Wei Zhuen Chew1, Aimee Lloyd2
1. Foundation Year 1 Doctor, University Hospital Crosshouse, Kilmarnock
2. Ophthalmology Specialty Doctor Year 2, East Lancashire NHS Foundation Trust, Blackburn
Introduction
Cataracts are the leading cause of blindness worldwide (1). Estimates attributing blindness due to cataracts range from 50% cause of all-blindness in middle-low income countries to 90% cause of all-blindness in developed countries (2,3). Beyond the age of 60 years old, the average person is more likely to suffer from cataracts than not (4). This combination of a high incidence rate among the population and highly effective treatment available makes cataract surgery the most common surgical procedure performed in the NHS (5). This article explores and establishes the benefits of cataract surgery from multiple perspectives.
Cataract surgery has overseen many developments in technique with a wide range of benefits for patients and ophthalmologists. Cataract surgery commonly employs the use of local anaesthetic and minimally invasive surgery through self-sealing incisions which allows this procedure to be performed as a day case, allowing patients to return home without staying in hospital. Advancements in surgical technique makes completing this operation within 10 minutes a possibility among elite surgeons (6). This procedure has a 95% success rate of improving visual acuity (7), the primary indication of cataract surgery, and 0.79%-5% intraoperative rate of complications (8), cataract surgery’s advancements have established this procedure as one with high technical success if done correctly.
Cataract Surgery and Primary Care
Cataract surgery also places ophthalmologists in a unique position to work closely and optimise workflows with primary care eye providers irrespective of the primary care provider’s role as a general practitioner or an optometrist. Good communication can lead to an improved patient experience and better patient health outcomes. Firstly, ophthalmologists should communicate the importance of adequately assessing cataract patients’ initial presentation to primary care providers to ensure appropriate stratification of cataract severity. The primary care physician can facilitate discussion regarding the cataract surgery with patients to allay their initial concerns while outlining the upcoming events (9). This can help patients understand the process of receiving cataract surgery therefore reducing anxiety.
On the other hand, ophthalmologists have the opportunity to assess and address their patient’s health literacy. This can improve a patient’s overall lifestyle in terms of their social habits and hopefully reduce their comorbidities. This is because the risk factors of developing cataracts include common pathology such as hypertension, diabetes mellitus and cigarette smoking (10). These factors are known to cause more serious pathology if they progress hence controlling them can help prevent unwanted outcomes. Ophthalmologists discussing these modifiable risk factors with their patients via opportunistic motivational interviewing can ameliorate the treatment burden of their diseases.
The Future of Cataract Treatment
The future of cataract surgery is exciting. New technology proposes to use intraocular lenses to deliver pharmacotherapy which can reduce the patient’s treatment burden in terms of post-operative care (11). In-vivo research also seems to suggest that cataract surgery might not even be necessary with pharmacological intervention, for example, lanosterol, which has been found to reverse protein aggregation in cataracts. It remains to be seen how this research finding will translate to human subjects (12).
The Wider Health Impact of Cataract Surgery
Cataract surgery benefits patients across multiple health domains; the most obvious change being improved visual acuity. In a real-world setting, the Royal College of Ophthalmologist (RCO) states that 95% of patients will have LogMar 0.3 best-corrected distance vision post cataract surgery (13). This minimises the need for correcting visual acuity with glasses or contact lenses thus reducing potential sources of distress for patients as contact lens use is a risk factor for eye infections while the co-usage of glasses and face masks can cause glasses to steam up. However, post-cataract surgery patients will still require glasses for reading.
