Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery

1. Scientific basis for measuring visual acuity outcomes after cataract surgery The only reason to perform cataract surgery (other than for a limited set of medical indications) is to improve a patient’s vision and associated functioning. The use of a 20/40 visual acuity threshold is based on several considerations. First, it is the level for unrestricted operation of a motor vehicle in the US. Second, it has been consistently used by the Food and Drug Administration in its assessment for approval of intraocular lens (IOL) and other vision devices. Third, it is the literature standard to denote success in cataract surgery. Fourth, work by West et al. in the Salisbury Eye Study suggests that 20/40 is a useful threshold for 50th percentile functioning for several vision-related tasks.

Most patients achieve excellent visual acuity after cataract surgery (20/40 or better). This outcome is achieved consistently through careful attention through the accurate measurement of axial length and corneal power and the appropriate selection of an IOL power calculation formula. As such, it reflects the care and diligence with which the surgery is assessed, planned and executed. Failure to achieve this after surgery in eyes without comorbid ocular conditions that would impact the success of the surgery would reflect care that should be assessed for opportunities for improvement.

The exclusion of patients with other ocular and systemic conditions known to increase the risk of an adverse outcome reflects the findings of the two published prediction rule papers for cataract surgery outcomes, by Mangione et al. (1995) and Steinberg et al. (1994). In both papers, the presence of comorbid glaucoma and macular degeneration negatively impacted the likelihood of successful outcomes of surgery. Further, as noted in the prior indicator, exclusion of eyes with ocular conditions that could impact the success of the surgery would NOT eliminate the large majority of eyes undergoing surgery while also minimizing the potential adverse selection that might otherwise occur relative to those patients with the most complex situations who might benefit the most from having surgery to maximize their remaining vision.

2. Evidence of a gap in care Cataract surgery successfully restores vision in the majority of people who have the procedure.

Data from a study of 368,256 cataract surgeries show that corrected visual acuity (CDVA) of 0.5 (20/40) or better was achieved in 94.3% and CDVA of 1.0 (20/20) or better was achieved in 61.3% of cases (Lundstrom et al., 2013).

Additionally, data from a UK multi-center Cataract National Dataset found a postoperative visual acuity of 6/12 (20/40) or better was achieved for 94.7% of eyes with no co-pathologies and in 79.9% of eyes with one or more co-pathologies (Jaycock et al., 2009).

A rate of 85.5-94.7% of patients achieving a 20/40 or better visual acuity in the context of approximately 3 million cataract surgeries in the US annually would mean that between 160,000 to 435,000 individuals would not achieve a 20/40 or better visual acuity which suggests an opportunity for improvement.

Only procedures performed during January 1 – September 30 of the measurement period will be considered for this measure, in order to determine if 20/40 or better visual acuity has been achieved within the 90 days following the cataract procedure. Cataract procedures performed during October 1 – December 31 are excluded from the initial population.

The measure, as written, does not specifically require documentation of laterality. Coding limitations in particular clinical terminologies do not currently allow for that level of specificity (ICD-10-CM includes laterality, but SNOMED-CT does not uniformly include this distinction). Therefore, at this time, it is not a requirement of this measure to indicate laterality of the diagnoses, findings or procedures. Available coding to capture the data elements specified in this measure has been provided. It is assumed that the eligible clinician will record laterality in the patient medical record, as quality care and clinical documentation should include laterality.

This measure is to be reported by the clinician performing the cataract surgery procedure. Clinicians who provide only preoperative or postoperative management of cataract patients are not eligible for this measure.

Telehealth encounters are not eligible for this measure because the measure does not contain telehealth-eligible encounter codes.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

Significant ocular conditions include: amblyopia, burn confined to eye and adnexa, cataracts econdary to ocular disorders, congenital cataract, mature or hypermature cataract, posterior polar cataract, central corneal ulcer, certain types of iridocyclitis, choroidal degenerations, choroidal detachment, choroidal hemorrhage and rupture, cloudy cornea, corneal edema, disorders of cornea including corneal opacity, degeneration of macula and posterior pole, degenerative disorders of globe, diabetic macular edema, diabetic retinopathy disorders of optic chiasm, disorders of visual cortex, disseminated chorioretinitis and disseminated retinochoroiditis, focal chorioretinitis and focal retinochoroiditis, glaucoma, hereditary dystrophies (choroidal, corneal, retinal), hypotony of eye, injury to optic nerve and pathways, macular scare of posterior polar, morgagnian cataract, nystagmus and other irregular eye movements, open wound of eyeball, optic atrophy, optic neuritis, pathologic myopia, posterior lenticonus, prior penetrating keratoplasty, purulent endophthalmitis, retinal detachment with retinal defect, retinal vascular occlusion, retrolental fibroplasias, scleritis, separation of retinal layers, traumatic cataract, uveitis, vascular disorders of iris and ciliary body, and visual field defects