Cataracts

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					Cataracts
Absolute Criteria
The PCT will only fund elective cataract surgery where the following apply:
     The patient understands the surgery and wants to have the operation.
     Best corrected visual acuity is ≤ 6/9 or reading vision is ≤ N6 in the affected eye.
     Patients score ≥12 (out of 48) on the visual disability score (Appendix A).


Rationale/Evidence
    There is good evidence that cataract surgery is a very cost effective procedure.
     Recent cost utility studies based on a prospective cohort study determined a cost
     utility value of £1000/QALY1 for first eye and around £1300/QALY for second eye
     surgery2.
    There is good evidence that there is a small subgroup of patients who do not
     benefit from surgery3,4. A cataract surgical index (CSI)5 has been developed to
     predict those most likely to benefit from surgery. In an observational study6,
     patients with a CSI of 10 had a 30% probability of improving whereas those with
     a CSI of 11 or higher had a 5-20% probability of improving. In a US study,
     patients older than 64 with bilateral age related cataracts going for first eye
     surgery were assessed at baseline and 6-12 months after surgery. They found
     that 70% of those with CSI > 11 had some health benefit but their overall cost
     effectiveness ratio was $53,500.
    The most relevant UK findings come from a study7 in which 368 consecutive
     patients listed for cataract surgery over two years at two hospital outpatients in
     South England were followed for up to two years after their operation to assess
     their perceived improvement in outcomes. Visual disability was measured using a
     previously validated ‘TyPE’ visual function questionnaire which covered self rated
     vision rating as well as visual disability. The results were used to give a score
     from 0(bad) to 100(good) to quantify the degree of visual disability. Multiple

1
  Busbee BG, Brown MM, Brown GC, Sharma S. Incremental cost-effectiveness of initial cataract
surgery.
Source: OPHTHALMOLOGY 109 (3): 606-612 MAR 2002
2
  B. Busbee Cost-utility analysis of cataract surgery in the second eye. Ophthalmology, Volume
110, Issue 12, Pages 2310-2317
3
  Tobacman JK, Lee P, Zimmerman B, Kolder H, Hilborne L, Assessment of appropriateness of cataract
surgery at ten academic medical centers in 1990. Ophthalmology. 1996 Feb;103(2):207-15.
4
  Choi YJ, Hong YJ, Kang H. Appropriateness ratings in cataract surgery. Yonsei Med J 2004;45:396-
405
5
  CSI= 0.1 (preoperatoin activities of daily Vision Scale) + Points for age + 1 (Macular Degeneration) + 2
(DM) – 1 (posterior subcapsular cataract)
6
  Mangione CM, Oray EJ, Lawrence MG et al. Prediction of visual function after cataract surgery. A
prospectively validated model. Arch Opthal. 1995;113:1305-1311.
7
  Brogan C, Lawrence D, Pickard D, Benjamin L. Can the use of visual disability questionnaires in
primary care help reduce inequalities in cataract surgery rates?–a long term cohort study. In press




South West London Effective Commissioning Network. Approved 31 March 08. Adopted by KPCT 1 April 2008
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    linear regression was used to examine how far pre-operative patient
    characteristics might be used to predict potential reduction in visual disability from
    cataract surgery. The authors found that 38% (111/292) of patients did not
    reduce their visual disability following surgery. Their results indicate that it is
    possible to predict which patients are likely to benefit from surgery (and which are
    likely not to benefit), using a visual disability questionnaire. The questions used in
    the visual disability score in Appendix A are taken directly from this study. The
    threshold score has been set very low (≥12) to allow for some uncertainties in the
    applicability of the findings from this study.


Appendix A: Visual Disability Score
How much does your vision hinder, limit or disable you in each of the following activities?
(Please score as 1 if you/they don’t do the activity)
          Activity             Not at all    A little      Some        Quite a      Totally
                                                                                                  Score
                                               bit                       lot       Disabled


Your usual daily activities        0            1            2            3            4

Recognising people or
                                   0            1            2            3            4
objects across the street
Reading price labels in
                                   0            1            2            3            4
shops & supermarkets
Reading a magazine,
                                   0            1            2            3            4
newspaper or book.

Watching Television                0            1            2            3            4

Knitting/Sewing                    0            1            2            3            4

Daytime Driving                    0            1            2            3            4

Night-time Driving                 0            1            2            3            4

How much is your vision hindered, limited or disabled by glare (dazzling light) in each of the
following activities? (Please score as 1 if you/they don’t do the activity)

Your usual daily activities        0            1            2            3            4

Walking outside on a sunny
                                   0            1            2            3            4
day

Driving towards the sun or
                                   0            1            2            3            4
oncoming headlights

Reading shiny paper (such
                                   0            1            2            3            4
as a magazine)




South West London Effective Commissioning Network. Approved 31 March 08. Adopted by KPCT 1 April 2008
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