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Cataract Glos Care Pathway Overview

The direct cataract referral system is currently in operation within Gloucestershire, involving community Optometrists and GPs.  This service will continue but all of the clinical data from Optometrists will now be captured on Webstar Health's Optomanager software.

Gloucestershire GPs can refer patients for cataract surgery if they complete a direct cataract referral form and a Gloucestershire cataract questionnaire (CAQ) in the event that the patient meets the criteria for surgery.  

Please click the relevant flowchart box to be taken directly to textual information.

                

Red Flags
  • Blurred/hazy vision
  • Glare- particularly of concern if the patient drives
  • Loss of binocularity due to poor vision in one eye
  • Risk of falls/history of falls
Presence of cataract can sometimes severely mask the view of the retina on examination.  If this occurs, the patient should also be referred to GHNHSFT General Clinic to establish that there are no retinal or other unseen complications not visible in community practice. 
Presentation

The patient may complain of a drop in visual acuity, reduction in colour contrast, or general blurring/haziness of their vision in one or both eyes.

  • Blurred vision
  • Loss of contrast
  • Faded colour perception
  • Difficulty recognising faces or reading car number plates
  • Glare - dazzled by headlights and sunlight
  • Poor vision in bright light
  • Monocular diplopia
  • Fixed spots or haloes around bright lights

  • Development of cataract is multifactorial. The vast majority of cataracts are age-related and inevitable
  • Cataracts tend to run in families, women are more affected than men, Environmental factors include ocular inflammation, ultraviolet light, trauma and radiation exposure.
  • Systemic and topical steroids have long been associated with increased cataract.
  • Diabetes is associated with earlier onset and increased progression of cortical cataract, with increased risk associated with poorer diabetic control.
  • Poor nutrition, low socio-economic status and education, dehydration, chronic disease, smoking, and some medical treatments (such as radiotherapy, psoralens, chlorpromazine, amiodarone, tamoxifen, tetracyclines) have all been linked to increased prevalence of cataract.
  • People with learning disabilities are at higher risk of developing cataract.
Differential Diagnosis

  • Refractive error
  • Some types of corneal disease (for example Fuch's endothelial dystrophy)
  • Presbyopia
  • Age-related macular degeneration
  • Primary open-angle glaucoma — central visual field loss occurs late in the course of the disease
  • Chemicals or drugs — for example methanol, chloroquine, hydroxychloroquine, isoniazid, thioridazine, isotretinoin, tetracycline, and ethambutol
  • Pituitary tumour and papilloedema — particularly if chronic, such as in idiopathic intracranial hypertension
  • Diabetic lens — undiagnosed or uncontrolled diabetes can cause vision changes
  • Retinoblastoma — nearly always affects children younger than five years of age. The pupil may look white (loss of red reflex), the eye may be red and inflamed (usually painless), and vision may be impaired
  • Chronic uveitis
  • Diabetic retinopathy
  • Diabetic maculopathy — type 2 diabetes may present with chronic visual loss from maculopathy

  • Cerebrovascular disease, including amaurosis fugax, transient ischaemic attack, and stroke
  • Posterior vitreous detachment, vitreous haemorrhage, or retinal detachment (usually present with floaters or flashing lights)
  • Central or branch retinal vein thromboses
  • Retinal artery occlusions
  • Wet AMD
Initial GP Assessment/Management

Cataract assessment should include examination to rule out other pathology and assessment/grading of the cataract, measurement of visual acuity, measurement of refractive error, discussion on any outstanding visual or quality of life issues, communication of the relative risks and benefits of cataract extraction, ascertaining the patient's willingness for surgery, completion of the direct cataract referral form and cataract assessment questionnaire (CAQ).

Current guidance states that the cataract should be causing sufficient issue with the patient's vision and/or quality of life that they would benefit from cataract surgery.  A score of ≥10 on the CAQ warrants the possibility of referral.  Borderline sub-thresholds of scores of 8 or 9 may be considered, but strong clinical reason for such a referral must be made.  If the patient is willing to undergo surgery and the practitioner considers that they are suitable the referral should be sent to the hospital booking office.

If the patient does not meet the criteria for cataract surgery, or declines cataract surgery then several options are available:

1. Monitor for progression- this can be done through routine sight test by an Optometrist or the GP may wish to monitor the patient.

2. Direct the patient to their Optical practice to find out if their sight test is due or a need for sight test is indicated - a change in refraction and/or lens treatments often improve a patient's vision and quality of life for sub-threshold cataracts.

3. Signpost the patient to voluntary services such as Forest Sensory Services or Insight who can offer advice and practical help for patients with deteriorating sight.

When to Refer

When patient has significant symptoms as result of cataract/s and Cataract Assessment Questionnaire (CAQ) has been completed with a score of 10 or more, complete direct referral to either GHFT serviceNewmedicaCare UK Service or Tetbury Hospital.

If unsure of diagnosis direct patient to Community Optometrist for further assessment with a referral letter.

Cataract surgery is restricted as part of the CCG's policy in relation to Individual Funding Requests.  Please see the full policy for further information.

Community Eye Service

The examining Optometrist will discuss this with the patient.  If the cataract is not presenting any significant visual or lifestyle difficulties, then they will continue to be reviewed by the Optometrist in the normal way.  If the patient does wish to be considered for surgery, then the Optometrist will complete a cataract assessment questionnaire (CAQ). This will provide guidance as to whether the cataract is causing sufficient issue with the patient's vision and/or quality of life that they would benefit from discussing the possibility of cataract surgery.

