Feature, Report

Knock-on effect: Cataract surgery but not as we know it

Cataract surgeons are reporting unexpected flow on effects as a result of the pandemic. RHIANNON BOWMAN finds out how they are faring as they return to operating theatres, albeit at reduced capacity with an ever-increasing backlog.

Quantitative data on the true impact of the recent suspension on cataract surgery won’t be known for some time, but early anecdotal evidence suggests a myriad of challenges have emerged for patients and surgeons alike.

Denser cataracts, anisometropia and logistical headaches in terms of hygiene practices and through-put levels feature near the top of a list of knock-on effects caused by a month-long hiatus on non-urgent procedures.

Cataracts are the most common elective surgical procedure in Australia, accounting for 245,797 hospitalisations alone in 2014-15. As surgeries and hospitals work through an overwhelming backlog and brace for pent-up demand, concerns are also increasing over the potential deterioration of quality of life for some patients, with the incidence of falls and other accidents to possibly increase as delays prolong.

Cataracts are the most common elective surgical procedure in Australia.

Complicating matters are limits on the operating capacity for elective surgery from state-to-state. Hospitals in New South Wales and Victoria were given the green light to increase elective surgery from 25% of pre-pandemic levels to 50% by May 31, then 75% by June 30.

South Australia was the first to fully restore all elective procedure capacity by early-to-mid-June, while Western Australia was sitting on 50% surgery volume, with just two COVID-19 cases. In Tasmania there has been a gradual and progressive restart at the discretion of medical professionals.

Meanwhile, in the public system, Australian Society of Ophthalmologists president and Sydney cataract and refractive surgeon Dr Peter Sumich believes COVID will blow out cataract wait times by up to two years in some places.

Dr Peter Sumich.

He says optometrists and GPs should warn patients about this and make them aware of local private services as an alternative.

“Many patients who are faced with a two-year public wait will ‘find the funding’ through their Gen X and Gen Y children who are often unaware that their parents even had a problem accessing services,” he says.

“Whilst it is important that cataract surgeries are done, we must remember that there are many other eye surgeries on retina, eyelids and corneas which must not be deferred in order for state governments to tidy up their cataract KPI figures.”

With so many challenges to consider, Insight asks how surgeons are managing their cataract surgery caseloads and what unforeseen circumstances have arisen with COVID.

Longer wait

“First and foremost, in my mind, is how will COVID change the way we perform cataract surgery? What will be the new normal?” asks Associate Professor Colin Chan.

Chan is an internationally recognised expert in laser eye surgery, refractive lens exchange and laser cataract surgery, and has performed more than 7,000 eye surgery procedures. He practices at the Vision Eye Institute in Chatswood and Bondi Junction and is an Adjunct Associate Professor at the University of Canberra and a senior clinical lecturer at the University of Sydney.

He spoke to Insight in May when ophthalmologists in New South Wales were restricted to performing up to 25% of normal surgical activity levels for patients needing treatment within 90 days (Category 2) or at some point in the next 12 months (Category 3).

Associate Professor Colin Chan.

“The partial return to volume has been good. It has provided an opportunity to look closer at our processes and ease our way into it with a focus on the safety of patients and the general public,” he says.

“We’re trying to address the current situation. We’re not necessarily thinking about the latest intraocular lenses and new technology. We’re trying to do what’s necessary, what’s essential.”

A major concern for Chan is the impact of a six to 10-week delay or longer for appointments, leading to denser cataracts for some patients. In turn, this could result in poorer outcomes in visual acuity.

Further, Chan explains that denser cataracts can lead to longer surgical times and requiring more thermal energy to remove via phacoemulsification.

“There is greater risk of tissue damage and that can have an effect on visual acuity. There is greater risk of corneal oedema,” he says.

The knock-on effect of the cancellation of scheduled surgery, and re-prioritising and rescheduling patients, is longer waiting lists. Even with social distancing measures, and stringent practice hygiene, Chan notes there is also a lingering fear among elderly patients to leave their home for care.

“The term ‘elective surgery’ sounds optional but patients could potentially fall and fracture their hip or not be able to drive because of poor visibility due to cataract,” he says, his point being that for some patients, cataract surgery is not a lifestyle choice; it’s a necessity.

“Australian ophthalmologists are some of the best in the world. The reality is it’s going to take longer to get through the system than before COVID, whether public or private.

“There are delays getting an appointment, it’s taking longer than usual. This is going to have sequential effects on the system. There’ll be an extended backlog.”

With the emphasis now on timelines, some cases that would have previously warranted surgery sooner, are being scheduled later.

