Reducing wait time for cataract surgery: comparison

of 2 historical cohorts of patients in Montreal

Hélène Boisjoly,*{ MD, FRCSC, MPH; Ellen E. Freeman,*{ PhD; Fawzia Djafari,*{ MD, MSc;
Marie-Josée Aubin,*{ MD, FRCSC, MSc; Simon Couture,*{ MD, DMV, MSc; Robin P. Bruen,*{ MD;
Robert Gizicki,*{ MD; Jacques Gresset,{{ OD, PhD
ABSTRACT N RÉSUMÉ
Objective: A cataract efficiency program was implemented in Montreal in 2003 to decrease surgery wait time. Our
goal was to determine whether health, adverse events during wait time, and outcome of patients presenting for
cataract surgery differed from 1999 to 2006 in Montreal.
Design: Prospective preoperative and postoperative observational study performed at 2 time points 6 years apart.
Participants: Patients awaiting first-eye cataract surgery at Maisonneuve-Rosemont Hospital: 509 patients in 1999–
2000 and 206 patients in 2006–2007.
Methods: Patients awaiting first-eye cataract surgery were recruited from Maisonneuve-Rosemont Hospital in 1999–
2000 (n 5 509) and a second cohort was recruited in 2006–2007 (n 5 206). Date of entry onto the hospital waiting list
and date of cataract surgery were recorded. About 2 weeks before surgery, patients were asked about accidents and
falls while waiting, visual difficulty, and satisfaction with vision and wait time. Visual acuity was measured in each eye.
Patients also completed interviewer-administered questionnaires: the 5-item Cataract Symptom Scale, Visual
Function–14 Questionnaire (VF-14), Short Form Health Survey–36, Geriatric Depression Scale, and the 14-item
Systemic Comorbidity Scale. The interview was repeated after surgery.
Results: In 1999, 39% of patients waited more than 6 months for cataract surgery, and this was reduced to 29% in 2006.
Patients had better preoperative visual acuity in the surgical eye, less visual difficulty, and fewer cataract symptoms,
and reported fewer accidents while waiting for surgery in 2006. The change in visual acuity after surgery was
nonetheless the same in the 2 cohorts. The 2006 cohort achieved significantly higher VF-14 scores and reported
more satisfaction with vision after surgery than did the 1999 cohort.
Conclusions: Patients had cataract surgery sooner in the disease process in 2006–2007 compared with 1999–2000,
with changes in visual acuity after surgery that were clinically significant in both cohorts.
Objet : Un programme d’efficacité concernant la chirurgie de la cataracte a été lancé en 2003 à Montréal pour en
réduire les délais d’attente. Notre but était d’établir si la santé, les délais d’attente et les résultats avaient changé
entre 1999 et 2006 chez les patients qui s’étaient présentés pour une chirurgie de la cataracte à Montréal.
Nature : Étude prospective préopératoire et postopératoire reposant sur l’observation, effectuée à deux moments, à
6 années d’intervalle.
Participants : Patients en attente d’une première chirurgie de la cataracte à l’hôpital Maisonneuve-Rosemont : 509
patients en 1999–2000 et 206 patients en 2006–2007.
Méthodes : Les patients attendant une première chirurgie de la cataracte à l’hôpital Maisonneuve-Rosemont ont été
recrutés en 1999–2000 (n 5 509) et la deuxième cohorte le fut en 2006–2007 (n 5 206). Les dates d’inscription sur la
liste d’attente de l’hôpital et celles de la chirurgie de la cataracte ont été relevées. Environ 2 semaines avant la
chirurgie, on interrogeait les patients sur les accidents et les chutes pendant le délai d’attente, ainsi que sur les
problèmes visuels et le degré de satisfaction visuelle. On a mesuré l’acuité visuelle de chaque œil. Les patients ont
aussi répondu à des questionnaires de l’intervieweur : échelle en 5 points des symptômes de la cataracte, question-
naire sur la fonction visuelle VF-14, Short Form Health Survey–36, échelle de dépression gériatrique et échelle de
comorbidité systémique en 14 points. L’entrevue a été reprise après la chirurgie.
