Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Patient information

1.1.1 Give people with cataracts, and their family members or carers (as appropriate), both oral and written information. Information should be tailored to the person's needs, for example, in an accessible format. For more guidance on giving information to people and discussing their preferences, see the NICE guideline on patient experience in adult NHS services, particularly recommendations 1.2.12 and 1.2.13 on capacity and consent. For guidance on eye tests for people living with dementia, see sensory impairment in the NICE guideline on dementia.

At referral for cataract surgery

1.1.2 At referral for cataract surgery, give people information about:

  • cataracts:

    • what cataracts are

    • how they can affect vision

    • how they can affect quality of life

  • cataract surgery:

    • what it involves and how long it takes

    • possible risks and benefits

    • what support might be needed after surgery

    • likely recovery time

    • likely long-term outcomes, including the possibility that people might need spectacles for some tasks

    • how vision and quality of life may be affected without surgery.

Before cataract surgery

1.1.3 At the preoperative outpatient appointment, review and expand on the topics in recommendation 1.1.2, and give people information about:

  • the refractive implications of different intraocular lenses (see recommendation 1.5.3)

  • types of anaesthesia

  • the person's individual risk of complications during or after surgery (for example, the risk of postoperative retinal detachment in people with high myopia; also see recommendations 1.3.10 and 1.3.11)

  • what to do and what to expect on the day of cataract surgery

  • what to do and what to expect after cataract surgery

  • what support might be needed after surgery

  • medicines after surgery (for example, eye drops) and medicines that people may be already taking (for example, anticoagulants)

  • the refractive implications after previous corneal refractive surgery, if appropriate (see recommendation 1.3.6)

  • bilateral simultaneous cataract surgery, if appropriate (also see recommendations 1.6.3 and 1.6.4).

On the day of cataract surgery

1.1.4 On the day of surgery, before the operation, give people information about:

  • their position on the list

  • what to expect during and after surgery.

1.1.5 On the day of surgery, after the operation, give people information about:

  • what visual changes to expect

  • signs and symptoms of potential complications to look out for

  • any restrictions on activities, for example, driving

  • possible problems and who to contact

  • emergency situations and who to contact

  • eye drops

  • pain management

  • their next appointment and who they will see.

After cataract surgery

1.1.6 At the first appointment after cataract surgery, give people information about:

  • eye drops

  • what to do if their vision changes

  • who to contact if they have concerns or queries

  • when it is appropriate to get new spectacles and how to do so

  • second-eye cataract surgery if there is a cataract in the non-operated eye

  • arrangements for managing ocular comorbidities.

1.2 Referral for cataract surgery

1.2.1 Base the decision to refer a person with a cataract for surgery on a discussion with them (and their family members or carers, as appropriate) that includes:

  • how the cataract affects the person's vision and quality of life

  • whether 1 or both eyes are affected

  • what cataract surgery involves, including possible risks and benefits

  • how the person's quality of life may be affected if they choose not to have cataract surgery

  • whether the person wants to have cataract surgery.

1.2.2 Do not restrict access to cataract surgery on the basis of visual acuity.

1.3 Preoperative assessment and biometry

Biometry techniques

1.3.1 Use optical biometry to measure the axial length of the eye for people having cataract surgery.

1.3.2 Use ultrasound biometry if optical biometry:

  • is not possible or

  • does not give accurate measurements.

1.3.3 Use keratometry to measure the curvature of the cornea for people having cataract surgery.

1.3.4 Consider corneal topography for people having cataract surgery:

  • who have abnormally flat or steep corneas

  • who have irregular corneas

  • who have significant astigmatism

  • who have had previous corneal refractive surgery or

  • if it is not possible to get an accurate keratometry measurement.

Biometry formulas

1.3.5 For people who have not had previous corneal refractive surgery, use 1 of the following to calculate the intraocular lens power before cataract surgery:

  • If the axial length is less than 22.00 mm, use Haigis or Hoffer Q.

  • If the axial length is between 22.00 and 26.00 mm, use Barrett Universal II if it is installed on the biometry device and does not need the results to be transcribed by hand. Use SRK/T if not.

  • If the axial length is more than 26.00 mm, use Haigis or SRK/T.