Chan says the ‘new normal’ will not return to the previous capacity.

“A cataract patient who is experiencing night-time driving vision issues such as glare and halos, who would normally be scheduled for surgery, may have to wait longer because we can’t operate at our previous capacity and technically they still meet the legal standards of being able to drive,” he explains.

Prioritising critical care

Cataract surgeon Dr Andrew Atkins was on the road to Shepparton when he first spoke with Insight. His practice is divided between metropolitan Melbourne (Footscray and Brighton) and rural Shepparton, and encompasses surgery on both private and public cases.

The restrictions on surgery volume following a month-long hiatus on all surgery is creating a “reasonable backlog” and patients are subsequently growing frustrated and anxious.

“The restrictions on surgery volume is a grey area; it’s not clear what 25% means. Is it 25% of your overall capacity, or is it 25% of your pre-COVID patient load?”

His cataract patients typically want their surgery done in April and May, but that hasn’t been possible this year.

Dr Andrew Atkins.

“Those months are usually a busy time of year for cataract surgeons because patients want to go travelling during the Southern Hemisphere winter. Some want to travel overseas for summer in the Northern Hemisphere, others want to hook up their caravan and head up to Queensland for the warmer weather,” he says.

An enforced quiet period is not the only disruption to routine cataract surgery this year. Atkins says the level of infection-risk precautions has also increased sharply.

“Right from the first phone call to a patient, we’re taking precautions to protect public health and triage our patients. If they are at-risk [of COVID], we postpone their appointment; if they are not at risk, we see them but under controlled restrictions, such as measuring their temperature on arrival, and taking less than 15 minutes for a consultation,” he says.

“We also have signs up asking patients about any risk factors, and all patients are directly questioned on arrival. Due to social distancing requirements we ask relatives to stay in the car park in their cars and the patient numbers are reduced overall and at any one time with regards to the number in the actual waiting room. I consider all of these actions to be very important.”

He says another significant difference in routine cataract surgery – between pre-COVID and the present – is a heightened need to prioritise critical care.

“When surgery was restricted I did manage to do a cataract operation on a patient with a dense cataract who was blind in the other eye and I considered this to be a priority but essentially the vast majority of cataracts are Category 3 and hence we were restricted regarding cases.”

Atkins says there is a silver lining for most ophthalmologists and optometrists as the stages of restrictions are gradually eased.

“The good news is that the usual ‘quiet period’ in July will be busy, as long as the number of coronavirus cases remains low and there isn’t a second-wave outbreak.”

Disruption causes dilemma

Perth-based surgeon Dr Tom Cunneen specialises in cataract, laser, and eyelid surgery. He operates privately at St John of God Subiaco and the Perth Eye Hospital and holds a consultant position at Sir Charles Gairdner Hospital, a teaching hospital colloquially referred to as “Charlies”.

Despite ophthalmologists in Western Australia being able to increase elective surgery to 50% of all normal elective surgical activity in May, unlike colleagues on the eastern seaboard who were still only operating at 25%, it’s been a frustrating set of circumstances. (Surgical capacity was reinstated 100% in WA on 15 June.)

“It’s frustrating. We’re consulting at full capacity, but operating surgically at 50% of our previous through-put,” Cunneen says.

Dr Tom Cunneen.

“This is creating a friction whereby a patient is diagnosed with a condition, but can’t have surgery in a timely manner.”

The Federal Government introduced staged guidelines for gradually returning to full elective surgery capacity but the reality on the ground varies from state-to-state.

Speaking in May, Cunneen said there were only two active COVID cases in Western Australia.

“I feel that the state government [in WA] can use their discretion based on the number of positive COVID cases and lift the capacity restrictions,” he says.

Cunneen says he hasn’t observed cataract cases worsening or growing denser among his patient cohort during the surgery hiatus, but it has caused another unexpected knock-on effect.

“The issue has been the patient’s second eye. Cataract patients who I operated on before COVID are now in a holding pattern. They’re struggling as they’ve had one eye operated on but now there’s a delay in getting their second eye done. They’re troubled by anisometropic symptoms as a result.”

Anisometropia is another way of describing an imbalance between the two eyes. This can sometimes occur following surgery as the brain tries to adjust to the changes in vision.

“I’m prioritising patients who are waiting for a cataract operation on their second eye,” Cunneen says.

“Optometrists can prescribe a contact lens to tide these patients over so they are not suffering anisometropic symptoms which can include poor depth perception, dizziness, headaches, and nausea.”

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