Résultats : En 1999, 39 % des patients ont attendu la chirurgie de la cataracte plus de 6 mois. Ce taux avait baissé à 29 %
en 2006. Les patients avaient alors une meilleure acuité visuelle préopératoire dans l’œil opéré, moins de difficulté
visuelle et moins de symptômes de la cataracte; et ils ont signalé moins d’accidents en attendant la chirurgie.
Le changement d’acuité visuelle après la chirurgie était néanmoins le même dans les 2 cohortes. La cohorte de
2006 a atteint de meilleurs résultats VF-14 et s’est montrée plus satisfaite de la vision après la chirurgie que la
cohorte de 1999.
Conclusions : Les patients ont eu leur chirurgie de la cataracte plus tôt dans la progression] de la maladie en 2006–
2007, comparativement à ceux de 1999–2000, et les changements d’acuité visuelle après la chirurgie étaient
cliniquement significatifs dans les deux cohortes.

From *the Department of Ophthalmology; {the Research Center, Hôpital
Maisonneuve-Rosemont, Montreal, Que.; and {the Department of
Optometry, University of Montreal, Montreal, Que.
Originally received Sep. 11, 2009. Final revision Oct. 26, 2009
Accepted Nov. 14, 2009
Published online Mar. 8, 2010
Correspondence to Hélène Boisjoly, MD, Research Center, Hôpital
Maisonneuve-Rosemont, Room F119, 5415 L’Assomption Blvd., Montreal,
QC H1T 2M4; helene.boisjoly@umontreal.ca
This article has been peer-reviewed. Cet article a été évalué par les pairs.
Can J Ophthalmol 2010;45:135–9
doi:10.3129/i09-256

CAN J OPHTHALMOL—VOL. 45, NO. 2, 2010 135

Reducing wait time for cataract surgery—Boisjoly et al.
C ataract is the most frequent treatable blinding con-
dition worldwide.1–2 Given the aging population, it is
estimated that 1 out of 2 persons will have cataract sur-
gery.3 With the advent of technical improvements, surgery
is now safer, with excellent outcomes, and the vision loss
threshold for surgery has decreased. In the late 1990s, wait
time for cataract surgery was a problem in many countries,
including Canada.4 We conducted a prospective study in
1999–2000 to evaluate patient health and distress during
their wait.5 Canadian provincial health ministries later
mandated local health agencies to improve efficiency to
provide higher cataract surgery volumes at lower costs per
case. Performing surgery in ambulatory care centres is an
avenue of efficiency taken by many centres. After the imple-
mentation of a cataract efficiency program (shorter time
delays between cases, newest technology, trained surgical
technicians, and more operating room time) in 2003 at the
Maisonneuve-Rosemont Hospital in Montreal, Que., the
cataract surgery volume doubled. We repeated the evalu-
ation of cataract patients in 2006–2007, and compared
health, adverse events during wait time, and outcome of
patients from this second cohort with that of 1999–2000.
METHODS
Study design
The study design was a prospective preoperative and
postoperative hospital-based observational study per-
formed at 2 time points 6 years apart.
Study population
Patients awaiting first-eye cataract surgery were
recruited from the Maisonneuve-Rosemont Hospital, a
large teaching hospital in Montreal, Que.: cohort 1 from
1999–2000 (n 5 509) and cohort 2 from 2006–2007 (n 5
206). The later cohort was much smaller, based on sample
size calculations done for variables of interest with data
obtained from the first cohort. Consecutive patients were
contacted by telephone about participation in the study
once their name appeared on the cataract surgery waiting
list of the hospital. Eligibility criteria were age older than
45 years, first-eye cataract surgery, and no obvious cogni-
tive or auditory deficit. Signed informed consent was
obtained from each patient. The Ethics Committee of
the hospital approved the study.
Data collection
Approximately 2 weeks before surgery, patients were
invited by phone to come for a research interview. Con-
senting patients were enrolled. Habitual (presenting visual
acuity with current correction) and pinhole-corrected
visual acuities (pinhole was used as a surrogate for best-
corrected visual acuity) were measured in each eye using
an Early Treatment of Diabetic Retinopathy Study acuity
chart and were converted to logarithm of the minimum
angle of resolution (logMAR). Patients were asked about
136 CAN J OPHTHALMOL—VOL. 45, NO. 2, 2010
their perceived wait time and its acceptability on a 0–4
scale, and about the occurrence of accidents and falls dur-
ing the wait. Difficulty and satisfaction with vision at the
time of the interview was graded on a 0–3 scale. Patients
also completed interviewer-administered questionnaires.
