Quality statement 2: Referral for cataract surgery

Quality statement

Adults with cataracts are not refused surgery based on visual acuity alone.

Rationale

The decision to undertake cataract surgery should be based on discussions with the person about the effect of cataract on their quality of life, the risks and benefits of surgery and what may happen if they choose not to have surgery. Measurement of visual acuity often fails to detect vision problems that may benefit from cataract surgery (for example, glare and loss of colour vision). The decision should include consideration of a patient's quality of life and symptoms such as difficulty with reading, night driving, work or home activities, glare and loss of contrast, despite appropriate optical correction. Restricting access to surgery based on visual acuity alone has an impact on quality of life for some people with cataracts. The decision to undertake cataract surgery should be made on the same basis for first and second eyes.

Quality measures

Structure

Evidence of local agreements to include vision difficulties affecting quality of life in the criteria for referral and access to cataract surgery. The same criteria should be used for first- and second-eye cataract surgery.

Data source: Local data collection, for example, service specifications and local commissioning agreements for cataract surgery.

Process

a) Proportion of presentations of cataract where the person has a discussion about how their vision affects their quality of life.

Numerator – the number in the denominator where the person has a discussion about how their vision affects their quality of life.

Denominator – the number of presentations of cataract.

Data source: Local data collection, for example, patient records.

b) Proportion of presentations of cataract that are refused referral for surgery based on visual acuity alone.

Numerator – the number in the denominator that are refused referral for surgery based on visual acuity alone.

Denominator – the number of presentations of cataract.

Data source: Local data collection, for example, patient records or referral records.

c) Proportion of referrals for cataract surgery that are not accepted based on visual acuity alone.

Numerator – the number in the denominator that are not accepted based on visual acuity alone.

Denominator – the number of referrals for cataract surgery.

Data source: Local data collection, for example, patient records or referral records.

Outcome

Health-related quality of life for adults with cataracts.

Data source: Local data collection, for example, results from a questionnaire or patient-reported outcome measure on self-reported improvement after surgery, such as the Cat-PROM5 questionnaire (National Cataract Surgery Audit – Cat-PROM5 currently being piloted).

What the quality statement means for different audiences

Service providers (such as community optometry practices, referral management centres and NHS hospital trusts) ensure that referral pathways for cataract surgery are based on criteria that include vision difficulties affecting quality of life, and not just visual acuity alone. The decision to undertake cataract surgery should be made on the same basis for first and second eyes.

Healthcare professionals (such as ophthalmologists, optometrists, orthoptists and advanced nurse practitioners) base decisions about cataract surgery on a discussion with the person of the impact of the cataract(s) on their quality of life and the risks and benefits of having, and not having, surgery. Visual acuity should not be used as the sole basis for deciding to refer for or perform surgery. The decision to undertake cataract surgery should be made on the same basis for first and second eyes.

Commissioners (clinical commissioning groups and NHS England) commission services that provide access for adults to cataract surgery based on criteria other than visual acuity alone. The other criteria include vision difficulties affecting quality of life. They monitor services to ensure that this is happening. The decision to undertake cataract surgery should be made on the same basis for first and second eyes.

Adults with cataracts are involved in discussion of how cataracts affect their everyday life, how they affect their vision, the risks and benefits of surgery, and what would happen if they chose not to have surgery. Referral for cataract surgery is based on this discussion, and not only on the clarity and sharpness (particularly fine details) with which they can see objects. The decision to perform cataract surgery on the second eye should be made on the same basis.

Source guidance

Cataracts in adults: management (2017) NICE guideline 77, recommendations 1.2.1 and 1.2.2

Definitions of terms used in this quality statement

Based on visual acuity alone

The decision to refer an adult with cataracts for surgery should be based on a discussion with the person of the issues listed below, not on visual acuity alone:

  • 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.

[NICE's guideline on cataracts in adults, recommendation 1.2.1]