Recommendations for research

The guideline committee has made the following recommendations for research. The committee's full set of recommendations for research are detailed in the full guideline.

1 Toric lenses for astigmatism

What is the cost effectiveness of toric lenses compared with on‑axis or limbal-relaxing incision surgery, or non‑toric lenses with no further intervention, in an NHS context, taking account of the whole care pathway cost implications from pre- to postoperative phases, stratified by the preoperative level of astigmatism?

Why this is important

There is clear evidence that toric lenses are effective at reducing levels of postoperative astigmatism, but evidence on their cost effectiveness is much less conclusive. Although a cost–utility analysis of toric lenses was evidenced from the USA, it was not possible to relate the costs to a UK NHS perspective. Acquisition costs of toric lenses are unlikely to exceed those of standard monofocal lenses, but their use has possible associated costs, including additional preoperative tests, biometry measurements, surgical time and equipment (toric markers), postoperative assessments and further surgery, which could be significant. A comparison with on‑axis or limbal-relaxing incisions would be advantageous because there are currently no resource constraints for using these techniques. Further cost-effectiveness research using UK NHS costings would be of benefit in helping to formulate future recommendations about their use.

2 Quality of life in cataract surgery

What vision-specific, quality-of-life measures best capture visual changes in a population with cataracts?

Why this is important

Although visual acuity is still commonly used to decide whether cataract surgery is needed, it is a crude measure that will often fail to detect other vision problems that may justify surgery (for example, glare and loss of colour vision). The best possible decision-making aids would be measures of preoperative and postoperative vision-related quality of life, which could then be used to identity groups of people who do not have an improvement in quality of life after surgery. However, most prioritisation criteria are based primarily on visual acuity and visual function (usually measured using the VF‑14), which capture only part of the impact of a cataract on quality of life. The development and validation of suitable vision-specific, quality-of-life measures would aid the decision-making process for cataract surgery, and help to accurately quantify the quality of life gains that may be expected from surgery. Particular consideration should be given to people with learning disabilities/cognitive impairment, or any other groups who may find it more difficult to self-report their own symptoms or quality of life.

3 Indicators and thresholds for referral for cataract surgery

What is the association between preoperative vision- and health-related quality of life, and postoperative vision-related quality of life, health-related quality of life, and self-reported postoperative improvement?

Why this is important

In contrast to the data linking preoperative visual acuity and visual function with postoperative visual acuity and visual function, there is a lack of evidence on the association between preoperative vision- and health-related quality on postoperative outcomes and levels of satisfaction for people having cataract surgery. This makes it difficult either to identify those groups of individuals who may achieve the largest gains from surgery, or to provide people with accurate information about what their potential gains may be. Robust information around the link between preoperative patient characteristics and outcomes would be useful both for prioritisation of surgery, and to help better inform individuals about the levels of gain they may individually expect to get from surgery.

4 Interventions to manage cystoid macular oedema

What is the most effective postoperative medical management for cystoid macular oedema?

Why this is important

Although there is evidence for using steroids and non-steroidal anti-inflammatory drugs (NSAIDs) in treating cystoid macular oedema, no evidence has been identified for interventions such as acetazolamide, steroid-based anti-inflammatory drugs or intraocular anti-vascular endothelial growth factors (anti-VEGFs). Further randomised controlled trials with increased numbers of participants would be of benefit to the evidence base, which would help lead to the formulation of future recommendations for the postoperative treatment cystoid macular oedema.

5 Interventions to prevent endophthalmitis

What is the effectiveness of postoperative antibiotic drops to reduce rates of endophthalmitis after cataract surgery?

Why this is important

There is a lack of evidence on postoperative antibiotics to reduce rates of endophthalmitis, which may be because they are provided as part of standard good clinical practice in the UK. In addition, it is recognised that patients are invariably receiving other drops (for example, steroids), which are likely to be offered in combination with postoperative antibiotic drops, and often in a single-drop product. Well-conducted randomised controlled trials of postoperative antibiotics in people having cataract surgery would help add to the evidence base and so inform future recommendations on their use.