Form Doh-Mqa 1255 - Cataract Operation With Or Without Implantation Of Intraocular Lens - Florida Board Of Medicine
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LORIDA
OARD OF
EDICINE AND
LORIDA
OARD OF
STEOPATHIC
EDICINE
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PPROVED
NFORMED
ONSENT
ORM FOR
ATARACT
PERATION WITH
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WITHOUT
MPLANTATION OF
NTRAOCULAR LENS
DOES THE PATIENT NEED OR WANT A TRANSLATOR, INTERPRETOR OR READER?
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YES
NO
TO THE PATIENT: You have the right, as a patient, to be informed about your cataract
condition and the recommended surgical procedure to be used, so that you may make
the decision whether or not to undergo the cataract surgery, after knowing the risks,
possible complications, and alternatives involved. This disclosure is not meant to scare
or alarm you; it is simply an effort to make you better informed so that you may give or
withhold your consent to cataract surgery and should reflect the information provided by
your eye surgeon. If you have any questions or do not understand the information,
please discuss the procedure with your eye surgeon prior to signing.
WHAT IS A CATARACT, AND HOW IS IT TREATED?
The lens in the eye can become cloudy and hard, a condition known as a cataract. Cataracts can
develop from normal aging, from an eye injury, various medical conditions or if you have taken
certain medications such as steroids. Cataracts may cause blurred vision, dulled vision,
sensitivity to light and glare, and/or ghost images. If the cataract changes vision so much that it
interferes with your daily life, the cataract may need to be removed to try to improve your vision.
Surgery is the only way to remove a cataract. You can decide to postpone surgery or not to have
the cataract removed.
ALTERNATIVE TREATMENTS:
I understand that I may decide not to have a cataract operation, at all. However, if I do not have
the cataract surgery, I understand my vision loss from the cataract usually will continue to get
worse. Corrective lenses, eyeglasses, or contact lenses will not improve my vision or reverse the
worsening of the cataract.
HOW WILL REMOVING THE CATARACT AFFECT MY VISION?
The goal of cataract surgery is to correct the decreased vision that was caused by the cataract.
During the surgery, the ophthalmologist (eye surgeon) removes the cataract and may place in a
new artificial lens called an intraocular lens or IOL. Cataract surgery will not correct other
causes of decreased vision, such as glaucoma, optic nerve or retinal problems, diabetes, age-
related macular degeneration, or dry eye. In order to obtain the best possible vision, many
Patient initials _________
Page 1 of 6
Eye Surgeon’s initials __________
Date __________
DOH‐MQA 1255, 10/11, Rules 64B8‐9.017 and 64B15‐14.012
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