The 5-item Cataract Symptom Scale (CSS)6–7, the Visual
Function–14 Questionnaire ([VF-14], which measures self-
report of difficulty with visual tasks on a 100–0 scale),6–7
the Short Form Health Survey-36 ([SF-36], which measures
general health with questions about physical, mental, and
social well-being on a 0–100 scale),8 the 30-item Geriatric
Depression Scale (on a 0–30 scale), 9–10 and the 14-item
Systemic Comorbidity Scale (on a 0–42 scale) were given.11
The date of entry onto the hospital waiting list and the date
of cataract surgery were recorded. The difference between
these 2 dates was defined as the cataract surgery wait time.
Patients were interviewed again between 1 and 4 months
after surgery prior to the fellow eye surgery.
Statistical analysis
For continuous data, medians and interquartile ranges
(75th–25th percentile) were given for each cohort because
many of the measures were fairly skewed. Tests between the
2 cohorts were done using Mann-Whitney U tests for non-
parametric data. For categorical data, x2 tests were done to
test for between–cohort differences. A p value of 0.05 was
considered statistically significant. SAS software, version
9.1 (SAS Institute, Cary, N.C.) was used for the analyses.
RESULTS
Five hundred and nine participant patients in the first
cohort (1999–2000) and 206 in the second cohort (2006–
2007) completed preoperative data collection and had cat-
aract surgery. More than 1000 nonparticipant patients
were compared with study participants for age and gender
in the first cohort, and no significant difference was found
(data not shown). Four hundred and seventy-eight patients
(94%) in the first cohort and 182 patients (88%) in the
second cohort also completed the postoperative evaluation.
Patients who did not complete the postoperative evalu-
ation were not significantly different in age and gender
from those who did (data not shown).
Patients in the 2 cohorts were fairly similar in age, gen-
der, and general health (comorbidity level, depressive
symptoms, and SF-36 scores), although the median age
was 1 year younger (p 5 0.04) and patients had higher
social scores on the SF-36 questionnaire in the 2006 cohort
(p 5 0.01) (Table 1).
Vision in the surgical eye was slightly better in the more
recent cohort (Table 2). Although the 50th percentile, or
median, pinhole-corrected visual acuities (an estimate of
the best-corrected visual acuity) were the same in the 2
studies (0.4 logMAR, or 6/15 on the Snellen chart), the
75th percentile acuities were better in the later cohort
(0.5 logMAR, or 6/19 vs 0.6 logMAR, or 6/24, p 5 0.002).
 Reducing wait time for cataract surgery—Boisjoly et al.

The same was true of habitual visual acuity in the surgical percentile wait time in 1999–2000 was 8.5 months,
eye. Although the median habitual visual acuities were the decreasing to 6.6 months in 2006–2007 (p 5 0.01). There
same in the 2 cohorts (0.6 logMAR, or 6/24), the 75th per- were differences in how patients rated the acceptability of
centile acuities were better in the later cohort (0.9 logMAR, their cataract surgery wait time (p , 0.001) (Table 3). A
or 6/48 vs 1.0 logMAR, or 6/60, p 5 0.02). The median much greater percentage of patients in the earlier cohort
pinhole-corrected acuities in the nonsurgical fellow eye thought that their cataract surgery wait time was ‘‘not at all
were not statistically different between the 2 studies. acceptable,’’ compared with the later cohort (16% vs 4%,
However, the median habitual acuity in the nonsurgical p , 0.001). A larger percentage of patients in the first
eye was slightly better in the earlier cohort. cohort reported accidents or falls during their wait time,
Patients in the later cohort reported much less difficulty compared with the second cohort (p 5 0.001 and p 5 0.02,
on the VF-14 scale and fewer symptoms on the 5-item CSS respectively). Of the 73 accidental events, 38 were falls
(Table 2). The median VF-14 score was 66 in the 1999– (52%), 5 were auto accidents (7%), and 3 were burns (4%).
