Cataract surgery in New Zealand/Aotearoa approaching 2020:
demand, supply, politics,economics & shared care
Professor Charles NJ McGhee

MB.ChB, BSc(Hons), PhD, DSc, FRCS, FRCOphth, FRANZCO

Maurice Paykel Professor & Chair of Ophthalmology
Director, New Zealand National Eye Centre,
SMO, Auckland District Health Board,
Consultant, Eye Institute, Auckland© CNJ McGhee 2017

Introduction: cataract
The most common cause of visual impairment
The most common surgical procedure in the developed world
Extremely efficient, effective and safe health-dollar investment!
Why can we never meet the annual demand?
New ZealandAustralia
United Kingdom
United States
Globally> 30,000> 160,000> 390,000> 3,600,000> 20 million© CNJ McGhee 2017

Political solutions or misdirection

Cataracts and hip replacement surgery the currency of election healthcare policies© CNJ McGhee 2017

Considering Cataract Outcomes in NZ
The Auckland Cataract Studies 2000-2017

OUTLINE OF LECTURE
Cataract surgery ismost common surgicalprocedure in New
Zealand
Typically presents tooptometrists andgeneral practitioners

International Cataract Costs
We are more, not less, expensive!
xx© CNJ McGhee 2017

Potential barriers to successful cataract
surgery & visual rehabilitation in NZ
1. Identifying visually significant cataract
2. Referral and first specialist visit
3. Assessing suitability, eligibility, listing
4. Pre-operative assessment
5. Provision of excellent surgical services
6. Post-operative care
7. Dealing with complications
8. Potential barriers to discharge*
9. Long term Optical correction
10. Funding the process: Government, Health Insurers, Self
© CNJ McGhee 2017

Aetiology of cataract
 Congenital Inherited Age-related (the majority) Metabolic – e.g. diabetes
 Toxic – e.g. corticosteroids

 Traumatic – e.g. irradiation
 Secondary – e.g. uveitis
9Diagnosing cataract• Reduced visual acuity– Snellen, glare, contrast
sensitivity, driving• Entirely clinical diagnosis– Distance & near vision– Ophthalmoscope– Slit lamp microscope– Significant lens opacity• Exclude other ocularpathologies*
10Effect of differing cataracts• Nuclear Cataract– Common, VA may be preserved– may induce myopia• Cortical Cataract

Cortical cataract– Often associated with nuclear– May cause distortion/glare• Subcapsular Cataract– May have good vision in test conditions– Variable vision particularly in low light– Consider history and test glare vision

Posterior Subcapsular11

Burden of cataracts: visual impairment
Global cataract surgical rates (2004)“cataract is responsible for
51% of world blindness,
which represents about
20 million people (2010)”

World Health Organisation

http://www.who.int/blindness/data_maps/cataract_surgery_rate/en/

The Auckland Cataract Study 1:
2000-2001: Waiting – the harbor bridge study N=193

Mean age
Mean wait
Mean BCVA

77.2 years
18.2+/-11.6 mths
6/36*

Outcome
Still waiting
Expedited Rx
Private surgery
Deceased
Declined surgery

49%*
4%
21%
12%
2%

The Waiting Game: The natural history of a cataract waiting list in New Zealand
AF Riley, C Grupcheva, TY Malik, JP Craig, CN McGhee. Clin Expt Ophthalmol 2001

Auckland Cataract Study Systemic Disease

The majority of those with significant cataract have
General Health issues
Hypertension
Cerebral vascular disease
Diabetes Melitus
Ischaemic Heart disease
RxAspirin
Warfarin

25%
12%
11%
10%
42%
6%
Pre-proliferative diabetic retinopathy

The Auckland Cataract Study: Demographic, Corneal Topographic and Ocular Biometric Parameters.
AF Riley, CN Grupcheva, TY Malik, JP Craig, CN McGhee. Clinical & Experimental Ophthalmology 2001

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Auckland Cataract Study Ocular Disease

