Initial Screening

senior man and doctor with tablet pc at hospitalA quick initial patient screening can be performed by using the questionnaire below. It can be filled before the medical eye examination for initial screening for saving time. The following questionnaire is only an option, not mandatory.

Since our web site enables the patients to perform some initial self-tests, if your patient has filled this questionnaire, enter his/her username and password for your initial evaluation.

Please keep in mind that there are some differences between the forms that the patient can fill and the form below.


Preliminary screening form:

Please check “Yes” or “No” for each question

If any of the answers are “No”, the patient may not participate:

Yes No
1.   The patient suffers from bilateral macular degeneration.
2.   The patient is 60 years old or more.
3.   The patient has shown interest and understands the need for visual improvement.
4.   The patient has visual acuity between 20/80 and 20/800 (in the operated eye).
5.   The eye being considered for surgery shows an improvement in visual acuity when tested with an external telescope with x2.5 magnification.
6.   The patient has no ocular pathology or previous surgery in the operative eye except for cataract and age-related macular degeneration.
7.   The fellow eye has no ocular disease that may affect the peripheral visual field.
8.   The patient has the mental ability to undergo the testing required for the surgery and is likely to complete the entire course of follow-up.
9.   The patient agrees to sign a written informed consent.


Answers to questions “1 through 9” must all be “Yes” for the patient to be a candidate for implantation.

Please check “Yes” and “No” for each question.

Yes No
10.   The patient is currently involved, or in last 30 days, has been involved in any clinical trial of an investigational drug or device.
11.   The patient is immunosuppressed, uses systemic steroid or anticoagulants.
12.   The patient has known sensitivity to any of the medications that will be used after surgery.
13.   The patient has severe communication impairment or a severe neurological disorder, which would prevent or interfere with the requirements.


Answers to questions “10 through 13” must all be “No” for the patient to be a candidate for further evaluation.

If the answers to questions, “1 through 9” are all “Yes” and the answers to questions “10 through 13” are all “No”, proceed to the more thorough eye test.


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