Quality of Care in Cataract Surgery Management

• A thorough history of the patient should be obtained before surgery, including past ocular and medical history, use of medications, history of allergies, and previous ocular surgeries.

• All patients should undergo a preoperative comprehensive eye examination, to confirm the indication for surgery and to tailor their perioperative care plan.
• Accurate evaluation of preoperative presenting visual acuity and best corrected visual acuity should be obtained in order to monitor postoperative visual acuity improvement. The diagnosis of visually significant cataract should be based ideally on symptoms that include blur, glare, and refractive change, and not visual acuity alone.
• Decisions about surgery should be discussed with patients and be based on their visual needs and preferences for daily life activities, such as working, reading and driving.

• Ocular comorbidities that may affect surgery outcomes should be managed appropriately ahead of surgery.
• Ocular conditions that require extra equipment or an experienced surgeon (e.g. pseudoexfoliation or zonular weakness) should be identified and prepared for appropriately ahead of surgery to ensure surgical safety.
• Ocular comorbidities impacting visual outcomes or surgical complexity should be discussed with the patient before surgery

General medical assessment

• The basic cognitive function required by a patient to cooperate during surgery and postoperative care should be determined.
• Preoperative medical examinations and laboratory investigations, as appropriate, should be performed according to the patient’s status, symptoms, and medical conditions.

Management of systemic comorbidities

• Active infection should be managed before proceeding with surgery.
• Blood pressure and blood glucose should be tested and recorded; both should be within acceptable limits.
• Uncontrolled systemic conditions, such as high blood glucose, coronary heart disease, or severe hypertension, should be properly treated and stabilized before surgery to avoid intraoperative and postoperative complications.

Medication management

• Systemic medications should be carefully considered and managed close to surgery in consultation with other care providers.

• Personalized counselling should be provided to the patient before they give their consent to ensure that detailed information about the surgery, such as anaesthesia type, expected outcomes, and potential risks, have been clearly communicated and understood.
• An informed consent form should be signed by the patient prior to surgery, indicating that the patient understands the information provided and voluntarily agrees to proceed with the procedure.
• It must be ensured that the patient understands the information being provided, and a translator, interpreter, or reader should be available if necessary. For vulnerable people who cannot consent, it is essential to obtain consent from the appropriate authority (for example, carer/family member) for the surgery.
• The informed consent form should be written in plain language. At a minimum, this document must contain: the patient identification; description of the condition and the procedure; potential benefits; possible risks and complications; IOL options; alternatives to the intervention; and postoperative expectations.
• Patients should also confirm they had the opportunity to clarify any concerns and ask questions, receiving satisfactory answers.

• Possible wait times for surgery, and the factors affecting delays, should be communicated to patients.
• Prioritization for surgery may be scheduled (e.g. for high-risk patients, such as those with monocular vision, serious ocular comorbidities, or patients who struggle with independent living)

• The clinical and visual status, and the needs and of the patient, should be considered when planning the timing of cataract surgery for the second eye.
• In general, cataract surgery for the second eye follows that for the first eye after a period of one week. This is to closely monitor for any complications, such as endophthalmitis, before second surgery is performed.
• The benefits and risks of immediate sequential bilateral cataract surgery (ISBCS) versus delayed second eye surgery should be made clear, to allow patients to make informed decisions. ISBCS may be considered an option for patients who have significant barriers to surgery, such as those needing general anaesthesia, or those with serious travel constraints.
• ISBCS should be recommended only in settings where strict control measures against infection are consistently assured; the high risks involved should never be neglected.

Biometry and measurements

• Reliable axial length measurements should be mandatory for all patients who plan to undergo cataract surgery. Wherever feasible, optical biometry should be considered for all patients as a first-line method for measuring axial length. Ultrasound A-scan biometry remains an effective option to obtain reliable axial length measurements, where optical biometry is not available or not feasible due to significant lens opacity.
• Reliable keratometry measurements should be obtained for all patients. As far as possible, measurements should be performed before any eye drops are instilled or intraocular pressure is measured.
• Evidence-based protocols should be followed when measuring axial length and keratometry.

Equipment maintenance and calibration

• Manufacturer’s recommendations for the maintenance and calibration of optical biometry equipment should be regularly followed to maintain accuracy.

Intraocular lens selection

• Wherever feasible, the decision about the selection of intraocular lens type, material, and power should take into account the patient’s visual goals and preferences.

• Preoperative topical antibiotic use is not routinely recommended.

• Recommendations for maintaining safe operating theatres, including for surgical procedures, infection control and sterilization, should adhere to national and international standards, and be in line with manufacturer’s guidelines. (Additional information is provided in the list of resources in Annex 3.)
• The sterilization of operating theatres should be integrated into infection control programmes and carried out by trained personnel.
• The safety of operating theatres, in terms of design and maintenance, must be ensured. This includes ventilation/cooling systems, sharps disposal bins, and back-up power supply.
• Staff must be immunized against diseases relevant to the locality.
• Safe and adequate staffing levels must be ensured for the size and duration of the daily operation list and complexity of cases.
• The maintenance and sterilization procedures of operating instruments must consider the volume of surgery lists.
• Document sterilization processes for monitoring purposes (e.g., in case of post-operative infections)

• Ensure application of povidone-iodine or chlorhexidine prior to surgery and ensure that adequate supplies are available for the planned volume of surgeries.

• Reusable sterilized drapes and equipment can be a cost–effective alternative to single-use items. However appropriate sterilization protocols must be adhered to, as set out in WHO’s guidelines on decontamination and reprocessing of medical devices for health-care facilities.

• Disposable drapes and single-use sterile instruments may be considered, if resources permit, to reduce preparation time without compromising sterility. Planning for environmentally-respectful disposal should be considered.

