Downloaded from http://bjo.bmj.com/ on July 13, 2016 - Published by group.bmj.

com

62 Br J Ophthalmol 1999;83:62–65

The need for cataract surgery: projections based

on lens opacity, visual acuity, and personal
concern
Cathy A McCarty, Jill E KeeVe, Hugh R Taylor

Abstract but estimates for the USA for the year 1991
Aim—To assess the projected needs for were $3.4 billion for typical cases2 and costs are
cataract surgery by lens opacity, visual likely to rise in the USA and in other developed
acuity, and patient concern. countries to meet increases in the demand for
Methods—Data were collected as part of cataract surgery concomitant with the relative
the Melbourne Visual Impairment aging of the populations. A decrease in the
Project, a population based study of age threshold visual acuity for cataract surgery has
related eye disease in a representative been shown in the UK to double the number of
sample of Melbourne residents aged 40 people potentially eligible for cataract
and over. Participants were recruited by a surgery,3 4 thus doubling the costs. The Pre-
household census and invited to attend a ferred Practice Pattern of the Royal Australian
local screening centre. At the study sites, College of Ophthalmologists for cataract sur-
the following data were collected: present- gery states that the “indications for surgery are
ing and best corrected visual acuity, visual dependent on various levels of visual impair-
fields, intraocular pressure, satisfaction ment and cataract surgery is justified and
with current vision, personal health his- appropriate when the subjective, objective, and
tory and habits, and a standardised eye education criteria are met”, but does not have
examination and photography of the lens a visual acuity threshold at which cataract sur-
and fundus. Lens photographs were gery is not advised.5 There has also been much
graded twice and adjudicated to document discussion about the relative merit and cost of
lens opacities. Cataract was defined as second eye cataract surgery.6 7
nuclear greater than or equal to standard The influence of visual acuity, visual func-
2, 4/16 or greater cortical opacity, or any tion, and surgeon on the demand for cataract
posterior subcapsular opacities. surgery has been studied in a number of coun-
Results—3271 (83% response) people liv- tries, with the general conclusion that func-
ing in their own homes were examined. tional impact and concern, not surgeon prefer-
The participants ranged in age from 40 to ence or visual acuity, are the major
98 years and 1511 (46.2%) were men. Pre- determinants of demand.8–11 The purpose of
vious cataract surgery had been per- this study was to predict the number of
formed in 107 (3.4%) of the participants. cataract operations per 1000 people at risk that
The overall prevalence of any type of cata- may be needed in Australia (and similar coun-
ract that had not been surgically corrected tries) by level of visual acuity and patient con-
was 18%. If the presence of cataract as cern. These data will be useful for healthcare
defined was considered the sole criterion administrators to estimate demand for cataract
for cataract surgery with no reference to services.
visual acuity, there would be 309 cataract
operations per 1000 people aged 40 and
over (96 eyes of people who were not satis- Methods
Centre for Eye STUDY POPULATION
Research Australia, fied with their vision, 210 eyes of people
University of who were satisfied with their vision, and Details of the Melbourne Visual Impairment
Melbourne three previous cataract operations). At a Project methodology have been published
Department of visual acuity criterion of less than 6/12 previously.12 In brief, nine pairs of census
Ophthalmology, Royal
(the vision required to legally drive a car), collector districts from the Melbourne Statisti-
Victorian Eye and Ear
48 cataract operations per 1000 would cal Division were randomly selected from
Hospital, Australia which to recruit residents who had resided in
C A McCarty occur and people would be twice as likely
J E KeeVe to report dissatisfaction with their vision. their homes for at least 6 months to attend a
H R Taylor Conclusions—Estimates of the need for local screening centre.
cataract surgery vary dramatically by
Correspondence to: STUDY PROTOCOL
Dr Cathy McCarty, Centre level of lens opacity, visual acuity, and
for Eye Research Australia, patient concern. These data should be Procedures at the local screening centre
University of Melbourne useful for the planning of health services. included assessment of presenting and best
Department of (Br J Ophthalmol 1999;83:62–65) corrected distance visual acuity,13 reading
Ophthalmology, Royal
Victorian Eye and Ear
vision, visual fields, intraocular pressure, fun-
Hospital, 32 Gisborne Street, dus and lens photography, a standardised clini-
East Melbourne, Vic 3002, We have shown previously that the volume of cal slit lamp examination, a detailed interview
Australia.
cataract surgery in Australia increased 2.6 about medical history and personal health
Accepted for publication times in the years 1985 to 1994.1 The exact habits. People were asked to rate their personal
29 July 1998 cost of cataract surgery in Australia is unknown satisfaction with their current vision (with
 Downloaded from http://bjo.bmj.com/ on July 13, 2016 - Published by group.bmj.com