Ocular co-morbidities in cataract patients
Open-angle glaucoma

10%

Diabetic retinopathy

6%

Vein occlusion

2%

Advanced AMD

1%**Advanced Optic disc cupping in glaucoma

The Auckland Cataract Study: Demographic, Corneal Topographic and Ocular Biometric Parameters.
AF Riley, CN Grupcheva, TY Malik, JP Craig, CN McGhee. Clinical & Experimental Ophthalmology 2001

15

Cataract Surgery
Ancient Techniques– Couching

Current cataract techniques
Intra-capsular –Now mainly in developing world
Extra-capsular –Some use in developed world
Phacoemulsification –most popular techniqueFemto-laser assisted
Use increasing developed world
16

Contemporary Cataract Surgery
1990’s small incision phacoemulsification and the evolutionof foldable/injectable Intraocularlenses revolutionized cataract
surgery in developed world17Extracapsular surgery: ECCE vs PhacoPhacoemulsification in practiceAuckland Cataract Study 1: 2000-2001
Outcome:Mean BSCVA 6/7.5 (88% > 6/12)
Mean SphEq –0.46+/-0.89D
Complications:
4.9% capsular tears
3.7% cystoid macular oedema
0.2% endophthalmitis
1.5% of eyes red’n BSCVA due to surgery
The Auckland Cataract Study: co-morbidity, surgical techniques and clinical outcomes in a Public Hospital Service.
Andrew Riley, Tahira Malik, Christina Grupcheva, Michael Fisk, Jennifer Craig, Charles McGhee. BJO 2002

Cataract Pathway 2017
The timing of referral varies significantly with available local DHB funding,however, many would consider referring when vision ≤6/12

Current cataract referral waiting times:
1. From referral to FSA (4 months)
2. From FSA to surgery (4 months)

Cataract referrals at ADHB via three main routes:
General Practice
Optometrist*
Ophthalmologist
21

Efficiency:
Radical streamlining of existing systems?
1. Immediate listing from the community
2. Combined Optometry/General Practitioner electronic referrals
Enables collection of demographic data and risk analysis
3. Same day FSA clinic review and surgery
4. Electronic surgical records
Enables ongoing audit and creates discharge
5. Bilateral same day cataract surgery
6. Immediate discharge to optometric shared care
© CNJ McGhee 2017

J Cataract Refract Surg 2013; 39:712–715

One stop cataract clinic N=4657 (Bristol, 2008-2010)
Two referral routes – traditional GP route and Refined Direct
Optometrist (RDO) pathway
Operative rates higher for RDO (92%) than GP (82%) routes“ By combining referral information from optometrists and GPs, a highquality and efficient cataract surgery patient pathway can be established.

This has major economic advantages, and this scheme could be adopted
at a national level.”© CNJ McGhee 2017

Uncomplicated surgery and no signiﬁcant ocular comorbidity - same daydischarge to community optometrists.
Over 2 years, 1492 of 2461 (61%) Cambridgeshire patients discharged tocommunity on day of cataract surgery.
Complete feedback in 97%, uneventful in 94% and 3% of patients re-referred.
CMO 0.6%, uveitis 1.0% and raised IOP 0.1%.
No patients had sight-threatening complications in this study© CNJ McGhee 2017

Preoperative RISK stratification
maximizing outcomes, safety and audit• Scores for patient risk factors documented in the clinical notes• A validated system devised by Muhtaseb et al. (2004, UK)
1 point

3 points

Age >88 years

Brunescent/white/dense/total cataract/
no fundus view

Ametropia (>6D of myopia or hyperopia)

Pseudoexfoliation

Corneal scar
Posterior capsule plaque
Posterior polar cataract
Previous vitrectomy
Shallow AC <2.5mm
Small pupil <3mm
Miscellaneous (poor position, etc)

Auckland Cataract Study IIa and IIb
Risk of intraoperative complications• Observed higher complication rates with high risk scores• Significant increase for scores >3

Intraoperativecomplication rate(%)

