EDITORIAL 601 Cataract surgery On the other hand, successful imple- Br J Ophthalmol: first published as 10.1136/bjo.2003.034918 on 16 April 2004. Downloaded from ....................................................................................... mentation of high quality, high volume units within the NHS can be achieved and be a positive experience. Some exem- Cataract surgery plary units, including the one reporting in this issue, were used as examples of R P Wormald, A Foster best practice to form policies in the ‘‘Action on cataract’’ document. These ................................................................................... units show that despite many barriers, The times they are a changing progress can and has been made within the National Health Service. It is puz- zling why more effort has not been re our cataract surgical outcomes The cataract surgical rate (CSR, catar- made to disseminate and implement as good as they can get? If the act operations per million population per these examples of best practice. Aanswer is that there is still room year) in the United Kingdom is probably There is a separate point to consider for improvement, then how? between 4000 and 4500. This is about from Habib and colleagues’ article. The The outcome of cataract surgery is 100 operations per working week per authors were able to review complication determined by the patient, the techni- million population. If a rate of 8–10 cata- rates from a database of nearly 17 000 que, and the surgeon: the patient where ract operations per week is associated cases. Over time the complication rates there is coexisting morbidity; modern with a lower complication rate then 10– fell for those performing fewer than 400 techniques (most notably the implanta- 12 ‘‘cataract surgeons’’ are needed per operations per year as well as for those tion of an intraocular lens and probably million population. (Of course it may be performing more than 400. Yorston et al small incision methods) have trans- that doing 12–14 per week gives even have shown that prospective monitoring formed the quality of visual rehabilita- lower complication rates.) At present the of complications and visual outcome tion; and—dare we say—the ‘‘better’’ the United Kingdom has approximately 14 leads to an improvement in results over surgeon the ‘‘better’’ the results. There is ophthalmologists per million population time.3 This strategy of routine monitoring often little we can do to influence co- (all specialties). Australia has a CSR of every 100 cases is now being encouraged morbidity. As for technique, we have around 6500, or 150 cataract operations as part of the ‘‘Vision 2020—right to countless papers, posters, presentations, per week per million population. If the sight’’ strategy to improve the results of and videos promoting new techniques United Kingdom wish to have a CSR like cataract surgery worldwide. High volume, claiming excellent results (but rarely of Australia (currently the highest world- high quality, and low cost units have sufficient study design quality to justify wide) then it would require 75% of UK been pioneered in many parts of south the claims). But what of the surgeon? ophthalmologists performing 14 catar- Asia and are now emerging in Africa. Can the surgeon improve and if so how? acts per week (approximately 7 hours Increasingly, these centres are monitor- Habib et al’s paper in this issue of operating), 44 weeks per year. It would ing the visual outcome in order to give BJO (p 643) describes the association therefore seem that the number of ‘‘cata- objective real time feedback of the results between higher volume and lower com- ract surgeons’’ is not the main limiting to the surgeon. This is not to compare one plication rates which has been noted in factor in reducing cataract waiting times, surgeon with another, but rather for each other spheres of surgery but not so far in and one could argue that if too many surgeon to monitor his own results over http://bjo.bmj.com/ ophthalmology. The message is—the people are performing cataract surgery, time. more you do, the fewer the complica- the complication rate may be more than Ophthalmology has pioneered and tions. This is just an association, and optimal. embraced many changes in technology— one cannot tell from this kind of study cataract extraction is just one example. A which way the cause and effect works. Change in the way cataract services growing elderly population with a greater It could be that ‘‘better’’ surgeons do are provided may be difficult to expectation of good vision, means that more surgery because they have fewer high volume, high quality cataract ser- on September 24, 2021 by guest. Protected copyright. complications or is it, as the old adage accept but, if well planned, could become a rewarding challenge for vices are required. Change in the way states, ‘‘practice makes perfect’’ and cataract services are provided may be that doing more makes you better? the profession with significant socie- tal benefits difficult to accept, but, if well planned, If, as seems plausible, practice does could become