Cataract surgery also has repercussions on the workload of geriatricians, psychiatrists, and orthopaedic surgeons. Most recently in 2022, a study by Lee et al (14), showed that patients undergoing cataract extraction were at significantly lower risk of developing all-cause dementia compared to patients not undergoing the procedure. The impact of this cannot be overstated because dementia can cause patients to lose confidence in themselves and their general abilities which can lead to depressed mood and ultimately depression (15). Dementia currently does not have a cure. This intervention potentially lessens the treatment burden while improving the prognosis of a patient suffering from dementia thus making cataract surgery an effective management option for patients suffering from dementia who also suffer from cataracts. This has provided direction for my upcoming prospective study which aims to establish the relationship between cataract extraction and dementia. This research question has also been posed by Dawes et al (16). The authors recommend further investigation regarding vision impairment and dementia care to form the foundation which aims to inform clinical practice and national guidelines. Next, Robledo and colleagues proved that having a single cataract surgery reduced the frequency of falls by 34% (17). Falls are the second leading cause of unintentional injury and deaths worldwide, affecting around 684,000 individuals, represent a significant public health issue (18). While the cause of falls is multifactorial, there have been suggestions that vision impairment compromises the ability of a patient to remain upright. Falls are painful and can also lead to fractured bones which can require surgical attention. This can result in a long recovery period leading to reduced confidence in mobility and musculoskeletal function which can result in a sedentary lifestyle that has various health repercussions which can prove to be life changing.
A study reviewing the impact of cataract surgery and the relationship with patient’s lives has shown that cataract surgery significantly improves vision specific functioning which is fundamental in carrying out activities of daily living such as reading, writing, driving, and climbing steps, regardless of patient reported outcome tool utilised (19). These crucial interactions with the environment can support a patient’s self-esteem which can be pivotal in supporting these patients who are at greater risk of depression because of their reduced vision (20). Much like dementia, treating patients suffering from depression is a difficult process with various pharmacological therapies and electroconvulsive therapy being utilised with various success rates. Potentially, cataract surgery prevents depression from occurring thus representing a feasible treatment option.
Risk vs Benefits of Cataract Surgery
At the same time, while modern cataract surgery techniques are very safe, around 4% of patients undergoing this operation will experience some complications. The most common risks are posterior capsule rupture or vitreous loss, and these occurred in 1.95% of cases (21). Other commonly quoted figures include a 0.001% risk of blindness, 0.03% risk of endophthalmitis within 3 months of operation. Events which are uncommon also include iris trauma, zonule dialysis, endothelial damage. Patients discussing the utility of cataract surgery should be informed of the various benefits and risks to ensure they have sufficient information to make their decision.
The benefits and health economics of cataract surgery are overwhelmingly positive and outweigh its costs. However, the waiting lists for surgical procedures are ever expanding while the need for surgical intervention also grows more acute as the cataract matures. In 2017, NICE declared that cataract surgery should not be rationed (22). This guideline was meant to address health inequalities like the postcode lottery and how cataracts are affecting patients’ quality of life. The guideline also aimed to achieve this by contextualising the individual need for good vision by stating that good visual acuity should not be prohibiting a patient from receiving cataract surgery (23).
Health Economics and Cataract Surgery
Research shows that the mean annual expense per person for sight loss and blindness for developed countries such as the United States of America and Japan were around £9,700 to £28,672 (24,25). As previously outlined, by avoiding falls, other operations can be avoided which might not be as cost effective yet have lasting effects on a patient’s quality of life. Argawal and colleagues quantified that conducting cataract surgery is more cost effective than a knee arthroplasty and inserting a defibrillator in absolute dollar cost terms (26). These factors explain why theatre managers want more cataract surgeries performed from a financial point of view. Restoration of sight in a working adult will also increase individual and institution productivity levels. The positive relationship between eyesight and quality of life further strengthens the argument for increasing the number of cataract surgery operations (27). These factors along with the waiting lists caused by COVID-19 has translated into some theatre staff entering their respective units on a Saturday to carry out cataract extractions for patient benefit.
Cataract Surgery and Climate Change
Cataract surgery releases harmful emissions. While this topic typically does not receive much focus (28), climate change should be considered by ophthalmologists after the 26th United Nations Climate Change Conference (COP26) hosted in Glasgow. The National Health Service (NHS) is responsible for 3% of the United Kingdom’s greenhouse gases emissions (29). Greenhouse gas emissions from healthcare increases to 10% in the United States (30). Thiel et al stated that if India’s ophthalmologists utilised similar phacoemulsification techniques as British ophthalmologists, their greenhouse emissions will increase 28-fold with the equivalent equal to increasing a passenger car journey from 25 kilometres to nearly 700 kilometres (31). Thiel et al also proposed a model which reduces the waste generated in cataract surgery theatres significantly (31). This comprises decreasing surgery duration and turnaround time to decrease electricity use per case and the implementation of reusable instruments in theatre. Beyond consideration for the environment, this measure produced superior patient outcomes and complication rates to a level superior to the United Kingdom (UK) (32,33).
