Cataract Consent

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, or if you have taken medications known 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. Surgery is the only way to remove a cataract.  You can decide not to have the cataract removed.  If you don’t have the surgery, your vision loss from the cataract will continue to get worse.

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 puts in a new artificial lens called an intraocular lens or IOL.  Cataract surgery will not correct other causes of decreased vision, such as glaucoma, diabetes, or age-related macular degeneration.  Most people still need to wear glasses or contact lens after cataract surgery for either near and/or distance vision and astigmatism.

WHAT TYPES OF IOLs ARE AVAILABLE?
Your ophthalmologist will help you decide on the type of IOL that will replace your cloudy lens.  There are IOLs available to treat nearsightedness (myopia), farsightedness (hyperopia), and astigmatism.  IOLs usually provide either near or distance vision:  these single focus lenses are called monofocal IOLs.  Some newer IOLs can provide for near, intermediate, and distance vision:  these multiple focus lenses are called multifocal IOLs.  IOLs that treat astigmatism are called toric IOLs.  You can also have one eye corrected for near vision, and the other for distance vision, a choice called monovision.

WHAT IS ASTIGMATISM?  ARE THERE OTHER TREATMENTS FOR IT?
Patients with nearsightedness and farsightedness often also have astigmatism.  An astigmatism is caused by an irregularly shaped cornea; instead of being round like a basketball, the cornea is shaped like a football.  This can make your vision blurry.  In addition to toric IOLs, astigmatism can be reduced by glasses, contact lenses, and refractive surgery (LASIK or PRK).  There is also a procedure called a limbal relaxing incision (LRI), which can be done at the same time as the cataract operation, or as a separate procedure.  A limbal relaxing incision (LRI) is a small cut or incision the ophthalmologist makes into your cornea to make its shape rounder.  Any attempt at astigmatism reduction could result in over- or under-correction, in which case glasses, contact lenses, or another procedure may be needed.

WHAT ARE THE MAJOR RISKS OF CATARACT SURGERY?
All operations and procedures are risky and can result in unsuccessful results, complications, injury, or even death, from both known and unknown causes.  The major risks of cataract surgery include, but are not limited to bleeding; infection; injury to parts of the eye and nearby structures from the anesthesia, the operation itself, or pieces of the lens that cannot be removed; high eye pressure; a detached retina, and a droopy eyelid.  The major risks of a limbal relaxing incision are similar to those for cataract surgery, but also include loss of vision, damage to the cornea, and scarring; under- or over-correction could occur.

Depending upon your eye and the type of IOL, you may have increased night glare or halos, double vision, ghost images, impaired depth perception, blurry vision, and trouble driving at night.   The ophthalmologist might not be able to put in the IOL you choose.  In addition, the IOL may later need to be repositioned or replaced.

Depending upon the type of anesthesia, other risks are possible, including cardiac and respiratory problems, and, in rare cases, death.

There is no guarantee that cataract surgery or astigmatism reduction will improve your vision.  As a result of the surgery and/or anesthesia, it is possible that your vision could be made worse.  In some cases, complications may occur weeks, months or even years later.  These and other complications may result in poor vision, total loss of vision, or even loss of the eye in rare situations.  You may need additional treatment or surgery to treat these complications.  This additional treatment is not included in the fee for this procedure.

Presbyopia Correction

Presbyopia makes it hard for the eye to focus on near vision. This happens to most people as they age. It can also happen after cataract surgery to people of any age if they have a monofocal IOL for distance vision. People with presbyopia might hold a book or menu at arm’s length to see it more clearly. Reading glasses can improve vision problems caused by presbyopia. 

Your eye surgeon can correct presbyopia during cataract surgery. The goal is to reduce your need to wear eyeglasses. The options for correcting presbyopia during cataract surgery offered by your surgeon is 

Premium IOL. Another option to correct presbyopia is for your eye surgeon to put in a premium IOL. Premium IOLs allow your eye to focus at more than one distance so that you do not have to wear glasses as much. Premium IOLs work best if put into both eyes. There are different types of premium IOLs. Your eye surgeon told you about them and helped you decide which is best for you. 

You have to pay extra for a premium IOL. Medicare and private insurance do not pay for this.

Risks. As with all surgery, problems can happen. In addition to all the risks for cataract surgery, here are some common or serious risks for presbyopia correction:

• You may see halos and ghost images. Or you could have night glare, double vision, or blurry vision. 
• You might have trouble with depth perception (seeing which of two objects is closer) or problems driving at night.
• Premium IOLs may not work well if you have certain eye problems or large pupils.
• You may need to wear glasses at all times or just for some activities, even after getting premium IOLs.

PATIENT’S ACCEPTANCE OF RISKS
I understand that it is impossible for the doctor to inform me of every possible complication that may occur.  By signing below, I agree that my doctor has answered all of my questions, that I have been offered a copy of this consent form, and that I understand and accept the risks, benefits, and alternatives of cataract surgery.  I have checked my choice for astigmatism correction and type of IOL.

By signing below, you consent (agree) that:

You read this informed consent form, or someone read it to you.
You understand the information in this informed consent form.
The eye surgeon or staff offered you a copy of this informed consent form. 
The eye surgeon or staff answered your questions about presbyopia correction.
You understand that you may need to wear glasses after surgery.

A. Notifier: Ophthalmic Consultant of New York, PLLC

NOTE: If Medicare doesn’t pay for D.  below, you may have to pay. Medicare does not pay for everything, even some care that you or your healthcare provider have good reason to think you need. We expect Medicare may not pay for the D.  below.

E. Reason Medicare May Not Pay: Medicare statutory exclusion, coverage policy limitation, or other restriction.

WHAT YOU NEED TO DO NOW: 

• Read this notice, so you can make an informed decision about your care. 

• Ask us any questions that you may have after you finish reading. 

• Choose an option below about whether to receive the D.  listed above. 

Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

G. OPTIONS: Check only one box. We cannot choose a box for you. 

H. Additional Information:

This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy.

CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: altformatrequest@cms.hhs.gov

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850. Form CMS-R-131 (Exp. 03/2023) Form Approved OMB No. 0938-0566

This service is not a covered benefit and consequently your health plan willnot pay fir it. When you receive a serice taht is not a covered benefit, you are responsible to pay for it.

The purpose of this notice is to help you make an infomed choice about whether or not you wan tto receive these items or services, knowing that you will have to pay for them yourself. Ask us to explain, if you do not understand why your helath care service plan will not pay.