics. 21


General principles of care in relation to this 1

clinical care standard 2

Patient-centred care 3

Clinical care standards support the key principles of patient-centred care. Patient-centred 4 care is health care that is respectful of, and responsive to, the preferences, needs and 5 values of patients and consumers. 6

Person-centred care is care that is respectful of, and responsive to, the preferences, needs 7 and values of the individual patient. Person-centred care involves seeking out, and 8 understanding what is important to the patient, fostering trust, establishing mutual respect 9 and working together to share decisions and plan care. 10 11 Key dimensions of person-centred care include respect, emotional support, physical comfort, 12 information and communication, continuity and transition, care coordination, involvement of 13 carers and family, and access to care.30 14 15

Carers and families 16

Carers and family members have a central role in the prevention, early recognition, 17 assessment and recovery relating to patients’ health conditions. They often know the patient 18 very well and can provide detailed information about the patient’s history, routines or 19 symptoms, which may assist in determining treatment and ongoing support. 20

Although this clinical care standard does not specifically refer to carers and family members, 21 each quality statement should be understood to mean that carers and family members are 22 involved in clinicians’ discussions with patients about their care, if the patient prefers carer 23 involvement. 24

Multidisciplinary care 25

In this document, the term “clinician” refers to all types of health professionals who provide 26 direct clinical care to patients. Multidisciplinary care refers to comprehensive care provided 27 by a range of clinicians (for example, doctors, nurses, optometrists, orthoptists and other 28 allied health professionals) from one or more organisations, who work collectively with the 29 aim of addressing as many of a patient’s health and other needs as possible.31 A 30 coordinated multidisciplinary team approach can improve health outcomes, and offers more 31 efficient use of health resources. 32


Using the clinical care standard 1

An integrated approach to delivering care 2

Central to the delivery of patient-centred care identified in this clinical care standard is an 3 integrated, systems-based approach, supported by individual health services and networks 4 of services with resources, policies, processes and procedures. 5

Key elements of this approach include: 6 An understanding of the capacity and limitations of each component of the health 7

system across metropolitan, regional and remote settings 8 Clear lines of communication between components of the healthcare system including 9

primary care, hospital, sub-acute and community services 10 Appropriate coordination so that patients receive timely access to optimal care 11

regardless of how or where they enter the system. 12

To achieve these aims, health service organisations implementing this standard may need 13 to: 14

Deploy an active implementation plan and feedback mechanisms 15 Include agreed protocols and guidelines, decision-support tools and other resource 16

material 17 Employ a range of incentives and sanctions to influence behaviours and encourage 18

compliance with policy, protocol, regulation and procedures 19 Integrate risk management, governance, operational processes and procedures, 20

including education, training and orientation. 32 21

Integration with the National Safety and Quality Health 22

Service Standards 23

The National Safety and Quality Health Service (NSQHS) Standards were developed by the 24 Commission in collaboration with the Australian government, states and territories, clinical 25 experts, and consumers. The primary aims of the NSQHS Standards are to protect the 26 public from harm and improve the quality of health service provision. They provide a quality 27 assurance mechanism that tests whether relevant systems are in place to ensure expected 28 standards of safety and quality are met. 29

The second edition of the NSQHS Standards was launched in November 2017 and has 30 been used to assess health service organisations since January 2019. In the NSQHS 31 Standards (2nd ed.), the Clinical Governance Standard and Partnering with Consumers 32 Standard combine to form the clinical governance framework for all health service 33 organisations. 34

The Clinical Governance Standard aims to ensure that there are systems in place within 35 health service organisations to maintain and improve the reliability, safety and quality of 36 health care. 37

The Partnering with Consumers Standard aims to ensure that consumers are partners in the 38 design, delivery and evaluation of healthcare systems and services, and that patients are 39 given the opportunity to be partners in their own care. 40

As part of the Clinical Governance Standard (NSQHS Standards 2nd ed.), health service 41 organisations are expected to support clinicians to use the best available evidence, 42


including, where relevant, clinical care standards such as the Cataract Clinical Care 1 Standard (see Action 1.27b). 2

Health service organisations are expected to implement the NSQHS Standards in a manner 3 that suits the clinical services provided and their associated risks. Other aspects of the 4 NSQHS Standards (2nd ed.) which are particularly relevant to the Cataract Clinical Care 5 Standard include, but are not limited to, those listed in Table 1. 6

Table 1: Relevance of NSQHS Standards to the Cataract Clinical Care Standard 7

Clinical Governance Standard

Partnering with Consumers Standard

Preventing and Controlling Healthcare-Associated Infection Standard

Medication Safety Standard

Communicating for Safety Standard

Recognising and Responding to Acute Deterioration Standard

Governance, leadership and culture (1.1 and 1.2)

Informed consent (2.3, 2.4 and 2.5)

Infection prevention and control systems (3.5–3.9)

Clinical governance and quality improvement to support medication management (4.1 to 4.4)

Communication of critical information (6.9, 6.10)

Responding to deterioration (8.10–8.13)

Policies and procedures (1.7)

Sharing decisions and planning care (2.6 and 2.7)

Antimicrobial stewardship (3.15-3.16)

Documentation of patient information (4.5 to 4.9)

Documentation of information (6.11)

Safety and quality monitoring, including incident reporting systems (1.8, 1.11)

Information for consumers (2.9)

Continuity of medication management (4.10 to 4.12)

Credentialing and scope of clinical practice (1.23 and 1.24)

Communication of clinical information (2.10)

Evidence-based care (1.27), including clinical care standards

Variation in clinical practice and health outcomes (1.28)

Safe environment (1.29) including for Aboriginal and Torres Strait Islander people (1.33)

8

Information about the NSQHS Standards is available at: 9 nationalstandards.safetyandquality.gov.au 10

11


Indicators to support local monitoring 1

The Commission has developed a set of indicators to support healthcare providers and 2 health service organisations to monitor how well they implement the care described in the 3 clinical care standard. The indicators are a tool to support local clinical quality-improvement 4 activities. There are no benchmarks set for any of the indicators. 5

Monitoring the implementation of the clinical care standard will assist in meeting some of the 6 requirements of the National Safety and Quality Health Service (NSQHS) Standards. 7

The process to develop the indicators specified in this document comprised: 8 A review of existing local and international indicators 9 Consultation with the Cataract Clinical Care Standard Topic Working Group. 10

