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Two thirds of eye units restricting access to cataract surgery

Commissioners are ignoring NICE guidance, says Royal College of Ophthalmologists

Caroline White

Friday, 10 November 2017

Two thirds of eye units restrict access to cataract surgery on the grounds of visual acuity thresholds, reveals a survey* of 82 eye units in England and Northern Ireland, carried out by the Royal College of Ophthalmologists (RCOphth).

This is despite recent guidance from the National Institute for Health and Care Excellence, which emphasises that the use of these thresholds to restrict access is not justified based on the available evidence and long-term costs to health and social care services.

The RCOphth says that the procedure is of enormous benefit for patients. “It is crucial that patients who will benefit from cataract surgery are able to access it, whether for their first eye or second eye operation.

“Restrictions or delays to access cataract surgery can limit people’s ability to lead independent lives and care for others, they are twice as likely to have falls and can have significantly reduced quality of life, with increased levels of depression and anxiety.” 

Importantly, says the College: “All have a long-term financial and resource impact on primary, social and community care systems.”

The College surveyed 140 clinical leads in England and Northern Ireland to understand how visual acuity thresholds and other imposed restrictions are affecting access to cataract surgery. Some 87 replies were received, a response rate of 62%.

For access to first eye surgery, around a third (34%) of units don’t restrict access, while 62% have thresholds of moderate visual acuity reduction (vision of 6/9 or 6/12 or worse), but 4% have thresholds of marked acuity reduction that is 6/18 or worse.

And for second eye surgery, around a third of eye units don’t restrict second eye surgery, but nearly half (45%) restrict on the grounds of moderate acuity reduction and one in five do so on the grounds of marked visual acuity reduction (6/18 or 6/24 or worse).

This means that in units where it is harder to access first eye surgery, there is a tendency for the access to second eye surgery to be even more restrictive, says the College.

“It is important that patients regain as much vision as possible and are able to use both that restoring sight in both eyes is essential to good visual function and the patient’s quality of life.”

The survey did not highlight any obvious geographical variations, or difference in access between large teaching hospitals and smaller district general units.

The survey also looked at how ophthalmologists are required to use individual funding request forms (IFRs) and if there is any monitoring of adherence to thresholds for access.

Most units (73%) said this wasn’t monitored, while in around one in five (22%) clinicians are required to fill in a short form usually with tick boxes for each criterion, and 5% use lengthy IFR forms. 

Where there are visual acuity restrictions imposed by commissioners, the College asked whether there were alternative criteria or access to surgery. Approximately 20% had no alternative access route, while 80% said they had.

There was considerable feedback in the survey that any monitoring or refusal by CCGs was minimal and that most patients who required surgery did obtain it once the process had been followed.

But the College points out the use of restriction criteria is variable and seems to have no clear logic behind it.

“This survey provides evidence that the use of visual acuity restrictions to accessing cataract surgery places an unnecessary burden on the NHS, creates barriers for patients and clinicians and is not justified as the restrictions do not seem to achieve the aim of limiting surgical numbers,” it says.

“As demand for surgery is predicted to rise by 25% over the next 10 years and by 50% over the next 20 years, it is crucial that commissioners act now to ensure sustainable and equitable cataract services,” it concludes.


* Cataract surgery: current limitations to patients accessing treatment. The Royal College of Ophthalmologists, November 2017.

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