Cataract surgery by opacity, vision, and concern 63

glasses if used) as very dissatisfied, dissatisfied, Results

satisfied or very satisfied. These responses were STUDY POPULATION
then classified in to the two categories of “dis- A total of 3271 eligible (83%) residents
satisfied” or “satisfied” for the analyses. All participated. The only significant diVerence
participants gave written informed consent between attenders and non-attenders was
and the study protocol was approved by the language spoken at home; non-attenders were
Royal Victorian Eye and Ear Hospital human more likely to be non-English speakers.15 The
research ethics committee. following variables were used to compare
Lens opacities were graded clinically at the participants and non-participants and partici-
time of the examination and subsequently from pants with the census data from the Australian
photos using the Wilmer cataract photo Bureau of Statistics: age, sex, education,
grading system.14 Cortical opacities were as- ethnicity. The study cohort has been shown to
sessed with retroillumination and measured as be representative of all Melburnians aged 40
the proportion in 16ths of pupil circumference and up.15 The participants ranged in age from
occupied by opacity. For these analyses, 40 to 98 years (mean 58.7, SD 11.4) and 1511
cortical cataract is defined as 4/16 or greater (46.2%) were men. Photos were used to
opacity. The area of posterior subcapsular classify cortical and PSC opacities in 2919
(PSC) opacities was measured in square milli- (90%) right eyes and 2891 (89%) left eyes.
metres. The presence of any PSC opacity was Photos were used to classify nuclear cataract in
classified as cataract. Nuclear opacities were 2969 (92%) right eyes and 2957 (91%) left
compared against four standard photographs eyes. All available data are employed for each
and decimalised. For these analyses, nuclear separate analysis.
cataract was defined as opacity equal to or
greater than standard photo 2. These defini- CATARACT PREVALENCE

tions of cataract are similar to what has been The overall prevalence of any type of cataract
used in previous population based studies. that had not been surgically removed was 18%.
A Topcon SL5 photo slit lamp with a 0.1 The age and sex specific cataract status of each
mm slit beam of 9.0 mm in height set to an eye reveals the dramatic increase in cataract
incident angle of 30º and Ektachrome 200 and cataract surgery with each decade of life
ASA colour slide film were used to photograph (Table 1). Previous cataract surgery had been
nuclear opacities. Cortical and PSC opacities performed in 107 (3.4%) of the participants; of
were photographed with an Oxford retroillu- the 103 with available information on their
mination camera and T-Max 400 film. cataract surgery, 18% had occurred in the pre-
All of the photos were graded independently vious year. Controlling for age, women were
by two trained research assistants and discrep- significantly more likely to have cataract than
ancies were adjudicated by the ophthalmic men (OR=1.45, 95%CL=1.18, 1.78).
research fellow. With the exception of ungrada-
RELATION OF LENS OPACITIES TO VISUAL ACUITY
ble or missing photos, the photo grades were
AND PERSONAL SATISFACTION WITH VISION
used for analyses.
People who were dissatisfied with their vision
were more likely to have cataract (÷2, 1 df
DATA MANAGEMENT =22.0, p=0.001) and this was true at nearly all
Interview data were entered directly into the levels of best corrected visual acuity. It is inter-
computer. All other data were entered twice esting to note that 462 of 2300 (11.9%) people
and verified. Analyses were performed in SAS with 6/6 or better visual acuity reported dissat-
Version 6.10 (SAS Institute Inc, Cary, NC, isfaction with their vision and that for the
USA) and are documented in the SAS majority of these people, their dissatisfaction
procedure manuals. A p value <0.05 was con- would not be attributed to cataract.
sidered to be statistically significant. ÷2 analyses A backwards multivariate logistic regression
were employed to evaluate significant univari- model was fitted to predict dissatisfaction with
ate relation among categorical variables while current vision. The following variables were
backwards logistic regression was used to included as potential predictors: 10 year age
assess the independent eVect of categorical group, lines of best corrected visual acuity
variables in multivariate models. (Snellen equivalent from logMAR), presence
Table 1 Prevalence of cataract* and previous cataract surgery by age and sex