Most of the data underlying these indicators require collection from local sources, mainly, 11 through prospective collection or a retrospective chart review. Where an indicator refers to 12 ‘local arrangements’, these can include clinical guidelines, protocols, care pathways or any 13 other documentation providing guidance to clinicians on the care of patients with cataract. 14

Measuring and monitoring patient experience and outcomes 15

Systematic routine monitoring of patients’ experiences of healthcare and patient-reported 16 outcomes is an important way to ensure that service improvements and patient-centredness 17 are driven by the patients’ perspective. This is the case in all health service organisations, 18 including those providing cataract surgery. 19

Patient-reported outcome measures (PROMs) 20

In Australia, patient-reported outcome measures (PROMs) are an emerging method of 21 assessing the quality of health care. The Commission is leading a national work program to 22 support the consistent and routine use of PROMs to drive quality improvement. 23

PROMs are standardised, validated questionnaires that patients complete, without any input 24 from health professionals. They are often administered at least twice to an individual 25 patient at baseline and again after an intervention or at regular intervals during a chronic 26 illness. The information contributed by patients filling out PROMs questionnaires, can be 27 used to support and monitor the movement of health systems towards person-centred, 28 value-based health care. 29

PROMs are being used to evaluate healthcare effectiveness at different levels of the health 30 system, from the individual to service and system levels. There is growing interest across 31 Australia and internationally in the routine interrogation of patient reported outcome 32 information for evaluation and decision-making activities at levels of the health system 33 beyond the clinical consultation. 34

A number of questionnaires and measures have been developed to assess the impact of 35 cataract on patient’s daily lives and to assess the benefit of cataract surgery and although 36 some have serious limitations, others have been validated and evaluated in English-37 speaking cataract populations.33-35 38

The CATQuest-9SF is a 9-item questionnaire that is recommended for pre- and post-39 surgery measurement of patient-reported outcomes by the International Consortium of 40 Healthcare Improvement35,36 and which has been validated in Australia. 41

The CAT-PROM5, is a 5 item questionnaire recently developed in the UK for use in the 42 NHS that compares favourably with the CATQuest-9SF, but has not been validated in 43 Australia.37,38 44


Patient experience measures 1

While there are no indicators in this standard specific to patient experience measurement, 2 the Commission strongly encourages health service organisations to adopt the Australian 3 Hospital Patient Experience Question Set (AHPEQS). The AHPEQS is a short 12 question 4 generic patient experience survey which has been tested and found reliable and valid for 5 both day-only and admitted hospital patients across a wide variety of clinical settings. The 6 instrument is available free of charge to both private and public sector health service 7 organisations. The Commission’s website contains more information about this tool at: 8 www.ahpeqs.safetyandquality.gov.au. 9


Quality Statement 1: Primary care assessment 1

and referral 2

A patient with visual problems and suspected cataract has an initial assessment in 3 primary care of their visual impairment, vision-related activity limitations, 4 comorbidities and willingness to have surgery. When referral is appropriate based on 5 these criteria, the patient is referred for consideration for cataract surgery and this 6 information is included in the referral form. 7

Purpose 8

To ensure the appropriate management and referral of patients with suspected cataract in 9 primary care and that when patients are referred, adequate information is provided to 10 support triage by the receiving clinician or health service organisation. 11

What the quality statement means 12

For patients 13

Cataract is a common eye problem, especially as people get older. General practitioners 14 (GPs), Aboriginal health workers, optometrists and orthoptists are all primary care clinicians 15 who may be your first point of contact for eye problems. 16

Cataract may be found as part of a routine eye test or because you are having trouble with 17 your vision. When assessing you, your clinician will ask whether your eyesight has changed 18 and whether your visual problems are affecting your life, including the sorts of things that you 19 can no longer do. Vision tests and an eye examination to confirm cataract can be carried out 20 by an optometrist or orthoptist, or by a specialist eye doctor (ophthalmologist). 21

Your primary care clinician(s) will discuss the possible ways to manage your symptoms. If 22 cataract is not affecting your ability to carry out your usual activities, then you may not need 23 to consider surgery yet. Prescription glasses or other equipment or aids might be worth 24 considering – your GP or optometrist can advise you about the services available. 25

If cataract surgery is a suitable option for you, and you are willing to consider surgery, your 26 clinician can refer you to a specialist eye doctor for further assessment and to discuss 27 possible surgery. Some specialist eye clinics will need specific information in your referral 28 before they offer you an appointment. This might include eye test results from an optometrist 29 and information about other medical conditions and treatments from your GP or other 30 clinician. 31

For clinicians 32

If a patient has visual problems that you suspect are due to cataract, test their vision and ask 33 them how their visual problems are affecting their life. Ocular examination can confirm the 34 presence of cataract, and optometry referral may be a suitable initial option. 35

Discuss the possible options to manage the patient’s symptoms and advise them that the 36 presence of cataract alone is not an indication for surgery. Patients with lens opacities that 37 do not cause visual symptoms or limit daily activities can continue to be managed and 38 monitored in the primary care setting. 39

Assess visual impairment in terms of visual acuity and other impacts such as disabling glare 40 or contrast sensitivity. Vision-related activity limitations may include a loss of ability to work, 41


drive, carry out daily tasks, or care for themselves or others. Falls risk is a significant 1 consideration particularly in older people with multiple risk factors. Box 1 provides 2 information about assessment of vision-related activity limitation and lists some examples of 3 assessment tools. 4

Refer patients for consideration of cataract surgery when they have visual impairment which 5 interferes with their ability to carry out important daily tasks and live independently. Consider 6 any ocular or medical comorbidities and whether these affect the urgency of referral. 7 Ophthalmology assessment can confirm whether patients with ocular comorbidity are more 8 likely to benefit from surgery, or have an increased risk of complications.7 Discuss the 9 potential benefits and harms of cataract surgery. 10

Check the referral criteria for the receiving organisation and ensure that all required 11 information is provided; use a standardised cataract referral template if available. Both 12 general practice and optometry assessment may be needed to provide the information 13 required.39-42 Improving the quality of the referral42 can reduce delays for patients by helping 14 ophthalmology services triage access to ophthalmology services and assess medical 15 suitability for surgery.43,44 Elements of a comprehensive referral are listed in Box 2. 16

Assess the patient’s willingness to proceed with surgery if offered. If the patient does not to 17 want to consider cataract surgery and there are no other indications for ophthalmology 18 assessment, then referral to an ophthalmology service may not be appropriate. Provide 19 support for patients to reduce the impact of their visual problems including refractive 20 correction, tinted lenses to reduce glare, or use of suitable equipment to optimise vision and 21 improve the patient’s capacity for activities of daily living.7 Refer to an optometrist, orthoptist, 22 occupational therapist or a vision clinic if appropriate. 23

