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Editor,—Allan and co-authors raised an interesting question in their recent suggestion that alternatives to conventional postoperative care, including shared care with non-ophthalmologists, should be evaluated.1 Previous studies looking at this issue have been contradictory. A study by the American Office of Technology looked at the differences in education and training between optometrists and ophthalmologists and concluded that the co-management of postoperative cataract patients may carry “potential risks”.2 In contrast, a large retrospective review of over 2000 co-managed patients concluded that co-managed postoperative care with optometrists “can be successfully organised, coordinated and delivered”.3 Similar suggestions have been made by other authors.4 5
In 1994 we carried out a prospective study to determine whether the postoperative management of cataract patients by optometrists is a safe and viable option. The optometrists involved in the study were a selected group who were not only already participating in our local glaucoma monitoring scheme, but also received education, by ourselves, on the care of postoperative cataract patients. In all, 121 patients, who had undergone uncomplicated extracapsular cataract extraction or phacoemulsification, were examined at 6 weeks postoperatively by an optometrist who performed both a refraction and a full ocular examination, following a strict examination protocol. A telephone “hotline” was available for the optometrist to seek advice if any abnormality was found. The patients were then examined by an ophthalmologist following the same examination protocol. The findings of the optometrist and ophthalmologist were compared. There was a high degree of consistency between the examination findings of the two groups, with only minor discrepancies in a few patients over the degree of posterior capsule thickening and age related macular degeneration. Most importantly, there were no clinically significant abnormalities missed by the optometrists. We therefore felt that, in our region, it was both safe and feasible for optometrists to carry out the postoperative management of uncomplicated postoperative cataract patients.
Since this initial study, we have routinely involved optometrists in the postoperative care of cataract patients. A recent audit confirmed the safety and feasibility of the practice. Patients welcome the opportunity to visit an optometrist for their postoperative care, citing improved access and convenience as major advantages. The benefits stemming from a reduction in our routine outpatient workload are obvious.
Editor,—Booth et al highlight some interesting elements of the way in which shared care with non-ophthalmologists could work to reduce the burden of postoperative review after routine cataract surgery.
Open access to an ophthalmologist’s opinion in problem cases is clearly a vital safety element for any shared care protocol. How often was their telephone hotline used? To justify shared care, it would be important to demonstrate a genuine cost saving. This would require details of time spent in telephone advice and any additional hospital visits.
No clinically significant complications were missed by optometrists in this study. In addition to screening for problems, review visits represent an opportunity for collecting outcome data (for example, visual acuity, refraction, etc). If routine review is to be devolved to optometrists or nurse practitioners, some mechanism for feeding this data back to the hospital should exist.
Another key issue is patient satisfaction. Booth et alnote that their patients welcomed local optometric review. How was this assessed?
The complete findings of this and related studies should be published to expand debate in this important area.