2000 cohort and 82 in the 2006–2007 cohort (lower scores The remaining 27 (37%) were not specifically described.
indicate greater difficulty) (p , 0.001). The median CSS The change in habitual and pinhole-corrected visual
score was 6 in the 1999–2000 cohort and 3 in the 2006– acuity after surgery was clinically significant in the 2
2007 cohort (p , 0.001). Patients in both cohorts cohorts (i.e., 0.3 logMAR units [3 lines on the chart] in
expressed a moderate amount of trouble with their vision the first cohort and 0.2 logMAR units [2 lines on the chart]
(median 5 moderate), although in the first cohort, patients in the second cohort [Table 4]). Postoperative habitual
were more dissatisfied with their vision (39% vs 23% were
very dissatisfied) (p 5 0.001). Table 3—Adverse events during wait of participants in 1999–2000
In 1999, 39% of patients waited more than 6 months for (cohort 1) versus 2006–2007 (cohort 2)
cataract surgery, and this was reduced to 29% in 2006. The Cohort 1 (n 5 509) Cohort 2 (n 5 206) p value
mean wait time in the more recent cohort was 1.1 months Acceptance of wait time, %
shorter, falling from 6 to 4.9 months (p , 0.001). The 75th Very acceptable 20 25 ,0.001
Moderately acceptable 7 6
Acceptable 42 54
Table 1—Demographic and health characteristics of participants
in 1999–2000 (cohort 1) versus 2006–2007 (cohort 2) Somewhat acceptable 14 10
Not at all acceptable 16 4
Cohort 1 (n 5 509) Cohort 2 (n 5 206) p value
Report of accident while waiting, %
Age, y 73 (68, 79) 72 (67, 77) 0.04 Any accident* 13 4 0.001
Female gender, % 67 63 0.26 Fall 7 2 0.02
Comorbidity score 12 (7, 17) 10 (5, 17) 0.13 *Includes falls, burns, cuts, bruises, and car accidents.
SF-36 Physical 75 (50, 90) 75 (50, 90) 0.29
SF-36 Mental 76 (56, 88) 76 (64, 88) 0.06
SF-36 Social 88 (63, 100) 100 (75, 100) 0.01 Table 4—Postoperative vision after cataract surgery in 1999–2000
Geriatric Depression 6 (3, 10) 6 (3, 10) 0.79 (cohort 1) versus 2006–2007 (cohort 2)
Scale score
Data are presented as median (25%, 75%) unless otherwise indicated.
Cohort 1 Cohort 2
(n 5 478)* (n 5 182)* p value
Vision, median (25%, 75%)
Table 2—Preoperative vision of participants in 1999–2000 (cohort 1) Postop pinhole-corrected VA, 0.1 (0, 0.3) 0.1 (0, 0.2) 0.13
versus 2006–2007 (cohort 2) logMAR
Cohort 1 (n 5 509) Cohort 2 (n 5 206) p value Change in pinhole VA in surgical 0.3 (0.1, 0.4) 0.2 (0.1, 0.4) 0.08
eye, logMAR
Visual acuity,* median Postop habitual VA, logMAR 0.3 (0.1, 0.5) 0.2 (0.1, 0.5) 0.01
(25%, 75%) logMAR
Change in habitual VA in surgical 0.3 (0.1, 0.7) 0.3 (0.1, 0.6) 0.74
Pinhole in surgical eye 0.4 (0.3, 0.6) 0.4 (0.3, 0.5) 0.002 eye, logMAR
Habitual in surgical eye 0.6 (0.4, 1.0) 0.6 (0.4, 0.9) 0.02 Postop VF-14 93 (83, 100) 98 (92, 100) ,0.001
Pinhole in other eye 0.2 (0.1, 0,4) 0.3 (0.2, 0,4) 0.69 Change in VF-14 23 (13, 37) 13 (2, 25) ,0.001
Habitual in other eye 0.3 (0.2, 0.5) 0.4 (0.3, 0.6) 0.02 Postop 5-item CSS 0 (0, 1) 0 (0, 1) 0.58
VF-14 66 (48, 77) 82 (68, 91) ,0.001
Change in 5-item CSS 5 (2, 7) 3 (1, 6) ,0.001
5-item CSS 6 (3, 8) 3 (1, 7) ,0.001
Problems with vision at postop, %
Problems with vision, % None 32 47 0.002
None 6 7 0.38 Few 37 32
Few 23 28 Moderate 22 16
Moderate 37 32 Many 9 4
Many 35 32 Satisfaction with vision at postop, %
Satisfaction with vision, % Very dissatisfied 8 2 ,0.001
Very dissatisfied 39 23 0.001 Moderately dissatisfied 18 8
Moderately dissatisfied 38 45 Some satisfaction 32 30
Some satisfaction 19 29 Very satisfied 42 60
Very satisfied 4 3 *Thirty-one patients (6%) in cohort 1 and 24 patients (12%) in cohort 2 were lost to follow-up
*Minimal angle resolution. after their cataract surgery.