For health service organisations 24

Primary care services making referrals should maintain awareness of any local referral 25 guidelines or criteria for referral to ophthalmology or other eye services and have protocols 26 to ensure that relevant information is included in the patient referral. Patient information 27 about cataract and its management should be available for primary care clinicians to provide 28 to patients, as well as any alternative community-based referral options. 29

Ophthalmology services receiving referrals should have guidelines that describe what 30 information is required in referrals from primary care, and where relevant, describe any 31 criteria for accepting and prioritising referrals. Referral guidelines should be published online 32 in an accessible, relevant location and made readily available to referring clinicians and 33 through Primary Health Networks. 34

A standardised referral template can be effective for improving the appropriateness of 35 referral as well as improving the quality of information needed to triage patients for 36 ophthalmology appointments.13,43,44 37 38


Additional information for assessing and referring patients 1

with cataract 2

Vision-related activity limitation 3

Vision-related activity limitation is: 4 An assessment of the impact of poor vision on usual activities.33 5 Different to quality of life 6 A useful assessment for measuring potential to benefit from surgery. 7

8 There are many scales and tools measuring vision-related activity limitation33,34; two useful, 9 validated measures which correlate with benefit from cataract surgery are listed below.* 10

11

Box 1: Assessment of vision-related activity limitation – patient-related outcomes 12

Question domains Assessment tool Catquest-936,45,46 CAT-PROM-537,38 Global ratings of visual difficulty No. of items () No. of items ()

Visual problems interfere with normal activities

Overall self- rating of vision or ability to see well (corrected with usual glasses or lenses)

Satisfaction with sight

Specific activities

Difficulty reading normal print/text (such as newspapers, books, price tags, medicine labels)

Recognising faces because of sight

Seeing on uneven surfaces because of sight

Seeing to do handicrafts, woodwork or hobbies

Reading text on TV

Validated in Australia and Sweden. Adopted by International Consortium for Health Outcomes Measurement. 36

Validated in UK for use by NHS

* The Priquest tool has been validated and shown to predict benefit from cataract surgery. It is used in 13 Sweden and other Scandinavian countries, but an English version has not been validated. 15,22 14

15


Box 2: Key components of referrals for ophthalmology assessment and consideration 1 of cataract surgery 2

Referral information for cataract patients

Key questions13

Does the cataract affect the patient’s sight and quality of life? Does the patient understand the risks and wish to have surgery if it is offered?

Purpose of referral

1. Reason for referral

Ophthalmic assessment

Consideration for first cataract surgery

Second eye surgery.

General information

2. Patient details including Indigenous status, interpreter needs

3. Consent for referral and for sharing relevant information

4. Social circumstances (support at home, employment-related needs)

5. Patient willingness to consider cataract surgery

Ocular/ophthalmic history

Include the date and results of the most recent optometry or ophthalmology assessment

6. Cataract details including severity of disease (grade of cataract)

7. Extent of visual impairment such as*; Best corrected visual acuity (in each eye and both eyes) Glare or contrast sensitivity (based on clinical assessment).

8. Other assessment results* Subjective refraction results Intra-ocular pressure.

9. Ocular diagnoses made or suspected including: Previous ocular surgery or trauma, glaucoma, acute macular degeneration, macular oedema,

amblyopia.

10. Vision-related activity limitations including falls risk, impact on activities of daily living, ability to care for oneself, driving, recreational, educational and occupational activities.

General medical history*

11. Other medical history, including comorbidities such as diabetes

12. List of current medication

13. Allergies.

*May require assessment by an ophthalmic clinician (ophthalmologist, optometrist, or orthoptist)prior to referral

3


Quality Statement 2: Patient information and 1

shared decision making 2

A patient with suspected or confirmed cataract receives information to support 3 shared decision making. Information is provided in a way that meets the patient’s 4 needs and is easy to use and understand. The patient is given the opportunity to 5 discuss the likely benefits and potential harms of the available options, as well as 6 their needs and preferences. 7

Purpose 8

To ensure patients with cataract receive accurate and balanced information about the 9 surgical and non-surgical options available to them and the likely benefits and potential 10 harms of each option to enable an informed decision about whether to have cataract 11 surgery. 12


For patients 14

Your clinician will talk to you about cataract and its treatment in a way that you can 15 understand, and will provide written information in a way that is easy for you to use. This will 16 include information about the available options including the expected benefits, as well as 17 the possible adverse outcomes, including unsatisfactory changes in your vision and more 18 serious complications. You will be asked about the effect that vision problems are having on 19 your life, and have the opportunity to discuss the advantages and potential disadvantages of 20 surgery for your individual circumstances. Other options including visual aids and watchful 21 waiting should also be discussed. 22

For clinicians 23

Provide patients who have cataract with clinically accurate evidence-based information 24 about their options both verbally and in a format that is easy to use, for example in large font 25 or electronically. Suitable options may include surgical or non-surgical options, such as 26 visual aids or watchful waiting. Ask the patient about their needs, preferences and their 27 quality of life concerns, and any psychosocial issues to help support them in shared decision 28 making. 29


Ensure that policies support shared decision making and the competence of clinical staff, 31 who should be appropriately trained and have access to suitable resources. Ensure that any 32 patient information resources provided are clinically accurate, balanced and evidence-based, 33 and suitable to your patient population. These resources should include information about 34 surgical and non-surgical options, be easy to understand and presented in a format that is 35 easy to use for patients with impaired vision. Provide a culturally safe environment for your 36 patient community.47 37

38


Quality Statement 3: Access to ophthalmology 1

assessment 2

A patient who has been referred for consideration for cataract surgery is prioritised 3 for ophthalmology assessment according to clinical need, based on a locally 4 approved protocol and following receipt of a detailed referral. 5

Purpose 6

To ensure that a patient’s first clinic appointment is allocated in a timely manner appropriate 7 to their clinical need, based on documented approved protocols which specify how patients 8 will be assessed and prioritised. 9


For patients 11

When you are referred to a specialist eye doctor, you will usually be given the next available 12 appointment. However some clinicians or health services may use the information in your 13 referral to decide when you receive an appointment. This means that people with more 14 urgent needs may be seen more quickly. If you are referred to a health service or specialist 15 eye doctor using this type of system, they may check the information in your referral to 16 decide when you will receive an appointment. If key information is missing from your referral 17 they may ask you or the referring clinician to provide the missing details. 18

