Paul Ursell MD
The backlog of patients to be seen after the immediate COVID-19 pandemic is over will stretch capacity to the absolute limits, especially as the new social distancing requirements will change our pathways.
All the elective surgical procedures which have been put on hold for months will need to be taken care of, adding up to a major logistical and organizational challenge for ophthalmic services everywhere.
To meet the challenge, some ophthalmologists are already putting in place strategies to ensure that the backlog is tackled as efficiently and effectively as possible.
Paul Ursell MD, FRCOphth, a consultant ophthalmologist at Epsom & St Helier University NHS Trust, Surrey, United Kingdom, has come up with a system specifically designed for the 1,000 or so cataract patients on his waiting list.
“The usual approach in the NHS is to simply operate on patients in terms of time order, but that needs to be re-evaluated with the backlog that we will all be facing when the lockdown restrictions are over. I looked at how specialists in other fields such as medical retina and glaucoma have been applying strategies to telephone triage and stratifying their patients according to their level of risk and whether we could find something similarly useful for cataract. My idea was to apply a red, amber, green (RAG) score to our cataract patients so that when we do start performing surgery again that we will give priority to the most urgent cases first,” he said.
Patients categorised as red, for instance, are deemed high risk and in danger of falls or other accidents and should be treated first, said Dr Ursell.
“If you can see well out of one eye then you’re not too badly off and the other eye can probably wait. But if both eyes are bad, worse than 6/24 in the better eye, then you are classified as red. There are also a few special cases as well – raised intraocular pressure of over 30mmHg, and phacomorphic glaucoma and phacoanaphylactic uveitis, both of which are really rare. All those cases need to be brought in quickly and are priority,” he said.
Amber cases are defined as patients with vision between 6/12 and 6/18 in their better eye, over 80 years of age and not in a care home.
“These people cannot drive and so they need to be seen ahead of the green patients who can drive without too much difficulty or they are living in a care home with greater supervision. If you are elderly and living at home, you don’t want to have bad vision as you are greater risk of a fall or an accident, so these patients are moved up the list,” he said.
The stratification system can also factor in other issues such as anisometropia, said Dr Ursell.
“This can be quite upsetting for some people. They have had one eye done and they need the other one done as well. If you have had it for quite a while you can adjust to it to some extent, so we decided that anisometropia of 2.0D or more for a period of less than one year moves you into the amber category,” he said.
With experience, applying the system to patient waiting lists is a relatively rapid and straightforward process, said Dr Ursell.
“I have just been through all our patients breakdown is about 5% red, 35% amber and 60% green. It really is not too difficult to categorise patients in this way with experience as all of the information we need is already in our electronic hospital ophthalmology records. It gives us a starting point and a rough-and-ready guide to dealing with the more pressing cases and then we can work through the amber patients and perform a telephone triage to see how they are getting on and who needs to be treated more quickly. Anything which helps to relieve the pressure somewhat for the months ahead and ensures that the more urgent cases are seen to has to be a positive step,” he concluded.
RAG Stratification system
RED: Better eye visual acuity 6/24 or worse, Intraocular pressure over 30mmHg, phakoanaphylactic uveitis or phakomorphic glaucoma.
AMBER: Better eye visual acuity 6/12-6/18, IOP between 21-30, Age >80 and living at home, Anisometropia >2D for less than 1 year.
GREEN: Not Amber or Red.