Note: On the Snellen chart, 0.2 logMAR corresponds to 6/9.5, 0.3 to 6/12, 0.4 to 6/15, 0.5 to 6/19, Note: VA, visual acuity; logMAR, logarithm of the minimum angle of resolution; VF-14, Visual
0.6 to 6/24, 0.7 to 6/30, 0.8 to 6/38, 0.9 to 6/48, and 1.0 to 6/60. CSS, Cataract Symptom Scale. Function–14 Questionnaire; CSS, Cataract Symptom Scale.

CAN J OPHTHALMOL—VOL. 45, NO. 2, 2010 137

Reducing wait time for cataract surgery—Boisjoly et al.
visual acuity was slightly better in the later cohort
compared with the earlier (p 5 0.01). Conversely, there
were larger improvements in VF-14 scores and in 5-item
CSS scores in the earlier cohort than in the later cohort
because VF-14 and CSS preoperative scores were worse in
1999–2000 (p , 0.001). With surgery, the 2006 cohort
nonetheless achieved significantly higher VF-14 scores.
The median VF-14 postoperative score in the 2006–
2007 cohort was 98 and in the 1999–2000 cohort was
93 (p , 0.001). Patients in 2006–2007 were more likely
to report fewer problems with their vision (p 5 0.002) and
greater satisfaction with their vision (p , 0.001) post
operation than did patients in 1999–2000.
CONCLUSIONS
Our data suggest that patients at the Maisonneuve-
Rosemont Hospital in Montreal were operated on sooner
in the disease process in 2006–2007, with changes in visual
acuity after surgery that were clinically significant in
both cohorts.
The Montreal Health Agency invests significant
resources to provide higher cataract surgery volumes at
lower cost. We felt it was important to monitor the cataract
efficiency program implemented in Montreal since 2003.
We took advantage of the opportunity created by the fact
that we had collected data prospectively in 1999–2000 and
were in a position to compare patient population and sur-
gical outcome of cataract patients from the same insti-
tution in 2006–2007.
The Maisonneuve-Rosemont Hospital serves a popu-
lation of approximately 0.5 million people. We therefore
estimate that the cataract surgical rate (cataracts operated per
1000 population per year) increased from 3 in 1999 (1587
cataracts surgeries/0.5 million population/year 1999) to 8 in
2006 (3888 cataracts surgeries/0.5 million population/year
2006). This last number may be somewhat overestimated
because the program attracted some patients from areas
served by other hospitals. Our numbers appear to be lower
than those reported in Ontario by Rachmiel et al.12 How-
ever, they are comparable to those from England, where the
cataract surgical rate went from 3 in 1997 to 6 in 2005 after
the ‘‘Action on Cataract’’ initiative.13
The Canadian Ophthalmological Society and the Amer-
ican Academy of Ophthalmology have eliminated a spe-
cific visual acuity level from the criteria for performing
cataract surgery. Visual needs and functional symptoms
have become accepted as the fundamental basis for decid-
ing when cataract surgery is appropriate.14–15 Our study
patients were therefore evaluated with the 5-item CSS,
the VF-14 scale, and questions about problems and sat-
isfaction with vision, in addition to visual acuity. The later
cohort perceived as many problems with their vision as the
earlier cohort, although they had better visual acuity, fewer
symptoms, and higher VF-14 scores. The VF-14 preopera-
tive median score of 66 in the 1999–2000 cohort is
138 CAN J OPHTHALMOL—VOL. 45, NO. 2, 2010
comparable to the score of 62 reported in Spain in
2004–2005 in a study on 3321 patients.16
Although visual function was less impaired preopera-
tively in our 2006–2007 cohort, we still see a 16% average
improvement on the VF-14 scale, from a median score of
82 preoperatively to 98 after surgery. A ceiling effect is now
to be expected with the VF-14 visual function scale for
cataract surgery (i.e., some patients have very little room
for improvement on this scale).17 This explains why the
percentage change on the VF-14 scale is lower in the later
cohort even though the postoperative satisfaction with
vision is significantly higher in the 2006–2007 cohort
and the change in habitual visual acuity is the same in
both cohorts.
