Optimising The Cataract Pathway And Evaluating Patient Outcomes For Patients Without Capacity In A Large Tertiary Referral Centre

Patients who lack capacity, for example those with advanced dementia or learning disability (LD), pose a challenge for cataract surgeons. Poor cooperation makes examination difficult, consent requires a multidisciplinary team approach, and various factors can make surgery unpredictable. Visual impairment in these patients, who often can't express their symptoms, can cause depression, aggression, and worsen cognition. It is vital to identify and treat causes of visual impairment as early as possible. Despite this, there is a lack of information in the literature on cataract surgery in this cohort. We aimed to analyse the cataract pathway and surgical outcomes in patients lacking capacity at our unit to guide best practice. 

A large tertiary referral centre and its satellite sites across London, United Kingdom. 

Patients were identified on an electronic patient database (OpenEyesTM, Apperta Foundation). All adult patients with an electronic “flag” for dementia or LD who had cataract surgery between 1st January 2021 and 31st May 2023 were included. Exclusion criteria were age under 18 years and patients who had capacity to consent for cataract surgery (evident from the electronic record). Examination data from the pre-operative and post-operative assessment as well as intra-operative details were collected. Information about the completion of a best interests meeting (BIM) was also collected. A BIM is a formal meeting that is part of best practice in the UK when making decisions on behalf of a patient without capacity to consent. 

51 patients (67 eyes) were included: median age 81(70-86), 39 dementia,12 LD. Pre-operative visual acuity (VA) assessment was not possible in 7/67(10%) eyes and 33% patients/carers could not describe symptoms. Median pre-operative logMar corrected distance VA (CDVA) was 1.00(0.48-1.81). 24/67(36%) eyes had hypermature cataracts. A BIM was completed for 60/67(91%) (7/67 on the day of surgery). 30/67(45%) had general anaesthetic (GA), 22/67(33%) had local, and 15/67(22%) had local/sedation. 10/35 of GA cases had ISBCS. There were no intraoperative complications. Median post-operative CDVA was 0.2(0.12-0.48). Post-operative complications were cystoid macula oedema (4/67), rebound uveitis (6/67), and raised intraocular pressure (1/67).

Patients with advanced cognitive decline and reduced capacity present later to the cataract service with more advanced cataracts. They are challenging to examine and need an adapted approach with retinoscopy, a portable slit-lamp, and indirect ophthalmoscopy. Help of orthoptists/optometrists skilled in alternative VA testing methods should be considered. More emphasis must be placed on understanding behavioural changes e.g. difficulty eating, and targeted questionnaires may be useful. A BIM, ideally before the day of surgery, is good practice when making best interests decisions. Local anaesthesia +/- sedation is appropriate for many cases. Visual outcomes are promising and access to cataract surgery for these patients must be improved.