Each year, an estimated 27 million cataract operations are carried out globally, making it one of the most common operations in the world.

While the procedure has often been accused of being politicised, cataract surgery is not a lifestyle choice; it saves sight. As the population ages, demand for cataract surgery continues to grow, and without capacity being scaled up, patients will need to wait even longer for surgery, adding further clinical risk to their outlook.

Cataracts are common

In Australia, it is estimated that 1.5 million people over the age of 55 suffer from cataracts; and they are the most common cause of vision loss among older Australians. Almost everyone will develop cataracts by the age of 80.

Whilst most common among the older generation, cataracts can also develop in younger people and some people are even born with the condition. An eye injury or previous surgery for another eye problem can also cause a cataract to develop.

In mild cases, stronger glasses or brighter reading lights may help initially, but most cataracts get gradually worse, and treatment will eventually be needed to avoid a significant reduction in a patient’s quality of life. Surgery is currently the only effective way to remove a cataract.

Most studies on the prevalence of cataracts report this is an increasing problem. The fact that more people are presenting with cataracts does not mean more people are living with it – the number reflects an increase in both awareness of the condition and accessibility of treatment, meaning more people are diagnosed and referred for surgery – but we know the share of older people among the population is growing, meaning the prevalence of cataracts will increase in the future.

What is clear also, is that the number of cataract removal procedures in hospital settings or dedicated eye clinics have increased substantially over the past decade. Government data shows that cataract removal is now one of the most common elective surgeries taking place nationally. The number of admissions to public hospitals for cataract extraction increased by 7% between 2015/16 and 2018/19, with over 70,000 people admitted each year, although activity fell temporarily due to Covid-19.

Data from insurance companies are echoing these findings. Medibank, for example, saw a 9.5% uplift in claims for cataract removal procedures between 2011 and 2017.

Surgery saves sight

Essentially a clouding of the clear lens in the eye, cataracts can cause symptoms such as blurred vision, glare sensitivity, distortion or double vision, and a feeling of looking through a veil or curtain. Cataracts are also the leading cause of blindness in the world, and living with cataracts means experiencing major changes to or loss of vision to an extent that restricts daily activities such as driving or reading.

Studies have shown that having cataracts can make people twice as likely to fall. A higher number of falls and accidents caused by poor vision can lead to more acute visits to emergency departments or put additional pressure on other parts of the healthcare system. People with poor vision are also more likely to suffer depression and increased social isolation because of their restricted mobility.

Thankfully, cataract surgery is a hugely successful procedure and the majority of patients are extremely pleased with the results, with some reporting additional benefits such as seeing colours more vibrantly and experiencing improved night vision. It is clear surgery can improve lives dramatically. But just how much of a difference can surgery make?

In 2019, a team of researchers in New Zealand attempted to quantify the improved quality of vision. The research team, from the University of Otago, Adapt Research and Tairawhiti District Health Board, used a driving simulator to test patients’ vision before and after cataract surgery in an attempt to gain a better understanding of the true benefit of cataract surgery. The results showed that near misses and crashes decreased by 48% after surgery.

As a non-urgent procedure, some cataract surgeries were postponed during Covid-19, and waiting lists built up as a result. It is usually not a problem to have a slightly longer wait for this type of procedure; but delays of six months or more can have a major impact on the quality of patients’ lives.

Waiting times are increasing

The benefits of cataract surgery, in terms of both value and patient outcomes, are high in comparison to some other health interventions, meaning that providing timely surgery and keeping on top of waiting lists is a good investment.

The latest national data, which includes March 2020 when the impact of the pandemic started to evolve, shows that the number of cataract procedures fell as a result of Covid-19. In total, 60,200 patients were admitted in 2019/20, down significantly on previous years.

More recent data for individual states paints a more comprehensive picture of the impact of Covid-19. In New South Wales, for example, the number of procedures performed fell substantially in Q2 2020, but saw a big increase in Q3, as a result of efforts to recover lost ground, including outsourcing to private hospitals which has allowed hospitals to operate above 100% usual capacity.

