Well over 200,000 cataract operations are carried out per annum in the United Kingdom, making this one of the most common surgical procedures in the country [2
]. In addition, small incision cataract extraction (phacoemulsification) is effective in terms of increase in vision and is safe with respect to the low incidence of surgical complications [3
]. However, nationally the average patient wait was 8 to 10 weeks for an initial outpatient consultation and then a further seven months for surgery [1
]. This called for long waiting times to be reduced and for services to be redesigned from the patients' point of view. As a result, one stop cataract surgery was introduced, but not without shortcomings [5
], including difficulties in using theatre time efficiently, and without time for patients to consider whether to go ahead with surgery. We developed a new method of delivery of cataract surgery, "Cataract Surgery by Appointment", a modification of day case cataract surgery. We conducted the above pilot study as a prelude to a randomised controlled trial comparing "Cataract Surgery by Appointment" with Day Case Cataract Surgery.
Of note, no non-steroidal anti-inflammatory preparation such as diclofenac drops (Voltarol Ophtha) was used pre-operatively in this study. We felt it would be too complex to instil three different types of eye drops. In no case did the pupil come down in size during surgery. We are working on combining the dilating drops with diclofenac or similar in a single slow release preparation. In addition, there is now emerging evidence for the feasibility of per-operative intracameral administration of pupil dilating medication [6
]. If this proves to be satisfactory, it would make "Cataract Surgery by Appointment" even more patient-friendly. Whilst it has proven to be the case that patients or their carers could be trusted to instil pre-operative dilating eyedrops, the availability of intracameral preparations for pupil dilation for per-operative use can also expand "Cataract Surgery by Appointment" to those patients who cannot instil eye drops themselves, for example due to rheumatoid arthritis.
In terms of patient safety the following apply. The fact that each patient arrives at an appointed time reduces the risk of operating on the wrong patient; there is only ever one patient on site at a time. Patients are fully awake without sedation, so we are in constant conversation with them as to what is about to happen. They know which eye is to be operated on and will have instilled dilating eye drops in that eye only. This reduces the risk of operating on the wrong eye.
"Cataract Surgery by Appointment" performed under local anaesthesia has obvious benefits for patients in reducing waiting time at the hospital on the day of operation. This frees up resources and is also popular with patients.
Routine medical testing before cataract surgery was not employed, as it does not measurably increase the safety of the surgery [8
]. The per-operative and post-operative complications in our study compare favourably with the national rate of complications [9
]. We had no case of posterior capsule rupture, vitreous loss or endophthalmitis.
Patient satisfaction is related to the patient's pre-operative expectations and the quality of care given during the hospital stay and follow-up [10
]. Satisfaction with the process of treatment and facilities was high. Most patients were satisfied with every aspect on which they were questioned. Patient satisfaction may be further improved if Day 1 review could be omitted. We have already started to omit Day 1 review for second eye surgery, but as the time spent in hospital on the day of their operation is so short, it is necessary to spend some time to explain how to use their post-operative eye drops, what activities to avoid, and what to do if symptoms suggestive of a serious post-operative complication should occur. We feel this may be better done on Day 1, but it is possible that the same effect could be achieved by Day 1 telephone review.
"Cataract Surgery by Appointment" performed under local anaesthesia gave a high level of patient satisfaction. This method of delivery of cataract surgery is safe, effective, and is the ultimate form of day case cataract surgery for highly selected cases, when performed by a skilled ophthalmic surgeon. We recommend this method of delivery of cataract surgery to surgeons who are competent, consistent in speed, and have a low rate of complications. Attention should be paid to risk-stratification, so complex cases are allocated more time on the operating list [11
]. This type of delivery of cataract surgery is probably not suitable for teaching lists. It may be particularly suited to hospitals where the ward or day case unit are physically remote from the operating theatre.