1.3.6 Advise people who have had previous corneal refractive surgery that refractive outcomes after cataract surgery are difficult to predict, and that they may need further surgery if they do not want to wear spectacles for distance vision.

1.3.7 If people have had previous corneal refractive surgery, adjust for the altered relationship between the anterior and posterior corneal curvature. Do not use standard biometry techniques or historical data alone.

1.3.8 Surgeons should think about modifying a manufacturer's recommended intraocular lens constant, guided by learning gained from their previous deviations from predicted refractive outcomes.

Second-eye prediction

1.3.9 Consider using 50% of the first-eye prediction error in observed refractive outcome to guide calculations for the intraocular lens power for second-eye cataract surgery.

Risk stratification

1.3.10 Consider using a validated risk stratification algorithm for people who have been referred for cataract surgery, to identify people at increased risk of complications during and after surgery.

1.3.11 Explain the results of the risk stratification to the person, and discuss how it may affect their decisions.

1.3.12 To minimise the risk of complications during and after surgery, ensure that surgeons in training are closely supervised when they perform cataract surgery in:

  • people who are at high risk of complications or

  • people for whom the impact of complications would be especially severe (for example, people with only 1 functional eye).

1.3.13 Explain to people who are at risk of developing a dense cataract that there is an increased risk of complications if surgery is delayed and the cataract becomes more dense.

1.4 Intraocular lens selection

1.4.1 Please note: the recommendations around lens design and material have been removed to allow for further consideration.

1.4.2 Do not offer multifocal intraocular lenses for people having cataract surgery.

1.4.3 Offer monovision for use after cataract surgery to people who have either anisometropia or monovision preoperatively and would like to remain with it.

1.4.4 Please note: the recommendations around lens design and material have been removed to allow for further consideration.

Addressing pre-existing astigmatism

1.4.5 Consider on‑axis surgery or limbal-relaxing incisions to reduce postoperative astigmatism.

1.5 Preventing wrong lens implant errors

Before cataract surgery

1.5.1 Before the preoperative biometry assessment, ensure that the person's correct medical notes are used by confirming the person's:

  • name

  • address and

  • date of birth.

1.5.2 Immediately after the preoperative biometry assessment:

  • check that the biometry results include the person's name, address, date of birth and hospital number

  • either

    • use electronic data transfer to upload the biometry results to an electronic health record or

    • securely fix the printed biometry results to the person's medical notes

  • do not transcribe the results by hand.

1.5.3 At the preoperative assessment:

  • discuss the refractive implications of different intraocular lenses with the person

  • base the choice of intraocular lens on the person's chosen refractive outcome

  • record the discussion and the person's choices in their medical notes.

On the day of cataract surgery

1.5.4 The person's medical notes, including biometry results, must be available in theatre on the day of the cataract surgery.

1.5.5 Use a checklist based on the World Health Organization (WHO) surgical safety checklist, modified to include the following cataract surgery checks, to ensure that:

  • the person's identity has been confirmed and matches information in:

    • the consent form

    • the biometry results and

    • the person's medical notes

  • the eye to be operated on has been checked and clearly marked

  • there is only 1 intraocular lens in the theatre, that matches the person's selected lens type and prescription

  • at least 1 additional identical intraocular lens is in stock

  • alternative intraocular lenses are in stock in case the selected lens needs to be changed if there are complications during surgery

  • at least 2 members of the team, including the surgeon, have previously checked the appropriateness, accuracy and consistency of all:

    • formulas

    • calculations and

    • intraocular lens constants.

1.5.6 Before giving the person anaesthetic, ensure that:

  • there is only 1 intraocular lens in the theatre, that matches the person's selected lens type and prescription

  • at least 1 additional identical intraocular lens is in stock

  • alternative intraocular lenses are in stock in case the selected lens needs to be changed if there are complications during surgery.

1.5.7 Immediately before the operation, the surgeon should:

  • confirm the person's identity and ensure that the correct medical notes are being used, especially if using electronic patient records

  • refer to the printed biometry results, not to transcribed information in the person's medical notes

  • refer to the person's medical notes to check which refractive outcome they preferred

  • verify that the correct intraocular lens has been selected and is available in theatre.

