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Cataracts

About

What is covered

This NICE Pathway covers managing cataracts in adults aged 18 and over. It aims to improve care before, during and after cataract surgery by optimising service organisation, referral and surgical management, and reducing complications. It further aims to improve the availability of information for people with cataracts before, during and after cataract surgery.

Updates

Updates to this NICE Pathway

11 February 2019 Serious eye disorders (NICE quality standard 180) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on cataracts in adults in an interactive flowchart

What is covered

This NICE Pathway covers managing cataracts in adults aged 18 and over. It aims to improve care before, during and after cataract surgery by optimising service organisation, referral and surgical management, and reducing complications. It further aims to improve the availability of information for people with cataracts before, during and after cataract surgery.

Updates

Updates to this NICE Pathway

11 February 2019 Serious eye disorders (NICE quality standard 180) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Cataracts in adults: management (2017) NICE guideline NG77
Implantation of multifocal (non-accommodative) intraocular lenses during cataract surgery (2008) NICE interventional procedures guidance 264
Implantation of accommodating intraocular lenses for cataract (2007) NICE interventional procedures guidance 209
Serious eye disorders (2019) NICE quality standard 180

Quality standards

Serious eye disorders

These quality statements are taken from the serious eye disorders quality standard. The quality standard defines clinical best practice for serious eye disorders and should be read in full.
1Referral – chronic open angle glaucoma and related conditions
2Referral for cataract surgery
3Treatment – late age-related macular degeneration (wet active)
4Monitoring late age-related macular degeneration (wet active)
5Reassessment – chronic open angle glaucoma or related conditions
6Certificate of vision impairment

Quality statements

Referral – chronic open angle glaucoma and related conditions

This quality statement is taken from the serious eye disorders quality standard. The quality standard defines clinical best practice for serious eye disorders and should be read in full.

Quality statement

Adults with signs of possible glaucoma or related conditions on a routine sight test have additional tests before they are referred for a diagnosis.

Rationale

Accurate diagnosis of chronic open angle glaucoma (COAG) or related conditions is important because they can lead to irreversible damage to the optic nerve and sight loss. As well as the routine sight test, additional tests are needed for people with possible glaucoma to support more accurate referrals for further investigation and diagnosis. They ensure that adults with COAG or related conditions have prompt diagnosis and treatment and people who do not need referral avoid unnecessary investigations.

Quality measures

Structure
a) Evidence of the availability of equipment for performing the additional tests needed before referral for further investigation and diagnosis of COAG or related conditions.
Data source: Local data collection, for example, service specifications.
b) Evidence of the availability of staff trained to perform the additional tests needed before referral for further investigation and diagnosis of COAG or related conditions.
Data source: Local data collection, for example, staff rotas and staff training records.
Process
Proportion of adults with signs of possible glaucoma on a routine sight test who had additional tests before referral for further investigation and diagnosis of COAG or related conditions.
Numerator – the number in the denominator who had additional tests before referral for further investigation and diagnosis of COAG or related conditions.
Denominator – the number of adults with signs of possible glaucoma on a routine sight test referred for further investigation and diagnosis of COAG or related conditions.
Data source: Local data collection, for example, patient records and referral records.
Outcome
Rates of false-positive referrals for further investigation and diagnosis of COAG or related conditions.
Data source: Local data collection, for example, patient records and referral records.

What the quality statement means for different audiences

Service providers (such as community optometry services) ensure that equipment, staff training and local referral pathways support adults with possible glaucoma to have additional tests after the routine sight test and before referral for further investigation and diagnosis of COAG or related conditions.
Healthcare professionals (such as community optometrists) ensure additional tests are performed when signs of possible glaucoma are detected on a routine sight test and refer on the basis of these results.
Commissioners (clinical commissioning groups and NHS England) ensure that services have agreed protocols and ensure service availability to support accurate referral into hospital eye services for adults with possible COAG or related conditions. They monitor referrals.
Adults with possible glaucoma have a range of tests after the routine sight test and before they are referred to hospital eye services. This means that only people needing further investigations are referred, which may reduce waiting times.

