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         Updated 3rd June 2009
Background to direct cataract referral and offering choice at the
point of referral.

The Department of Health now recommends direct referral for cataract patients
from Optometrists to secondary care/Ophthalmologists following the report from
the Chronic Eye Disease steering group for cataracts.

This pathway is an example of direct cataract referral but there are many
variations in existence around the country.

However the pathway has had to alter already to take on board the Government‟s
policy of offering patients a choice about where they have their treatment. Choice
at the Point of Referral must now be offered for cataract patients with effect from
1st January 2005. The offering of “Choice of Provider” for other ophthalmic and all
other services is being introduced gradually through an IT system in GP

It is up to each individual Primary Care Trust (PCT) to organise how direct
cataract referral and offering choice of provider is implemented and this protocol
currently only applies to Optometrists practising in Brighton and Hove City or
offering optometric advice to patients registered with a GP in Brighton and Hove
City. Our neighbouring PCTs may well make similar plans.

Fees are paid for the service, originally the PCT paid £7.50 for referral and
£22.50 for follow-up however with the added complication of offering choice of
provider this has been increased to £13.50 for referral and £25.00 for follow up.
The fees are handled by East Sussex, Brighton and Hove Primary Care Support
Services based in Lancing. (The same team that pays for NHS sight tests and
vouchers). However, as the follow up end of the pathway has only been agreed
with The Sussex Eye Hospital and Eastbourne, the fee of £25 is only paid if your
patient chooses The Sussex Eye Hospital or Eastbourne for surgery. (98% of
Brighton and Hove residents choose The Sussex Eye Hospital).

The other options for surgery for our patients are Worthing and Southlands or
Queen Victoria at East Grinstead. Please read the leaflet that is designed for
patients but covers all you should need to know about these other providers. The
pathway will not change but the choice booklet obviously will be revised.

Rather than expecting Optometrists to spend a great deal of time helping patients
decide where to choose the PCT has arranged for an intermediary service. The
Patient Care Advisory Service, based at BICS in Brighton will contact the patient
to ask them where they would like to be seen. All we ask of the referring
optometrist is that they issue the patient with the booklet giving details of the
providers available to them. There is a standard referral form which must be
completed in full and faxed to the PCA centre. In addition each patient should be
given the RNIB booklet and the Consent Advice Sheet included in this protocol.
                          Cataract Improvement Programme
                  Accreditation process for Optometrists and OMPs
     For post-operative follow up when patient chooses The Sussex Eye Hospital.

Optometrists and OMPs are required to register their interest in using the new pathway for
referral and must go through the following accreditation process before they start.

1. Register their desire to be on the list of accredited practitioners by contacting the training
   team at Brighton and Hove City PCT.
2. Each optometrist must:

   Watch a pre-operative clinic session.
   Watch at least three cataract operations.
   Watch a post-operative session.
   Attend an evening of lectures.

OMPs are not required to watch clinics or surgery but may do so if they wish.

To book a clinical session you need to contact June Vine or Conrad Eckersley at The Sussex
Eye Hospital on 01273 606126 xtn 4192. Conrad Eckersley is the Specialist Ophthalmic
Nurse in charge of the cataract pathway and if you cannot reach him you can also ask to
speak to Gaynor Paul his colleague.

The lecture evening will be held every annually but you may attend a lecture evening for a
neighbouring PCT and send proof of attendance which will count.

The accreditation card issued to training practitioners by the PCT has to be signed by the
person taking the clinic/theatre once the training has been completed. You will be expected
to provide photographic proof of identity. Once completed this should be returned to the
training team administrator at the PCT.

CET points have been applied for the whole accreditation process.
1. Diagnosing the patients who are appropriate for surgery

When you examine a person who has cataracts you should consider-

   a) If the cataract is causing visual symptoms that are affecting their quality of

   b) Does the rest of the visual system appear healthy?

   c) Are they in reasonable health? Do any of the exclusion criteria apply to
      them? (See below for exclusion criteria.)

Exclusion criteria for fast track entry to day case cataract surgery

   1. Ocular conditions

      There are no ocular conditions that would prevent referral to the fast track
      cataract service. Since they are either not treated any differently or minor
      adjustments in the surgical procedure can be planned as surgery is not
      taking place until approximately two weeks after their first visit to the
      Hospital. The fast track surgical lists are at present being undertaken by
      Consultant level Ophthalmologists. More difficult cases are normally given
      to Consultants but referring into the fast track service ensures this anyway.
      Patients already under The Sussex Eye Hospital must not be referred
      on this pathway.