Dr Bia Kim MD

150

100
50
001234
Risk Score

567Intraoperative complications in cataract surgery (N=1000)
Following introduction of risk analysis in ADHB
2015

2016

P-value fordifference

Intraoperativecomplications

8.4%(N=500)5.0%(N=500)0.042

PC tear ± vitreous loss

2.6%

1.8%

0.258

Anterior capsular tear

1.2%

0.4%

0.224

Zonular dialysis

1.6%

0.6%

0.224

Iris prolapse

2.6%

1.4%

0.258

Iris trauma

1.0%

1.4%

0.773

Dropped nucleus fragment

0.2%0.4%

1.000

The Auckland Cataract Study II: Reducing Complications by Preoperative Risk Stratification and Case Allocation in a
Teaching Hospital. Kim BZ, Patel DV, McKelvie J, Sherwin T, McGhee CNJ. Am J Ophthalmol. 2017 Sep;181:20-25.

Auckland Cataract Study 2:
Postoperative complications
2015

2016

P-value fordifference

Postoperative complications

8.1%(N=479)6.1%(N=472)

0.258

Cystoid macular oedema

3.5%

3.8%

0.865

Auckland Cataract Study 2:
Postoperative complications: Cystoid macular oedema• Rare• Endophthalmitis• Pain, redness, decreased vision in first week

• Intra-ocular haemorrhage• Severe uveitis• More common• Cystoid macular oedema• Typically in first month – suspect if vision has been
good and deteriorates moderately in quiet eye• Mild uveitis beyond 4 week

RADICAL ROUTES TO IMPROVED CATARACT SURGERYPROVISION: Excellence, Efficiency, Economy top ten
1. Fully electronic pathway
2. Optometry/GP referral / listing
3. Risk stratification analysis and audit
4. Consider one-stop surgical approach
5. Bilateral same day surgery where appropriate
6. In teaching units create (hi-volume) service vs training lists
7. Day-one discharge to community optometry in >50% cases
8. Standardised data set pre and post-op
9. Unified national program and agreed threshold
10. Continuous audit cycle – Local, DHB and National levelShared care in cataract surgery
 Identifying
 Appropriately referring Pre-operative assessment
 Post operative management* Unexpected complications*32

The fine-print of co-management

Common complications
 Striate keratopathy Elevated IOP Aqueous leak Ant. Uveitis
 Loose sutures* Rare complications

 Retinal detachment
 Choroidal haemorrhage Filtering bleb
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Endophthalmitis – always a risk?

 94,653 cataract procedures in 19 years
 Endophthalmitis in 188 patients
 Serious visual impairment in 70.6%

 Incidence of cataract surgery increased x3
 However, endophthalmitis rate constant at 2 per 1000
Semmens JB, Li J, Morlet N, Ng J. Trends in cataract surgery and post-operative endophthalmitis in WesternAustralia (1980-1998):The endophthalmitis Population Study of Western Australia. Clinical & Experiment
35
Ophthalmol June 2003

Post-operative management Day 1 review
 Symptoms
 Unaided VA
 Pinhole VA*
 Assess:
 Cornea Pupil Media
 IOL position
 IOP
36

Post-operative management

 Usually 2-4 weeks post-operative topical medication
 Typically an antibiotic and a steroid
 E.G. g. Chloramphenicol QDS / g. ciprofloxacin TDS* E.G. g. Predforte QDS / g. Maxidex QDS
 Or Maxitrol (dexamethasone + neomycin + polymyxin B)

 Or occasionally NSAIDS e.g. ketorolac/diclofenac
37

Post-operative management

Post-op vision & visual acuity
Day one and day seven: Usually 6/6 to 6/18
 If less than 6/12 unaided – refract

 More than 1.5D residual error - consult

38

Post-operative management

1/12 post-op vision & best corrected visual acuity
 Generally BSCVA ≥ 6/7.5
 BSCVA <6/12, exclude pathology:
 Cystoid macular oedema
 Posterior capsule opacity
 Macular degeneration

