Cataracts - when to operate?

RE: Cataracts - when to operate?

Elisabeth Knappett — Sat, 21 Apr 2018 10:55:40 GMT

[quote user="Robert Lowe"]

As inferred I was assuming that you were referring early for incipient or early immature cataract when I was talking about not intervening. Loads of older dogs have some forn of senile cataract and not many need surgery in their lifetime. However if there is a late immature, mature or hyper mature cataract affecting vision then we would intervene where possible.

We will also do surgery where we have active evidence of progression even when the cataract is at an early stage.

Best results are achieved before we get lens induced uveitis occuring as the cataract matures.

[/quote]

Many thanks for the clarification - I was meaning I refer for the mature cataracts causing vision issues, not the earlier ones - but this is what the insurance company seems to think should be done! Glad to know I've not knobbled a load of patients by not referring sooner!

RE: Cataracts - when to operate?

Robert Lowe — Sat, 21 Apr 2018 09:53:08 GMT

[quote user="robloxley"]

[quote user="Elisabeth Knappett"]

[quote user="Robert Lowe"]To answer the original post, I would rarely end up intervening in a senile cataract as you have described here so it may well be a moot point as to whether the insurance would cover it. In general however, early referral allows us to discuss the risks of progression while also assessment of the fundus directly for other diseases.[/quote]

Thanks for the information but can I ask why you would not intervene? The majority of cataracts we refer are fully mature and therefore causing significant impact on vision, once removed, vision returns! Loss of vision in this case is the major reason for sending this patient on.

[/quote]

My reading of the OP was asking whether they should be treated at an earlier stage, before visual impairment

[/quote]

We will also do surgery where we have active evidence of progression even when the cataract is at an early stage.

Best results are achieved before we get lens induced uveitis occuring as the cataract matures.

RE: Cataracts - when to operate?

Rob Loxley — Thu, 19 Apr 2018 08:41:11 GMT

[quote user="Elisabeth Knappett"]

[/quote]

My reading of the OP was asking whether they should be treated at an earlier stage, before visual impairment

RE: Cataracts - when to operate?

Niall Taylor — Thu, 19 Apr 2018 08:31:44 GMT

[quote user="Lucy Fleming"]I wonder if a client can submit a claim for £0.00 when eg murmurs, cataracts etc first noted to close this loophole?[/quote]

In a way this is what I often advise. If I find something - mild murmur, early cataract etc - that doesn't need treating there and then but is likely to in the future I will get people to phone and/or write to the insurance company to let them know (and carefully log all correspondence!) a potential problem has been identified so there is less room for this sort of argument in the future.

[quote user="Elisabeth Knappett"]due to this, the insurance company are refusing to cover for the surgery.[/quote]

To be fair to them, Petplan are the best of the insurance companies. It will say in these people's contract with them that they won't pay out on a condition if it's been going on more than 12 months and they haven't been notified about it. That's not sharp practice, it's the clients not understanding their agreement with the insurance company. Some companies are much worse, some will not honour a claim if they haven't been notified within a MONTH of diagnosis!

Niall

RE: Cataracts - when to operate?

Lucy Fleming — Wed, 18 Apr 2018 18:07:07 GMT

[quote user="Thomas Johnson"]This does appear to be a big problem with the '12 month'/'annual' insurance policies compared to the 'lifelong' policies, and I'm not sure I can see a way around it, another reason to suggest lifelong policies to clients.[/quote]

Not just the annual policies, unfortunately. I was reading the small print of a pet plan lifetime policy the other day (as you do) and they will only cover if claimed within 12 months of a condition first being noted. I wonder if a client can submit a claim for £0.00 when eg murmurs, cataracts etc first noted to close this loophole?

RE: Cataracts - when to operate?

Elisabeth Knappett — Wed, 18 Apr 2018 15:11:01 GMT

RE: Cataracts - when to operate?

Martin Atkinson — Wed, 18 Apr 2018 10:01:38 GMT

[quote user="Beats"]

I'd like to hear your experience in detail, Martin.