   2. Medical Conditions

      There are no medical exclusions for referral on this direct referral pathway
      however please indicate on the form if the patient is unsuitable for surgery
      under local anaesthetic. There are not many who will come into this
      category but dementia, anxiety and psychosis would be an indication for a
      general anaesthetic. Patients under 40 years of age almost always need a
      general anaesthetic, as their levels of anxiety and adrenalin are greater.
      Patients with head tremor also need a full general anaesthetic.

   3. Social exclusions

      There are really no social exclusions. If the patient has no telephone it is
      expected they will find a way around this themselves if they want to go
      ahead and have surgery.


        Direct Cataract Referral Pathway for Optometrists and OMPs

           Clinical Guidance Notes taken from the lecture evening

High risk eyes

   o High myope or high hyperope. No peribulbar block for a high myope
     because if complications they can be much worse.
   o Uveitis- will get worse after surgery and these patients have a greater
     chance of cystoid macula oedema after surgery. As a consequence
     they are put on higher steroid doses even systemic steroids after
   o Corneal endothelium - if this is in poor shape prior to surgery they may
     have corneal oedema after surgery or even require a corneal graft.
   o Pseudo exfoliation – generally they have lax zonules and therefore
     there is a greater chance of zonular dehiscence during surgery.
   o Glaucoma – especially if trabeculectomy previously.
   o History of trauma – weak zonules.
   o Uncontrolled hypertension – high blood pressure at the time of surgery
     increases the risk of choroidal haemorrhage and there is a risk of
     orbital haemorrhage from the local anaesthetic.
   o Diabetes - problems are that the pupil does not dilate well and on
     removal of the lens diabetic retinopathy gets worse. It is important that
     if possible this is treated fully with laser before the cataract operation.
   o Unstable lenses – most likely in a high myope or someone with a
     history of trauma. The lens will wobble as the patient looks to the left or
     the right. Phako can cause zonular dehiscence.

Patients not suitable for surgery under local anaesthetic.

   o Claustrophobic
   o Very anxious – under age 40 patients are more anxious than the
   o Unable to lie flat or still
   o Confused
   o No English
The following patients will be given a guarded prognosis.

When they are seen at the Eye Hospital the surgeon who consents the patient
will emphasise the additional risks/ limited benefits to these patients. To
reduce the number of wasted appointments for pre-op it would be ideal if
these risks have already been put to the patient.

   o ARMD – limited improvement in VA
   o Advanced Glaucoma – it can make glaucoma worse and if the
     glaucoma is very advanced then the high pressure from the phako
     could destroy the last remaining functioning nerve fibres leaving the
     patient with no perception of light after surgery.
   o Diabetic eyes – beware progression of retinopathy and increase risk of
     cystoid macula oedema.


A discussion with the optometrist or OMP prior to surgery about the desired
spectacle refraction after surgery and a prediction of possible problems
between 1st eye and 2nd eye should be had before referral. The final planned
prescription is almost always plano to -1.00 so if this will be a problem
between eyes some of the ways of solving this like contact lenses should be
explained even if it will only be a short term problem.

Problems at the time of surgery

   o Posterior capsule tear – the vitreous comes forward through a hole.
     10% may go on to have a retinal detachment if not realised at the time
     of surgery and the implant is still put in. The retinal detachment can
     happen immediately or many months later. At a post-op check the pupil
     will look jagged and there will be vitreous all around the pupil. They will
     have a poor VA and probable cystoid macula oedema. When spotted
     during surgery a vitrectomy is performed and an anterior chamber lens
     used. Post-op checks for patients who have had a vitrectomy at the
     time of surgery will be performed within the hospital.
   o Choroidal haemorrhage – Less than 1 in 1000 eyes. This happens
     because the intra-ocular pressure drops to zero when the eye is
     opened. The haemorrhage will continue until the eye is sewn up and
     the pressure builds again to stop the bleeding. It can happen to anyone
     and therefore if the pre-operative vision is 6/6 it must be discussed lots!
Post-operative inflammation.

At 4 weeks they should have no pain, no photophobia, no redness (except
remaining sub-conjunctival haemorrhage) and few or no cells in the anterior

Is it normal at 4 weeks?

If there is inflammation it may be due to:-
     1. Retained bits of lens hidden under the iris, however these tend to
        dissolve on their own over a few months and rarely need removing.
     2. Not used drops properly. Since Tobradex has been introduced this has
        been less of a problem.
     3. Reactivation of Uveitis – but these patients will almost always be seen
        in the Hospital for their follow-up.
     4. Endophthalmitis. If this is presenting at 4 weeks it must be a very low
        grade as the serious type occurs at 3-5 days is very painful and the
        vision drops suddenly so they will present themselves to A&E. The
        other symptoms are a big red upper lid, headache, feeling sick,
        hypopyon and afferent pupil defect.

