National ophthalmology workstream: hospital eye services

How we plan and manage the delivery of hospital eyecare services to provide timely care for patients.

Appendix 2

1. Complexity Grading, Suitability for Pooled Lists and Scheduling of Cataract Lists

At the GJNH at the time of listing the assessing Surgeon writes a surgical plan which specifies;

  • Whether patient is being listed for one eye only, first eye then second eye or second eye (we are currently not offering Immediate Sequential Bilateral Surgery)
  • Which eye and what IOL (style and Power)
  • What LA (this is indicative only and the surgeon on the day will make a final decision)
  • Identified Hazards (Medical, Ocular, Pharmacological)
  • What special measures may be required (again, indicative only) - temporal incision, vision blue, endothelial protection, hooks etc.
  • DSD (Degree of Surgical Difficulty) Grade, 1-4
  • Whether this case is suitable for a pooled list or not

2. Complexity Grading (aka DSD-degree of surgical difficulty)

The purpose of the complexity Grading/ DSD, which indicates how technically challenging a case is likely to be, is to enable booking staff to populate lists appropriately, making sure there are enough suitable cases for training where there are juniors and avoid overloading lists with too many complex cases.

To do so they use the following list reduction calculator;

No. Of Grade 3 cases on the list Reduce the list by Total on the list
0 0 7
1 0 7
2 1 6
3 2 5
4 or more *See below 5

Individual surgeons might elect to have more cases on a list if he/she is comfortable with that, for example;

  • When a junior normally allocated to this list is on leave
  • If there are no Grade 3s, some surgeons may be comfortable with 8 cases on a "Consultant only list".
  • *Some surgeons will be comfortable a list of "5 X 3", that is a list of 5 grade 3 cases. Booking office will avoid giving more than 3 DSD 3s to surgeons who are not happy to do this.
Complexity Grading / DSD Description… For example…
1 A very straightforward case, suitable for a novice phaco surgeon
2 A straightforward case which should cause an experienced surgeon no difficulties Perhaps one or two of the following; more difficult access, deep-set eye, sub-optimal dilation, on Tamsulosin, significant COPD, difficulty lying flat, anxious or jumpy patient, a dense or mature cataract, high Myopia or Hypermetropia, extreme age (>85), endothelial gutattae etc.
3 A more challenging case for an experienced surgeon, likely to take longer and carrying a higher risk of complication Perhaps 3 or more of the above, and certainly any of the following; PXF, poor dilation requiring Iris hooks, very difficult access, severe positional / mobility issues
4 A very challenging case with a very high risk of major complication Lots of the above and certainly any of the following; Phacodonesis, "black cataract", nanophthalmic eye
NB Not suitable for surgery at GJNH

3. "Suitable for a pooled list?"

The purpose of asking the assessor to state Yes or No to this question is to ensure that surgeons are not confronted with contentious or controversial surgical plans when they meet a patient for the first time on the day of surgery. The surgeon will not have time nor would it be fair on the patient for a re-evaluation of the surgical plan to take place on the day of surgery.

So, any possibility of reasonable disagreement amongst surgeons regarding the following would constitute a contraindication to pooling;

  • Whether surgery is indicated at all at this time (for example a patient with early cataract, minimal functional difficulties & still legal to drive. Or again, an only eye situation where the patient is not severely visually impaired )
  • which eye should be done (for example, where one eye is amblyopic)
  • whether one or both eyes should be done
  • What the target post op refraction should be (for example, a hyermetropic or myopic patient with uniocular cataract; do we aim for a balance or emetropia, accepting aneisometropia? Or a myope who currently reads without glasses; do we leave him / her myopic?)
  • Whether a toric IOL is indicated
  • The list is not exhaustive

NB Complexity/ DSD Grading is not a factor in determining if a patient can be pooled. So long as the listing is uncontroversial, a DSD3 case can nearly always be pooled. One could argue that listing a DSD4 is always controversial

4. Scheduling for theatre

Booking office staff will always try schedule a patient on an operating list of the Consultant who did the listing, unless that Consultant has no dates within the TTG. In that event, those patients who have been designated "ok for pooled list" can be scheduled for another consultant's list. For those who have been deemed not suitable for pooling, notes are passed for review to either PPK or LW (permanent GJNH Consultants) who may either then take the patient over themselves or re-designate the patient as suitable for a pooled list if the original decision appears questionable.


Email: Jacquie Dougall

Phone: 0300 244 4000 – Central Enquiry Unit

The Scottish Government
St Andrew's House
Regent Road

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