I've often wondered why a lendectomy isn't more commonly done for cataracts.

Can you do diabetic cataracts like this also?

[/quote]I used to refer lendectomies but found that there was only a 2/3 success rate so started to have a go myself. Obviously I prefer to refer for phaco if appropriate but some clients don't want this or they are hyper-mature before they bring them in.

I premed with a mydriactic and cprtiocseroid drops for a few says pre-op), make a dorsal incision 1 mm in from the sclera (presumably what Rob calls 'open sky') cut the lens capsule with a no 11 scalpel and use a vectis loop to free the lens then close the incision with 6/0 silk (I prefer this to soluble sutures even though I need to sedate the patient to get them out as there's a lot less inflammation) and continue with the mydriatic/steroid drops until sutures out or a bit longer if there is persistent uveitis. I have 2/3 success rate, the major limiting factor being permanent myosis despite the mydriatic.

I wouldn't differentiate between age related or diabetic cataracts but as Rob says the latter may need more careful, longer term after-care. All said the last one I did was an unmitigated disaster, it got severe uveitis and myosis and its eye turned into a whelk! Like many surgical procedures as I get older I'm getting less adventurous and confident.

RE: Cataracts - when to operate?

Wren — Wed, 18 Apr 2018 09:42:33 GMT

[quote user="Robert Lowe"]

[quote user="Wren"]

[quote user="Martin Atkinson"] I disagree with Francisco that they need ongoing medication: pre-surgical mydriatics and anti-inflammatory drops for a few days after certainly but they should normalise with no further need for treatment. [/quote]

I wondered about that too. I had one removed from my own eye 6 months ago and had chloramphenicol and dex drops for around 14d. No long term meds at all, no pre-op meds, and no painkillers of any sort.

[/quote]

And that is why human surgeons who have operated on their dog's first eye often get the second done by a veterinary ophthalmologist.

Horses - 1-2 months of post op meds

Cats - probably could get away with human timescales in majority

Dogs - 3-4 months and lifelong if diabetic

[/quote]

That's really interesting Robert, thanks!

(ps. if anyone else here needs cataract surgery, take the GA if offered. Conscious wasn't a great experience....)

RE: Cataracts - when to operate?

Robert Lowe — Wed, 18 Apr 2018 00:31:31 GMT

[quote user="Wren"]

[/quote]

And that is why human surgeons who have operated on their dog's first eye often get the second done by a veterinary ophthalmologist.

Horses - 1-2 months of post op meds

Cats - probably could get away with human timescales in majority

Dogs - 3-4 months and lifelong if diabetic

In Martin's cases as the lens was presumably being removed whole there is less post operative uveitis. The reason we have moved to small incision phacoemulsifcation rather than large incision extracaspsular extraction and open sky intracapsular extraction prior to this is that overall success rates are significantly higher across almost all parameters measured (corneal oedema, haemorrhage, retinal detachment etc)

To answer the original post, I would rarely end up intervening in a senile cataract as you have described here so it may well be a moot point as to whether the insurance would cover it. In general however, early referral allows us to discuss the risks of progression while also assessment of the fundus directly for other diseases.

RE: Cataracts - when to operate?

grumpyoldman — Wed, 18 Apr 2018 00:09:04 GMT

[quote user="Beats"]

I've often wondered why a lendectomy isn't more commonly done for cataracts.

Can you do diabetic cataracts like this also?

[/quote]

you can leave eyes Aphakic and its an improvement on blindness but its also far from ideal. Better to have a suitable IOL in situ. Diabetic cataracts are generally softer easier to phaco and require less BSS and much shorter phaco times and less energy than senile hyper mature cataracts. Aphakic eyes tend to be far more prone to 2ary glaucoma from vitreous prolapse. Leading to retinal detachment and ultimately loss of the globe.

RE: Cataracts - when to operate?

Rob Loxley — Tue, 17 Apr 2018 22:29:13 GMT

[quote user="Thomas Johnson"]This does appear to be a big problem with the '12 month'/'annual' insurance policies compared to the 'lifelong' policies[/quote]

The client pays their money and takes their choice?

