Cataract Surgery
Patient Name: _____________________________________ CR No.:
________________
AGE: _______________ Sex: □ M □ F IPD
No.:________________
A. Interpreter / cultural needs
An Interpreter Service is required? □ Yes □ No
If Yes, is a qualified Interpreter present? □ Yes □ No
A Cultural Support Person is required? □ Yes □ No
If Yes, is a Cultural Support Person present? □ Yes □ No
B. Condition and treatment
The doctor has explained that you have the following condition:
____________________________________________________________________________
This condition requires the following procedure.
____________________________________________________________________________
Left Eye □
Right Eye □
The following will be performed:
The cataract is surgically removed. The lens in the eye is replaced
by an artificial lens or what is commonly known as an implant.
C. Risks–
There are risks and complications with this procedure. They include but are
not limited to the following.
General risks:
Infection can occur, requiring antibiotics and further treatment.
Bleeding could occur and may require a return to the operating room.
Bleeding is more common if you have been taking blood thinning drugs such
as Warfarin, Asprin, Clopidogrel (Plavix or Iscover) or Dipyridamole (Persantin
or Asasantin).
Small areas of the lung can collapse, increasing the risk of chest infection.
This may need antibiotics and physiotherapy.
Increased risk in obese people of wound infection, chest infection, heart
and lung
Complications, and thrombosis.
Heart attack or stroke could occur due to the strain on the heart.
Blood clot in the leg (DVT) causing pain and swelling. In rare cases part of
the clot may break off and go to the lungs.
Death as a result of this procedure is possible.
Specific risks:
A cloudy cornea which may or may not settle. This may require
further surgery.
An acute inflammatory reaction causing pain. This may need
further treatment.
A fragment of the cataract may fall into the back of the eye. This
may require
Further surgery.
Infection of the eye which could cause loss of vision or loss of the
eye.
Glaucoma (eye disease). This may need further treatment.
Macular oedema (collection of fluid); and retinal haemorrhage
(bleed). This usually settles with time.
Retinal detachment may occur. This will require further treatment.
Any of these complications may occur but these complications are
now rare.
Any of these complications may permanently damage sight.
Any of these complications may involve a second operation being
necessary.
D. Alternatives-
______________________________________________________________
E. Interpreter’s statement
I have given a sight translation in
_______________________________________________
(State the patient’s language here) of the consent form and assisted in the
provision of any verbal and written information given to the patient/parent or
guardian/substitute decision-maker by the doctor.
Name of Interpreter
________________________________________________________
Signature:___________________________Date:_________________________________
F. CONSENT FOR PATIENT REPRESENTATIVE/SURROGATE
The patient is unable to consent because
_____________________________________________________________________________
And I _________________________________(Name/Relation to the patient)
therefore, consent for the patient. I acknowledge that I have had an
opportunity to discuss the risk, alternate and benefits of this procedure with
the doctor or doctor designee, and hereby consent for this procedure.
G. PATIENT’S CONSENT-I have been given the H. Doctor/delegate
following Patient Information Sheet/s Cataract Statement- I have
Surgery explained to the patient
I was able to ask questions and raise concerns with all the above points
the doctor about my condition, the proposed under the Patient
procedure and its risks, and my treatment options. Consent section (G) and
My questions and concerns have been discussed I am of the opinion that
and answered to my satisfaction. the patient/substitute
I understand I have the right to change my decision maker
mind at any time, including after I have signed has understood the
this form but, preferably following a discussion information.
with my doctor. I understand that image/s or
video footage may be recorded as part of and
during my procedure and that these image/s or
video/s will assist the doctor to provide
appropriate treatment.
On the basis of the above statements, I request to
have the procedure _________________
______________________________________ Doctor’s Signature
Patient/ patient’s relative Signature _______________________
______________________________________ Doctor’s Name
Name/ Name and Relation with patient
Date__________Time___
Date __________Time___________
