A quick initial patient screening process can be performed by using the questionnaire below. It can be filled before the medical eye examination for initial screening and 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 already filled this questionnaire through the website, you can enter his/her username and password by clicking here, for your evaluation.
Please keep in mind that there are some differences between the forms that the patient is advised to fill and the form below.
Preliminary screening form – click here for downloading this PDF form. You may use this form for initial screening.
Please check “Yes” or “No” for each question
If any of the answers are “No”, the patient may not participate:
|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.
|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 preoperative eye test.