• Ophthalmic Mutual Insurance Company (OMIC)

    Note: This form is intended as a sample form of the information that you as the surgeon should personally discuss with the patient. Please review and modify to fit your actual practice. Give the patient a copy and send this form to the hospital or surgery center as verification that you have obtained informed consent.



    Vision-correcting surgery such as Conductive Keratoplasty, LASIK and PRK can precisely and accurately correct fixed focal errors of the eye such as farsightedness, nearsightedness, and astigmatism. These optical conditions are fundamentally different than presbyopia, the loss of adjustability of focus for near viewing. Presbyopia is the reason that reading glasses become necessary, typically in the age range of mid-40, even for people who have excellent unaided distance vision. For those that require prescriptive correction to see clearly at distance, bifocals or separate (different prescription) reading glasses become necessary at that age to see clearly at close range.

    This information and the Patient Information booklet are being provided to you so that you can make an informed decision about the use of a device known as the ViewPoint™ CK System, which is utilized to perform the NearVision CK procedure. NearVision CK is one of a number of alternatives for correcting your vision. The NearVision CK procedure uses a controlled release of radiofrequency (RF) energy to increase the temperature of corneal tissue. The treatment is applied with a probe that is introduced 16 to 24 times into the cornea in a circular pattern, which results in an increased curvature of the cornea to treat your vision. The correction you achieve with NearVision CK may be temporary.

    NearVision CK is an elective procedure. There is no emergency condition or other reason that requires or demands that you have it performed. You could continue wearing contact lenses or glasses and have adequate visual acuity. This procedure, like all surgery, presents some risks, many of which are listed below. You should also understand that there might be other risks not known to your doctor, which may become known later. Despite the best of care, complications and side effects may occur; should this happen in your case, the result might be affected even to the extent of making your vision worse.


    There are several options available to those who are presbyopic, besides wearing bifocals or separate reading glasses. For example, for some individuals, wearing a contact lens in one eye for distance vision, and a contact lens in the other eye for reading, affords a reasonable solution. This is called monovision (mono for one; one eye for distance, one eye for near vision).

    If a person enjoys and functions well with monovision in contact lenses, the same option can be created on a more permanent basis with vision-correcting surgery such as NearVision CK. If you are contemplating such correction for yourself, it is important to understand the advantages and drawbacks of such care. If you decide not to have NearVision CK, alternative methods of correcting your vision include, among others, eyeglasses, contact lenses, and other refractive surgical procedures.

    Patient signature