The impact of global warming and climate change threatens food security, species survival, depletion of natural resource and can make human life incompatible with earth. A solution proposed among literature is reutilising phacoemulsification tips. This topic has generated debate regarding its real-world applications (34). Eye units across the UK can further investigate this to revamp their workflow and act sustainably to reduce their overall carbon emissions.
Cataract Surgery and Nursing
Nurses play an essential role in ensuring that cataract surgery runs smoothly. This begins from the preoperative stage where the eye is examined, and visual acuity is noted. This standard is now commonplace following a proposal by Gregory et al (35). Further, nurses often undertake the role of first assistant to the ophthalmologists once they have scrubbed in. Some units even have nurses assuming complete control of the cataract patient’s postoperative care including decision making regarding medication dosage and patient discharge (36). This utilisation of resource can make the entire experience more seamless for patients with less variation between the members of the multi-disciplinary team offering eye care. Nursing is an area which has been proven to benefit from the latest evidence base as Li has demonstrated with the psychological and postoperative quality of life of patients improving from having the most effective interventions (37). As with most medical interventions, nurses have a pivotal role in ensuring its success.
Conclusion
The RCOphth anticipate an increase of around 50% in the number of cataract operations they will be expected to perform over the next 20 years (2015-2035) (38). As the global population age increases, it is likely that the need for cataract intervention will increase. In a field where outcomes are improving and research is ongoing, it is not known what that intervention will look like in the future making this an exciting time to enter ophthalmology. In the meantime, patients and ophthalmologist can rely on the studied, tried and tested intervention of cataract surgery which achieves excellent results.
References
1. Common Eye Disorders and Diseases | CDC. (2020, June 4). Www.cdc.gov. https://www.cdc.gov/visionhealth/basics/ced/index.html#:~:text=Cataract%20is%20a%20clouding%20of
2. World Health Organization. (2021, October 11). Blindness and Vision Impairment. Who.int; World Health Organization: WHO. https://www.who.int/news-room/fact-sheets/detail/blindness-and-visual-impairment
3. Thompson, J., & Lakhani, N. (2015). Cataracts. Primary Care: Clinics in Office Practice, 42(3), 409–423. https://doi.org/10.1016/J.POP.2015.05.012
4. Hashemi, H., Pakzad, R., Yekta, A. et al. (2020) Global and regional prevalence of age-related cataract: a comprehensive systematic review and meta-analysis. Eye. https://doi.org/10.1038/s41433-020-0806-3
5. Allen D. Cataract. Clin Evid [online] 2008; 2008.
6. Rothschild, P. R., Grabar, S., Le Dû, B., Temstet, C., Rostaqui, O., & Brézin, A. P. (2013). Patients’ subjective assessment of the duration of cataract surgery: a case series. BMJ Open, 3(5). https://doi.org/10.1136/BMJOPEN-2012-002497