At 4 weeks they should have no pain, no photophobia, no redness (except
remaining sub-conjunctival haemorrhage) and few or no cells in the anterior

Endophthalmitis management.

The patient is admitted immediately, a vitreous biopsy and/or vitrectomy is
performed, they are given intravitreal antibiotics and the prognosis is often
good. Aggressive treatment gives a better outcome.
2. Obtaining the patients consent for surgery

As with all patients with cataracts you should:

   1. Tell them what a cataract is, and how symptoms that they are
      experiencing relate to the cataract. This could cover blurred vision,
      difficulty in poor light, glare and dazzle.

   2. Show them the difference that changing their spectacles would make.

   3. Discuss the option of cataract surgery and explain the process. This
      should include the fact that it is most commonly performed under local
      anaesthetic as a day case; the actual process; the general risks and
      benefits (their own personal risk assessment will be refined by the

   4. Give them a copy of and talk through Consent Advice Form and a
      copy of the RNIB booklet.

   5. Explain they now have a choice of where to go for their surgery and
      give them a copy of the PCT’s Choosing your hospital for cataract
      surgery booklet explaining the options they have. You do not need to
      decide with the patient there and then where they would like to go.
      There is a standard letter for you to copy onto your headed paper to
      give your patient if you wish.

3. How to refer and inform the GP

      Complete the PCA service referral form and fax/post it to them on the
       number on the form.
      It is vital that you include the GP‟s name and address on the form and
       if you wish to receive payment for the work and do the follow-up
       appointment your name and address must be clearly legible. Please
       understand this form will be faxed and then that fax will be faxed on
       again which will degrade the clarity significantly.
      Please do not forget to mark in the box that you are accredited
       otherwise you will not see the patient for the follow up appointment if
       they choose The Sussex Eye Hospital.
      If you are not yet accredited please have the form counter-signed by an
       accredited optometrist in your practice so the follow-up can come to
      LEGAL NOTE. Under our terms of service we have a duty to refer a
       patient to a medical practitioner where there is significant disease or
       abnormality. On this pathway we are referring to the PCA service. The
       East Sussex Local Optometric Committee, after consulting with the
       AOP, have obtained written confirmation from Brighton and Hove City
       PCT that the PCA service will inform the patient‟s GP and this means
       we have fulfilled our legal duty to the patient. The PCA have a contract
       which binds them to this. (However this makes the GPs name and
       address on the form a vital legal requirement to cover you!) see
       Appendix 1

If the patient has early cataract, which does not require onward referral yet,
they should be advised of this and asked to return if they feel their vision has

5. What happens next.

    On receipt of your faxed referral the PCA fax you back to confirm
       receipt. If you do not have a fax machine send it by post and they will
       reply by post to confirm receipt.
      They then fax a copy to the patient‟s GP requesting completion of the
       medical issues box within 7 days.
      They contact the patient to discuss their choice.
      They fax the referral form on again to the chosen provider.
      They fax/send notification to East Sussex Brighton and Hove Primary
       Care Support Services in Lancing to ask them to pay you for filling in
       the referral form.

6. Surgery

   Surgery at The Sussex Eye Hospital takes place after one pre-op clinic
   and unless there are complications the patient is referred back for a post-
   op appointment and post-op refraction with the referring optometrist or
   OMP (for which you claim the usual GOS ST fee). The Post-Op Form
   should be sent to you by the eye hospital, which you must complete and
   return to The Sussex Eye Hospital. The final part of this form is the trigger
   for you to be paid for performing the post-op appointment.

   Surgery elsewhere will include a pre-op and post-op session so when the
   patient returns to you all you need do is their post-op refraction for which
   you claim your usual GOS ST fee.

            Consent Advice for Cataract Patients

                    Cataract Extraction

Visual prognosis and Complications

Cataract surgery is safe and effective. It offers a 95% chance
of improvement in vision. However complications can occur.
These complications may affect the visual outcome.

Complications vary in frequency and their effect on vision.
Fortunately the most devastating complications are rare.

 Around one in a thousand patients will have an infection
  or haemorrhage which may lead to severe loss of vision or
  even blindness in that eye.
 Other complications such as damage of the membrane
  supporting the implant or swelling of the retina are not as
  severe but may affect the final vision.
 Around five patients per hundred will not notice any
  improvement and one in a hundred may get a significant
  drop in their vision.

