More than one in four New Zealanders declined cataract surgery had sight so bad they couldn’t legally drive, a study has found – and how likely people are to get their vision restored depends where they live.
Dr James McKelvie, a Hamilton-based ophthalmologist and senior lecturer at the University of Auckland, led an analysis of all 44,000 patients referred for cataract surgery from 2014-2019. The findings are published today in the NZ Medical Journal.
“You basically have to lose your licence before you get surgery,” he told the Herald. “And, in fact, in many DHBs it is significantly worse than that – it’s not losing your licence, it’s losing your vision.”
Māori and Pacific patients develop cataracts at a younger age, the research found, and “have worse visual acuity and typically severe visual impairment, compared to other ethnic groups at the time of prioritisation”.
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The Royal Australian and NZ College of Ophthalmologists (Ranzco) is now taking the rare step of calling on the Health Minister to reduce this glaring example of so-called “postcode healthcare” by setting a nationwide threshold for acceptance for surgery.
DHBs give referred patients a score from 0 to 100 (lowest to highest priority), according to clinical and social need, using the “clinical priority assessment criteria” (Cpac) system.
However, each DHB sets a different threshold for surgery, meaning people living in central Auckland get cataract surgery more easily than in Counties Manukau, for example. Last year the Herald surveyed DHBs and found the Cpac priority score needed to get cataract surgery varied from 45 to 61.
“The lack of a single national threshold creates significant geographic disparity in access,” concluded the research, co-authored by Stephen Ng, Corina Chilibeck and Jeremy Mathan.
“Over one quarter of patients who were declined for surgery did not meet the visual acuity requirement for driving a private vehicle in NZ.
“A small but significant number of patients  who were declined for public-funded surgery had such advanced visual impairment they would be eligible for registration with Blind Low Vision NZ (formerly the Blind Foundation).”
The percentage of referrals declined varied greatly by DHB. Lakes DHB approved just over half of referrals, for example, and West Coast DHB approved 93 per cent.
Most declined patients with visual acuity of 6/12 or worse (meaning at six metres you can read something which a person with normal vision could read at 12m, and the point at which driving is no longer legally allowed) were from the Waikato and Bay of Plenty DHB regions, but on a per-population basis, the highest rates were in Southern and Nelson-Marlborough DHBs.
New Zealand compares badly to other OECD countries. Canadian guidelines recommend surgery when visual acuity drops to 6/12 with symptoms of glare, for example, while just 35 per cent of Kiwi patients had visual acuity of 6/12 or better in the operative eye at the time of prioritisation.
Surgeries done per 100,000 population per year varied between DHBs from 95 to 737, with the Auckland region leading the way. The rate in Canada and Australia is more than double that of New Zealand’s, and we rank around 23 of 27 OECD countries.
Auckland and Waitematā DHBs’ low surgical threshold and large department means “referrers are more inclined to send people for surgery, because they know they’ll get their problem sorted”. McKelvie said of the regional differences.
“Everybody works hard and does their absolute best, but different departments are resourced to different extents.”
The analysis included records up to March 2019. Some DHBs have since toughened surgical thresholds in response to Covid-19.
Something has to change, McKelvie said.
“Cataracts are like wrinkles – they affect us all, eventually. It brings people’s lives to a standstill, and it’s so straightforward to fix these patients, if we can just get the resources to do it.”
Health Minister Chris Hipkins said any response to Ranzco’s call for a nationwide surgery threshold would be a matter for whoever is minister after the impending post-election reshuffle.
However, he noted Budget 2020 allocated more than $282m to catch up on elective surgery disrupted by Covid, including cataract surgeries, and during the election campaign Labour pledged another $200m to cut waiting lists.
“This additional support is on top of the considerable uplift in general DHB funding over the past three years.”
Demand for eye services has boomed as Kiwis age and sicken with conditions including diabetes which, if not well controlled, can destroy eyesight. New treatments such as Avastin injections for age-related wet macular degeneration have saved the sight of tens of thousands, but can be needed monthly and have put huge strain on resources.
'The gift of sight is so precious'
Paeroa retiree George Lomey got bad news from his optometrist after a check-up in July: his cataracts had worsened to the extent he’d have to give up driving.
That was hard for to take for Lomey, who had been behind a wheel since the age of 16 and spent a working life driving trucks, trailers and buses.
After confirming he couldn’t afford private surgery, his optometrist referred him to Waikato DHB, but his priority score didn’t meet the threshold for treatment.
“I wasn’t surprised. Friends of mine who have cataracts too, they’ve been turned down.”
Fortunately, Lomey, who turned 78 this week, was accepted by a charity scheme, and in mid October had cataracts removed from both eyes by McKelvie – one of many ophthalmologists who volunteer time and clinics.
The result was nothing short of life-changing.
“Now, I can see things that weren’t possible before,” Lomey said.
“Mate, it is just – you can’t describe it, I can’t put it into words. We are about eight feet from a bookcase and I’m trying to read the covers of the books, and it is just leaping out at me.”
Lomey, who can now drive without glasses, realises he is one of the lucky ones, and others declined by the public system are left to suffer a reducing world.
“It’s a miracle. There’s no two ways about that. The gift of sight is so precious.”
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