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Abstract
AIMS/METHODS A national data collection exercise was carried out in more than 100 hospital eye service units within the UK to provide clinical and administrative information on patients undergoing cataract surgery. This included patient clinical data such as visual acuity at the time of wait listing and at the time of admission for surgery, presence of other eye disorders, other serious medical disorders, and data on waiting time and type of admission.
RESULTS The profiles of the 18 454 patients aged 50 years or older are reported. Findings of particular note were as follows. At the time of wait listing for cataract surgery 31% had visual acuity of 6/12 or better, 54% had visual acuity between 6/18 and 6/60, and 15% had less than 6/60 vision. Considering those who had visual acuity of 6/12 or better at the time of wait listing, by the time of admission for surgery, the vision deteriorated to 6/18–6/60 in 33% and in a further 3% the vision deteriorated to below 6/60. In patients with moderately poor visual acuity (<6/12–6/60) at the time of wait listing, 13% had less than 6/60 vision by the time of admission for surgery.
CONCLUSION This type of data collection and reporting exercise provides new material that can be used in the planning and provision of cataract surgery services in the UK.
- patient profile
- cataract surgery
- United Kingdom
- data collection
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Information available on request from the Office for National Statistics on the cataract surgery workload in the UK is limited to the number and main type of operations completed and the age and sex of the patients. This provides no information on the general health and the eye health status of those undergoing surgery for cataract. Similarly, waiting list figures at the national level are also clinically uninformative.
It could be argued that broad patient profiling is a prerequisite for fruitful dialogue between providers of eye services and their public health colleagues within the Department of Health and the district health authority. This type of profiling would include patient clinical data such as visual acuity at the time of wait listing and at the time of admission for surgery, presence of other eye disorders, other serious medical disorders, and data on waiting time and type of admission. This article aims to initiate the practice of reporting specially collected but routinely available information on cataract surgery, for use by eye service providers in policy discussions.
Methods
More than 100 unselected hospital eye units within the UK agreed to collect data on patients undergoing cataract surgery, according to a predefined set of preoperative and postoperative forms. The data collection time was from September to December of 1997. The work in each unit was carried out under the auspices of the ophthalmic clinical director. The recording of data was devolved to varying degrees to clinical audit staff.
The data collection forms were developed by a team that included ophthalmologists and epidemiologists. A handbook of instructions for data collection and recording was prepared to complement the standardised forms. This was to help ensure a standard method of data extraction and recording. The forms were tested through pilot studies.
Visual acuity refers to distance Snellen visual acuity for each eye with correction (if worn) or pinhole, at time of listing for surgery (when a decision for surgery had been made), and on admission for surgery.
A specially designed computer database application was used for entry, validation, and preparation of the data for analysis. Thespss software was used for data analysis.
Results
Data on 19 000 patients undergoing cataract surgery were analysed. Of these, 546 who were under 50 years old and not representative of “age related” cataract were excluded from the main detailed analysis. The profile of the 18 454 patients aged 50 years or older is reported below.
AGE AND SEX STRUCTURE
Table 1 shows the age and sex distribution of the study sample. Women formed 65% (12 038/18 454) of the patients. The higher frequency of women was consistent in all age groups except for the youngest (50–54 age group), where 53% (198/371) were men and 47% (173/371) were women. The mean age was 76.3 years (74.3 in men and 77.3 in women). Sixteen per cent of the men and 9% of the women were under 65 years old.
Age and sex distribution of 18 454 patients on admission for cataract surgery
GENERAL MEDICAL DISORDERS
More than half (57%) of the patients wait listed for cataract surgery had a medical disorder, some having more than one; 11% had diabetes, 18% arthritis, 29% hypertension, and 5% had had stroke. As expected, the prevalence of medical disorders increased with age, except for diabetes.
SERIOUS EYE DISORDERS COEXISTING WITH CATARACT
Age related macular disease was present in 169 per 1000 patients, primary open angle glaucoma in 112 per 1000, diabetic retinopathy in 34 per 1000, and amblyopia in 14 per 1000. One or more of these disorders was present in 304 per 1000 patients. In 5 per 1000 patients, both diabetic retinopathy and age related macular disease were present. Of the self reported diabetics (2062 patients), 273 per 1000 had diabetic retinopathy. Sixty five patients who were not known as diabetic also had diabetic retinopathy.
FIRST OR SECOND EYE SURGERY
Sixty five per cent of patients were admitted for surgery to their first eye, and the remainder were for second eye cataract extractions.
VISION IN THE SURGERY EYE AT THE TIME OF WAIT LISTING
At the time of wait listing for cataract surgery, 31% (5385/17 445) had visual acuity of 6/12 or better, 54% (9390) had visual acuity between 6/18 and 6/60, and 15% (2670) had less than 6/60 vision. Complete data on visual acuity were available for 17 445/18 454 (95%) of patients.
