Sir,

An escalating elderly population and earlier surgery is increasing the demand for cataract surgery. It is suggested that the process of cataract surgery must be streamlined to maximise use of resources.1 Prasad et al2 in 1998 examined the current process used in most hospitals. A ‘three-stop’ arrangement is the norm; a clinic consultation including listing for surgery, a subsequent preassessment clinic, and finally surgery. Prasad et al2 proposed a modified ‘two-stop’ process; a clinic consultation including biometry/tests and subsequent surgery.

Two-stop surgery has progressed in some centres to ‘one-stop’ surgery. Patients are assessed and attend theatre the same day. Gaskell et al3 undertook an education programme with local optometrists who referred directly into a ‘one-stop’ facility. With the additional involvement of nurse practitioners telephoning patients prior to admission, they achieved a listing rate of 96%. Hughes et al4 listing rate was 82.1%, with an average of 6.5 patients operated on each day (range 4–8 patients). Currently in our eye unit, there is a ‘two-stop’ process in place. The purpose of our study was to assess the feasibility of one-stop cataract surgery without prior training requirements or additional resources.

Study

A retrospective study was carried out on cataract clinics held between May 2001 and February 2002. Information was collected including details of referral quality and the outcome of the clinic visit. For patients who were listed, it was assessed if coexistent problems precluded same day surgery. Ten cataract clinics took place with 191 patients invited to attend. Referral information received is shown in Table 1. Did-not-attend (DNA) rate was 9.4% (range 5–25% per clinic) with 173 patients attending. Surgery for cataracts was not required in 45 patients. Of these, 26 had asymptomatic cataracts and eight had a minimal cataract with age-related macular degeneration. In total, 128 (67%) patients were listed for surgery with a range of 42–80% (8–16 patients per clinic). However, of those listed, 17 were not suitable for same day surgery. This lowered the average ‘same day’ listing rate to 56.6% with a range of 26–80%. This is illustrated for each clinic in Figure 1. Of the 17 patients not suitable for same day surgery, 15 had uncontrolled hypertension (88%) and two had severe blepharitis (12%).

Table 1 Quality of referral information from each source
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Figure 1
figure 1

Listing rates at dedicated cataract clinics.

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Comment

The listing rate was calculated to include DNA patients because one would have to make theatre allocation for all patients invited to attend clinic. The listing rate is lower than that found by Hughes et al4 (82.1%) and Gaskell et al3 (96%). Gaskell et al's3 impressive listing rate is due to optometrist training and telephone preassessment; both requiring additional resources. Of those optometrists invited to participate, only 67% agreed leaving a significant short fall for a universal service. It has been suggested that a one-stop service does not necessarily provide more effective use of resources as the same staff time, counselling, etc are needed irrespective of the number of visits.5 Patient orientated benefit is cited as a reason to pursue a ‘one-stop’ service. However, Hughes et al4 found that patient satisfaction was equal between one-stop cataract surgery patients and those attending for three hospital visits. Before developing a one-stop service, the variability in the listing rate would have to be improved. An extensive programme of training together with telephone preassessment may allow reasonable theatre utilisation, but with current referral quality and available resources, the wide range in listing rate makes planning efficient use of theatre impossible. While one-stop cataract surgery is technically feasible, at the moment it has two major flaws: the resources required and the lack of evidence of improved patient satisfaction.

This work was previously presented as a poster at Royal College of Ophthalmologists Congress 2002.