Source: NSW Health, Waiting List Collection On-line System

Although some states, including NSW, say they have now more or less caught up on waiting lists, waiting times have gradually increased for cataract surgery over time. Data has shown that cataract surgery had some of the longest waiting times after the initial temporary suspension.

The latest data available through the NSW Bureau of Health Information’s new portal shows the wait time for cataract extraction in NSW increased by 71 days between Q2 and Q3, to reach a median waiting time in September at 343 days. However, the private sector, in which many cataract operations take place, often have shorter waiting times.

Hidden referrals

In some states, there has been a ‘blitz’ on elective surgery, including cataract procedures, with funding packages being offered by state governments, and this has led to good progress in many areas..

But the reduction in referrals compared with before the pandemic is a concerning issue. There is a potentially large number of patients who have either not yet contacted a doctor about their symptoms, or not yet been referred to a specialist during the Covid-19 outbreak. In some states, hospitals have also been asked to reassess their referral lists and GPs have been asked to re-refer patients as elective surgery restarted, meaning patients may have come off or been moved further down the list.

Catching up on waiting lists doesn’t necessarily mean all those with cataracts are being treated. Some people take the view that, during the pandemic, many people have realised that can manage without surgery and therefore the ‘hidden backlog’ may never appear. But a more likely scenario is that people are suffering in silence and have put off reporting their symptoms or seeking care in fear of contracting Covid-19 or to avoid putting unnecessary pressure on the health system. Once people start to feel safe attending health settings again, demand could increase substantially.

Something else that impacts on the size of the waiting list is the access people have to healthcare. It appears that since the start of the pandemic, a large number of people have opted out of private health care because they can no longer afford it. Data from the Australian Prudential Regulation Authority shows that more than 10,000 people cancelled their policies in the first quarter of 2020 alone and basic hospital cover was at its lowest level in more than a decade.

Access is not equal

Access to healthcare can also depend on a patient’s geographical location. A recent study that was published in the NZ Medical Journal, for example, found that the percentage of referrals that were declined varied greatly by DHB, ranging from referring just over 50% that applied in one area, to 93% in another DHB. The survey covered all patients referred for cataract surgery between 2014 and 2019.

This was because each DHB sets a different threshold for surgery and has different resources, meaning people living in central Auckland could get cataract surgery more easily than those in Counties Manukau, for example. In general, people in cities were more likely to be referred than those in rural or remote areas.

In remote communities and among minority groups, access and take-up of treatment is also lower. The Roadmap to Close the Gap for Vision, was launched in 2012 following the National Indigenous Eye Health Survey results that showed Aboriginal and Torres Strait Island adults were six times more likely to experience blindness than other Australians.

In over 90% of cases, the vision loss was unnecessary, preventable or treatable, but more than a third had never had an eye exam. Although much progress has been made since then, with a 2015 survey showing the gap for blindness had halved and another finding outreach eye exams had tripled, there is still a lot of work to do in this area. Indigenous patients also face longer waits for the initial outpatient appointment.

Improving access to treatment

Both increasing capacity overall and improving access to these services are important. In other countries, such as the UK, mobile and modular facilities are being used to achieve both. While outsourcing to the private sector is an option, bringing a dedicated ophthalmic theatre onto the hospital site means greater control and increased flexibility.

It can allow a hospital to substantially scale up activity in terms of cataract surgery, even while continuing to treat Covid-19 patients within the hospital. The number of patients requiring cataract procedures is going to continue to increase as the older population gets larger so additional capacity will be needed, not just to tackle a temporary build up, but on a more ongoing basis.

Mobile operating theatres can also be used to provide greater access for patients in rural and remote areas, or to ‘blitz’ areas with lower demand, as they can be easily moved between locations and can be set up quickly in a new location.