If you are having problems with your vision then you should
ask yourself whether the problems are affecting your vision
sufficiently to have an operation.
                                  To be printed on opticians own headed paper
                                      Or at least to be typed with their contact
                                                      Details in this top corner.


Dear Patient’s name,

I have today referred you for cataract surgery. You may now
choose where you have your cataract surgery and very shortly will
be contacted by our patient advisers who will discuss your choices
with you. I have given you a booklet about your options.

If at any time in the next few weeks you have doubts about going
ahead with the surgery please contact me so we can discuss your
concerns. If you have second thoughts I can arrange for you to be
taken off the list for surgery and we will continue to monitor your
cataract development here.

Please remember to take a list of your current medication with
you to your first appointment. (Your GP surgery can print this
off for you if you do not have an up to date list)Your operation will
take place very soon after the initial appointment for measurements
and you will be directed back to me for a health check up and new
glasses prescription.

I am enclosing a leaflet from the RNIB about cataracts that
contains some helpful information and also a booklet explaining
your choices for places to have surgery.

Yours sincerely,

Name of Optometrist


On the following sheet is a draft version of the
Fax form which should go to the PCA service
in Brighton. Please only use the proper version
as the print quality will be superior which is
important as the form is faxed several times.
                                               REFERRAL FORM FOR CATARACT SURGERY                                                                     V6 08-06
  ** Please print clearly in capitals**                                                      **Please refer to back of form for guidance**
  PATIENT DETAILS (Please Print)
  Surname:                                                                               First Name:                                         Title:

  Address:                                                                               D.O.B.                                              Sex:      M            F

                                                                                         NHS No:

                                                                                         Day time Tel. No:

  Postcode:                                                                              Best time to call patient:

  GP DETAILS                                                                             PCCC use only
  GP Name:                                                                               PCT:

  Address:                                                                               Tel. No:

                                                                                         Fax No:

  TO BE COMPLETED BY THE OPTOMETRIST/OMP – please complete all information clearly to receive payment

  ** Please see back of form for guidance **
         This patient has a cataract
         The cataract is causing the patient visual symptoms such that the quality of life is impaired e.g. for driving, reading, etc.
         I have explained the cataract surgery process, the risks/ benefits and given the booklets
    The patient wishes to undergo cataract surgery under local anaesthetic via the one-stop clinic
     YES                 NO      If no, please state below reasons why

  Please indicate the patients need for surgery in which eye:               Left eye           Right eye              Both eyes, priority being         Left      Right
               Refraction details from current sight test
               V              Sph               Cyl            Axis           Prism             Base               VA                  Add              Near VA


 Intra-Ocular Pressures:
Other ocular pathology and relevant information: eg Amblyopia, large increase in myopia:

Comments: Please include current medication (including eye drops etc.), allergies or relevant medical or social issues, e.g. communication needs


Name:                                                                             Optometrist/ OMP- GOC/ GMC No:

Address:                                                                          Accredited:       Brighton          Other – please state

                                                                                 NOT Accredited

I declare that the information I have given on this form is correct and complete and I understand that if it is not, action may be taken against me. For the purpose of
verification of this claim, I consent to the disclosure of relevant information. I claim payment of fees due to me for work carried out under this NHS scheme .
Signature:                                                                      Date:
Print:                                                                          Please send to: BICS, Brighton & Hove City PCT, 171-173 Preston Road,
                                                                                Brighton BN1 6AG or secure fax 01273 543758
 Guidance notes for completing the direct cataract referral forms .

The referral form.

    There are several useful pieces of information which could go into the
     comments box but not enough space on the form to suggest them all
     without filling the box! Please bear in mind the following list :-

          1. Patient’s holidays. The dates for pre-operative assessment
             and surgery will be 3 to 4 months from the date of your referral.
             If your patient is away all winter or will be away at around that
             time please mark in the comments box the unsuitable dates.
          2. Final Rx. As the patient‟s primary eye care practitioner often
             their optometrist/OMP is more aware of their likely preferred Rx
             following surgery. There is also often more chance to discuss
             this before referral and therefore if there is a desired Rx please
             mark this in the comments box.
          3. Second eye. If the referral is for a second eye please mark this
             clearly in the comments box so that their previous notes are
             found and a new set not made. Often the biometry readings will
             already have been taken

    Commonly missed off the current forms are the GP‟s name and
    Please ask patients to bring with them a list of all their current
     medication to the pre-operative clinic.
    Please ensure your contact details make it through to the final sheet for
     payments to be made.

