CATARACT SURGERY Date of referral _ _ / _ _ / _ _ _ _ D.O.B: ... /... / Patient Name: …………………………… NHS No: ………………… …. Referring GP and Practice Name: …………………………………………………………………. Indication Delete as appropriate Reduced visual acuity documented to be at best 6/12 or Meets criteria: worse in the affected eye (corrected) Yes / No Please also confirm which is the affected eye Right eye/ Left eye / Both AND The patient is willing to have cataract surgery. The referring optometrist or GP has discussed the risks and benefits Yes / No using an approved information leaflet (national or locally agreed) and ensured the patient understands and is willing to undergo surgery before referring. AND impairment of lifestyle such as: The patient is at risk of falls, or Yes / No The is affecting their eligibility to drive, or patient’s vision Yes / No The is substantially affecting their Yes / No patient’s vision ability to work, or The is substantially affecting their ability to Yes / No patient’s vision undertake leisure activities such as reading, watching television or recognising faces OR The patient has best corrected visual acuity of better than 6/12 in the worst eye but they are working in an occupation in which good visual acuity is essential to their ability to Yes / No continue to work e.g. watchmaker, microsurgeon. (Please specify overleaf) OR Cataracts are binocular The patient has bilateral cataracts, neither of which fulfils the Yes / No threshold for surgery, but which together reduce binocular vision below the DVLA standard for driving. (Binocular vision Binocular vision as of 6/12 or worse) Snellen chart: OR Patients with diabetes in whom the removal of cataract is considered Yes / No necessary to facilitate effective digital retinal photography. OR The patient has best corrected visual acuity of better than Yes / No 6/12 in the worst eye but they are experiencing some other significant impact on their quality of life, as a result of their visual symptoms. A description of this impact must accompany the referral information.
CATARACT SURGERY Date of referral _ _ / _ _ / _ _ _ _ Patient Name: …………………………… NHS No: ………………… D.O.B: ... /... / …. Referring GP and Practice Name: …………………………………………………………………. Indication Delete as appropriate Reduced visual acuity documented to be at best 6/12 or worse in the affected eye (corrected) Please also confirm which is the affected eye Meets criteria: Yes / No Right eye/ Left eye / Both AND The patient is willing to have cataract surgery. The referring optometrist or GP has discussed the risks and benefits using an approved information leaflet (national or locally agreed) and ensured the patient understands and is willing to undergo surgery before referring. Yes / No AND impairment of lifestyle such as: The patient is at risk of falls, or The patient’s vision is affecting their eligibility to drive, or The patient’s vision is substantially affecting their ability to work, or The patient’s vision is substantially affecting their ability to undertake leisure activities such as reading, watching television or recognising faces Yes / No Yes / No Yes / No Yes / No OR The patient has best corrected visual acuity of better than 6/12 in the worst eye but they are working in an occupation in which good visual acuity is essential to their ability to continue to work e.g. watchmaker, microsurgeon. (Please specify overleaf) Yes / No OR The patient has bilateral cataracts, neither of which fulfils the threshold for surgery, but which together reduce binocular vision below the DVLA standard for driving. (Binocular vision of 6/12 or worse) Cataracts are binocular Yes / No Binocular vision as Snellen chart: OR Patients with diabetes in whom the removal of cataract is considered necessary to facilitate effective digital retinal photography. Yes / No OR The patient has best corrected visual acuity of better than 6/12 in the worst eye but they are experiencing some other significant impact on their quality of life, as a result of their visual symptoms. A description of this impact must accompany the referral information. Yes / No
GP%20Cataract%20form%20%28No%20E%20referral%29%20v3.2.docx