Prevalent cataract in Previous surgery in one

No cataract in Prevalent cataract in Prevalent cataract in one eye, previous eye, no cataract in 2nd Previous surgery in
Age Sex either eye one eye only both eyes surgery in 2nd eye eye both eyes

40–49 Men, n=352 339 (96.3%) 8 (2.27%) 1 (0.26%) 0 (0%) 3 (0.85%) 1 (0.28%)
Women, n=459 447 (97.4%) 10 (2.18%) 2 (0.44%) 0 (0%) 0 (0%) 0 (0%)
50–59 Men, n=442 406 (91.9%) 24 (5.4%) 9 (2.04%) 2 (0.45%) 0 (0%) 1 (0.23%)
Women, n=524 489 (93.3%) 20 (3.82%) 12 (2.29%) 2 (0.38%) 0 (0%) 1 (0.19%)
60–69 Men, n=423 331 (78.3%) 35 (8.27%) 49 (11.6%) 3 (0.71%) 1 (0.24%) 4 (0.95%)
Women, n=429 304 (70.9%) 53 (12.4%) 61 (14.2%) 4 (0.93%) 2 (0.47%) 5 (1.17%)
70–79 Men, n=218 117 (53.7%) 22 (10.1%) 61 (28.0%) 6 (2.75%) 2 (0.92%) 10 (4.59%)
Women, n=220 87 (40.0%) 33 (15.0%) 86 (39.1%) 6 (2.73%) 2 (0.91%) 6 (2.73%)
80–89 Men, n=56 12 (21.4%) 8 (14.3%) 22 (39.3%) 7 (12.5%) 1 (1.79%) 6 (10.7%)
Women, n=86 4 (4.65%) 7 (8.14%) 51 (59.3%) 10 (11.6%) 2 (2.33%) 12 (14.0%)
90+ Men, n=3 0 (0%) 0 (0%) 3 (100%) 0 (0%) 0 (0%) 0 (0%)
Women, n=12 0 (0%) 1 (8.33%) 4 (33.3%) 2 (16.7%) 0 (0%) 5 (41.7%)
All ages Total, n=3224 2536 (78.7%) 221 (6.85%) 361 (11.2%) 42 (1.3%) 13 (0.40%) 51

*Nuclear opacity > photo standard 2, > 4/16 cortical opacity, any PSC.
 Downloaded from http://bjo.bmj.com/ on July 13, 2016 - Published by group.bmj.com