a rewarding challenge for make perfect and increasing one’s surgi- the profession with significant societal In order to reduce time on waiting lists cal experience improves results, then benefits. Efficient use of an ophthalmol- there is a need to increase volume (CSR); what is the optimum number of cataract ogist’s time making best use of surgical a point made in an editorial several years surgeries per week? Habib et al suggest skills in a way which optimises those ago in response to Minassian et al’s that the complication rate is lower in skills seems a sensible part of planning a modelling of cataract backlog in the those who perform more than 400 opera- sustainable cataract service for the NHS. tions per year (8–10 per week) than in United Kingdom.12 The government, in those who perform fewer. Given there order to reduce cataract waiting time, Br J Ophthalmol 2004;88:601–602. are not a limitless number of cataracts to has introduced ‘‘treatment centres’’ as doi: 10.1136/bjo.2003.032623 be extracted each year, what is the they are now termed. This move has not ...................... optimum number of cataract surgeons been welcomed by many consultants and for the population operating at an opti- there is a concern about training the next Authors’ affiliations R P Wormald, mum rate? We know that in the generation of eye surgeons. The use of Moorfields Eye Hospital, City Road, London EC1 2PD, UK surgical teams from outside the United Americas and western Europe there are A Foster, London School of Hygiene and too many ophthalmologists for most of Kingdom has further aggravated the Tropical Medicine, UK them to perform regular cataract surgery. situation and does not provide the basis So are more cataract surgeons actually for a sustainable cataract service for the Correspondence to: R P Wormald, Moorfields required in the United Kingdom to United Kingdom which can meet the Eye Hospital, City Road, London EC1 2PD, UK; reduce time on the waiting lists? growing needs of an ageing population. [email protected] www.bjophthalmol.com 602 EDITORIAL REFERENCES epidemiological modelling of the population 3 Yorston D, Gichuhi S, Wood M, et al. Br J Ophthalmol: first published as 10.1136/bjo.2003.034918 on 16 April 2004. Downloaded from dynamics ofcataract. Br J Ophthalmol Does prospective monitoring improve 1 Minassian DC, Reidy A, Desai P, et al. The deficit 2000;84:4–8. cataract surgery outcomes in Africa? in cataract surgery in England and Wales and the 2 Wormald R. Cataract surgery—quantity and Br J Ophthalmol escalating problem of visual impairment: quality. Br J Ophthalmol 1999;83:889–90. 2002;86:543–7. Opticin providing linkage to form a contiguous ....................................................................................... collagen network; on the other hand, these molecules also might prevent aggregation of the vitreous fibrils which Shedding light on a new eye protein would destabilise the gel. During ageing or disease, particularly after cellular J V Forrester infiltration of the gel, these molecules are likely to be damaged or degraded ................................................................................... and thus lead to collagen fibril aggrega- tion, lacunae formation, and gel con- Opticin is a proteoglycan of the small leucine rich repeat family densation, clinically known as vitreous located in the extracellular matrix syneresis. Most recently a further role for opticin t is reassuring to realise that there are important structural roles. In addition has been suggested—namely, as a repo- 4 still new molecules to be discovered to versican and fibulin mentioned sitory for growth factors. Binding of Iusing classic biochemical methods already, fibrillin containing microfibrils growth factors by matrix molecules is rather than the blockbuster genomic are an important component although well recognised. For instance, vitreous approach. Opticin is an eye specific without their usual partner elastin. type II collagen binds TGF-b and BMP- 56 molecule discovered by Reardon and Other minor proteins are present 2. Fibroblast growth factor among colleagues in 20001 using a 4 M guani- instead such as microfibril associated many other factors is stored extracellu- dine hydrochloride extract from bovine glycoprotein-1 (MAGP-1). Opticin is larly in basement membranes bound to vitreous collagen fibrils to prepare pep- a heparan sulphate proteoglycan (syn- present in significant amounts in vitr- 7 tides as a starting point for molecular decan). Now opticin appears to bind eous and it is surprising that it has not 4 cloning. Almost simultaneously, a sepa- been identified previously. It binds to growth hormone. Growth hormone has rate group of researchers discovered an heterotypic vitreous collagen fibrils and been implicated in new vessel growth both directly and through its mediator iris specific molecule which they termed appears to be the only member of the 2 insulin-like growth factor 1 (IGF-1), oculoglycan and was later found to be LRR family of proteins present in the particularly during development, and identical with opticin.