It was recently reported in the Sunday Times that the Greenwich Clinical Commissioning Group, an NHS body which plans health services for the London Borough, proposes to stop one of the most common NHS operations as part of cost-cutting measures. It reportedly blames rising demand from an ageing population. In future, it is suggested the funding for cataract surgery is granted only on an ‘exceptional basis’.
According to the article, both the Royal College Ophthalmologists and the Royal National Institute of Blind People (RNIB) were alarmed by this proposal, with Fazilet Hadi the latter’s director of engagement quoted as saying: ‘All patients should be given access to cataract treatment without delay and based on their clinical need’. In September 2016, the RNIB reported that ‘Patients with severe cataracts are at risk of social isolation, depression, and fall-related injuries such as hip fractures’. According to the RNIB, some patients were being left to wait up to 15 months for this urgently required surgery. In future, patients in Greenwich might themselves be waiting even longer if this proposal is implemented.
Cataract removal procedures are generally considered routine, they are generally safe, and usually produce excellent results (with subjective benefit occurring in 84-95% of patients). They are performed under local anaesthesia as a day case. Cost is however becoming more of a factor because the prevalence of cataract is increasing in the ageing population and many NHS Trusts (that can afford it) are offering private treatment as an alternative to long waiting lists.
As with everything there are exceptions, and occasionally complications will occur, sometimes erroneously caused but not always. Examples can include the following:
The traditional advice given to patients, certainly in the last century, was that removal surgery should not be performed until the cataract is sufficiently ‘mature’. Delayed cataract surgery will not ultimately worsen the final outcome but of course as seen above, severe cataracts carry their own burden in real time.
The twenty first century has seen a marked change in approach, commensurate with improved surgical technique allowing a more favourable risk / benefit ratio. Many individuals are now being advised to have cataract surgery even where their vision is adequate for their needs (although probably not in Greenwich), and so objectively at least, even the relatively small risks of routine cataract surgery are not justified.
Patients need to be informed of the benefits of cataract surgery, but also the risks. Operative and post-operative complications in routine cataract surgery occur 10-20% of the time which is significant. In the hands of an experienced ophthalmic surgeon, the risks are probably less than 5%.
Many patients who had but didn’t need immediate cataract surgery and subsequently developed complications (which can lead to a poor visual outcome or even a complete loss of vision in the eye, or even both eyes) might in retrospect have waited.
2. Direct Referral by Optometrists
Where cataract is first diagnosed by optometrists (as is often the case), and the patient is referred on, there is sometimes an incorrect assumption by the ophthalmologist that the patient wants cataract surgery and has already been advised of the potential risks. However optometrists have little or no experience of these.
3. Bilateral Surgery
Cataracts usually occur in both eyes simultaneously. Guidance on specific pre and post operative precautions has been provided by the Royal College of Ophthalmologists. The general rule is that ideally, surgery should not be performed on both eyes at once. However bilateral surgery is advocated by some surgeons and may be requested by patients. The main problem is the possible risk of serious post-operative complications occurring in both eyes (particularly the risk of endometritis – see below).
4. Posterior Capsule Tear
Posterior capsule tear is the most common complication during surgery, but in the majority of cases it is not considered due to an unacceptable standard of care. If it occurs at the beginning of the procedure there is usually a greater risk of poor outcome than if it occurs at the end. Sometimes even though the occurrence of the tear is non-negligently caused, its subsequent management is.
5. Post-Operative Infection
The risk of post-operative bacterial infection (endophthalmitis) after routine cataract surgery is about 0.1%. Prophylactic antibiotic therapy at the end and/or during the surgical procedure by inclusion in the irrigating fluid is universally used. Since review during the early post-operative period is no longer routine and patients are discharged home and are not seen until some weeks after surgery, the early signs of infection are often missed. There is sometimes a failure to provide clear warning of these. Sadly, endophtalmitis carries a very poor visual prognosis.
6. Incorrect Intraocular Lens
The cataract procedure involves the insertion of a new intraocular lens in the eye. Choice of power of the lens to achieve the desired refractive outcome is guided by preoperative biometry (including taken measurements). Occasionally due to inaccurate axial length measurements or an error by the operating theatre team meaning the wrong intraocular lens package is used, an undesired refractive outcome is achieved. This often requires further corrective surgery with increased risks of complication occurring, which can lead to an actionable claim in negligence.
If you have suffered a poor visual outcome as a consequence of suspected sub-standard cataract surgery (or indeed general ophthalmic medical care) you may be entitled to financial compensation. A specialist in legal claims involving eye injuries will be able to advise further.