Source guidance

Glaucoma: diagnosis and management. NICE guideline NG81 (2017), recommendation 1.1.1

Definitions of terms used in this quality statement

Possible glaucoma or related conditions
Signs of possible glaucoma or related conditions include:
  • a glaucomatous-type visual field defect
  • visible structural damage to the optic nerve head
  • an intraocular pressure of 24 mmHg or more.
[Adapted from NICE’s guideline on glaucoma, recommendation 1.1.5, and expert opinion]
Additional tests
If a routine sight test suggests signs of possible glaucoma, all of the following additional tests should be undertaken before referral:
  • central visual field assessment using standard automated perimetry (full threshold or supra threshold)
  • optic nerve assessment and fundus examination using stereoscopic slit lamp biomicroscopy (with pupil dilatation if necessary), and optical coherence tomography (OCT) or optic nerve head image if available
  • intraocular pressure measurement using Goldmann-type applanation tonometry
  • peripheral anterior chamber configuration and depth assessments using gonioscopy or, if not available or the person prefers, the van Herick test or OCT.
[NICE’s guideline on glaucoma, recommendation 1.1.1]

Referral for cataract surgery

This quality statement is taken from the serious eye disorders quality standard. The quality standard defines clinical best practice for serious eye disorders and should be read in full.

Quality statement

Adults with cataracts are not refused surgery based on visual acuity alone.

Rationale

The decision to undertake cataract surgery should be based on discussions with the person about the effect of cataract on their quality of life, the risks and benefits of surgery and what may happen if they choose not to have surgery. Measurement of visual acuity often fails to detect vision problems that may benefit from cataract surgery (for example, glare and loss of colour vision). The decision should include consideration of a patient’s quality of life and symptoms such as difficulty with reading, night driving, work or home activities, glare and loss of contrast, despite appropriate optical correction. Restricting access to surgery based on visual acuity alone has an impact on quality of life for some people with cataracts. The decision to undertake cataract surgery should be made on the same basis for first and second eyes.

Quality measures

Structure
Evidence of local agreements to include vision difficulties affecting quality of life in the criteria for referral and access to cataract surgery. The same criteria should be used for first- and second-eye cataract surgery.
Data source: Local data collection, for example, service specifications and local commissioning agreements for cataract surgery.
Process
a) Proportion of presentations of cataract where the person has a discussion about how their vision affects their quality of life.
Numerator – the number in the denominator where the person has a discussion about how their vision affects their quality of life.
Denominator – the number of presentations of cataract.
Data source: Local data collection, for example, patient records.
b) Proportion of presentations of cataract that are refused referral for surgery based on visual acuity alone.
Numerator – the number in the denominator that are refused referral for surgery based on visual acuity alone.
Denominator – the number of presentations of cataract.
Data source: Local data collection, for example, patient records or referral records.
c) Proportion of referrals for cataract surgery that are not accepted based on visual acuity alone.
Numerator – the number in the denominator that are not accepted based on visual acuity alone.
Denominator – the number of referrals for cataract surgery.
Data source: Local data collection, for example, patient records or referral records.
Outcome
Health-related quality of life for adults with cataracts.
Data source: Local data collection, for example, results from a questionnaire or patient-reported outcome measure on self-reported improvement after surgery, such as the Cat-PROM5 questionnaire (National Cataract Surgery Audit – Cat-PROM5 currently being piloted).

What the quality statement means for different audiences

Service providers (such as community optometry practices, referral management centres and NHS hospital trusts) ensure that referral pathways for cataract surgery are based on criteria that include vision difficulties affecting quality of life, and not just visual acuity alone. The decision to undertake cataract surgery should be made on the same basis for first and second eyes.
Healthcare professionals (such as ophthalmologists, optometrists, orthoptists and advanced nurse practitioners) base decisions about cataract surgery on a discussion with the person of the impact of the cataract(s) on their quality of life and the risks and benefits of having, and not having, surgery. Visual acuity should not be used as the sole basis for deciding to refer for or perform surgery. The decision to undertake cataract surgery should be made on the same basis for first and second eyes.
Commissioners (clinical commissioning groups and NHS England) commission services that provide access for adults to cataract surgery based on criteria other than visual acuity alone. The other criteria include vision difficulties affecting quality of life. They monitor services to ensure that this is happening. The decision to undertake cataract surgery should be made on the same basis for first and second eyes.
Adults with cataracts are involved in discussion of how cataracts affect their everyday life, how they affect their vision, the risks and benefits of surgery, and what would happen if they chose not to have surgery. Referral for cataract surgery is based on this discussion, and not only on the clarity and sharpness (particularly fine details) with which they can see objects. The decision to perform cataract surgery on the second eye should be made on the same basis.

