Vision Together: Access Pathway (Accessible Community Eyecare Specialist Support) For Care Home Residents Requiring Cataract Surgery

Sight loss affects 64% of older people living in care homes, negatively impacting their quality of life with increased falls and reduced mobility. Frailty, cognitive impairment and functional dependency create significant barriers to accessing eye care at ophthalmology outpatient clinics. High did-not-attend (DNA) rates in this population with low discharge rates from ophthalmology outpatient clinics highlight the need for alternative care models. This study was performed to determine the extent of perioperative support and prehospital optimisation required for access to cataract surgery. An observational plan do study act cycle was initiated to develop dementia friendly cataract surgery pathways fully supported by community services. 

Pilot care model across seven care homes in London with referrals to a public sector teaching hospital. Integrated partnership working between domiciliary providers, minor eye condition scheme (MECS) optometrists, geriatricians, general practitioners, anaesthetists and ophthalmologists to bring specialist multi-disciplinary support to the community. Each of these parts were publicly funded (National Health Service) so costings and logistics for the services were evaluated for maximum efficiency.

The Vision Together AcCESS Pathway (Accessible Community Eyecare Specialist Support) was piloted over 12 months (October 2023- September 2024).  Existing domiciliary optometrists were upskilled to deliver enhanced assessments through the NHS Minor Eye Condition Service (MECS). The pathway embedded multidisciplinary working with general practitioners (GP), care homes, residents and families, supported by virtual advice and guidance from secondary care ophthalmology and geriatrics. Feasibility, clinical utility, patient experience and system outcomes were evaluated. Peri-operative assessments, cataract surgery outcomes, complications, and recommendations for elderly, frail and dementia patients involved in this pilot study collated. 

40 MECS consults were delivered for 37 residents. Cataract assessment accounted for 70% of reviews. GPs and next of kin (NOK) discussions were required in 70%, 55% needed secondary care MDT. This reduced referrals by 48% where surgery did not align with patients’ best interests. Optimisation of glaucoma treatment and minor acute conditions took place concurrently with cataract workups. Our pilot model was highly efficient at integrating 15- 30min MECS assessments with <5minute secondary MDT support for all residents. One patient with a dense cataract required a second procedure to remove a retained small lens fragment. All care (apart from surgery) was provided in the community with no cases of worsening of vision after intervention. 

Our study showed the need for integrated support to deliver safe cataract sugery in elderly, frail, patients who often suffer from dementia. Standardised peri-operative assessments and joined up support with NOK and clinicians with prior knowledge of care home residents allowed best practice in complex decision making such as type of anaesthesia, ability to co-operate in early dementia under local anaesthesia, NOK power of attorney, treatment preferences and post-operative care delivered at home with upskilled domiciliary optometrists. Standardised frailty assessments, glaucoma and MECS treatment algorithms made it time efficient as well as cost effective in managing cataract, glaucoma and minor acute eye conditions in care homes.