Cataract assessment should include examination, discussion on any outstanding visual or quality of life issues, communication of the relative risks and benefits of cataract extraction, ascertaining the patient's willingness for surgery.

Current guidance states that the cataract should be causing sufficient issue with the patient's vision and/or quality of life that they would benefit from cataract surgery.  A score of >10 on the CAQ warrants the possibility of referral.  Borderline sub-thresholds of scores of 8 or 9 may be considered, but strong clinical reason for such a referral must be made.  If the patient is willing to undergo surgery and the practitioner considers that they are suitable the referral will be faxed via the Optomomanager system to the hospital booking office.

Should examination reveal a condition other than cataract is responsible for the patients symptoms, they will be re-directed to the appropriate pathway by the community Optometrist.

1. The patient will be monitored by their optometrist.

2. An updated refraction may be advised if the patient's vision can be improved/symptoms alleviated, and advice given on lifestyle, lighting, glare reduction.

3. Signposting to voluntary services for practical help and advice may be appropriate. 

Secondary Care Management

When the patient is assessed by the ophthalmologist at the hospital following referral, in consultation with the patient, a decision may be taken with regard to the care pathway and in many cases whether surgery will be offered for one or both eyes.  The following criteria will be used in reaching a decision: where operating on the first eye would create anisometropia of 2 dioptres or more, surgery will be offered for both eyes, but where patients are keen to have only one eye operated then one eye will be offered and the post-operative result matched to the unoperated eye.

It is recognised that the referring Optometrist/GP may have examined the patient on a number of occasions prior to referral.  It will be possible for the Optometrist/GP, having discussed the options available with the patient, to express an opinion as to the preferred refractive outcome post operatively and to give reasons for this opinion.  This will be taken into account when the patient is examined by the ophthalmologist in the hospital. 

Following Surgery

Post-operative follow up

Patients who have received cataract surgery on their First Eye or have complicated surgery or Significant co-morbidities, will have their follow up appointment at the Hospital.

Patients who have second eye cataract surgery, without complication or co-morbidities will receive their follow appointment at a registered community optometrist.  

Post-Cataract Surgery Second Eye – Follow up

Community Optometrists will now conduct the post-operative examination and refraction for patients having had uncomplicated cataract surgery on their second eye with no significant co-morbidities. This will provide care closer to home for the patient- they will no longer be routinely reviewed at the hospital.

Patients eligible for this community service will have had uncomplicated surgery on the first and second eyes and be low risk.

During the discharge procedure the nurse practitioner arranges the post-op examination appointment at a community optical practice of the patient's choosing for 4 weeks post operatively.

If:

The patient does not experience any symptoms in the interim and attends their post-op examination appointment at the community optical practice as planned. Patient is discharged and a report is sent to the hospital and GP.

Or

Patient is found to have a complication during the examination and the Optometrist refers back to the treatment centre with the appropriate urgency.

If:

The patient experiences symptoms within four weeks of the surgery- patient should call the eye casualty triage service for advice/be referred urgently to eye casualty. Eye Casualty Phone Line: 0300 422 3578 (Mon - Thurs 9am - 5.30pm and Fri 9am - 1pm) Patient given an appointment in eye casualty clinic and managed by the hospital

Or

Patient reassured and advised to continue with post-op drops and attend post op follow up in a community optical practice if no further symptoms arise.

If:

The patient fails to attend the arranged post-op examination appointment at the Optical practice. The Optical practice makes several phone calls and writes a letter attempting to rearrange the patient's follow up appointment.

If:

Patient does not rebook/fails to attend again- the Optical practice writes to patient's GP and hospital informing them that the patient has failed to attend.

    

Ongoing Care
  • Any ongoing surgical care will be offered by the hospital. 
  • General ophthalmic services will be provided by the community optometrist.

  • a throbbing or severe pain in or around the eye
  • a severe frontal headache with or without nausea and vomiting
  • a sudden deterioration or loss of vision
  • increasing redness in the eye with or without discharge
  • the sudden appearance of black dots, specks or streaks in the field of vision (floaters) or flashes of light in the eye

If a patient presents with any of these symptoms within 4 weeks of the cataract surgery the GP should call the eye casualty phone line for advice and an immediate/urgent referral to the treatment centre should be arranged.

Eye Casualty Phone Line: 0300 422 3578 (Mon - Thurs 9am - 5.30pm and Fri 9am - 1pm)

For ~ 1 in 10, capsular Fibrosis or Posterior Capsular Opacification (PCO) can occur within months or years of the surgery. This is when the lens implant starts to become cloudy- a patient may liken this to the original cataract coming back. This can cause hazy and/or blurred vision- onset is usually gradual. Patients can be referred for YAG laser capsulotomy to remove the capsular haze- referral to an Optometrist for a sight test, diagnosis and onward referral is indicated when a GP is unsure of the diagnosis.

It is common for there to be some irritation for a short while after surgery and for some the eye can continue to feel slightly irritable, dry or watery. This can be treated with frequent use of artificial tears to be used on an ongoing basis. Artificial tears should be administered at least three times per day if the treatment is to be effective.

There are commonly ‘floaters’ in the vision and, sometimes, quick flashes of light or shadows may be seen that may be due to the different way light is focussed onto the retina through the new implant lens. However, persistent or enlarging shadows could be signs of retinal detachment- urgent referral to the treatment centre for investigation is required.

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