Occurrence of wrong lens implant errors

1.5.8 If a wrong lens is implanted, refer to NHS England's Never Events policy, and together with the whole multidisciplinary team:

  • undertake a root-cause analysis to determine the reasons for the incident

  • establish strategies and implementation tools to stop it from happening again.

1.6 Surgical timing and technique

Laser-assisted cataract surgery

1.6.1 Only use femtosecond laser-assisted cataract surgery as part of a randomised controlled trial that includes collection of resource-use data, comparing femtosecond laser-assisted cataract surgery with ultrasound phacoemulsification.

Bilateral surgery

1.6.2 Offer second-eye cataract surgery using the same criteria as for the first-eye surgery (see referral for cataract surgery).

1.6.3 Consider bilateral simultaneous cataract surgery for:

  • people who are at low risk of ocular complications during and after surgery or

  • people who need to have general anaesthesia for cataract surgery but for whom general anaesthesia carries an increased risk of complications or distress.

1.6.4 Discuss the potential risks and benefits of bilateral simultaneous cataract surgery with people, which should include:

  • the potential immediate visual improvement in both eyes

  • how it will not be possible to choose a different intraocular lens based on the outcome in the first eye

  • the risk of complications in both eyes during and after surgery that could cause long-term visual impairment

  • the likely need for additional support after the operation.

1.7 Anaesthesia

1.7.1 Offer sub‑Tenon's or topical (with or without intracameral) anaesthesia for people having cataract surgery.

1.7.2 If both sub‑Tenon's and topical (with or without intracameral) anaesthesia are contraindicated, consider peribulbar anaesthesia.

1.7.3 Do not offer retrobulbar anaesthesia for people having cataract surgery.

1.7.4 Consider sedation, administered by an experienced ophthalmic anaesthetist, as an adjunct to anaesthesia for people if, for example:

  • they have high levels of anxiety

  • they have postural or musculoskeletal problems

  • surgery is expected to take longer than usual.

1.7.5 Consider hyaluronidase as an adjunct to sub‑Tenon's anaesthesia, particularly if trying to stop the eye moving during surgery.

1.8 Preventing and managing complications

Floppy iris syndrome

1.8.1 Consider intracameral phenylephrine to increase pupil size in people at risk of floppy iris syndrome.

Capsular tension rings

1.8.2 Do not use capsular tension rings in routine, uncomplicated cataract surgery.

1.8.3 Consider using capsular tension rings for people with pseudoexfoliation.

Endophthalmitis

1.8.4 Use preoperative antiseptics in line with standard surgical practice.

1.8.5 Use intracameral cefuroxime during cataract surgery to prevent endophthalmitis.

1.8.6 Use commercially prepared or pharmacy-prepared intracameral antibiotic solutions to prevent dilution errors.

Cystoid macular oedema

1.8.7 Consider topical steroids in combination with non-steroidal anti-inflammatory drugs (NSAIDs):

  • after cataract surgery for people at increased risk of cystoid macular oedema, for example, people with diabetes or uveitis

  • to manage cystoid macular oedema.

1.8.8 Offer topical steroids and/or NSAIDs after cataract surgery to prevent inflammation and cystoid macular oedema.

Posterior capsule rupture

1.8.9 When dealing with posterior capsule rupture, follow a protocol that covers:

  • removing vitreous from the wound and anterior chamber

  • minimising traction on the retina

  • removing lens fragments in the posterior chamber or vitreous cavity

  • removing soft lens matter

  • implications for any lens insertion.

Postoperative eye protection

1.8.10 Offer eye protection for people whose eye shows residual effects of anaesthesia at the time of discharge after cataract surgery.

1.9 Postoperative assessment

1.9.1 Commissioners and service providers should ensure that the following are in place:

  • Processes that identify complications after surgery and ensure that there is prompt access to specialist ophthalmology services.

  • Processes to ensure that the UK Minimum Cataract Dataset for National Audit is completed.

  • Arrangements so that healthcare professionals discuss second-eye cataract surgery with people who have a cataract in their non-operated eye.

1.9.2 Consider collecting patient visual function and quality-of-life data for entry into an electronic dataset.

1.9.3 Do not offer in‑person, first-day review to people after uncomplicated cataract surgery.

  • National Institute for Health and Care Excellence (NICE)