Decisiones acertadas Socoftal

1. Do not review uncomplicated cataract cases on day one post-op

Shared decision making aid to use with patients

• NHS Right Care decision making aid for cataracts

Evidence/guidance

• The Royal College of Ophthalmologists Cataract Guidelines

• Randomised control trial published in BMJ

• Prospective study

2. If a child is under 12 months old and has a blocked nasolacrimal duct, do not try to unblock.

3. Do not carry out laser retinopexy for asymptomatic lattice degeneration/atrophic retinal holes.

Evidence/guidance

• Cochrane Review – Interventions for asymptomatic retinal breaks and lattice degeneration for preventing retinal detachment 

4. If conjunctivitis is thought to be viral, there is no need to send samples to the laboratory or to treat with antibiotics.

Evidence/guidance

• NICE Scenario: Acute infective conjunctivitis

5. The initial episode of unilateral anterior uveitis does not usually need further investigation

Recommendation 1

Referral for cataract surgery should be made based on a shared decision-making process about how it may impact quality of life. It should not be restricted because of visual acuity alone.

The decision to refer a person with a cataract for surgery should be based on a discussion that includes:

• How the cataract affects the person’s vision and quality of life

• Whether 1 or both eyes are affected

• What cataract surgery involves, including possible risks and benefits

• How the person’s quality of life may be affected if they choose not to have cataract surgery

• Whether the person wants to have cataract surgery.

Evidence/guidance

NICE guideline NG77

Recommendation 2

Patients and doctors should use shared decision making to decide when to initiate treatment and what treatment to use for wet active age related macular degeneration. This should take into consideration evidence for visual outcomes to make a fully informed choice of treatment.

Evidence/guidance

NICE guideline NG82

Cohen D (2018) Doctors are cleared to prescribe cheaper drug for wet AMD. BMJ 360:k344 . doi: 10.1136/BMJ.K344

The GMC’s position on the use of off label bevacizumab for treating age related macular degeneration as opposed to one the licensed alternatives is outline here.

Some background on the EU competition law case looking at “off label” use of bevacizumab can be found here.

Recommendation 3

Doctors and patients should discuss the risks and benefits of having cataracts surgery on both eyes on the same day.

Evidence/guidelines 

NICE guideline NG77

Patient information/decision aids

Patient information on Cataract surgery can be found at NHS Choices, and there is an NHS Right Care shared decision aid 

Recommendation 4

Before referring a patient for chronic open angle glaucoma and related conditions and related conditions ensure you have considered the following tests available in the community including:

• central visual field assessment using standard automated perimetry (full threshold or supra-threshold)

• optic nerve assessment and fundus examination using stereoscopic slit lamp biomicroscopy (with pupil dilatation if necessary), and optical coherence tomography (OCT) or optic nerve head image if available

• intraocular pressure (IOP) measurement using Goldmann-type applanation tonometry

• peripheral anterior chamber configuration and depth assessments using gonioscopy or, if not available or the patient prefers, the van Herick test or OCT.

Patients should be referred for further investigation and diagnosis of COAG and related conditions, after considering repeat measures if:

• there is optic nerve head damage on stereoscopic slit lamp biomicroscopy or

• there is a visual field defect consistent with glaucoma or

• IOP is 24 mmHg or more using Goldmann-type applanation tonometry

If these criteria are not met, people with IOP below 24 mmHg are advised to continue regular visits to their primary eye

Evidence/guidance

For background about glaucoma referral see NICE guideline CG81

Patient information/decision aids

Patient information on Glaucoma can be found at NHS Choices, and on the International Glaucoma Association website

Recommendation 5

When considering whether a patient should have cataracts surgery, you should use a validated risk stratification algorithm.

Evidence/guidance

For background about cataract surgery risk stratification see NICE guideline NG77

Blomquist PH, Sargent JW, Winslow HH (2010) Validation of Najjar-Awwad cataract surgery risk score for resident phacoemulsification surgery Journal of Cataract & Refractive Surgery 36 (10) 1753-1757

Muhtaseb M, Kalhoro A, Ionides A (2004) A system for preoperative stratification of cataract patients according to risk of intraoperative complications: a prospective analysis of 1441 cases British Journal of Ophthalmology 88 (10) 1242-1246

Osborne SA, Adams WE, Bunce C, V et al. (2006) Validation of two scoring systems for the prediction of posterior capsule rupture during phacoemulsification surgery British Journal of Ophthalmology 90 (3) 333-336

Tsinopoulos IT, Lamprogiannis LP, Tsaousis KT et al. (2013) Surgical outcomes in phacoemulsification after application of a risk stratification system Clinical Ophthalmology 7 895-899

Patient information/decision aids 

Patient information on Cataract surgery can be found at NHS Choices,  and there is an NHS Right Care shared decision aid