Questionnaire Before Cataract Surgery

A cataract is a cloudy lens that causes a decrease in vision over time.  Cataract surgery is available to remove the cloudy lens, and implant a new lens in your eye.  There are several intraocular lens (IOL) options that may be available to you when you have cataract surgery.  The main IOL options include:

1)  Monofocal aspheric (ie. Tecnis ZCBOO, Acrysof SN60WF) – these lenses give excellent vision at a single distance, either distance or near.  It does not correct for astigmatism, and can be calculated to correct for distance, reading, or monovision (one eye for distance and one eye for near).

2)  Toric monofocal (ie. ZCT125, SN6AT3) – similar to #1, but also correct for astigmatism.

3)  Multifocal (ie. Tecnis Multifocal, ReSTOR) – these lenses give good distance and reading vision, but some patients report halos or limitation of mid-range vision.  

4)  Accommodative (ie. Crystalens, Trulign Toric) – these lenses give excellent distance vision, and have hinges on them to allow them to be flexed to give good mid-range vision, and in some cases reading vision.  Patients often use reading glasses for fine print or extended reading.  

None of the lens options is perfect, and knowing your goals and expectations are helpful in determining the lens that best suits the vision demands of your lifestyle.  Please fill this form out completely and return it to us at your pre-operative visit for cataract surgery.

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  1.  Are you interested in not having to wear glasses after cataract surgery?

    _____Yes     _____No

  1.  Are you interested in seeing well at distance (driving, golf, skiing, tennis) without glasses after surgery?

    _____Prefer no distance glasses

    _____I wouldn’t mind wearing distance glasses

  1.  Are you interested in seeing well at mid-range (computer, cooking, grocery shopping) without glasses after surgery?

    _____Prefer no mid-range glasses

    _____I wouldn’t mind wearing mid-range glasses

  1.  Are you interested in seeing well at near (reading, sewing) without glasses after surgery?

    _____Prefer no reading glasses

    _____I wouldn’t mind wearing reading glasses

  1.  If you had to wear glasses after surgery for one activity, for which activity would you be MOST WILLING to use glasses?

    _____Reading fine print     _____Computer     _____Driving

  1.  If you could have good distance vision during the day without glasses, and good near vision for reading without glasses, but the compromise was that you might see some glare and halos around lights at night, would you like that option?

    _____Yes     _____No

  1.  If you could have good distance vision and mid-range vision during the day and night without glasses, but the compromise was that you would need glasses for extended reading or fine print, would you like that option?

    _____Yes     _____No

  1.  Have you ever been told you have astigmatism?

    _____Yes     _____No

  1.  Have you ever had monovision, either with contact lenses, LASIK, or naturally?

    _____Yes     _____No

  1.  Have you ever had LASIK, PRK, RK or other surgery on your eyes?

    _____Yes     _____No   

  1.  Please place an “X” on the following scale to describe your personality as best you can:

 

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Easy going                                                                                        Perfectionist


Name _____________________________      Date ______/______/_____

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