7. Moshirfar, M., Milner, D., & Patel, B. C. (2022). Cataract Surgery.
8. Haripriya, A., Chang, D. F., Reena, M., & Shekhar, M. (2012). Complication rates of phacoemulsification and manual small-incision cataract surgery at Aravind Eye Hospital. Journal of Cataract and Refractive Surgery, 38(8), 1360–1369. https://doi.org/10.1016/J.JCRS.2012.04.025
9. Thompson, J., & Lakhani, N. (2015). Cataracts. Primary Care: Clinics in Office Practice, 42(3), 409–423. https://doi.org/10.1016/J.POP.2015.05.012
10. Mukesh, B. N., Le, A., Dimitrov, P. N., Ahmed, S., Taylor, H. R., & McCarty, C. A. (2006). Development of Cataract and Associated Risk Factors: The Visual Impairment Project. Archives of Ophthalmology, 124(1), 79–85. https://doi.org/10.1001/ARCHOPHT.124.1.79
11. Liu, Y. C., Wilkins, M., Kim, T., Malyugin, B., & Mehta, J. S. (2017). Cataracts. The Lancet, 390(10094), 600–612. https://doi.org/10.1016/S0140-6736(17)30544-5
12. Zhao, L., Chen, X. J., Zhu, J., Xi, Y. B., Yang, X., Hu, L. D., Ouyang, H., Patel, S. H., Jin, X., Lin, D., Wu, F., Flagg, K., Cai, H., Li, G., Cao, G., Lin, Y., Chen, D., Wen, C., Chung, C., … Zhang, K. (2015). Lanosterol reverses protein aggregation in cataracts. Nature, 523(7562), 607–611. https://doi.org/10.1038/NATURE14650
13. RCO (2018) Commissioning guide: adult cataract surgery. Royal College of Ophthalmologists. http://www.rcophth.ac.uk<https://www.rcophth.ac.uk/wp-content/uploads/2018/02/Cataract-Commissioning-Guide-January-2018.pdf> [Free Full-text]
14. Lee, C. S., Gibbons, L. E., Lee, A. Y., Yanagihara, R. T., Blazes, M. S., Lee, M. L., Mccurry, S. M., Bowen, J. D., Mccormick, W. C., Crane, P. K., & Larson, E. B. (2022). Association Between Cataract Extraction and Development of Dementia. JAMA Internal Medicine, 182(2), 134. https://doi.org/10.1001/JAMAINTERNMED.2021.6990
15. The psychological and emotional impact of dementia. (n.d.). Alzheimer’s Society. https://www.alzheimers.org.uk/get-support/help-dementia-care/understanding-supporting-person-dementia-psychological-emotional-impact#:~:text=Dementia%20may%20cause%20people%20to
16. Dawes, P., Wolski, L., Himmelsbach, I., Regan, J., & Leroi, I. (2019). Interventions for hearing and vision impairment to improve outcomes for people with dementia: a scoping review. International Psychogeriatrics, 31(2), 203–221. https://doi.org/10.1017/S1041610218000728
17. Gutiérrez-Robledo, L. M., Villasís-Keever, M. A., Avila-Avila, A., Medina-Campos, R. H., Castrejón-Pérez, R. C., & García-Peña, C. (2021). Effect of Cataract Surgery on Frequency of Falls among Older Persons: A Systematic Review and Meta-Analysis. Journal of Ophthalmology, 2021. https://doi.org/10.1155/2021/2169571
18. World Health Organization, 2021. Falls. [online] Who.int. Available at: https://www.who.int/news-room/fact-sheets/detail/falls [Accessed 7 August 2022].