Conner-Spady et al.4 and Hodge et al.18 conducted 2
comprehensive reviews of literature pertaining to wait
times for cataract surgery. They found studies reporting
deterioration in vision after waits of more than 6 months,
with an increased risk of falls, hip fractures, and motor
vehicle accidents, and a reduced quality of life. We recently
added depression to this list of adverse outcomes of
patients waiting for cataract surgery.11
We found that the self-reported accident rate while wait-
ing for cataract surgery decreased in the second cohort. To
determine if this was due to a shorter wait time or because
patients in the second cohort had better vision, we ran a
logistic regression model adjusted for age and cohort and
found that risk factors for a self-reported accident attri-
buted to a vision problem during the wait time were length
of wait time (odds ratio [OR] 5 1.09 per 30 days, p 5
0.04); visual acuity in the eye to be operated on (OR 5
1.08 per 0.1 logMAR, p , 0.001); and worse 5-item CSS
score (OR 5 1.15, p , 0.001) (data not shown).
The Canadian Wait Time Alliance now recommends a
maximum 16-week wait time for cataract surgery.19 In our
2006–2007 cohort, more than 50% of patients still waited
more than 4 months. The Montreal Health Agency has
since added the 6-month upper limit to wait time, and the
hospital must offer a private alternative if a patient has been
waiting 6 months or more for cataract surgery.
One limitation of our studies on wait time is that we
do not have information about the wait time to see the
surgeon (i.e., the time from referral by the optometrist
or the general practitioner to being seen by the ophthal-
mologist). More studies are required to carefully evaluate
wait times.
We found that a health management program to reduce
cataract surgery wait time and improve surgical efficiency
seems to have benefited cataract patients by allowing phy-
sicians to treat them sooner in the disease process, with
excellent surgical results and better quality of life while
waiting and immediately after surgery. The number of
years lived with good quality of life after surgery may also
improve with such programs. The fact that the second
cohort was slightly younger at the time of surgery tends
to support this assertion.

Future directions for this research program are to mon-
itor changes in patient population profile, wait times, and
patient expectancy and outcome from cataract surgery
in Montreal, and ideally, to compare prospective data
obtained from different regions in Canada.
This study was supported by the Fonds de Recherche en Santé du Qué-
bec (FRSQ; J. Gresset and H. Boisjoly), the Fonds de Recherche en
Ophtalmologie de l’Université de Montréal (FROUM; H. Boisjoly),
and Alcon Canada (H. Boisjoly). The authors acknowledge the signifi-
cant contributions of Lucille Crépin and Annie Laporte. Surgeons
included Marcel Amyot, MD; Marie-Josée Aubin, MD, MSc; Hélène
Boisjoly, MD, MPH; Marie-Carole Boucher, MD; Isabelle Brunette,
MD; Jean-André DeGroot, MD; Daniel Desjardins, MD, MSc; Jean
Dumas, MD; Éric Fortin, MD; Paul Harasymowycz, MD, MSc; Pierre
Labelle, MD; Michel LeFrançois, MD; Mark Lesk, MD, MSc; Michèle
Mabon, MD; and Francine Mathieu-Millaire, MD. The authors have
no proprietary or commercial interest in any materials discussed in
this article.
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Keywords: cataract surgery, health care delivery, functional vision,
wait time
CAN J OPHTHALMOL—VOL. 45, NO. 2, 2010 139