Source guidance

Cataracts in adults: management. NICE guideline NG77 (2017), recommendations 1.2.1 and 1.2.2

Definitions of terms used in this quality statement

Based on visual acuity alone
The decision to refer an adult with cataracts for surgery should be based on a discussion with the person of the issues listed below, not on visual acuity alone:
  • how the cataract affects the person's vision and quality of life
  • whether 1 or both eyes are affected
  • what cataract surgery involves, including possible risks and benefits
  • how the person's quality of life may be affected if they choose not to have cataract surgery
  • whether the person wants to have cataract surgery.
[NICE’s guideline on cataracts in adults, recommendation 1.2.1]

Treatment – late age-related macular degeneration (wet active)

This quality statement is taken from the serious eye disorders quality standard. The quality standard defines clinical best practice for serious eye disorders and should be read in full.

Quality statement

Adults with late age-related macular degeneration (AMD) (wet active) start treatment within 14 days of referral to the macular service.

Rationale

Late AMD (wet active) can deteriorate rapidly. Any delay to starting treatment may lead to a worsening of outcomes over the long term. Minimising delays in starting treatment increases the chances of preserving vision and so quality of life.

Quality measures

Structure
Evidence of local arrangements and clinical protocols to ensure that adults with late AMD (wet active) start treatment within 14 days of referral to the macular service.
Data source: Local data collection, for example, referral pathways.
Process
Proportion of adults with late AMD (wet active) who start treatment within 14 days of referral to the macular service.
Numerator – the number in the denominator who start treatment within 14 days.
Denominator – the number of adults with late AMD (wet active) referred to the macular service.
Data source: Local data collection, for example, patient records, referral records and appointment systems.
Outcomes
a) Loss of vision (changes to visual acuity) of people with late AMD (wet active).
Data source: Database audit – National Electronic AMD Audit feasibility report contains: mean change in visual acuity between baseline and month 12 (figure 7) and percentage of eyes losing ≥3 LogMAR lines between baseline and month 12 (figure 8). Data, collected from 40 centres dating from January 2012 to December 2013 (8 had low numbers and the data were excluded) were last collected in 2016. Available from the National Ophthalmology Database Audit.
b) Health-related quality of life of adults with late AMD (wet active).
Data source: Local data collection, for example, a questionnaire.

What the quality statement means for different audiences

Service providers (NHS hospital trusts) have agreed protocols to ensure that adults with late AMD (wet active) start treatment within 14 days of referral to the macular service.
Healthcare professionals (such as ophthalmologists, advanced nurse practitioners, optometrists and orthoptists working in secondary care) treating late AMD (wet active) in adults adhere to local protocols and start treatment within 14 days of referral to the macular service.
Commissioners (clinical commissioning groups) monitor providers to ensure that treatment for adults with late AMD (wet active) starts within 14 days of referral to the macular service.
Adults with late AMD (wet active) start their treatment within 14 days of being referred to the specialist service so that they have the best possible chance of keeping their sight.

Source guidance

Age-related macular degeneration. NICE guideline NG82 (2018), recommendation 1.4.10

Monitoring late age-related macular degeneration (wet active)

This quality statement is taken from the serious eye disorders quality standard. The quality standard defines clinical best practice for serious eye disorders and should be read in full.

Quality statement

Adults with late age-related macular degeneration (AMD) (wet active) have monitoring for both eyes.

Rationale

Monitoring of late AMD (wet active) in both eyes is important for identifying changes that are associated with the condition. Monitoring supports treatment planning, which helps to avoid under-treatment, which could result in loss of vision, and over-treatment (unnecessary anti-VEGF injections), which could be associated with harm and affect quality of life. The interval between appointments should be determined by the healthcare professional responsible for planning the person’s care.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with late AMD (wet active) have monitoring for both eyes.
Data source: Local data collection, for example, service specifications and local protocols for monitoring appointments for adults with late AMD (wet active).
Process
a) Proportion of adults with late AMD (wet active) who have a monitoring appointment scheduled.
Numerator – the number in the denominator who have a monitoring appointment scheduled.
Denominator – the number of adults with late AMD (wet active).
Data source: Local data collection, for example, patient records and appointment systems.
b) Proportion of scheduled monitoring appointments for adults with late AMD (wet active) that are cancelled or delayed by the hospital.
Numerator – the number in the denominator that are cancelled or delayed by the hospital.
Denominator – the number of scheduled monitoring appointments for adults with late AMD (wet active).
Data source: Local data collection, for example, patient records and appointment systems.
c) Proportion of hospital appointments for adults with late AMD (wet active) that occur within 25% of their intended monitoring period, including rescheduling of hospital cancellations and non-attendance by adults with late AMD (wet active).
Numerator – the number in the denominator that occur within 25% of their intended monitoring period.
Denominator – the number of monitoring appointments scheduled, including those rescheduled after hospital-initiated cancellation and non-attendance by adults with late AMD (wet active).
Data source: Local data collection: Portfolio of Indicators for eye health and care - indicator 11 for the System and assurance framework for eye health (SAFE), which has been adopted as an outcome measure by NHS England's Elective care transformation programme: Transforming elective care services: ophthalmology.
Outcome
Loss of vision (changes to visual acuity) in adults with late AMD (wet active).
Data source: Database audit – National Electronic AMD Audit feasibility report contains: mean change in visual acuity between baseline and month 12 (figure 7), percentage of eyes losing ≥3 LogMAR lines between baseline and month 12 (figure 8), visual acuity change from month 3 to month 12 (figure 10) and percentage of patients retaining visual acuity of 70 letters/LogMAR visual acuity of 0.3 or better (at 1 year; figure 11). Data, collected from 40 centres dating from January 2012 to December 2013 (8 had low numbers and the data were excluded) were last collected in 2016. Available from the National Ophthalmology Database Audit.

