Download Cataract Grade

Cambridgeshire and Peterborough Clinical Commissioning Group
Direct Referral Form for Cataract Surgery
Patient’s Name:
GP’s Name:
Optometrist’s Name:
Address:
Address:
Address:
Postcode:
Tel No:
NHS No:
Postcode:
Tel No:
Postcode:
Tel No:
DOB:
Reason for referral / symptoms/
likely functional benefit of surgery:
Ocular Co-morbidity / POH:
Rx
Current
Previous
R Sph.
Cyl.
Axis
BC VA
L Sph.
Cyl
Axis
BC VA
Add
CCG Referral Threshold met?1 BCVA ≤6/12 or worse in worst eye;
YES/NO
OR
bilateral cataracts, binocular vision does not meet DVLA standards;
OR
significant optical imbalance (anisometropia or anisekonia)
YES/NO
affecting activities of daily living only corrected with cataract surgery;
AND patient willing to undergo surgery.
YES/NO
Cataract Grade
Clear
R
L Clear
Nuclear
Nuclear
mild / mod / severe
mild / mod / severe
Cortical
Cortical
mild / mod / severe
mild / mod / severe
PSC
PSC
mild / mod / severe
mild / mod / severe
Pseudophakia
Pseudophakia
List for cataract surgery in right or left eye?
Blepharitis: Yes /No. A/C depth: Deep / Shallow. Pupil dilates well: Yes / No. Difficult fundoscopy: Yes / No.
RAPD present: Yes / No.
Cornea:
L:
R:
Indicate if opacity
IOP:
mmHg
R:
mmHg L:
Disc:
L:
R:
Indicate cup-disc ratio
Fundus:
L:
R:
Indicate macular status
Medical History (to be completed by the Optometrist). Circle Yes/No below appropriate.
Diabetes: Yes / No. Hypertension: Yes / No. Heart attack: Yes / No.
Stroke: Yes / No. Short of breath: Yes / No.
Poor mobility: Yes / No. Is able to lie down flat: Yes / No.
Current Drugs:
Choice of care
provider
Social History:
(eg driver, working, carer)
Other:
Transport needed? Yes / No
Written information provided? Yes / No
Patient Consent
 Is the patient aware of this referral and the content of this form, and any supporting documents?
 I confirm the patient has consented to the sharing of personal and clinical information contained within
this form with clinical staff involved with their care to enable full consideration of this referral.
By submitting this referral you are confirming that you have fully explained to the patient the proposed
treatment and they have consented to you raising this referral on their behalf.
Optometrist’s signature: ___________________________________
Circle as appropriate
Yes / No
Yes / No
Date: _____________
Date: ____________________________________
Copes to be printed: (Please circle once printed): Care Provider Copy / Patient Copy / GP Copy / Optometrist Copy
1
For patients who do not meet the policy threshold, treatment is considered of low priority and will only be commissioned
by the NHS on an exceptional case basis. Optometrists or GPs need to apply to the Exceptional and Individual Funding
Request Panel for approval of funding.
Click the links to access the CCG Cataract Policy and Exceptional/Individual Funding Request Form: Policy; Funding Rqst Frm
Doc Ref
R:/CPF Pols & working Area/Surg Threshold Pols - Draft and Agreed/referral pfrma/cataract/ CATARACT REFERRAL PROFORMA MAY 14 V5
May 2014