64 McCarty, KeeVe, Taylor

350 of referral for cataract surgery by Australian

308.8 Vision satisfaction ophthalmologists is patient concern.8
Cataract surgeries per 1000 300 Satisfied The Royal Australian College of Ophthal-
Not satisfied mologists acknowledge that although “no
250 Previous surgery single eye test adequately describes the eVect of
213.2
200
cataracts on a patient’s visual status or
functional ability”, “simple Snellen visual acu-
150 ity is the most universally used index of visual
function”. However, as we and other research-
100 87.7 ers have shown, visual acuity is not highly
47.9 related to satisfaction with vision. A study of
50 33.2 patients’ perception of their need for cataract
26.4
16.9 13.4 11.8 9.52 9.28 6.52
0
surgery conducted in Norway revealed that
>=6/6 6/7.5 6/9 6/12 6/15 6/18 6/24 6/30 6/36 6/48 6/60 <6/60 visual function and visual acuity were not
Visual acuity highly correlated until visual acuity was less
Figure 1 Cumulative number of cataract (defined as nuclear opacity > photo standard 2, than 6/24 in the worse eye.16 The VF-14,17 an
> 4/16 cortical opacity or any posterior subcapsular opacities (PSC) operations required index of functional impairment in patients with
per 1000 population aged 40+ by level of best corrected visual acuity and patient cataract, has recently been used with cataract
satisfaction with vision. patients in the USA. Researchers have shown
of unoperated cataract, and sex. The only fac- that the VF-14 is a better measure of improve-
tors that remained in the model were best ment in visual function after cataract surgery
corrected visual acuity (OR=1.45 for each one than visual acuity.18
line decrease, 95%CL=1.30, 1.61) and the Another important reason to consider pa-
presence of unoperated cataract (OR=1.24, tient concern with vision simultaneously with
95%CL=1.001, 1.53). visual acuity is the expected improvement in
The potential number of cataract operations outcomes with cataract surgery. Several studies
needed per 1000 population aged 40 and over have now shown that visual function before
at risk varies dramatically by level of visual surgery is the strongest predictor of visual out-
acuity and personal satisfaction with current come and quality of life after cataract surgery,
vision (Fig 1). If visual acuity was not a independent of visual acuity.19–22 This implies
criterion for number of cataract operations per that if cataract surgery were advised solely on
1000 population at risk aged 40 and over, the the basis of visual acuity, the change in
number of cataract operations would be 309 satisfaction and visual outcome would not be
(96 eyes of people who are not satisfied with as great. Our data support this hypothesis; at
their vision, 210 eyes of people who are better levels of visual acuity, the majority of
satisfied with their vision and three previous people are satisfied with their vision and would
cataract operations). The total number of not be expected to benefit substantially from
potential cataract operations decreases by one cataract surgery.
third by imposing a threshold of 6/7.5 visual As cataract surgery improves, giving better
acuity. By the level of <6/12 visual acuity (the visual results with fewer adverse reactions, the
vision required to legally drive a car), the total procedure is done for less severe visual impair-
number of cataract operations per 1000 drops ment. Our data are consistent with a doubling
to 48 and people were twice as likely to report of the need for cataract surgery with each two
dissatisfaction with their vision. If the visual line change in visual acuity. The change from
acuity required for a blind pension (<6/60) aphakic ICCE to ECCE/IOL was associated
were imposed as a threshold for cataract with a drop in the visual acuity threshold from
surgery, only 6.5 operations per 1000 popula- 6/60 to 6/18. The use of phacoemulsification is
tion would need to be performed. now further lowering that threshold to 6/6,
6/7.5 or 6/9.
The level of lens opacity, visual acuity, and
visual function all need to be considered in the
Discussion recommendation of patients for cataract sur-
To our knowledge, this is the first population gery. The establishment or enforcement of
based estimate of the need for cataract surgery guidelines and thresholds for cataract surgery
to consider lens opacity, visual acuity, and sat- will have obvious implications for total costs to
isfaction with vision. We have shown that the community, the expected size of improve-
significant lens opacities are prevalent in the 40 ment in outcomes, the cost utility and cost
and over age group and that both visual acuity eVectiveness of the procedure, and the size of
and personal dissatisfaction with vision can be the waiting lists at public hospitals. The infor-
strong determinants of the potential need for mation from this study should assist in the
cataract surgery in the community. planning of services to address the expected
Our results confirm the results from studies increase in demand for cataract surgery in
conducted in the UK which have revealed that developed countries.
by decreasing the visual acuity threshold for
cataract surgery, the estimated need for cata- The Melbourne Visual Impairment Project was funded in part
ract operations increases dramatically.3 4 How- by grants from the National Health and Medical Research
ever, it is equally important to consider the Council, the Victorian Health Promotion Foundation, the
Ansell Ophthalmology Foundation, and the Dorothy Edols
level of satisfaction with vision in conjunction Estate. Kodak Australia donated slide film for the project.
with lens opacity and visual acuity as we have Humphrey Zeiss donated the autorefractor for use in the study.
The authors acknowledge the contributions of the following
shown previously that the strongest predictor individuals: Ms Sharon Bayley, Ms Marie Bissinella, Dr Charles
 Downloaded from http://bjo.bmj.com/ on July 13, 2016 - Published by group.bmj.com