• A structured timeout verification list including key information such as the patient’s name, targeted eye to be operated, procedure, intraocular lens type and power should be used to avoid incorrect surgical events.
• The WHO surgical safety checklist may be modified to include a cataract surgery checklist and be integrated into broader patient safety programmes.

• The choice of anaesthesia type should be determined by the surgeon taking into consideration the patient’s needs and circumstances.
• The choice of anaesthesia type should be discussed with the patient to ensure they are informed of, and understand, the potential outcomes and risks.
• Topical anaesthesia is a safe and cost–effective option, requiring fewer procedural steps than general anaesthesia and reducing the need for additional instruments.
• Surgeons should receive proper training on peribulbar and retrobulbar anaesthesia techniques as these reduce the risk of globe perforation.
• When general anaesthesia is recommended, the availability of trained personnel and adequate equipment, such as resuscitation devices and medication, should be ensured.

• Phacoemulsification, small-incision cataract surgery, and extracapsular cataract extraction, are all acceptable surgical techniques for cataract removal.
• The choice of technique should be guided by the patient’s clinical condition, resource availability and surgeon expertise.
• The surgeon should explain to the patient, as appropriate, the benefits and risks of all available surgical options.
• In low- and intermediate-resource settings, extracapsular cataract extraction and small-incision cataract surgery are the most performed techniques, presenting the advantages of a good safety profile, a relatively simple technique, low cost, and low dependence on costly devices.

• Intracameral antibiotic injections should be used as standard practice to prevent endophthalmitis.
• Both intracameral antibiotic cefuroxime and moxifloxacin are equally effective in preventing endophthalmitis.
• The use of commercially-available intracameral antibiotics (such as cefuroxime and moxifloxacin) should be preferred over locally-compounded solutions, to minimize the risk of endophthalmitis, toxic anterior segment syndrome, or retinal toxicity.

• Intraoperative complications and the mechanisms for monitoring complication rates should be documented.
• Clear guidelines should be adopted on how to manage common
• complications, such as posterior capsule rupture, vitreous loss, and dropped nucleus. An anterior vitrectomy machine should be available.
• Access to vitreoretinal surgery should be ensured so that complications requiring vitreoretinal surgery can be addressed within 24 hours.
• For complications with anaesthesia, close coordination between surgeons, anaesthetists, and nursing staff is crucial to enhance timely response and improve outcomes.
• It is important to match the expected surgical complexity with the surgeon’s experience using standardized cataract grading and complexity system (30).
• For low-risk patients, whose surgery may be assigned to senior trainees, a more experienced surgeon should be at hand to complete the procedure should unexpected complications arise.

Postoperative antibiotic eye drops

• Postoperative topical antibiotics are used as standard practice to reduce the risk of infection. Decisions on the type, frequency, and duration of antibiotic use should be made based on the patient’s risk of infection and the current patterns of antimicrobial resistance of the common ocular pathogens.

Postoperative anti-inflammatory eye drops

• Steroid eye drops are used as standard practice for all patients to reduce the risk of inflammation. The frequency and duration of steroid eye drops should be tailored based on the patient’s risk of postoperative inflammation, such as in diabetic patients, and the postoperative status of the eye.
• A tapering regimen is recommended for the use of steroid eye drops, starting with high-frequency doses, followed by gradual withdrawal to ensure effectiveness while reducing the risk of steroid-induced glaucoma.
• A combined regimen of anti-inflammatory eye drops, such as steroids and nonsteroidal anti-inflammatory drugs (NSAIDs), should be considered for patients at high risk of developing cystoid macular oedema.

Postoperative eye pad/shield

• A sterile eye pad or shield can be used to maintain wound healing postoperatively for a time period based on the patient’s potential risks.

Frequency of follow-up visit

• The frequency of postoperative follow-up visits should be scheduled based on the patient’s risks and needs.
• All patients are normally examined at 24–48 hours following surgery to check wound integrity and inflammation.
• A follow-up visit at 1 week after surgery is commonly recommended in practice guidelines to check visual acuity, intraocular pressure, and wound healing. Postoperative care can be modified depending on the findings.
• A follow-up visit 4–6 weeks after surgery is recommended in practice guidelines to evaluate visual acuity and address the need for refractive correction for both distance and near vision.

Special considerations

• In patients with high-risk conditions, such as monocular vision, glaucomatous eyes, or surgical complications, it is strongly recommended that examinations take place within 24 hours after surgery and additional follow-up visits can be considered.
• In the event of an outbreak of endophthalmitis, additional follow-up visits should be considered.

• Surgical outcomes can be monitored through patient satisfaction surveys and patient reported outcome measures. This ensures that both subjective (patient feedback) and objective (visual acuity) aspects of postoperative care are considered.
• Key postoperative outcome data, such as postoperative visual acuity, should be integrated within facility health information systems and be used by providers to audit outcomes.
• Modified from previous WHO guidance, the benchmark of ≥80% should be considered for the percentage of patients attaining a postoperative presenting visual acuity of 6/12 or better, tested between 4 and 12 weeks postoperatively.

• Patient counselling is important if complications occur during surgery. Patients should be engaged in a discussion about the next steps.
• Patients and caregivers should be instructed to contact the surgeon, or the hospital, directly if the patient develops symptoms that require immediate attention, such as sudden reduced vision; pain or increased redness in the eye; or other red flags that could indicate endophthalmitis. A referral pathway must be agreed with patients to ensure timely advice and treatment for any potential postoperative complications.
• Specific benchmarks or targets for intraoperative and postoperative complication rates (for example, capsule rupture, vitreous loss, endophthalmitis incidence, corneal oedema) should be based on local evidence-based criteria or by using clinical practice guidelines as a reference.