Clinical update

Visual acuity should not restrict access to cataract surgery

The National Institute for Health and Care Excellence has published guidance to improve care before, during and after cataract surgery  

Essential facts

A cataract is a common condition caused by opacity in the lens of one or both eyes. The changes to the transparency and refractive index of the lens result in visual impairment.

Cataract surgery is the most common operation performed in the NHS. Picture: Alamy

Cataracts are associated with decreased quality of life as they may restrict the person's ability to carry out daily activities and function independently, while increasing the risk of accidents and falls.

What’s new?

Guidance to improve care before, during and after cataract surgery has been published by the National Institute for Health and Care Excellence (NICE). It aims to optimise referral, surgical management, reduce complications and improve information given to patients. Cataract surgery has a high success rate and is the most common operation performed in the NHS, with an ever-growing need as the population ages. But NICE points out that the clinical threshold for referral to surgery varies across England, leading to a postcode lottery.

Signs and symptoms

Symptoms can develop over years, with vision becoming cloudier, blurred and washed out. Colours may start to look more yellow and there may be double vision. Bright lights can glare or dazzle, and can be surrounded by a halo. In severe cases vision can become very reduced.

Causes and risk factors

The most common cause of cataracts is growing older. Other causes include diabetes, trauma, some medication such as steroids, eye surgery for other conditions and other eye conditions. Smoking, excess alcohol, lifelong exposure to sunlight and a diet lacking in essential vitamins are thought to increase risk.

How you can help your patient

Be aware that visual impairment because of cataract can have a negative effect on the quality of older people’s lives. Experiencing diminished sight can be unsettling, stressful and anxiety-provoking, and can lead to loss of confidence, independence and freedom.

Encourage older people whose sight appears to be declining to visit the optician. Optometrists can refer directly to ophthalmic surgical teams.

Ensure that people with cataracts, and their family members or carers receive oral and written information.

Expert comment

Janet Marsden is professor of ophthalmology and emergency care at Manchester Metropolitan University and member of the NICE guideline committee

‘Nurses must advocate for patients with cataracts. Declining vision can happen over years, and many people don’t realise. Nurses must recognise the signs that an individual’s vision may be affected and encourage them to visit an optometrist, who can refer them to secondary care. Older people may think that cataracts are a normal part of ageing, but they are curable with surgery.

‘Many clinical commissioning groups have imposed visual acuity thresholds above which people cannot have surgery and may also limit patients to surgery to only one eye. This guidance makes clear that all the evidence shows that visual acuity is a poor test to decide when someone should have surgery, and that it should not be used to restrict access to surgery. It does not show if the cataract is restricting daily life. We hope that the new NICE guidance will improve access to surgery.’


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