Discussion
ISBCS offers benefits of convenience and cost-efficiency for patients, by reducing attendance at clinics/hospitals and postoperative recovery time.16 17 Similarly, it allows convenience and cost-efficiency to hospitals by decreasing patient visits15 and potentially improving OR productivity.18 With modern aseptic techniques and intracameral antibiotics, rare bilateral sight-threatening complications are very unlikely,11 whereas with modern biometric methodologies and careful preoperative patient selection and management, other complications are uncommon.12–14 During the current COVID-19 pandemic, it would be hoped that the adoption of ISBCS would allow the provision of CS while limiting hospital attendances, thereby reducing COVID-19 contagion risks for both patients and medical personnel alike. For these reasons in the UK and globally, the introduction of more routine ISBCS into CS management pathways is under consideration.22 Clearly, when introducing such new pathways, it is essential to fully engage medical personnel to ensure safety and efficacy. However, it is also vital to gauge patient opinion and acceptance. For this reason, we undertook this survey to elucidate patient attitudes/concerns with regard to ISBCS.
Most respondents were female individuals, which might be expected given that several studies have reported the cataract burden, possibly because of older age and reduced socioeconomic status, is increased in women.23 How this gender disparity might have influenced our results is undetermined, but male respondents were less likely to fear ISBCS. Increased fear of CS in women compared with men has been reported, with the experience of a good operative outcome in the first eye reducing fear of surgery on the second.24 This suggests that gender differences concerning fear of ISBCS might be expected and need to be taken into consideration with a wider ISBCS introduction.
Most respondents were aged 71 years or over, which is expected given the association of cataract with increasing age.25 Older patient groups were less likely to report being scared compared with younger groups, perhaps reflecting a greater degree of stoicism and possible acceptance of new medical interventions that warrant further investigation. Older patient age groups were less likely to need to minimise the time taken off work, conceivably reflecting that they were retired and not employed.
Almost half of the respondents had previously undergone CS in one eye and interestingly of these, 53% agreed/strongly agreed that they would opt for ISBCS if they had been given the choice, compared with 42% who had not yet undergone CS. This suggests that, as found in previous studies,24 the experience of a good outcome for CS in the first eye reduces fear of further ocular surgery, although differences in fear of ISBCS were not evident between pseudophakic and non-pseudophakic groups. However, it does indicate that approximately 50% of patients currently listed for DSBCS would prefer ISBCS and would opt for it given the choice by their surgeons.
Almost one-third reported previous ophthalmic problems. This might be expected given most were over the age of 71. Although not part of this survey, these problems were mainly pertaining to glaucoma and medical retina, which given the age ranges of our patients is expected. Having previous ophthalmic problems did not appear to influence attitudes towards ISBCS, suggesting that this is not an important factor when considering patient acceptance of ISBCS.
Just over half of the respondents agreed/strongly agreed that cataract was affecting the vision on both eyes, 53% of whom agreed/strongly agreed that they would opt for ISBCS (table 2). Interestingly, there was no difference between the degree of reported visual symptomology between patients with cataracts in both eyes and those who had previous CS in one eye, perhaps highlighting the known benefits of second eye surgery on QOL.6
For patients themselves and their family/carer/partner, just under half agreed/strongly agreed that they professed ISBCS as being convenient (table 2). As expected, perceived convenience for patients and family/carer/partners were strongly correlated. Perceived convenience was also strongly correlated to agreeing/strongly agreeing to opt for ISBCS if given a choice, suggesting that this is an important factor that patients consider for the adoption of ISBCS. No significant differences were noted in response to questions of convenience for family/carer/partners across different age groups, suggesting that it is not only the very elderly who rely on friends and family to access their hospital eye services and help them during their postoperative recovery.
Just under half of the respondents (45%) agreed/strongly agreed with opting for ISBCS if given the option (table 2). This was positively correlated to questions concerning convenience and limiting hospital visits. This quite high percentage is encouraging, suggesting the limited routine implementation of ISBCS in the National Health Service (NHS) is possible, with all its associated cost savings15–17 and potential for improving surgical productivity.18
Under a quarter agreed/strongly agreed that they had any familiarity with the concept of ISBCS (table 2). Although, there were no strong correlations between this factor and the other ISBCS questions, given the reported lack of knowledge of ISBCS, patient education in this area is required and further studies needed to see if by informing patients of the nature of ISBCS and the very small risk of bilateral sight-threatening complications, acceptance well above 50% can be achieved.