Form E the post-operative report form

    Please return this to “The Cataract Co-ordinator”
    Payment post-op check will be made on receipt of the post-op form.
    Patients should arrive with a copy of this form but if not use the ones in
     your pack.
    During the post-op check if you need to speak to someone try the
     Nurse Practitioners on 606126 xtn 4875. The following nurses are
     currently performing the Hospital post-op checks: Gaynor Paul, Lilian
     Michael, Sue Harris, Caroline Challoner.

Existing Sussex Eye Hospital Patients

If the patient is currently being seen at the Sussex Eye Hospital please do not
use this pathway for cataract surgery. This does not apply to patients who
have been to the Sussex Eye Hospital at some time in the past but have been
discharged although for these patients it would be helpful to indicate they
already have notes made up.
Appendix 1

Confidentiality arrangements for BHCPCT

The BICS has been established in accordance with Caldicott Guidelines
and is housed in a discrete secure office within Brighton & Hove PCT
headquarters. There follows a draft of the wording to be include in the
SLA with BICS reference processing of referrals:

“BICS will ensure Optometrists can satisfy their legal obligation to refer
abnormalities to a medical practitioner in the following ways:

   1. They will fax back confirmation of receipt of a referral to the optometrist
   2. They undertake to forward on the referral to the chosen provider,
   3. They guarantee to email or fax a copy of this referral to the patient’s GP
      asking for any relevant medical details to be included.”

On the next page is a copy of the confidentiality agreement which all employees
working in the PCCC sign:


LOCATION:              Brighton & Hove PCT HQ

BICS has been declared a „Safe Haven‟, in order to maintain a „safe haven‟ it is
essential that you abide by the „Safe Haven‟ guidelines and procedures that have
been implemented in the PCCC, in order to protect peoples confidentiality.

During your assignment here you may gain privileged knowledge of a highly
confidential nature relating to the private affairs, diagnosis and treatment of patients,
information affecting members of the public, members of staff, general practitioners
and items under consideration by the PCT.

You are not permitted to disclose such information outside the PCT‟s procedures.

Breaches of confidence or other failures to comply with the PCT‟s procedures and
the Data Protection Act 1998 will result in the immediate termination of your
assignment, possible disciplinary action and may also lead to legal proceedings.


I agree to adhere to the PCT‟s policies in relation to Data Protection and Information
Security. I will not disclose any privileged, sensitive or confidential information to any
unauthorised person. I understand the conditions and principles of processing
personal data in relation to the Data Protection Act 1998. I understand and agree to
abide by the requirements around confidentiality.


Print Name: ……………………………………………………………………………

Job title/ Department:.…..……………………………………………………………

Date valid from:………………………………………………………………………

Date Valid to:………………………………………………………………………….

Authorised by:………………………………………………………………………….
On the following pages there is a version of
the Form E / Post-operative form which could
be photocopied if necessary and used if the
patient has forgotten to bring theirs.
Form E : Community Post Cataract Operation Report Form

Patient details (Please print)
Surname:___________________ First name:___________________
Address:____________________ D.O.B.______________________
         ____________________   Male /Female
         ____________________  Tel.No:_____________________
        ____________________ NHS Number:__________________
Post code:___________________

The above named patient underwent RIGHT /LEFT cataract surgery on          /   /

Their Consultant is: Mr Eckstein / Mr McLeod / Mr Casswell / Mr Liu / Mr Brittain/
Mr Hughes
Please complete the following and return to Cataract Coordinator, Sussex Eye
Hospital, Eastern Road, Brighton, BN2 5BF.
Date of visit: / /

                                  RIGHT                           LEFT
Unaided visions                     6/                             6/
 (plus cyl form) SPH
BEST-CORRECTED                       6/                             6/



anterior chamber


Form E : Community Post Cataract Operation Report Form


Tonometry reading
Instrument used

Additional comments:-

Form E : Community Post Cataract Operation Report Form

PATIENT REPORT. Please ask the patient these
questions and record their answers.
Is your vision better?

Are you experiencing any discomfort?

Are you instilling your post-op drops?

Any other comments?

Opticians name:

Practice Stamp:

Form E : Community Post Cataract Operation Report Form


Forward to Matthew Brown
36-38 Friars Walk
East Sussex BN7 2PB

The following optometrist/OMP has completed a post-cataract surgery
appointment on :
Patient‟s Name and DOB:-
and is therefore due the appropriate fee.

Name of optometrist/OMP:-



Signature of practitioner:-

Verified by



For comments and feedback on this protocol please contact Vicki Macken at

BHC PCT, Prestamex House, 171-173 Preston Road, Brighton, BN1 6AG


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