RE: Cataracts - when to operate?

Beats — Tue, 17 Apr 2018 19:39:45 GMT

[quote user="Martin Atkinson"]I used to do a lot of lendectomies, they are pretty straightforward, half hour job with a decent ophthalmic kit but I don't see so many cases these days. I left them until they were mature but before any other problems occurred. I disagree with Francisco that they need ongoing medication: pre-surgical mydriatics and anti-inflammatory drops for a few days after certainly but they should normalise with no further need for treatment. And I would do one side at a time just in case there is some residual vision and, God forbid, you cock-up both sides! [/quote]

I'd like to hear your experience in detail, Martin.

I've often wondered why a lendectomy isn't more commonly done for cataracts.

Can you do diabetic cataracts like this also?

RE: Cataracts - when to operate?

Thomas Johnson — Tue, 17 Apr 2018 17:21:26 GMT

[quote user="KMurphy"]

Sorry to jump in on this but not totally off topic - I've had a similar argument with Petplan recently regarding a dog with mitral valve disease. The murmur was present for some time (around 3 years) but no clinical signs were present until recently. However, because the murmur was present for more than 12 months they won't cover any heart treatment.

I think this is a similar situation to yours. It isn't clinically appropriate to treat heart murmurs/cataracts as soon as they develop but by waiting until it becomes necessary to do so the insurance company effectively punishes the client/pet.

[/quote]

This does appear to be a big problem with the '12 month'/'annual' insurance policies compared to the 'lifelong' policies, and I'm not sure I can see a way around it, another reason to suggest lifelong policies to clients.

RE: Cataracts - when to operate?

KMurphy — Tue, 17 Apr 2018 15:06:49 GMT

RE: Cataracts - when to operate?

Wren — Tue, 17 Apr 2018 14:35:51 GMT

RE: Cataracts - when to operate?

Martin Atkinson — Tue, 17 Apr 2018 13:52:53 GMT

[quote user="Elisabeth Knappett"]So my question becomes, when to operate? As far as I understand, there should be visual impairment and full development before surgery is necessary but this may take several months from initial presentation. Is this wrong? Should surgeries be taking place sooner? Or should I be trying to educate this insurance company about the time lapse between diagnosis and treatment required?[/quote]I would politely suggest to them that it would have cost them at least as much, probably more, if it had been sent to a specialist for phacoemulsification when the problem started.

I used to do a lot of lendectomies, they are pretty straightforward, half hour job with a decent ophthalmic kit but I don't see so many cases these days. I left them until they were mature but before any other problems occurred. I disagree with Francisco that they need ongoing medication: pre-surgical mydriatics and anti-inflammatory drops for a few days after certainly but they should normalise with no further need for treatment. And I would do one side at a time just in case there is some residual vision and, God forbid, you cock-up both sides!

RE: Cataracts - when to operate?

Francisco Gomez — Tue, 17 Apr 2018 13:36:44 GMT

Cataract formation isn't a benign process. The development of it will lead to abnormal metabolism in the lens which in turn can cause secondary uveitis. On the other hand, cataract removal isn't too benign either as it requires long term medical attention and a lot of work from the owner.

The decision whether your patient needs this op and when it needs it isn't the insurance company job IMO. It is yours, your referral ophthalmologist's and your client's

RE: Cataracts - when to operate?

Rob Loxley — Tue, 17 Apr 2018 13:35:26 GMT

[quote user="Elisabeth Knappett"]when to operate? As far as I understand, there should be visual impairment and full development before surgery is necessary[/quote]

Most senile cataracts we see never develop to a point where they affect the dog's life, so yes a degree of wait-and-see is needed (on the other hand I'd refer off diabetic cataracts at an early stage)

[quote user="Elisabeth Knappett"]Or should I be trying to educate this insurance company about the time lapse between diagnosis and treatment required?[/quote]

You could try...! I suspect an argument to try might be along the lines that the delay has not made treatment more complicated/expensive (e.g. raging uveitis), but may well fall on deaf ears...