Procedure that requires prior approval
Application form: - Cataract Removal in Adults
GP Name and Surgery
Patients NHS Number
Is the patient/guardian aware of the proposed treatment and have they consented to you raising this request on their behalf? / Yes ☐No ☐
Has the patient/guardian consented for their personal and clinical information to be provided to the IFR service via all means, including electronic and automated approvals, to enable full consideration of this funding request? / Yes ☐No ☐
Is this a patient/guardian led application? / Yes ☐No ☐
Most Urgent: Decision needed within a week as the patient’s life may be in danger. / ☐ /
Immediate: Decision needed within 3 weeks as delay will not be clinically appropriate. / ☐ /
Routine: Decision needed in 4 to 6 weeks. / ☐ /
When considering referral for first or second eye cataract surgery the policy thresholds must be met.
Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service:or consideration.
The policy statements are available
Clinical Criteria required for consideration of treatment / Please Tick
Either complete Question 1 or 2 then 3, 4 & 5
- Is the cataract sufficient enough to account for the visual symptoms (visual loss or disturbance) experienced by the patient?(Alternative causes for the reported visual symptoms should be excluded prior to referring a patient for cataract surgery).
Is the best corrected Visual Acuity documented at least 6/12 or worse in the cataract affected eye?
Please attach a copy of the acuity report from the optician or the GOS18 form to the case file. If bilateral treatment is requested both eyes must meet the criteria in full. / YES☐NO☐
- Is the cataract and visual symptoms experienced by the patient negatively affecting the patient’s lifestyle? Please confirm which are applicable below:
☐Difficulty with night vision due to lens opacities particularly if driving
☐A requirement for good vision for employment or caring purposes
☐Difficulty in reading e.g. Significant Anispmetropia/ Aniseikonia
☐Management of other coexisting eye conditions, including DRSS (Diabetic Retinopathy Screening Service) ungradable photograph
☐Refractive error primarily due to cataract
Please provide details of any of those indicated above and also any other symptoms experienced by the patient which are negatively affecting the patient’s lifestyle / YES☐NO☐
- The patient understands the general benefits and risks of surgery AND The patient wants to undertake the surgery
- Patient’s Body Mass Index:
Height / cm
Weight / kg
- Is the patient a non-smoker?
South, Central and West Commissioning Support Unit April 2018 TVPC60 BE