19. Lamoureux, E. L., Fenwick, E., Pesudovs, K., & Tan, D. (2011). The impact of cataract surgery on quality of life. Current Opinion in Ophthalmology, 22(1), 19–27. https://doi.org/10.1097/ICU.0B013E3283414284
20. Osaba, M., Doro, J., Liberal, M., Lagunas, J., Kuo, I. C., Víctor, ;, & Reviglio, E. (2019). Relationship Between Legal Blindness and Depression. Medical Hypothesis, Discovery and Innovation in Ophthalmology, 8(4), 306. /pmc/articles/PMC6778679/
21. Day, A. C., Donachie, P. H., Sparrow, J. M., Johnston, R. L., & Royal College of Ophthalmologists’ National Ophthalmology Database (2015). The Royal College of Ophthalmologists’ National Ophthalmology Database study of cataract surgery: report 1, visual outcomes and complications. Eye (London, England), 29(4), 552–560. https://doi.org/10.1038/eye.2015.3
22. Iacobucci, G. (2017). Cataract surgery is cost effective and should not be rationed, says NICE. BMJ, 358, j3588. https://doi.org/10.1136/BMJ.J3588
23. Cataracts in adults: management NICE guideline. (2017). https://www.nice.org.uk/guidance/ng77/resources/cataracts-in-adults-management-pdf-1837639266757
24. Köberlein, J., Beifus, K., Schaffert, C., & Finger, R. P. (2013). The economic burden of visual impairment and blindness: a systematic review. BMJ Open, 3(11). https://doi.org/10.1136/BMJOPEN-2013-003471
25. Roberts, C. B., Hiratsuka, Y., Yamada, M., Pezzullo, M. L., Yates, K., Takano, S., Miyake, K., & Taylor, H. R. (2010). Economic cost of visual impairment in Japan. Archives of Ophthalmology (Chicago, Ill. : 1960), 128(6), 766–771. https://doi.org/10.1001/ARCHOPHTHALMOL.2010.86
26. Agarwal, A., & Kumar, D. A. (2011). Cost-effectiveness of cataract surgery. Current Opinion in Ophthalmology, 22(1), 15–18. https://doi.org/10.1097/ICU.0B013E3283414F64
27. Weih, L. M., Hassell, J. B., & Keeffe, J. (2002). Assessment of the impact of vision impairment. Investigative Ophthalmology & Visual Science, 43(4), 927–935.
28. Mamalis, N. (2018). Reducing the environmental impact of cataract surgery: Sustainability versus safety: A tradeoff? Journal of Cataract and Refractive Surgery, 44(1), 1–2. https://doi.org/10.1016/J.JCRS.2018.01.001
29. Sustainable Development Unit. Carbon Footprint Update for NHS in England 2012. Cambridge, UK: Sustainable Development Unit; 2013. [Accessed September 25, 2017]. Available at: http://www.sduhealth.org.uk/documents/carbon_footprint_summary_nhs_update_2013.pdf
30. Eckelman, M. J., & Sherman, J. (2016). Environmental Impacts of the U.S. Health Care System and Effects on Public Health. PLoS ONE, 11(6). https://doi.org/10.1371/JOURNAL.PONE.0157014
31. Thiel, C. L., Schehlein, E., Ravilla, T., Ravindran, R. D., Robin, A. L., Saeedi, O. J., Schuman, J. S., & Venkatesh, R. (2017). Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility. Journal of Cataract and Refractive Surgery, 43(11), 1391. https://doi.org/10.1016/J.JCRS.2017.08.017
32. Haripriya A, Chang DF, Reena M, Shekhar M. Complication rates of phaco-emulsification and manual small-incision cataract surgery at Aravind Eye Hospital. J Cataract Refract Surg. 2012;38:1360–1369.
33. Vickers T, Rosen E. Driving Down the Cost of High-Quality Care: Lessons From the Aravind Eye Care System. London, UK: McKinsey and Co; 2011. [Accessed September 25, 2017].
34. Tsaousis, K. T., Chang, D. F., Werner, L., Perez, J. P., Guan, J. J., Reiter, N., Li, H. J., & Mamalis, N. (2018). Comparison of different types of phacoemulsification tips. III. Morphological changes induced after multiple uses in an ex vivo model. Journal of Cataract and Refractive Surgery, 44(1), 91–97. https://doi.org/10.1016/J.JCRS.2017.08.023
35. Gregory, D., & Lowe, K. J. (1991). An enhanced role for the ophthalmic nurse. A control study on day case cataract surgery. Professional Nurse (London, England), 7(1), 43–44, 46, 48 passim.
36. Marsden, J. (2004). Cataract: the role of nurses in diagnosis, surgery and aftercare. Nursing Times, 100(7), 36–40.
37. Li, X. (2021). Application of evidence-based nursing in patients after cataract surgery and its impacts on visual acuity recovery and psychological status. American Journal of Translational Research, 13(8), 9784. /pmc/articles/PMC8430197/
38. The Way Forward Cataract Options to help meet demand for the current and future care of patients with eye disease. (n.d.). https://www.rcophth.ac.uk/wp-content/uploads/2021/12/RCOphth-The-Way-Forward-Cataract-300117.pdf