If your eyesight worsens or other circumstances change while you are waiting for an 19 appointment, get in contact with the clinician who referred you and let them know. If you do 20 not meet the requirements, they may suggest other ways for you to manage your eye 21 problems. 22

For clinicians 23

Use local protocols to allocate appointments for referred patients, prioritising according to 24 clinical need, including social circumstances. This is particularly important where there are 25 waiting times for the first specialist assessment. 26

Assessment of clinical need includes both visual impairment and resulting limitations in 27 vision-related activities. Social factors including the impact of poor vision on the person’s 28 ability to work and live independently should also be considered. 29

If the referral is incomplete, the referring clinician should be prompted for further information. 30 The assessment should be scheduled in a timeframe that is consistent with agreed health 31 service protocols. 32

Referrals should be reviewed by a credentialed ophthalmic clinician who can make an initial 33 assessment about the appropriateness of referral, severity and relative priority for 34 ophthalmological assessment based on the information contained in the referral. Use of 35 standardised criteria and tools allows consistency of assessment, and assists when 36 prioritising patients within a health service or system.21,25 37



When patients are referred for consideration for cataract surgery appointments are allocated 2 using protocols that prioritise patients based on clinical need, including social circumstances. 3 This is particularly important in health service organisations where there are substantial 4 waiting lists for the first specialist assessment. 5

These protocols should describe criteria for accepting referrals and prioritising patients for 6 ophthalmology assessment. They should include any tools to be used for providing 7 standardised information and allow for a credentialed ophthalmic clinician to review referrals 8 to determine the priority and timing of ophthalmology assessments. In some states and 9 territories, these protocols may be determined at a health department level for public hospital 10 clinics. 11

Where referral criteria apply, these should be readily available and communicated to 12 referring clinicians and patients. Consider providing a standardised referral template for 13 referrals from the community to help ensure that adequate information is provided. 14

Protocols should include pathways for patients who do not meet referral criteria, who choose 15 non-surgical options, or for whom surgery is considered unsuitable or inappropriate at 16 ophthalmologic assessment. These options may include reassessment or follow-up, or 17 referral to other services such as optometry, orthoptist, occupational therapy or vision clinics. 18 Provide information back to the referring clinician. 19

Processes should be in place to monitor patients waiting for first ophthalmology 20 appointments in case their clinical needs and priority changes. 21

Monitor and audit outcomes within a quality improvement framework to assess whether 22 desired outcomes are being achieved. 23

Indicators for local monitoring 24

Indicator 1 25

A locally approved protocol in place to allocate appointments for patients considering 26 cataract surgery, based on standardised referral criteria and according to clinical 27 need. 28

Evidence that locally approved protocols are in place to assess referrals and allocate first 29 ophthalmology appointments for patients with cataract based on clinical need. 30

A healthcare setting that provides cataract surgery and which has a documented 31 process should record ‘Yes’. Otherwise, the healthcare setting should record ‘No'. 32

Indicator 2 33

Proportion of referrals for possible cataract surgery received which include required 34 information (as defined by the local protocol). 35

The proportion of referrals received for patients with cataracts, which have all the relevant 36 information provided (as defined by the local protocol) 37

Numerator: Number of referrals for patients referred for consideration of cataract 38 surgery in which all required information is provided 39

Denominator: Number of referrals for patients referred for consideration of cataract 40 surgery 41


Indicator 3 1

Proportion of referrals not meeting referral criteria for an appointment for cataract 2 surgery. 3

The proportion of referrals received for patients with cataract, that provided the information 4 required by the locally approved protocol), but did not meet criteria for a first appointment for 5 assessment for cataract surgery. 6

Numerator: Number of referrals for cataract patients with all relevant information 7 provided, that did not meet criteria for cataract surgery. 8

Denominator: Number of referrals for consideration of cataract surgery with all relevant 9 information provided 10

Indicator 4 11

Proportion of patients referred for cataract surgery who progress to cataract surgery 12

The proportion of patients referred for consideration of cataract surgery who are assessed 13 as suitable for surgery (conversion rate) 14

Numerator: Number of patients who were referred, assessed as suitable for cataract 15 surgery and went on to have surgery. 16

Denominator: Number of patients referred for cataract surgery. 17


Quality Statement 4: Indications for cataract 1

surgery 2

A patient is offered cataract surgery when they have a lens opacity that limits their 3 vision-related activities and causes clinically significant visual impairment involving 4 reduced visual acuity of 6/12 or worse, or disabling glare or contrast sensitivity. 5

Purpose 6

To ensure that patients with clinically significant cataract are offered cataract surgery when 7 appropriate according to clinical criteria.48 8


For patients 10

Cataract surgery is usually recommended when you have trouble seeing well enough to 11 carry out your normal daily activities. As part of your assessment, your clinician may test 12 how clearly you can read an eye chart (visual acuity). They will also take into account other 13 visual problems, including any difficulty you have seeing in bright light or dim light. 14

Your clinician will ask you questions about the effect of your eye problems on your daily 15 activities. What this means may differ from person to person. Your clinician may ask about 16 activities such as working, driving, and reading as part of your daily life as well as your ability 17 to live independently and safely with your visual problems (for example, whether you are at 18 risk of falls). They may ask you to complete a questionnaire. 19

The likely benefits and possible harms of surgery might also depend on whether you have 20 any other health conditions, including other eye problems. Your clinician will consider these 21 factors when discussing the possibility of cataract surgery with you, and will let you know if 22 you have a condition that means surgery is not recommended or there is a higher risk of 23 complications. 24

There are some people to whom this statement may not apply. These include people who 25 need very good vision to carry out their daily activities, such as professional drivers. 26 Sometimes cataract surgery is recommended for medical reasons rather than for improving 27 vision. This includes surgery for people who need regular check-ups of the retina (back of 28 the eye) but it cannot be seen because of the cataract. 29

For clinicians 30

Note: This statement applies to people having cataract surgery primarily to improve vision. 31 Some of these patients will have an indication for cataract surgery at better levels of visual 32 acuity, for example professional drivers complying with licence requirements. Other clinical 33 scenarios may exist where these criteria do not apply, for example, people having cataract 34 surgery for other reasons such as to enable monitoring of retinal conditions. Some patients 35 will have a contraindication which will prevent surgery from being offered. 36