The majority (85%) of patients with visual acuity of 6/12 or better in the eye for surgery also had this level of acuity in the fellow eye at the time of wait listing. One in five patients (20%) with visual acuity less than 6/60 in the surgery eye had the same level of acuity in their fellow eye. Thirty one per cent of all patients had visual acuity of less than 6/12 (6/18 to less than 6/60) in both eyes.
The proportion having 6/12 or better vision in the surgery eye was considerably higher in the youngest age group (50–54) compared with that in the oldest group (36% v 22%). The proportion having poor vision (<6/60) was also highest in the three youngest age groups (Table 2).
Visual acuity at the time of wait listing for cataract surgery. Complete data available on 17 445 patients
Men and women had similar distribution of visual acuity: 32% of men and 31% of women had 6/12 or better vision, and 16% and 15%, respectively, had poor visual acuity of <6/60. Among patients who had 6/12 or better vision in the surgery eye at the time of listing, 85% were free of age related macular disease and of diabetic retinopathy.
Diabetics had poorer visual acuity, 20% having visual acuity of poorer than 6/60 compared with 15% in non-diabetics. The finding was consistent in all but the youngest age group where similar proportions had <6/60 vision (22% and 23% respectively).
The finding for diabetic retinopathy was similar to that for diabetics. A higher proportion of diabetic retinopathy cases had poor vision of <6/60 (19% v 15%).
The proportion with poor visual acuity of <6/60 in patients with age related macular disease was 19%—that is, very similar to that in diabetic retinopathy. In patients who did not have diabetic retinopathy or age related macular disease, 14% had <6/60 vision.
The risk of having poor vision (<6/60) was not related to the presence of glaucoma (15% in those with and also in those without glaucoma).
TYPE OF ADMISSION
Seventy per cent of the patients were surgical day cases. There was considerable variation between the participating centres (from 100% to less than 10% day cases). Patients aged 85 years or older were more likely to be inpatients compared with the younger age groups (40% v 24–34%). Also, women were more likely than men to be inpatients (32% v26%), possibly because of the age structure differences. In the 844 patients with a history of stroke, 38% were inpatient admissions, compared with 30% in those without such history.
TYPE OF ANAESTHESIA
Local anaesthesia was used in 86% of the cataract operations. Older patients were more likely to have local anaesthesia (89% in the oldest group compared with 65% in the youngest).
USE OF PHACOEMULSIFICATION AND GRADE OF SURGEON
Phacoemulsification was used in 77% of the cataract operations. There was little variation by age or by sex. There was, however, considerable variation between the participating centres, the lowest proportion having phaco being 10%, and the highest being 99%.
Most of the cataract surgery (63%) was performed by consultant ophthalmologists, 7% by associate specialists, 16% by specialist registrars (SpR), 6% by senior house officers (SHO), and the remaining 8% by other eye surgeons. Phacoemulsification was used in a high proportion of the surgery by consultant and SpR grade surgeons (80% and 83% respectively). For SHO and associate specialist grades, the proportion of phacoemulsification was 67%.
ROUTE OF REFERRAL FROM PRIMARY CARE
General practitioners were the sole source of referral in 38% of the cases. A further 50% were referred by general practitioners but the primary source was the optometrist. A small number (3%) came directly from optometrists, and the remaining 9% from other sources.
WAITING TIME FOR SURGERY
On average, patients waited for 7.4 months (SE 0.04, SD 5.2; median wait 6.4 months) from time of wait listing to surgery. The mean waiting time for first eyes was 7.4 months (SE 0.1, SD 5.2; median 6.5 months). For second eyes the average wait was 7.3 months (SE 0.08, SD 5.3; median 6.3 months).
Older patients tended to have slightly longer waiting time. Comparing the youngest and the oldest age groups, the average waiting times were 6.9 and 7.7 months. Females tended to have slightly longer waiting times, the average being 7.5 months compared with 7.2 months for males. The mean waiting time for patients with 6/12 or better vision in both eyes at the time of wait listing was 7.4 months. Those with poor visual acuity (<6/12) in both eyes at the time of wait listing had a mean waiting time of 7.5 months.
Overall, 17% of patients had waited for more than 12 months from time of wait listing for surgery. The proportion of patients waiting for more than 12 months was similar for first and second eye surgery—17% v 16% respectively.
VISION IN THE SURGERY EYE AT THE TIME OF ADMISSION FOR SURGERY
Considering those who had visual acuity of 6/12 or better at time of wait listing, in 33% the vision deteriorated to 6/18–6/60, and in a further 3% the vision deteriorated to below 6/60, by the time of admission for surgery. In patients with moderately poor visual acuity (less than 6/12 to 6/60) at the time of wait listing, 13% had less than 6/60 vision by the time of admission for surgery.
The distribution of visual acuity at the time of admission for surgery is shown in Table 3. Overall, the proportion of patients with visual acuity of 6/12 or better in the eye undergoing cataract surgery was 27%. This was considerably lower (20%) in the oldest age group.
