Correct IOL implantation in cataract surgery – quality standard
22 March 2018
The insertion of wrong intraocular lenses (IOLs) in cataract surgery is the commonest cause of surgical never events in recent years.
The College has been working with NHS England and NHS Improvement (NHSI) to try to improve the situation, providing amendments to the new Never Event List and Frameworks and supporting the Healthcare Safety Investigation Branch (HSIB) in its current national investigation into wrong IOLs. The HISB is looking for innovative solutions to prevent ophthalmic never events including potential technical solutions.
As part of this work, the College and the recently formed UK Ophthalmology Alliance (UKOA), have produced new quality standard guidance which builds on the NICE guideline for cataract in adults and is based on published evidence and expert consensus.
It provides detailed guidance for units on possible precautions to reduce the likelihood of wrong IOL never events. The College recommends units develop a local protocol based on this guidance, adapted to fit with their local theatre policies, to reduce risk. It is also important to remember when performing cataract surgery, the surgeon must very clearly state the “procedural plan” for the IOL make and model at the start of the case to the theatre team, and to make sure the planned make and model are clearly recorded in the notes. Any wrong IOL beyond that point is a never event. All wrong IOLs should, however, still be reported as incidents and undergo a full root cause analysis investigation