The clinical decision about whether to offer cataract surgery takes into account the patient’s 37 level of visual impairment, the impact of visual deficits on their daily life, and the potential 38 benefits and harms associated with surgery. 39


Visual acuity of 6/12 or worse is a useful objective measure of visual impairment, however 1 glare or contrast sensitivity may be disabling without an impact on visual acuity. 2

Vision-related activity limitations include activities of daily living, which are specific to the 3 individual including occupational requirements and social circumstances. Validated tools for 4 assessing vision-related activity limitations and the impact of visual problems on activities 5 and social functioning are described in Box 2. Some of these tools correlate well with 6 positive patient-reported outcomes after cataract surgery.36,38,45,46,49 7

Use of standardised criteria and tools allows consistency of assessment, and assists when 8 prioritising patients within a health service or system.21,25 These criteria do not replace the 9 need for an individualised clinical assessment or clinical judgements about the severity of 10 impairment and the appropriate treatment options. 11

While most patients have an improvement in visual function after surgery, patients most 12 likely to report a poor outcome after surgery include those with good self-assessed 13 preoperative visual function.7,49,50 14

If the patient chooses not to have surgery or is not considered suitable for surgery at this 15 time, offer details of other healthcare providers who can help such as an occupational 16 therapist or optometrist. 17


Ensure that protocols support the use of suitability criteria for cataract surgery, and that 19 cataract surgery is offered to patients who meet agreed criteria. Protocols should also allow 20 for consideration of other compelling indications for surgery, based on clinical judgement, as 21 well as catering for patients who choose non-surgical options. 22

Consider implementing common clinical criteria and/or tools into protocols to enable 23 standardised assessment, documentation and prioritisation. Examples of tools that could be 24 considered are listed in Box 2. Implement tools and protocols within a quality improvement 25 framework, monitoring their use and impact to ensure that desired outcomes are being 26 achieved. Such outcomes may include whether criteria are being consistently applied, equity 27 of access, timeliness of access and patient-reported outcomes. 28


Quality Statement 5: Prioritisation for cataract 1

surgery 2

A patient is prioritised for cataract surgery according to clinical need. Prioritisation 3 protocols take into account the severity of the patient’s visual impairment and 4 vision-related activity limitations, the potential harms of delayed surgery, any 5 relevant comorbidity and the expected benefits of surgery. 6

Purpose 7

To ensure that patients with clinically significant cataract are prioritised for surgery according 8 to their clinical needs, including consideration of the possible adverse outcomes if surgery is 9 delayed. 10


For patients 12

If you and your eye surgeon agree that you could benefit from cataract surgery, and you 13 agree to have surgery, this will be arranged. 14

Where there is a high need for services, you will be put on a waiting list for surgery. Most 15 hospitals use a system to help make sure that patients with the greatest need for surgery are 16 scheduled for cataract surgery first. This means that the severity of your vision problems and 17 how much they affect your ability to carry out your daily activities should be taken into 18 account. These include activities such as working, driving, cooking, reading and writing, as 19 well as your ability to care for yourself or others. Your clinicians will also consider any other 20 health conditions you have and your risk of falls. Some health conditions may make it more 21 urgent for you to have cataract surgery, while others mean that surgery is less likely to help 22 you. 23

Let your GP, optometrist or eye specialist know if your vision worsens or other 24 circumstances change while you’re on a waiting list for cataract surgery, as this may affect 25 your priority on the waiting list. 26

For clinicians 27

Take into account protocols for prioritising patients in your local health service and provide 28 information to assist prioritisation of patients. Assess visual impairment and vision-related 29 activity limitations and document, using a standardised tool if required. 30

At an individual patient level, the benefit and relative priority for surgery is usually based on 31 expert clinical judgement, taking into account the degree of visual impairment, the impact of 32 visual impairment on activities of daily living (vision-related activity limitations), the risks of 33 delayed surgery, any relevant comorbidity and the expected benefit of surgery. 34

When patients are being prioritised for surgery across a health service organisation, 35 standardised protocols may be used to assess these factors systematically. Prioritisation 36 protocols should enable patients at greatest risk of harm and who are most likely to benefit 37 from surgery to be treated first. Potential harms associated with delayed surgery include 38 risks of falls, traffic accidents or increased complexity of later surgery, for example, in 39 patients with densely brunescent or white cataract. 4 40


Some comorbid conditions may increase the need for cataract surgery, such as where 1 fundal access is required for monitoring or treatment of posterior segment disease. Other 2 conditions may increase the risk of complications or a poor outcome from cataract surgery 3 (such as diabetes, diabetic retinopathy or uveitis) or limit the extent of visual gain (such as 4 age-related macular degeneration).7 5


Ensure that protocols are in place to support prioritisation of patients according to their 7 clinical needs and other key factors, based on their ophthalmology assessment. Prioritisation 8 protocols should include consideration of the patient’s visual impairment and vision-related 9 activity limitations, comorbidity, potential harms from delayed surgery and potential to 10 benefit. Surgery is scheduled based on this protocol. Monitor and if necessary, reassess 11 patients while they are on the waiting list in case their circumstances change. 12

Consider using validated tools or agreed clinical criteria to enable standardised assessment 13 and documentation. Implement prioritisation protocols in accordance with health service 14 and/or state or territory health department requirements. Examples of tools that could be 15 considered and adapted are listed in Box 3. Implement tools and protocols within a quality 16 improvement framework, monitoring their use to ensure that desired outcomes are being 17 achieved. These include whether criteria are being consistently applied, timeliness of 18 surgery, clinician perceptions and patient-reported outcomes. 19


Indicator 5 21

Protocol in place to prioritise patients for cataract surgery according to clinical need. 22

Evidence of a local protocol in place to prioritise patients for cataract surgery based on 23 clinical need. 24

The protocol should specify that patients will be prioritised according to clinical need using a 25 systematic, transparent method that takes into account the patient’s visual impairment and 26 vision-related activity limitations, co-morbidity, potential harms from delayed surgery and 27 potential to benefit. The method for prioritising and ranking patients should be stated. This 28 protocol should apply where there is a waiting list for surgery. 29

Use of the Elective surgery prioritisation criteria alone is not sufficient evidence, as even 30 within those categories, prioritisation should apply. 31

A healthcare setting where surgery is provided to patients with cataract which has a 32 documented process should record ‘Yes’. Otherwise, the healthcare setting should 33 record ‘No'.34

26

Box 3: Tools and measures for assessment and prioritisation of patients with cataract 1

PRIORITISATION TOOLS

Tool Description of use Visual impairment measure Vision-related activity limitation measures

Comments

NIKE National tool for indications for cataract extraction.15,25

For prioritising patients determined appropriate for cataract surgery, along with waiting time guarantee in Sweden and Denmark. Patients are prioritised into 4 groups from greatest to least need for surgery

Includes best corrected visual acuity in each eye, symptoms (glare, binocularity).

