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Cut useless medical treatments, says Audit Commission

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2438 (Published 13 April 2011) Cite this as: BMJ 2011;342:d2438

Rapid Response:

Delaying cataract surgery may be short-sighted

Cataract extraction is one of the commonest surgical procedures
worldwide, providing tremendous improvements in quality of life. NHS
waiting lists have come down significantly over the last decade. More
recently, with the drive for "efficiency savings", cataract surgery is in
some cases being designated a low priority procedure1,2 and will not be
funded above a specified level of visual acuity. Whilst exceptions are
acknowledged, for example when a patient experiences significant glare
limiting their driving, despite apparently good vision, the general thrust
has been to avoid operating at certain levels of acuity. This is logical
as the risk-benefit ratio is indeed close when the level of vision is
good, and surgery is usually not indicated if the patient is not
experiencing visual problems.

However, two important considerations are not usually factored into
cost-saving calculations. Firstly, delaying surgery in a patient with
significant cataract and subjective visual impairment until it has
progressed sufficiently so that their acuity falls below a certain level
can mean operating on a denser cataract, with a higher risk of
complications, potentially necessitating multiple procedures, and
therefore higher overall cost. Secondly, the risk of phacomorphic angle
closure glaucoma (where the increasing size of the lens blocks aqueous
drainage) is also higher, and this too has associated costs. Rates of
primary angle closure glaucoma have fallen in England as rates of cataract
surgery have risen,3 and, although this does not necessarily indicate a
causal relationship, it is possible that if cataract extraction rates are
to fall, the incidence of angle closure may rise again. Whilst it is
difficult to quantify such factors when costing, neglecting them could
mean that delaying cataract surgery proves a false economy in some cases.

1. BMJ 2011; 342:d2438

2. BMJ 2011; 342:d2380

3. Keenan TD, Salmon JF, Yeates D, Goldacre M. Trends in rates of
primary angle closure glaucoma and cataract surgery in England from 1968
to 2004. J Glaucoma. 2009 Mar;18(3):201-5.

Competing interests: No competing interests

19 April 2011
Omar A.R. Mahroo
Registrar in Ophthalmology
London Deanery