Cataract surgery by opacity, vision, and concern 65

Guest, Ms Cara Jin, Dr Patricia Livingston, Ms Claire McKean, 12 Livingston PM, Carson CA, Stanislavsky YL, et al. Methods
Dr Yury Stanislavsky, Ms Cathy Walker, and Mr Matthew for a population-based study of eye disease: the Melbourne
Wensor. Visual Impairment Project. Ophthalmic Epidemiol 1994;1:
139–48.
13 Taylor HR, Livingston PM, Stanislavsky YL, et al. Visual
1 KeeVe JE, Taylor HR. Cataract surgery in Australia impairment in Australia: distance visual acuity, near vision,
1985–94. Aust NZ J Ophthalmol 1996;24:313–17. and visual field findings of the Melbourne Visual
2 Steinberg EP, Javitt JC, Sharkey PD, et al. The content and Impairment Project. Am J Ophthalmol 1997;123:328–37.
cost of cataract surgery. Arch Ophthalmol 1993;111:1041– 14 Taylor HR, West SK. A simple system for the clinical grad-
9. ing of lens opacities. Lens Research 1988;5:175–81.
3 Desai P. The National Cataract Surgery Survey: III Process
features. Eye 1993;7:667–71. 15 Livingston PM, Lee SE, McCarty CA, et al. A comparison
4 Wormald RPL, Evans JR. When does a lens opacity become of participants with non-participants in a population-based
a cataract? Estimating the eVect of lowering the threshold epidemiologic study: the Melbourne Visual Impairment
for intervention on demand for services. Invest Ophthalmol Project. Ophthalmic Epidemiol 1997;4:73–81.
Vis Sci 1993(Suppl);35:1963. 16 Sletteberg O, Høvding G, Bertelson T. Do we operate too
5 The Royal Australian College of Ophthalmologists. Pre- many cataracts? The referred cataract patients’ own
ferred practice patterns. Cataract and intraocular lens sur- appraisal of their need for surgery. Acta Ophthalmol Scand
gery in the otherwise health adult eye. Sydney: Royal Aus- 1995;73:77–80.
tralian College of Ophthalmologists, 1995. 17 Steinberg EP, Tielsch JM, Schein OD, et al. The VF-14. An
6 Javitt JC, Brenner H, Curbow B, et al. Outcomes of cataract index of functional impairment in patients with cataract.
surgery. Improvements in visual acuity and subjective Arch Ophthalmol 1994;112:630–8.
visual function after surgery in the first, second, and both 18 Steinberg EP, Tielsch JM, Schein OD, J et al. National study
eyes. Arch Ophthalmol 1993;111:686–91. of cataract surgery outcomes. Variation in 4-month postop-
7 Javitt JC, Steinberg EP, Sharkey P, et al. Cataract surgery in erative oucomes as reflected in multiple outcome measures.
one eye or both. A billion dollar issue. Ophthalmology 1995; Ophthalmology 1994;101:1131–41.
102:1583–93. 19 Elam JT, Graney MJ, Applegate WB, et al. Functional out-
8 KeeVe JE, McCarty CA, Chang WP, et al. Relative come one year following cataract surgery in elderly persons.
importance of VA, patient concern and patient lifestyle on J Gerontol 1988;43:M122–6.
referral for cataract surgery. Invest Ophthalmol Vis Sci 1996; 20 Brenner MH, Curbow B, Javitt JC, et al. Vision change and
37:S183. quality of life in the elderly. Response to cataract surgery
9 Escarce JJ. Would eliminating diVerences in physician prac- and treatment of other chronic ocular conditions. Arch
tice style reduce geographic variations in cataract surgery Ophthalmol 1993;111:680–5.
rates? Med Care 1993;12:1106–18. 21 Mangione CM, Phillips RS, Lawrence MG, et al. Improved
10 Curbow B, Legro MW, Brenner MH. The influence of visual function and attenuation of declines in health-related
patient-related variables in the timing of cataract extrac- quality of life after cataract extraction. Arch Ophthalmol
tion. Am J Ophthalmol 1993;115:614–22. 1994;112:1419–25.
11 Mordue A, Parkin DW, Baxter C, et al. Thresholds for treat- 22 Schein OD, Steinberg EP, Cassard SD, et al. Predictors of
ment in cataract surgery. J Publ Health Med 1994;16:393– outcome in patients who underwent cataract surgery. Oph-
8. thalmology 1995;102:817–23.
 Downloaded from http://bjo.bmj.com/ on July 13, 2016 - Published by group.bmj.com

The need for cataract surgery: projections

based on lens opacity, visual acuity, and
personal concern
Cathy A McCarty, Jill E Keeffe and Hugh R Taylor

Br J Ophthalmol 1999 83: 62-65

doi: 10.1136/bjo.83.1.62

Updated information and services can be found at:

http://bjo.bmj.com/content/83/1/62

These include:

References This article cites 18 articles, 2 of which you can access for free at:
http://bjo.bmj.com/content/83/1/62#BIBL

Email alerting Receive free email alerts when new articles cite this article. Sign up in the
service box at the top right corner of the online article.

Topic Articles on similar topics can be found in the following collections

Collections Lens and zonules (798)

Notes

To request permissions go to:

http://group.bmj.com/group/rights-licensing/permissions

To order reprints go to:

http://journals.bmj.com/cgi/reprintform

To subscribe to BMJ go to:

http://group.bmj.com/subscribe/