Medical indications for surgery (e.g. mature cataract)

Comorbidity reducing potential benefit of surgery

PriQuest Takes into account difficulty in performing daily activities, work, drive, manage without assistance or care for others

Not in English

New Zealand - National Clinical Priority Assessment Criteria (CPAC)18

Patients are referred by GP using online system.

If referral is accepted, patient receives first specialist assessment. Specialist assigns priority score.

Different District Health Boards (have different systems for assessing and prioritising based on common criteria

51

Best corrected distance visual acuity in operative eye

Best corrected binocular distance visual acuity

Presence of axial posterior sub-capsular lens opacity

Potential visual acuity in the operative eye after surgery (taking into account comorbidity, such as maculopathy, keratopathy, optic neuropathy, amblyopia)

Impact of life questionnaire:

Social interaction Personal interaction Ability to fulfil responsibilities to

others Personal care Personal safety Leisure activities.

Manitoba Cataract Waiting List Program52

Uses a centralised database to track and prioritize all patients waiting for cataract surgery after initial ophthalmology assessment

Clinical assessment of need for surgery Visual Function Index (VF-14)33

VF-14 provides an objective measure for prioritising patients once the appropriateness of surgery is determined. Waiting time is tracked in the system.

IRYSS-Cataract Priority Score (ICPS) 17,21,53 (Spain)

Can be used to determine appropriateness and priority.

Two tools were developed (IRYSS Appropriateness of indication and IRYSS Cataract Priority Score) but were found to be highly correlated and similar for prioritising.

Ocular comorbidity

BCVA in both eyes

Surgical complexity of cataract extraction

Laterality of cataract

Anticipated VA after extraction

Visual function – 4 items Impairment level Glare Recreational difficulties Difficulties with activities of daily

living. Social dependence (Priority tool)

Appropriateness was rated as necessary, appropriate, uncertain or inappropriate and priority using a numeric score.

Cataract Impact Model22

Model for establishing relative surgical priority integrating clinical and questionnaire data

Visual acuity in the eye undergoing surgery, the fellow eye, the better eye

Catquest-9SF 36

Priquest

Proof of concept but not currently in use

27

Quality Statement 6: Second-eye surgery 1

Options for a patient with bilateral cataract are discussed when the decision about 2 first-eye surgery is being made. Second-eye surgery is offered using similar criteria 3 as for the first eye, but the potential benefits and harms of a delay in second-eye 4 surgery are also considered, leading to a shared decision about second-eye surgery 5 and its timing. 6

Purpose 7

To ensure that patients with bilateral cataract who have a higher risk of poorer visual 8 function after first-eye surgery are identified, the options for surgery are discussed, and a 9 decision about timing is made appropriate to their individual clinical circumstances and 10 personal preferences. 11


For patients 13

If you have cataract in both eyes, your eye surgeon will discuss whether you would benefit 14 from having surgery in both eyes. For many people, having cataract surgery in one eye is 15 enough to improve vision. If your eye surgeon thinks you may need operations on both eyes, 16 the options include: 17

Having surgery on the second eye sometime after the first eye has recovered from 18 surgery 19

Having surgery on the second eye on the same day as the first eye or the day 20 afterwards. 21

The option most suitable for you will depend on a number of factors. Some of the factors you 22 should take into account include: 23

How your overall vision is expected to change after surgery in the first eye. If one eye 24 is very different to the other one (for example much more short-sighted) then it may be 25 hard to see clearly with both eyes, even if the operated eye is much better than it was 26 previously. 27

The risks of an infection or another complication. If you are at high risk of 28 complications, or have other eye problems, having operations on both eyes at the 29 same time may not be recommended. While the risks of complications are small, 30 having complications in both eyes could be very serious. 31

Your general health, any other eye problems and your personal circumstances and 32 preferences. 33

Discussing these issues with your eye surgeon and understanding the potential harms and 34 benefits will help you decide if and when you want to arrange surgery for your second eye, 35 and how to go about doing so. 36

For clinicians 37

Discuss second-eye surgery and its timing when first eye surgery is being planned. The 38 same criteria apply when assessing the need for second-eye surgery as for the first eye54 39 (clinically significant visual impairment, vision-related activity limitations and 40 comorbidities - see Quality statements 4 and 5). In addition, consider the likelihood of a 41 significant difference in refractive error between the two eyes after first-eye surgery and its 42


impact on vision and visual function including stereopsis (depth perception), stereoacuity 1 and falls risk. 2

Advise patients of the options available to them including no surgery, surgery on two 3 separate days some time apart or immediately sequential bilateral cataract surgery (second 4 eye surgery on the same or next day). Explain to patients what they can expect from having, 5 or not having, second-eye surgery and discuss the benefits and potential harms with them to 6 help decide between options. 7

Having second-eye surgery later allows for complete postoperative recovery (and where 8 needed, treatment of postoperative complications) from first eye surgery, and the opportunity 9 to assess and plan surgery based on the results of first-eye surgery. If the patient chooses to 10 have second-eye surgery on a separate occasion, make arrangements for it as soon as it is 11 appropriate for the patient’s preferences and circumstances. 12

While there is limited evidence for immediately sequential bilateral cataract surgery55 it may 13 be considered for patients4,8: 14

At low risk of complications during and after surgery and/or at risk from delayed 15 second-eye surgery 16

To avoid a second general anaesthetic where this is required 17 For whom distance and travel are significant barriers. 18

Explain to patients considering this option that while they may experience improved vision in 19 both eyes sooner, they may need extra support at home after surgery. Ensure patients are 20 informed of the consequences of complications, including the risk of potentially blinding 21 complications in both eyes such as endophthalmitis or toxic anterior segment syndrome.4 22

Second-eye surgery may not be appropriate for some patients. As well as individual 23 preference, some patients may have another eye condition that makes it too risky for them, 24 or makes an improvement in vision less likely. 25