Post-operatively they all obtained atleast counting cats unaided vision Diabetic maculopathy
39

Post-operative management

Post-operative refractive error
Contact ophthalmologist if (*):
 ≥1.50D from intended refraction ≥1.50D of induced astigmatism

40

Post-operative management

Wound appearance and aqueous leakDay 1 wound should well apposed, if anterior chamber shallow orIOP <10mmHg exclude wound leak: Check for phaco burn or wound retraction
 Perform fluorescein test
 Spontaneous leak
 Leak to gentle compression

 Check pupil is round Exclude iris prolapse If AC compromised refer41

Post-operative intraocular pressure DAY 1
 Generally less than 24mmHg
 Less than 10mmHg consider leak
 Greater than 30mmHg or painful
Consider acetazolamide
Consider referral42

Corneal appearance day 1
Appearance related to cataract density,difficulty of case, nucleus density, FECDand phaco energy used:
1. Entirely clear
2. Occasional effete endothelial cells
3. Focal striae & oedema at incisions

4. Extensive striae & oedema
Generally resolves - <0.5% develop PBKPostoperative pupil Should be round, up to mid-dilated, If distorted exclude:• Iris prolapse• Vitreous to wound• Vitreous in anterior chamber• IOL displacement

Anterior chamber inflammation

 Day 1
Flare +Cells + to ++If heavy flare or cells +++ consider endophthalmitis

 Day 28
Usually no activity
5% may have persisting low-grade inflammation

Auckland Cataract Study 2 (2015-16)
Postoperative visual outcomes (N=1000)
Visual acuity

2015(N=476)2016(N=472)

P-value fordifference

Unaided

6/12

6/12

0.262

Best-corrected

6/9

6/90.648

Postoperative IOL position

 IOL should be well centred Relative to capsular bag / rhexis
 Relative to pupil If > 1.0mm IOL displacement
 Consider haptic position
 Assess for vitreous in AC Discuss with ophthalmologist

Fundal examination

If BSCVA less than expected
Assess macula
Exclude retinal detachment
Exclude vitreous/retinal
haemorrhagePost-operative day 28
 Day 28 review
 Symptoms
 Unaided VA
 Refraction
 Assess:
 Cornea Pupil Media
 IOL position
 IOP
 Dilated fundus

Delayed complications
 Posterior capsular
thickening 2-5%
Rx YAG laser

 Capsular phimosis

 Retinal detachment 1%

Posterior Capsular Opacification

Posterior capsule opacification

YAG Laser capsulotomy52Co-management SummaryAssessment

NormalAction

Unaided vision

6/18 - 6/5

Refract if <6/12

Corrected vision

6/6 – 6/12

Exclude causes of reduced BSCVA if <6/12

Refractive error
Exclude wound leak+/-1.00Dof intended
None

If greater than 1.50D deviation from intended
endpoint contact ophthalmologist
If spontaneous & AC compromised - refer

Wound appearance

Closedexclude phaco burn, retraction, or leak

Goldman IOP<24mmHg

If painful or >30mmHg Rx diamox or refer

Corneal striae or oedema

None/MinimalObserve, should settle in few days

Anterior chamber activity

Flare+,
cells + to ++If marked activity consider endophthalmitis orsecondary uveitis - refer

Pupil

Round, up to
mid-dilated

If distorted: exclude iris prolapse, vitreous in
AC or to wound, or IOL displacement - refer

IOL position

Well-centredin the bag
Clear viewIf greater than 1.0mm decentred - refer

Fundal examination

Exclude haemorrhage, detachment

Establishing eligibility

What to tell your patients?
• Public surgery at ≤ 6/12 vision (Private insurers typically ≤ 6/9)
• Will need to complete “Impact on life” questionnaire• Cataract surgery is safe and typically takes < 30 minutes• Small risk of intra/post-operative compilations < 5%
• More than 95% of patients will have significant improvement
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Thank you