What the quality statement means for different audiences

Service providers (NHS hospital trusts) ensure that they have agreed protocols for adults with late AMD (wet active) to have monitoring of both eyes at clinically appropriate intervals determined by the healthcare professional responsible for planning their care.
Healthcare professionals (such as ophthalmologists, advanced nurse practitioners, optometrists and orthoptists working in secondary care) monitor both eyes of adults with late AMD (wet active) at intervals determined by the healthcare professional responsible for planning their care.
Commissioners (clinical commissioning groups) ensure that services provide monitoring of both eyes for adults with late AMD (wet active) at intervals determined by the healthcare professional responsible for planning their care.
Adults with late AMD (wet active) have both their eyes monitored regularly so that treatment can be planned to preserve their sight and quality of life. The time between appointments is determined by the healthcare professional responsible for planning their care.

Source guidance

Age-related macular degeneration. NICE guideline NG82 (2018), recommendation 1.7.8

Reassessment – chronic open angle glaucoma or related conditions

This quality statement is taken from the serious eye disorders quality standard. The quality standard defines clinical best practice for serious eye disorders and should be read in full.

Quality statement

Adults with chronic open angle glaucoma (COAG) or related conditions have reassessment at specific intervals.

Rationale

Reassessment is important for identifying clinically significant changes in adults with COAG or adults at risk of conversion from ocular hypertension (OHT) or suspected COAG to COAG. Reassessment also supports maintaining a consistent intraocular pressure (IOP). Providing tailored treatment in response to disease progression and maintaining IOP levels reduces the risk of significant sight loss, and reduced quality of life.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with COAG or related conditions have reassessment appointments scheduled at specific intervals, according to their risk of conversion to COAG or progression to sight loss.
Data source: Local data collection, for example, service specifications and local protocols.
Process
a) Proportion of adults with COAG or related conditions who have reassessment at specific intervals.
Numerator – the number in the denominator who have reassessment at specific intervals.
Denominator – the number of adults with COAG or related conditions.
Data source: Local data collection, for example, patient records and appointment systems.
b) Proportion of scheduled reassessment appointments for COAG or related conditions that are cancelled or delayed by the service provider.
Numerator – the number in the denominator that are cancelled or delayed by the service provider.
Denominator – the number of scheduled reassessment appointments for COAG or related conditions.
Data source: Local data collection, for example, patient records and appointment systems.
c) Proportion of hospital appointments for adults with COAG or related conditions that occur within 25% of their intended reassessment period, including rescheduling of hospital cancellations and non-attendance by adults with COAG or related conditions.
Numerator – the number in the denominator that occur within 25% of their intended reassessment period.
Denominator – the number of reassessment appointments scheduled, including those rescheduled after hospital-initiated cancellation and non-attendance by adults with COAG or related conditions.
Data source: Local data collection: Portfolio of Indicators for eye health and care - indicator 11 for the System and assurance framework for eye health (SAFE), which has been adopted as an outcome measure by NHS England's Elective care transformation programme: Transforming elective care services: ophthalmology.
Outcomes
a) Loss of vision for adults with COAG or related conditions (visual field loss, changes to visual acuity).
Data source: Database audit – National Electronic Glaucoma Surgery and Visual Field Preservation Audit feasibility report contains: rates of visual field loss in the worst eyes (figure 44), speed of visual field progression (figure 45), and loss of sight years (table 11). Data were last collected in 2015 from 5 major glaucoma centres. Available from the National Ophthalmology Database Audit.
Local data collection, for example, patient records and local ophthalmology records of patient safety incidents.
b) Health-related quality of life for adults with COAG or related conditions.
Data source: Local data collection, for example, a questionnaire.

