Newsletter November 2018

Modern Cataract Surgery

Mr Hadi Zambarakji, Consultant Vitreoretinal & Cataract surgeon at the Spire London East Hospital and The Holly private hospital looks at the patient’s journey and decision-making process involved in today’s modern cataract surgery.

Cataract surgery is more and more about a precise refractive outcome and Optometrists skills are becoming increasingly important in the patient’s journey. This article aims to provide the Optometrist and the General Practitioner with useful information about the diagnostic process, the operative routine and the after-care received. They will be able to share this information with their patients to ensure the best care possible.

Measuring visual acuity

An important metric by which the outcome of surgery can be measured is Visual Acuity. Normally Snellen acuity is fine, but Doctors may use LogMAR especially with retinal patients.

Be familiar with both notations, but a comparison chart may be useful.

Snellen Chart


This is the most common scale for re-cording vision, usually at 6 metres

LogMAR


LogMAR is used more and more, especially in retinal clinics

Comparison


Snellen Notations are normally used, but for more precise recording, LogMAR is preferred

Always record the visual acuity with the patient’s distance glasses on. Record one eye at a time and if the spectacles are not available, use a pinhole.

Finally don’t forget the near vision, and some assessment of “real world vision” or contrast sensitivity can be useful. During the discussion, it is worth finding out from the patient if they are looking for freedom from all spectacles.

Lifestyle Questionnaire

1. Which activities are important in your life?
2. How important is it for you to have a full range of vision following surgery?
3. Following surgery, if you needed to wear glasses occasionally, for which activities would that be acceptable?
4. Following surgery would you spend more than an hour a day readying a book at a close distance<45cm?
5. If you had good vision during the day would it bother you if you experienced rings, halos or glare at night?
6. How important is it for you to discern subtle differences in colour?
7. How important is it for you to see well in low light conditions?
8. How would your friends describe you?
   Easy Going ———————— Perfectionist

Referral

To refer a patient it is useful to include the following information:

An Optometric up-to-date refraction with the near addition for reading visual acuity and what is the patient’s expectation from surgery.

The General Practitioner can supply general health and allergy information.

Referrals from colleague Ophthalmologists are usually for patients who may be at a higher risk of a vitreoretinal complication, unstable zonules, previous ocular trauma or lens injuries from previous intravitreal injections.

The patient journey

On speaking to Molly who runs the Retinacare office, practical issues around the clinic appointment date, date of surgery and post op review dates are organized in advance. Payment methods are also discussed and for patients who have health insurance, we have a cataract package arrangement with both Bupa and AXA PPP. The Pre-operative assessment is done at the time of the first clinic visit as well as all the necessary measurements for the lens implant to avoid unnecessary clinic appointments.

In the clinic the patient will be seen initially by Raj who is an experienced Optometrist with an interest in managing pre and post op cataract patients. Raj will carry out the necessary diagnostic tests, check the visual acuity and go through with the patient our standard cataract life-style questionnaire. This will give us an idea about the patient’s expectations and his or her needs.

Younger patients need an even more detailed assessment, as they are generally quite active and generally do not like to be reliant on distance or reading spectacles.

Practice Secretary: Molly Mapp

Specialist Optometrist: Raj Bharaj

Audit data (2017)

Monofocal lens implant surgery

89% within 0.5 D of refractive aim

93.3% within 1 D of refractive aim

After excluding eyes with macular pathology and glaucoma

Unaided visual acuity 6/12 or better (0.3 Log Mar) 83%

Best corrected visual acuity 6/12 or better (0.3 Log Mar) 100%

Unaided visual acuity 6/9 or better (0.2 Log Mar) 74%

Best corrected visual acuity 6/9 or better (0.2 Log Mar) 94%

Multifocal lens implant surgery with Oculentis MF20

Unaided reading visual acuity N8 or better 91%

Unaided visual acuity 6/12 or better (0.3 Log Mar) 100%

Unaided visual acuity 6/9 or better (0.2 Log Mar) 72%

Best corrected visual acuity 6/9 or better (0.2 Log Mar) 91%

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