Almost two-thirds (64%) wanted to minimise their number of hospital visits for having both cataracts removed, which was strongly correlated with opting for ISBCS and to the patient and family convenience. This desire to reduce hospital/clinic visits appears to be a principal factor for patients in deciding whether to choose ISBCS or not. It is also an important factor in the cost reduction for ISBCS for patients and hospital services15–17 and during the current COVID-19 pandemic limitation of such face-to-face hospital/clinic visits, it is perceived as beneficial to minimise contagion risks for patients and medical personnel alike.
Only 29% agreed/strongly agreed that they wanted to minimise the time taken off work with 43% remaining neutral on the matter (table 2). This is surprising given that minimising time off work is an important factor in the cost-effectiveness of ISBCS.16 17 The economic cost of cataract accounts for as much as 20% of healthcare system costs in the UK, with lower productivity from lower workforce participation and absenteeism contributing to this figure.26 However, given the age of our CS population, most of whom are likely to be retired and not in employment, this low figure might be expected. It is also likely to be confounded by the fact that although some patients completed the survey prior to lockdown measures, the majority (almost 75%) completed it remotely by telephone when the lockdown was in place and at this time a lot of the working population were not in work/could not work, thus potentially influencing results pertaining to this question.
Almost half (47%) of the respondents agreed/strongly agreed that they were scared by the idea of ISBCS, which was strongly correlated to being less likely to opt for ISBCS if given the choice, finding ISBCS to be less convenient for themselves and most strongly with concerns about the risks of bilateral ocular complications. Indeed, half of the patients surveyed were concerned about bilateral complications (table 2). It appears that such worries are important barriers to patient acceptance of ISBCS. Fear of the unknown is a rational response and patient familiarity with ISBCS was, from our survey, limited. It might be hoped that patient education might lessen this factor. The risk of simultaneous bilateral complication is a valid fear, but reported bilateral sight-threatening complications with modern surgical approaches are very rare events, with one report finding only four cases over a 60-year period, each with identified breaches to the standard infection control protocol.11 Thus, patient education, with continued vigilance and strict adherence to aseptic protocols, is mandatory to help lessen such concerns. It is of note that the notion that a longer hospital visit on the day to have surgery on both eyes in the same sitting did not appear to be a significant barrier to ISBCS acceptance with only a fifth of patients seeing it as a concern (table 2)
This survey was commenced in January 2020. Unfortunately, it was interrupted by the COVID-19 pandemic becoming evident in the UK. Prior to the pandemic, the patients completed the survey face to face. After lockdown measures were introduced, this was not possible and we conducted the survey remotely by telephone. Although this is not ideal and has to be taken into consideration when interpreting some of our results, it also provided a very unique opportunity to gauge how some opinions might be altered by the lockdown measures and the COVID-19 pandemic. It is of interest that in the lockdown period, patients were less likely to report their cataracts as symptomatic. This may relate to the coronavirus pandemic serving as a distraction away from their other health needs. Certainly, there has been concern reported in the media of patients not accessing healthcare services in the UK, for potentially life-threatening medical conditions such as cancer.27 In addition, in the lockdown, patients were less likely to report a need to minimise the time off work and were less intolerant of a longer hospital visit on the day, which might reflect a change due to many individuals working from home and many on ‘furlough’. Interestingly, there was not a significant difference in responses to the question of minimising hospital visits when comparing prelockdown and postlockdown responses (p=0.86), as we might have expected a difference, based on possible fears concerning contracting COVID-19 travelling to, from and during hospital appointments.
Our results indicate that ISBCS was acceptable to 45% of our sampled population, suggesting that the limited routine implementation of ISBCS in the NHS is possible. This is important, as ISBCS is being considered as part of the logistical and economic solution to the anticipated challenges faced by stretched CS services in the post-COVID-19 era. Convenience to patients and their carers/family/relatives and reduction in the number of hospital visits appeared to be important factors contributing to this acceptance. Half of the patients expressed concern regarding bilateral complications, which was strongly correlated with fear of ISBCS. Such concerns need addressing and might be addressed by patient education with regards to the rarity of such events. The familiarity of the concept of ISBCS is low, highlighting the need for patient education. Some attitudes did appear to change during the COVID-19 lockdown period, which requires further elucidation.