What the quality statement means for different audiences

Service providers (NHS hospital trusts and community optometry services) have agreed protocols to ensure that adults with COAG or related conditions have reassessment at specific intervals, according to their risk of progressive sight loss.
Healthcare professionals (such as ophthalmologists, advanced nurse practitioners, optometrists and orthoptists) carry out reassessment for adults with COAG or related conditions at specific, clinically appropriate intervals, according to their risk of progressive sight loss.
Commissioners (clinical commissioning groups) ensure that services provide reassessment for adults with COAG or related conditions at specific intervals, according to their risk of progressive sight loss.
Adults with glaucoma, suspected glaucoma or ocular hypertension have regular assessments to minimise their risk of sight loss. How often they have an assessment will depend on how well the treatment seems to be working.

Source guidance

Glaucoma: diagnosis and management. NICE guideline NG81 (2017), recommendations 1.4.9, 1.4.11, 1.4.12 and 1.4.13

Definitions of terms used in this quality statement

Specific intervals for reassessment of COAG or related conditions
Specific intervals for reassessment depend on the risk of progression to sight loss, as set out in tables 1 to 3 of NICE’s guideline on glaucoma. Clinical judgement is used to decide when the next appointment should take place within the recommended interval.

Certificate of vision impairment

This quality statement is taken from the serious eye disorders quality standard. The quality standard defines clinical best practice for serious eye disorders and should be read in full.

Quality statement

Adults with serious eye disorders are given a certificate of vision impairment (CVI) as soon as they are eligible.

Rationale

A CVI allows easier access to services and support for adults with serious eye disorders. Making a person aware of the benefits associated with a CVI, and giving them the choice of having a CVI as soon as they are eligible, rather than waiting for treatment to finish, allows earlier access to services and support. This can help people retain or regain their independence and improve their wellbeing and quality of life.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with serious eye disorders are given information about the CVI and those meeting the eligibility criteria are given a certificate.
Data source: Local data collection, for example, a service protocol.
Process
Proportion of adults with serious eye disorders that meet the eligibility criteria for a CVI who are given a CVI.
Numerator – the number in the denominator who are given a CVI.
Denominator – the number of adults with serious eye disorders that meet the eligibility criteria for a CVI.
Data source: Local data collection, for example, patient records.
Outcome
Health-related quality of life for adults with serious eye disorders.
Data source: Local data collection, for example, a questionnaire.

What the quality statement means for different audiences

Service providers (NHS hospital trusts and community optometry practices) have systems in place to ensure that adults with serious eye disorders are given information about the support and services associated with certification. They ensure that adults can engage in the process as soon as they meet the eligibility criteria, including while they are having treatment. Services make sure people know about the benefits of certification, and know that they have a choice to have a CVI or not.
Healthcare professionals (optometrists, and ophthalmologists, orthoptists and nurses working in secondary care) make sure that people with serious eye disorders know about the benefits of certification and that they can have a CVI if they choose as soon as they are eligible. This includes while they are having treatment. Professionals give information about the support and services associated with certification. Ophthalmologists sign the certificate to formally certify adults with serious eye disorders as visually impaired.
Commissioners (clinical commissioning groups) ensure that providers have the capacity and resources to give information about the support and services associated with certification to adults with serious eye disorders as soon as they meet the eligibility criteria.
Adults with serious eye disorders are given a certificate of vision impairment as soon as they are eligible. This may be while they are still having treatment. They are also told about support and services, which can help them improve or regain their independence and wellbeing.

Source guidance

Definitions of terms used in this quality statement

Certificate of vision impairment
See the Department of Health and Social Care’s Certificate of vision impairment: explanatory notes for consultant ophthalmologists and hospital eye clinic staff in England, executive summary, sections 4, 9, 21, 29 to 34 inclusive.

Equality and diversity considerations

Healthcare professionals should adapt their communication to the needs of adults with sight difficulties so that they have the opportunity to be involved in decisions relating to certification of vision impairment. This includes being made aware of the benefits associated with having a CVI.
Physical or learning disabilities, hearing problems and difficulties with reading or speaking English, which may affect the patient's involvement in the consultation, should also be considered.
For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.
Cataracts in adults: management
Treating cataracts by implanting multifocal lenses
Treating cataracts with implantable accommodating lenses

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

non-steroidal anti-inflammatory drugs

Paths in this pathway

Pathway created: October 2017 Last updated: October 2020

© NICE 2021. All rights reserved. Subject to Notice of rights.

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