CLINICAL PATHWAYS AND REFERRAL GUIDE



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CLINICAL PATHWAY AND REFERRAL GUIDE – CATARACT SURGERY

Introduction

The primary purpose of this document is to provide guidance to Primary Care on the cataract surgery pathway with criteria for referral to Secondary Care, in order to ensure a consistent, equitable and evidence based approach to patient care across Hampshire Primary Care Trust (PCT).

Health professionals are expected to take the guidance in this document fully into account when exercising their clinical judgement. The guidance does not, however, override the individual responsibility of health professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. It is assumed that the guidance outlined in the document will be followed in primary care prior to a referral being made to Secondary Care Services. Where an exceptional clinical need has been identified, which falls outside the scope of these guidelines, the PCT will consider funding for each request on a case-by-case basis via a Clinical Exceptions Panel.

OPHTHALMOLOGY

CATARACT

Community Services

Referrals for cataract surgery should only be made after an assessment from an optometrist, unless there are exceptional reasons why this has not been possible.

Optometrists should take into account the referral thresholds and the impact of the cataract(s) on the patients’ life, for example effect of glare, asymmetrical refraction, monocular, diplopia. Where option of direct referral from optometrist into secondary care is available this can be followed, however, discussion regarding benefit and fitness for surgery will need to take place. The patients still has the right to choose a provider.

Referral to Secondary Care Services

GPs will refer patients with cataracts that accord with Royal College of Ophthalmologist’s referral principles and meet the PCT criteria. Optometrists will have carried out the appropriate assessments and referred back to GP for onward referral to secondary care. A copy of the optometrist report (GOS18 or suitable referral form) must be included with the referral.

Patients should be referred where best corrected visual acuity as assessed by high contrast testing (Snellen) is:

• Binocular visual acuity of 6/10 or worse for drivers, OR

• Binocular visual acuity of 6/12 or worse for non-drivers, OR

• Reduced to 6/18 or worse irrespective of the acuity of the other eye OR:

• The patient wishes to/is required to drive and does not meet Driving and Licensing Authority (DVLA) eyesight requirements (see below)

Any suspicion of cataracts in children (e.g. altered or absence of red reflex at neonatal or 6 week check) should be referred urgently

DVLA requirements

• All vehicles: Able to read, in a good light (with the aid of glasses or

contact lenses if worn) a registration mark fixed to a motor vehicle and containing letters and figures 79.4 millimetres high and 50 millimetres wide at a distance of 20.5 metres. This corresponds to a binocular visual acuity of approximately 6/10 on the Snellen chart. NB: In the presence of cataract, glare may prevent the ability to meet the number plate requirement, even with apparently appropriate acuities.

• In addition, for Group 2 entitlement (LGV/PCV): the visual acuity, using

corrective lenses if necessary, must not be worse than 6/9 in the better eye or 6/12 in the other eye. Also, the uncorrected acuity in each eye MUST be at least 3/60.

• The Royal College of Ophthalmologists has also issued the following advice to the DVLA: The minimum visual field for safe driving is a field vision of at least 120º on the horizontal meridian measured by the Goldmann perimeter on the III4e settings (or equivalent perimetry). In addition there should be no significant field defect in the binocular field which encroaches within 20º of fixation either above or below the horizontal meridian. By this means, homonymous or bitemporal defects which come within 20º of fixation, whether hemianopic or quadrantanopic, are not accepted as safe for driving. Isolated scotomata represented in the binocular field near to the central fixation area are also inconsistent with safe driving.

Prior to referral

Patients should only be referred if they have undergone an assessment from an optometrist.

Second Eye

Patients should only undergo surgery of the second eye when that eye falls below the above threshold.

References

Driving and Licensing Authority Medical Standards for Medical Practitioners: At a glance guide to the current medical standards of fitness to drive (August 2006) Chapter 6, pages 36-37: Visual Disorders

Royal College of Ophthalmologists cataract surgery guidelines (2004)



Bibliography

Royal College of Ophthalmologists visual standards for driving (1999)

Produced by:

Jane Pike, Head of Service Redesign NHS Hampshire (Aug 2008)

Ian Pinkney, Cataract Project Manager NHS Hampshire

OPHTHALMOLOGY – CATARACT PATHWAY

Patient may be self referring, referred from GP (or other) or existing patient

Optometrist examines patient

Cataract identified

Assessed against criteria

Criteria met Criteria not met Criteria not met

(see box for criteria) but exceptional

circumstances

Complete Manage patient (if appropriate) until

referral to GP criteria met

GP to review patient and assess fit with criteria,

readiness, and benefit of surgery

Patient agrees to onward referral and is

offered choice of provider

GP refers to secondary care

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Referral criteria:

• Binocular visual acuity of 6/10 or worse for drivers ;-

OR

• Binocular visual acuity of 6/12 or worse for non-drivers;-

OR:

• Reduced to 6/18 or worse irrespective of the acuity of the other eye

OR:

• The patient wishes to/is required to drive and does not meet Driving and Licensing Authority (DVLA) eyesight requirements

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