Provide access to current evidence-based guideline recommendations for second-eye 27 surgery and support use by clinicians. Ensure adequate protocols regarding decisions about 28 second-eye surgery and its timing. For patients having delayed second-eye surgery, 29 prioritise surgery according to clinical need. 30

If immediately sequential bilateral cataract surgery is carried out in the health service, ensure 31 that facilities are appropriately equipped and that local protocols are in place to minimise the 32 risk of complications and manage them should they occur.4 33

34


Quality Statement 7: Preventive eye medicines 1

A patient receives an intracameral antibiotic injection at the time of cataract surgery, 2 according to evidence-based guidelines. After surgery, a patient receives antibiotics 3 or anti-inflammatory eye drops only when indicated. 4

Purpose 5

To improve patient care by ensuring appropriate use of intracameral antibiotics and post-6 operative eye drops such as antibiotics and anti-inflammatory medicines. 7


For patients 9

During cataract surgery, most patients will receive an antibiotic which is injected into the eye 10 during surgery. The technical term for this is an intracameral antibiotic. Most people who 11 have this antibiotic during surgery will not need to use eye drops after surgery. However 12 antibiotic eye drops may be recommended for you if you have certain health condition(s), or 13 if you develop complications after cataract surgery. If this is the case, your eye surgeon will 14 discuss this with you and explain how to use the eye drops. Follow the dosing instructions 15 carefully. 16

For clinicians 17

Evidence-based guidelines recommend use of intracameral antibiotics4,6,56; Therapeutic 18 Guidelines Antibiotic recommends cefazolin intracamerally as a single dose at the end of 19 surgery.56 20

Routine use of post-operative antibiotic eye drops is not required and there is little evidence 21 to support their use.4,56 Prescribe post-operative antibiotic eye drops according to a patient’s 22 clinical circumstances, consistent with evidence-based guidelines such as Therapeutic 23 Guidelines Antibiotic.56 If post-operative antibiotic eye drops are indicated, prescribe 24 chloramphenicol 0.5% eye drops, stipulating the duration (usually 7 days) to avoid overuse.56 25

For patients at risk of developing cystoid macular oedema after cataract surgery, for 26 example because of coexisting diabetes or uveitis, consider post-operative nonsteroidal anti-27 inflammatory eye drops in combination with topical steroids and discuss their benefits and 28 possible adverse effects with the patient.4, 6 Nonsteroidal anti-inflammatory eye drops, with 29 or without topical steroids, may be considered in lower risk patients to prevent inflammation 30 and/or cystoid macular oedema.4 31

Potential adverse effects include allergic reactions to antibiotics, increased intraocular 32 pressure with corticosteroids and, rarely, epithelial damage with nonsteroidal anti-33 inflammatories.6 34


Ensure that clinicians have access to current evidence-based guideline recommendations 36 for intracameral antibiotics and other postoperative eye drops, such as Therapeutic 37 Guidelines Antibiotic. Develop processes to measure compliance with guidelines.56 38



Indicator 6 2

Proportion of patients who received intracameral administration of antibiotics at the 3 end of surgery 4

The proportion of patients with cataract, who received intracameral administration of 5 antibiotics at the end of surgery. 6

Numerator: Number of patients who have cataract surgery who receive an 7 intracameral antibiotic injection at the end of their surgery. 8

Denominator: Number of patients admitted to hospital or day procedure service for 9 cataract surgery 10 11

Indicator 7 12

Proportion of patients who are prescribed post-operative antibiotic eye drops after 13 cataract surgery in accordance with evidence-based prescribing guidelines 14

The proportion of patients who are prescribed post-operative antibiotic eye drops after 15 cataract surgery in accordance with the Therapeutic Guidelines: Antibiotic or another locally 16 approved evidence-based guideline. 17

Numerator: Number of patients who had cataract surgery who are prescribed post-18 operative antibiotic eye drops in accordance with the Therapeutic Guidelines: 19 Antibiotic or another locally approved evidence-based guideline. 20

Denominator: Number of patients admitted to hospital or day procedure service for 21 cataract surgery. 22

23


Quality Statement 8: Postoperative care 1

A patient receives postoperative care that ensures the early detection and treatment 2 of complications of cataract surgery and the patient’s complete visual rehabilitation. 3 Postoperative care is provided by the operating ophthalmologist or a designated team 4 member. The patient is informed of the arrangements for postoperative care. 5

Purpose 6

To ensure that a patient remains under the care of the operating ophthalmologist (or where 7 necessary, that this care is delegated to an appropriately qualified clinician) until they have 8 recovered from cataract surgery. 9


For patients 11

Your eye surgeon (and members of the eye team) will see you regularly while you recover 12 from cataract surgery, until your eyes have fully recovered from the surgery. Usually this will 13 mean a check-up in the first 48 hours and again two to four weeks after surgery. They will 14 look at your eye to check how well it is healing and how well you can see. They will provide 15 information about: 16

What you can expect while your eye is healing 17 How to look after your eye while it is healing, including any eye drops if needed. 18 When to have your eyes checked after the operation so that any problems can be 19

treated early, even though the risk of complications after surgery is usually low. 20 When to get new glasses, if this applies to you. 21

It is important that you know who to contact if you have any concerns or questions, or if your 22 vision changes unexpectedly. If you have cataract in your non-operated eye, your eye 23 surgeon will talk to you about your options for future surgery, usually based on the recovery 24 of your operated eye. 25

For clinicians 26

Ensure appropriate postoperative care by regularly reviewing the patient’s postoperative 27 recovery. This usually means review in the first 48 hours and again within two to four weeks 28 of surgery. Determine the exact frequency of postoperative review taking into account the 29 surgical technique, and any operative and/or postoperative complications.8 Inform patients 30 about the need for follow-up appointments and potentially important visual changes. Provide 31 details of who to contact in case of concerns. 32

Postoperative care is the responsibility of the operating ophthalmologist. If this is not 33 possible, for example with some rural and remote patients, care should be delegated to an 34 appropriately qualified clinician with adequate clinical handover. Ensure that this team 35 member has the patient’s preoperative assessment and details of the surgery performed; is 36 able to recognise complications and can access urgent referral and specialist support if 37 needed. 38


Provide patients with information about what to expect during the postoperative period, how 1 to care for their eye post-operatively, use of medications, information about second-eye 2 surgery where relevant and when to get new glasses, if appropriate. Include this information 3 in reports back to the referring clinician, including details of intracameral antibiotics 4 administered during surgery. 5


Ensure that clinicians have access to local guidelines or protocols for appropriate 7 postoperative care, and that processes are in place to promptly identify and manage 8 complications. 9

