Category: For Clinicians

By Dr Sherif Ekram, Consultant Ophthalmic Surgeon, former Glaucoma Clinical Lead and RCOphth-approved surgical trainer

Summary: Efficient ophthalmic theatres are built before the patient reaches the operating room. The biggest gains come from accurate case classification at pre-assessment, deliberate case order, standardised kit for each procedure type, parallel patient preparation, and a team that briefs and debriefs every list. Combined cataract and glaucoma lists need extra planning because case length and risk vary widely, but with the right structure they can be both safe and productive.

Why mixed lists are hard

A routine phacoemulsification list is predictable. Add glaucoma surgery and the variation grows quickly. A phaco with iStent Inject may take only a few minutes longer than standalone cataract surgery. A GATT, a Preserflo MicroShunt or a non-valved tube such as the ClearPath GDD can take much longer, and complex cases such as IOL exchange or scleral-fixated IOLs add vitrectomy and further uncertainty.

When these cases are booked without structure, lists overrun, late cases are cancelled, and teams are pushed to rush, which is when errors happen. The solution is not to work faster. It is to plan better.

1. Classify complexity at pre-assessment

Every case should arrive in theatre with a complexity grade agreed in clinic, not discovered on the table. Useful flags include:

• small pupil, pseudoexfoliation or zonular weakness;
• dense or white cataract;
• previous glaucoma or vitreoretinal surgery;
• planned combined procedure (phaco plus MIGS, bleb surgery or tube);
• patient factors: anticoagulation, positioning difficulty, anxiety or need for a different anaesthetic.

A simple time allowance per grade lets schedulers build lists that fit the session. Audit the real times regularly and update the allowances.

2. Design the list order deliberately

Case order affects safety, flow and training. Principles that work well on mixed lists:

• Place the most complex case where the team is freshest, usually first or second, not at the end of a long session.
• Group similar procedures so the scrub team prepares equipment once, for example running phaco-iStent cases together.
• Keep a buffer case, a short, flexible case that can move forward if a longer one is cancelled.
• Plan training cases with time built in, rather than squeezing teaching into a full list.

3. Standardise kit for each procedure

Procedure-specific packs and trays reduce opening time, waste and errors. For glaucoma surgery this means a defined MIGS set, a bleb-surgery set with antimetabolite protocol, and a tube set with patch graft material ready. Surgeon preference cards should be agreed and kept current, so any trained scrub practitioner can prepare the case without waiting for instructions.

4. Prepare patients in parallel

Turnaround time between cases is often the largest hidden loss. Where staffing and space allow, the next patient should be checked, dilated, marked and anaesthetised while the current case finishes. In high-volume cataract settings, the high volume low complexity (HVLC) model used across NHS hubs shows how much capacity this can release. The same principle applies on mixed lists, with extra care for cases needing longer blocks or sedation.

5. Brief, debrief and measure

The WHO Surgical Safety Checklist is the minimum. A good team briefing also covers the order of the list, any expected difficulties, implant and lens checks, and who is training. A short debrief at the end captures what slowed the list and what went well.

Useful measures for a mixed ophthalmic list include:

• start time and finish time compared with the plan;
• turnaround time between cases;
• on-the-day cancellations and their causes;
• complication rates by procedure type, reviewed in governance meetings.

6. Make training part of the system

Training and efficiency are often treated as opposites. They do not need to be. Structured training lists, a clear graded responsibility for each step, and modular teaching (for example the trainee completes the capsulorhexis and phaco, while the trainer places the MIGS device) let trainees progress without destabilising the list. As an RCOphth-approved trainer and assessor, Dr Ekram has found that well-planned training lists are often more efficient than ad hoc teaching on service lists.

Leadership lessons from glaucoma services

As Glaucoma Clinical Lead for UK ophthalmic networks, Dr Ekram worked on clinic flow and theatre logistics alongside the clinical pathway itself. Three lessons stand out:

1. Theatre problems usually start in clinic. Better pre-assessment fixes more overruns than faster surgery.
2. Standardisation frees the team to focus on the patient. Fewer decisions about kit and process means more attention on the eye.
3. Data changes behaviour. Sharing honest list data with the whole team does more than any instruction from above.

For patients, this work is mostly invisible. What they notice is a calm, on-time list and a team that knows the plan. For a patient-facing explanation of the procedures discussed here, see our guide to MIGS and advanced glaucoma surgery, and for what patients should look for in a surgical team, see choosing an eye surgeon in the UK.

Frequently asked questions

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About the author
Dr Sherif Ekram is a UK Consultant Ophthalmic Surgeon with over 18 years of experience, dual-subspecialised in glaucoma and refractive surgery (CertLRS). He is a former Glaucoma Clinical Lead, an RCOphth-approved assessor and surgical trainer, and an invited international speaker, including at the Sinjab Academy. He has performed more than 16,000 cataract, 8,000 refractive and 3,000 glaucoma operations. More clinician notes are in the articles library.