Since the advent of phacoemulsification, we have observed ever-improving safety and clinical results. In the UK public sector amongst others, this has led to a trend in the re-organisation of the processes before and after cataract surgery. Over the years, the day one postoperative review has been abandoned, followed by any hospital based follow-up entirely for the majority of patients [9,10,11]. Some services have also moved towards pathways with various names whereby good-quality referrals of low-risk patients are triaged into an accelerated pathway [12,13,14]. NHS Trusts are universally encouraged to offer specific ‘high-volume, low-complexity’ theatre lists with a minimum of 10 eyes per theatre list [15]. Finally, while the rates of ISBCS remain low in the UK, there is a general trend of increasing interest on an established evidence base of equivalent safety to DSBCS [2, 4, 7, 16]. We believe we have for the first time, developed a service which combines all of the above elements to uniquely offer our patients the option of having clinical assessment, bilateral cataract surgery and safe discharge all on the same day within only one trip to the hospital as part of a high-volume theatre list.
Patient advantages of ISBCS include fewer hospital visits, quicker visual rehabilitation, avoidance of anisometropia and shorter waiting times [2]. From a healthcare provider standpoint, ISBCS has demonstrated enhanced theatre productivity and more optimised resource management [17, 18]. Other benefits of ISBCS include a reduced carbon footprint and reduced patient anxiety resulting from fewer hospital attendances [2, 4]. National ISBCS tariffs stand at 185% of those from unilateral cataracts, incentivising its implementation [19]. ISBCS is supported both by the National Institute for Health and Care Excellence (NICE) and the RCOphth [20, 21]. Although the RCOphth has encouraged ISBCS to help tackle backlogs resulting post-pandemic [21], uptake is still limited as suggested by recent National Ophthalmology Database (NOD) data and represents less than 1% of all UK cataract surgery [3, 22].
The disparity between the patient acceptance of ISBCS and its presence within cataract services nationwide is profound. Over half of participants in a London study [2], and 71.6% in our own population [23] preferred ISBCS, whilst recent data suggests approximately 0.5% of bilateral cataract operations nationally are immediately sequential [3]. However, the presence of ISBCS is increasing across trusts nationwide. Recently, ISBCS was implemented at Buckingham Healthcare NHS Trust (BHT), where 10.7% of all cataract operations across a one-year period were ISBCS [4]. Our cohort of 204 S&T ISBCS eyes represent 4.7% of all cataracts treated by the RDUH trust over the same time period (n = 4308). These results tangibly demonstrate the feasibility and success of offering ISBCS to a growing cohort of patients. The established efficiency benefits of ISBCS are further compounded when the pre-operative assessment is combined in the same visit, while simultaneously providing a convenient patient-centred approach with high levels of satisfaction.
Of the 17 patients who attended but did not receive ISBCS, 47.1% (n = 8) were still treated for one eye after identifying unprecedented ocular pathology precluding safe ISBCS on the day of surgery. Cancellations only accounted for 7.6% (n = 9) of all S&T attendances, of which all were due to clinical conditions detected at the time of the assessment. A certain rate of changing the management plan on the day is inevitable given the nature of the S&T service which is being run and applies to both the DSBCS and ISBCS patients. Patients on our S&T pathway are advised in writing before the day of surgery to expect a possibility of a change in management plan on the day. The rates of change in management plan are relatively low but could in future be factored in to how many patients are booked onto the list, or alternatively have local patients on standby to take the place of any cancellations.
Guidance from RCOphth advises against consenting on the day of surgery for one-stop ISBCS [1], however our consent process begins with the issuing of information to the patient and signposting to online resources prior to a telephone consultation with a consultant or optometrist. This ensures that patients are fully informed and consented prior to the day of surgery and merely confirm consent with a physical signature on the day. In the future we are moving towards the patient consenting electronically from home following the telephone consultation (MyChart, Epic Systems Corp., Verona WI, USA).
Traditionally, early postoperative review following cataract surgery was the standard, typically involving ‘day one’ reviews requiring an extra hospital attendance. However, evidence has suggested no further benefit is elicited through early review post-cataract surgery in low-risk patients with uneventful surgery [24]. Since the nature of S&T ISBCS means only low-risk patients are triaged into the pathway, discharging to community imminently post-cataract surgery remains a safe option [11]. With our service, the safety and efficacy of discharge to the community is built upon careful selection of patients to be offered S&T ISBCS, accuracy of optometry referrals, and ‘safety netting’ advice to patients to contact the department should concerns arise. In turn, unnecessary postoperative hospital attendances will be minimised without increased risk to patient safety or visual outcomes, saving valuable time and resources to be used for new referrals.
Both our intraoperative and postoperative rates of significant complications are below nationally reported rates and in the literature. National rates of post-cataract surgery vision loss stand at 0.48% [25], in comparison to our 0% rate of vision loss. A large retrospective analysis of 81,984 eyes found incidence of post-cataract surgery CMO to be 1.17% [26]. Moreover, a reported rate of CMO within a cohort of 9776 patients retrospectively analysed stood at 1.44% [27], similar to the recently published NOD rate of 1.4% [25]. A key limitation of these larger database studies is likely to be the underreporting and documentation of such complications. Our rate of 2.9% reflects a low incidence of CMO post-S&T ISBCS, in keeping with or lower than similar studies, for instance a UK based ISBCS study and the European Society of Cataract and Refractive Surgeons PREMED study, which had CMO rates of 4.3% and 3.4% respectively [28, 29].
Limitations
All ISBCS operations were performed by only two surgeons, potentially hindering the applicability of our results to other surgeons. Furthermore, postoperative refraction data is not available due to lack of a service level agreement between our trust and local community optometrists to receive postoperative data, meaning refractive outcomes cannot currently be assessed. Cataract services throughout our whole NHS trust, not just at the Nightingale Hospital, are currently unable to return information to the NOD but steps are being taken to remedy this. In keeping with guidelines from ‘Getting It Right First Time’ (GIRFT) [19], routine uncomplicated cataract operations were safely discharged to the community with no hospital follow-up, however this may mean that our observed complication rate was under-reported. Whilst our complication rates were below or similar to published figures [3, 25,26,27], this study was designed as a proof-of-concept and therefore not sufficiently powered to detect differences between complications rates of rarer complications such as CMO, rhegmatogenous retinal detachment, endophthalmitis or suprachoroidal haemorrhage. Such outcomes are to be investigated elsewhere in the literature as they fall beyond the scope of this study.
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