When post-operative care will be provided by a clinician other than the operating 10 ophthalmologist, ensure appropriate handover of clinical information required to provide 11 postoperative care. Ensure that systems are in place to provide patients with access to 12 emergency specialist ophthalmology services as needed. 13

Ensure that policies and procedures for information management and communication 14 support the reporting of surgical outcomes to referring clinicians, other relevant clinicians 15 and the patient, and that responsibilities are clearly delineated. 16

17


Glossary 1

Adverse effect An adverse effect is a side effect, or an unwanted symptom caused by medical treatment.57

Assessment A clinician’s evaluation of the disease or condition, based on the patient’s report of the symptoms and course of the illness or condition, on information reported by family members and other healthcare team members, and on the clinician’s objective findings (including data obtained through tests, physical examination, medical history, and information reported by family members and other healthcare team members).58

Best Corrected Visual Acuity

The best possible vision a person can achieve with corrective lenses, measured using a visual acuity chart.

See also Visual acuity

Cataract A cataract is a dense, cloudy area that forms in the lens of the eye. It develops slowly and eventually interferes with your vision.

Clinician A qualified and trained health professional who provides direct patient care (that is, the diagnosis and/or treatment of patients including recommending preventative action). In this document it may refer to a doctor, an ophthalmic specialist such as an ophthalmologist, optometrist or orthoptist, or, a nurse or nurse practitioner, depending on the care that is being described and the individual's scope of professional practice.58,59

Clinically significant cataract

A clinically significant cataract occurs where opacity of the lens causes visual impairment and significant vision related activity limitations.

Credentialing

The formal process used to verify the qualifications, experience, professional standing and other relevant professional attributes of health practitioners for the purpose of forming a view about their competence, performance and professional suitability to provide safe, high-quality health services within specific organisational environments. 60

Health service organisation

A service responsible for the clinical governance, administration and financial management of unit(s) providing health care. A service unit involves a group of clinicians and others working in a systematic way to deliver health care to patients and can be in any location or setting, including pharmacies, clinics, outpatient facilities, hospitals, patients’ homes, community settings, practices and clinicians’ rooms. 32

Hospital A health-care facility established under Commonwealth, state or territory legislation as a hospital or a free-standing day procedure unit and authorised to provide treatment and/or care to patients.9


Immediately sequential bilateral cataract surgery

Immediately sequential bilateral cataract surgery (ISBCS) is when surgery is performed on both eyes on the same day but as separate procedures. The term simultaneous bilateral cataract surgery might also be used. Regardless of terminology, if surgery on both eyes is performed on the same day it is important that the procedures are performed separately and that strict hygiene protocols are used to reduce the risk of infection.55

Intracameral injection

Administration of a medicine into the anterior chamber of the eye (the front part of the eyeball near the lens).56

Lens opacity A cloudiness of the natural lens which is part of the eye

Medicine A chemical substance given with the intention of preventing, curing, controlling or alleviating disease, or otherwise improving the physical or mental welfare of people. Prescription, non-prescription and complementary medicines, regardless of administration route (e.g. oral, intravenous, intra-articular, transdermal or intra-uterine), are included.61

Ophthalmologist Medical doctors who have taken additional specialist training in the diagnosis and management of eye disorders and disorders of the visual system.62 Cataract surgery is performed by ophthalmologists.

Optometrist Eye care professionals who examine eyes, give advice on visual problems, and prescribe and fit glasses or contact lenses. If eye disease is detected, optometrists will refer patients to an ophthalmologist for further management.

Orthoptist

Eye health care professionals who are trained to diagnose and manage disorders of eye movements and associated vision problems and to perform investigative testing of eye diseases.

Primary care The first level of care or entry point to the healthcare system for consumers. It is multidisciplinary and incorporates office-based practices (e.g. general practice clinics, family planning clinics and sexual health services), community health practice (e.g. clinics, outreach or home-visiting services), emergency services (e.g. ambulance services), community-based allied health services (e.g. pharmacists), services for specific populations (e.g. Aboriginal and Torres Strait Islander or refugee health services, or school health clinics).63

Quality of life An overall assessment of a person's wellbeing, which may include physical, emotional, and social dimensions, as well as stress level, sexual function, and self-perceived health status.58

Refractive error

A refractive error is a very common eye disorder. It occurs when the eye cannot clearly focus the images from the outside world. The result of refractive errors is blurred vision, which is sometimes so severe that it causes visual impairment.

Common refractive errors include being short sighted or being longsighted. Refractive errors can be diagnosed by an eye examination and treated with corrective glasses, contact lenses or refractive surgery.


Refractive implications

How well the eye can focus on objects after surgery and lens insertion. 4

Risk factor A characteristic, condition, or behaviour that increases the possibility of disease or injury.58

Shared decision making

A consultation process in which a clinician and a patient jointly participate in making a health decision, having discussed the options, and their benefits and harms, and having considered the patient’s values, preferences and circumstances64

Bilateral simultaneous cataract surgery

See Immediately sequential bilateral cataract surgery

System The resources, policies, processes and procedures that are organised, integrated, regulated and administered to provide health care. Systems enable the objectives of healthcare standards to be accomplished by addressing risk management, governance, operational processes and procedures, implementation and training, and by influencing behavior change to encourage compliance.

Visual acuity

The clarity and sharpness with which objects are seen, in particular the ability to see fine details. 4

See also Best Corrected Visual Acuity

Visual acuity chart

An eyechart commonly used to measure a person’s visual acuity. It consists of a series of letters of decreasing size and is viewed at a distance. A commonly used type of visual acuity chart is the Snellen Chart. Other similar but more reproducible and scientifically valid charts are beginning to supersede the Snellen (such as the logMAR chart). 4

Visual impairment A limitation of one or more functions of the eye (or visual system).65 In cataract, the most common impairment is in the sharpness or clarity of vision (visual acuity). You might also experience other impairments in vision including trouble seeing at night, seeing colours as faded, increased sensitivity to glare, halos surrounding lights or double vision in the affected eye. 66

Vision related activity limitations

The difficulty people have performing daily activities because of their vision. Sometimes called visual functioning or visual disability. 34

1

2


References 1

1. Australian Institute of Health and Welfare. Australia's Health 2014. Canberra: AIHW, 2 2014. Available from: http://www.aihw.gov.au/publication-detail/?id=60129547205 3 (accessed 21 January 2019). 4

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