Referral Guidance Criteria:CATARACT SURGERY

Patient Name: ……………………………NHS No:…………………D.O.B.:.. / .. / ….

Referring GP and Practice Name:

Referrals for cataract surgery should be based on reduced visual acuity, plus impairment of lifestyle plus willingness to have surgery. Please fax this form to 01707 369692,with the corresponding GP referral letter attached.

Referrals should be based on the following indications (*please delete as appropriate):

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 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) / 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.(Please specify) / 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.
And in all of the above, the patient is willing to have cataract surgery if appropriate / Yes* / No

If yes to above questions, please specify details below (continue on a separate sheet if needed)

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If the patient does not meet the above criteria but there may be grounds for exceptionality, please specify below (continue on a separate sheet if needed)

Second eye surgery in patients with bilateral cataracts

Second eye surgery will be funded if the criteria above are met again. This should be assessed not earlier than the post-operative review following surgery on the first eye.

This policy does not extend to cataract removal incidental to the management of other eye conditions.

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GP SIGNATURE:DATE:

Referral Management Criteria FormJanuary 2012