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CATARACT MANAGEMENT DECISIONS SHOULD BE BASED ON PATIENT HISTORY, OCULAR EXAM

This article was originally published in The Gray Sheet

Executive Summary

CATARACT MANAGEMENT DECISIONS SHOULD BE BASED ON PATIENT HISTORY, OCULAR EXAM, an Agency for Health Care Policy and Research clinical practice guideline on cataract treatment concludes. An AHCPR summary of the report, which was released Feb. 25, states that cataract "management decisions should be made primarily on the basis of a complete patient history and ocular examination," noting that "special preoperative tests are rarely of assistance in deciding whether to recommend cataract surgery." The report, which was written by a multi-disciplinary, non- governmental panel of health care professionals, evaluated four types of pre-operative ophthalmic tests that are currently used in assessing patients with cataracts. The report concluded that there are insufficient data to support the routine use of contrast sensitivity testing, glare testing, specular photographic microscopy and potential vision testing. For example, the panel concludes that "the relationship between contrast sensitivity testing and functional impairment has not been adequately examined." Therefore, it was "unable to assess the clinical usefulness of information from contrast sensitivity testing above and beyond that obtained from routine history or ocular examination, in determining whether a patient would benefit from cataract surgery." Regarding glare testing, the report says that "it is reasonable to perform a glare test as part of the evaluation of patients who complain of glare, or who have symptoms potentially attributable to glare, and who have a cataract...and good Snellen activity." However, "glare testing should not be required by utilization review or quality assessment organizations, such as peer review organizations, as objective documentation of visual disability sufficient to justify the potential benefit of surgery." The panel concludes that a test of potential vision "should not be included as a preoperative test in the routine management of" cataract patients. However, the group adds that "there may be a subset of patients (patients with specific types of macular degeneration and clear media) in whom such a test may be of value, but this has yet to be shown." Addressing specular photographic microscopy, the panel says that its literature review "failed to establish an association between the results" of this type of test "and the outcome of surgery for cataract." However, "there may be specific instances in which the endothelial cell count can contribute information pertinent to clinical decisionmaking," the report notes. AHCPR's guideline is intended to help ensure "quality care for patients with cataract." AHCPR encourages practitioners to use the information in the report "to care for the patient with functional impairment due to cataract," cautioning that the information provided "may not be appropriate for use in all circumstances." ACHPR cites several reasons for conducting the study, including the high prevalence of cataracts in the elderly population. In 1991, 1.35 mil. cataract surgeries were performed in the U.S., costing Medicare approximately $3.4 bil. AHCPR also notes a "wide variation" in cataract care practice and a lack of information on diagnosis and treatment of the condition for both practitioners and patients. The panel that wrote the guideline conducted a literature review of approximately 8,000 clinical studies conducted since 1975. In addition, information gathered at two public hearings was considered by the panel. The report also evaluates the two common types of cataract removal -- extracapsular cataract extraction and phacoemulsification. In ECCE, the surgeon removes the center of the lens, replacing it with an intraocular lens. For PE, high frequency sound waves are used to break the clouded lens apart. The pieces are then "vacuumed out" and an IOL is inserted. PE can be conducted through a smaller incision than is possible with ECCE. While the panel "felt it was logical that small incision surgery" provided by PE would cause less astigmatism than ECCE, it maintained that "there was inadequate published data...to determine whether there were clinically significant differences in the amount of astigmatism that occurs in association with PE." The panel noted, however, that "literature lags behind current practice in evaluating changes in clinical practice" and recommended that "research be undertaken to develop innovative approaches for evaluating surgical outcomes" more efficiently. The guideline also discusses YAG laser capsulotomy, a secondary surgery performed on 48% of all patients who have had their cataracts removed, according to AHCPR. YAG capsulotomies, which cost Medicare over $375 mil. annually, are performed to reverse a decrease in visual functioning caused by posterior capsular opacification (PCO), which is "a natural consequence of modern cataract surgery." The panel found that YAG "laser capsulotomy is appropriate and justified" when three criteria are met: the patient's ability to carry out needed or desired activities is impaired; the eye examination confirms the diagnosis of PCO and excludes other ocular causes of functional impairment; and the patient has been educated about the risks and benefits of laser surgery to the posterior capsule. While the panel found "no absolute contraindication to the performance of YAG capsulotomy in appropriately diagnosed patients," they noted that the procedure "should not be performed prophylactically" and "should never be scheduled at the time cataract surgery is scheduled or performed." Justification for the procedure should be "well-documented," the report adds, in light of evidence of increased overall risk of retinal detachment following YAG capsulotomy procedures.
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