Visual acuity at the time of admission for cataract surgery. Complete data available on 16 032 patients
Most (85%) of the patients with visual acuity of 6/12 or better in the surgery eye also had this level of acuity in their fellow eye on admission. Nineteen per cent of patients with visual acuity less than 6/60 had the same level of acuity in their fellow eye on admission for surgery. Thirty two per cent of all patients had visual acuity less than 6/12 (6/18 to less than 6/60) in both eyes.
Discussion
Many of the findings in this large national sample of cataract patients may confirm the local experience of ophthalmologists. However, having available robust national estimates from such a large data set provides useful source material to inform professional practice and for policy negotiations.
The main findings of interest from this work that could not have been otherwise ascertained include visual acuity details at the time of wait listing and at the time of admission for surgery. Other findings of interest include the national estimates for relative frequency of different surgical and anaesthetic procedures. Finally, the referral pathway to surgery and the waiting times for surgery have been analysed in more detail in relation to age and other characteristics.
Particular findings that should be considered further by clinicians in terms of acceptability at both local and national levels include the following: • The seemingly high proportion (31%) having 6/12 or better vision at the time of wait listing, and the 15% with <6/60 vision at that time • The reported deterioration of visual acuity from the time of wait listing, to the time of admission for surgery • The frequency of general anaesthesia, particularly in the younger patients.
Acknowledgments
This work was supported by a grant from the Department of Health.
The authors wish to thank the steering group members from the Royal College of Nursing, The College of Optometrists, and the Royal College of Ophthalmologists. Thanks are due also to Mr Tony Moore, Professor Andrew Elkington, and the staff of the Royal College of Ophthalmologists for their advice and support, and to Dr Andrew Burnett of the Department of Health
The authors particularly want to thank all those clinical and audit personnel within the UK who diligently collected data for this work from the following centres:
Addenbrooke’s Hospital, Hinchingbrooke Hospital, Ipswich Hospital, James Paget Hospital, Luton and Dunstable NHS Trust, Prince Charles Eye Unit Edward VII Hospital, Royal Berkshire Hospital, Stoke Mandeville Hospital, West Norwich Hospital, West Suffolk Hospital, Bedford General Hospital, Barnet General and Edgware Community Hospital, Royal Free Hospital, University College Hospital, Central Middlesex Hospital, Charing Cross Hospital, Essex County Hospital, Hillingdon Hospital, Moorfields Eye Hospital, Princess Alexandra Hospital, Queen Elizabeth II Hospital, Western Eye Hospital, Chelsea and Westminster Hospital, Arrowe Park and Wirral Hospital, Royal Bolton Hospital, Royal Infirmary Lancaster, Leighton Hospital, Royal Albert Edward Infirmary, Royal Oldham Hospital, Southport and Formby District General Hospital, Victoria Hospital, Warrington Hospital, Drayton House Clinic, Royal Informary, Balckburn, Burnley General Hospital, St Helen’s Hospital, West Cumberland Hospital, Bradford Royal Infirmary, Cumberland Infirmary, Darlington Memorial Hospital, Harrogate District Hospital, Huddersfield Royal Infirmary, Hull Royal Infirmary, Leeds General Infirmary, North Riding Infirmary, Pinderfields General Hospital, Royal Halifax Infirmary, Royal Victoria Infirmary, Scarborough Hospital, Sunderland Eye Infirmary, York District Hospital, North Devon District Hospital, North Hampshire Hospital, Princess Margaret Hospital, Queen Alexandra Hospital, Royal Hampshire County Hospital, Royal United Hospital, Royal Bournemouth and Christchurch Hospital, Southampton General Hospital, Torbay Hospital, Royal Devon and Exeter Hospital, St Mary’s Hospital, East Surrey Hospital, Kent and Canterbury Hospital, Kent County Ophthalmic and Aural Hospital, Kent and Sussex Hospital, King’s College Hospital, Queen Mary’s Hospital, West Sussex Eye Unit, Chesterfield and North Derbyshire Royal Hospital, Derbyshire Royal Hospital, King’s Mill Centre, Leicester Royal Infirmary, Lincoln County Hospital, Grimsby Hospital, Scunthorpe General Hospital, Alexandra Healthcare NHS Trust, Birmingham and Midlands Eye Centre, Selly Oak Hospital, Birmingham Heartlands Hospital, Guest Hospital, Sandwell General Hospital, Queen’s Hospital, County Hospital, Wolverhampton and Midland Counties Eye Infirmary, Worcester Royal Infirmary NHS Trust, Royal Group of Hospitals Belfast, Aberdeen Royal Infirmary, Ninewells Hospital, Princess Alexandra Eye Pavillion, Queen Margaret Hospital, Royal Alexandra Hospital, Southern General Hospital, West Glasgow Hospital, Stobhill Hospital, Stirling Royal Infirmary, Stonehouse Hospital, St John’s Hospital, East Glamorgan Hospital, Prince Charles Hospital, HM Stanley Hospital, Wrexham Maelor Hospital, Bronglais General Hospital.