[Table, Evidence to recommendations]. - Cataracts in adults: management

Relative value of different outcomes	The committee agreed that postoperative complications would be a relevant outcome, but that visual acuity outcomes would be unlikely to help answer this question as in non-randomised studies the aim of these interventions is to ensure people do not achieve worse outcomes than those with normal pupil sizes. Therefore, the committee noted that it would not expect to see any benefits when comparing these interventions in people with normal sized pupils. They noted that additional data on pupil size measurements would be of more interest and requested a deviation from the review question protocol to enable this.
Trade-off between benefits and harms	The committee discussed the evidence and raised concerns that the outcomes measured in many trials did not directly answer important clinical questions, as they were often tested in a very broad population, which included people who would not be likely to receive these interventions in clinical practice. From the range of evidence presented, the committee agreed that 1 paper was of relevance to show how phenylephrine increased pupil size in people taking tamsulosin and at risk of floppy iris syndrome. From this evidence the committee agreed that, although the benefit was seen in patients receiving tamsulosin, the benefit would be generalisable to patients at risk of floppy iris syndrome. Thus a consider recommendation could be made regarding increasing the pupil size of patients at risk of floppy iris syndrome. The committee noted that it would be useful to see evidence on the comparisons of drugs with devices but acknowledged that in most cases the surgeon will try a pharmacological intervention initially and only if this is not successful will revert to a mechanical one.
Consideration of health benefits and resource use	No health economic evidence was identified for this review question, and economic modelling was not prioritised. The committee agreed that, although the manual devices used to stretch pupils cost £50£100, their use was justified when compared with the alternative of failing to do the operation or causing intraoperative damage (e.g. PCR) which costs much more to correct. They further stated that such techniques are in common use and there is little alternative.
Quality of evidence	The committee agreed that the overall quality of the evidence was low. They noted that the outcomes reported in the trials often did not help in addressing important clinical questions. The committee requested that the evidence on pupil size be added to the evidence base from the 1 paper in which it was reported.
Other considerations	No other considerations were identified as part of this review question.

Relative value of different outcomes

The committee agreed that postoperative complications would be a relevant outcome, but that visual acuity outcomes would be unlikely to help answer this question as in non-randomised studies the aim of these interventions is to ensure people do not achieve worse outcomes than those with normal pupil sizes. Therefore, the committee noted that it would not expect to see any benefits when comparing these interventions in people with normal sized pupils. They noted that additional data on pupil size measurements would be of more interest and requested a deviation from the review question protocol to enable this.

Trade-off between benefits and harms

The committee discussed the evidence and raised concerns that the outcomes measured in many trials did not directly answer important clinical questions, as they were often tested in a very broad population, which included people who would not be likely to receive these interventions in clinical practice. From the range of evidence presented, the committee agreed that 1 paper was of relevance to show how phenylephrine increased pupil size in people taking tamsulosin and at risk of floppy iris syndrome. From this evidence the committee agreed that, although the benefit was seen in patients receiving tamsulosin, the benefit would be generalisable to patients at risk of floppy iris syndrome. Thus a consider recommendation could be made regarding increasing the pupil size of patients at risk of floppy iris syndrome.
The committee noted that it would be useful to see evidence on the comparisons of drugs with devices but acknowledged that in most cases the surgeon will try a pharmacological intervention initially and only if this is not successful will revert to a mechanical one.

Consideration of health benefits and resource use

No health economic evidence was identified for this review question, and economic modelling was not prioritised. The committee agreed that, although the manual devices used to stretch pupils cost £50£100, their use was justified when compared with the alternative of failing to do the operation or causing intraoperative damage (e.g. PCR) which costs much more to correct. They further stated that such techniques are in common use and there is little alternative.

Quality of evidence

The committee agreed that the overall quality of the evidence was low. They noted that the outcomes reported in the trials often did not help in addressing important clinical questions. The committee requested that the evidence on pupil size be added to the evidence base from the 1 paper in which it was reported.

Other considerations

No other considerations were identified as part of this review question.

From: 12, Preventing and managing complications

Cataracts in adults: management.

NICE Guideline, No. 77.

London: National Institute for Health and Care Excellence (NICE); 2017 Oct.

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