Risk stratification for the humble cataract

Cataract surgery has received more than its fair share of controversy. Senior figures in medicine, both ophthalmological and non-ophthalmological, have referred to cataract surgery as minor surgery, and advocated the deployment of non-medically qualified personnel. But “minor op” it certainly is not. There is a minute margin of error, with an anterior chamber volume of only 0.25 ml, the depth of which separates non-regenerating corneal endothelium, and the posterior capsule, which is only micrometres in thickness. Damage either at your own peril. “Experts” who worked on the Relative Values Review comparing how to remunerate surgeons working in different fields in the private sector should have taken this into consideration, and not how much time and physical work is involved.

In this issue of the BJO (p 1242), Muhtaseb et al found that over 40% of their cataract workload contained one or more risk factors. This was probably an underestimate with some risk factors not scored. These cases are more difficult to do and have a higher risk of developing operative complications. But even a routine case with a fully dilating pupil, crystal clear cornea with huge endothelial reserve, moderate nuclear hardness, a cooperative patient, and no problem with the first eye operation can go wrong. Patients often compare cataract surgery with a tooth extraction. They need to be reminded of the difference between the devastation of infective endophthalmitis and a tooth socket infection. In any case there are 32 teeth but only two eyes (in …