Cataract risk stratification and prioritisation protocol in the COVID-19 era

BackgroundThe COVID-19 pandemic halted non-emergency surgery across Scotland. Measures to mitigate the risks of transmitting COVID-19 are creating significant challenges to restarting all surgical services safely. We describe the development of a risk stratification tool to prioritise patients for cataract surgery taking account both specific risk factors for poor outcome from COVID-19 infection as well as surgical 'need'. In addition we report the demographics and comorbidities of patients on our waiting list.MethodsA prospective case review of electronic records was performed. A risk stratification tool was developed based on review of available literature on systemic risk factors for poor outcome from COVID-19 infection as well as a surgical 'need' score. Scores derived from the tool were used to generate 6 risk profile groups to allow prioritised allocation of surgery.ResultsThere were 744 patients awaiting cataract surgery of which 66 (8.9%) patients were 'shielding'. One hundred and thirty-two (19.5%) patients had no systemic comorbidities, 218 (32.1%) patients had 1 relevant systemic comorbidity and 316 (46.5%) patients had 2 or more comorbidities. Five hundred and ninety patients (88.7%) did not have significant ocular comorbidities. Using the risk stratification tool, 171 (23%) patients were allocated in the highest 3 priority stages. Given an aging cohort with associated increase in number of systemic comorbidities, the majority of patients were in the lower priority stages 4 to 6.ConclusionsCOVID-19 has created an urgent challenge to deal safely with cataract surgery waiting lists. This has driven the need for a prompt and pragmatic change to the way we assess risks and benefits of a previously regarded as low-risk intervention. This is further complicated by the majority of patients awaiting cataract surgery being elderly with comorbidities and at higher risk of mortality related to COVID-19. We present a pragmatic method of risk stratifying patients on waiting lists, blending an evidence-based objective assessment of risk and patient need combined with an element of shared decision-making. This has facilitated safe and successful restarting of our cataract service.