Survey

Are you taking this survey for yourself or a friend or loved one?

Myself

A friend or loved one

If you are taking this survey for a loved one, please answer the following questions from their perspective.

Have you been diagnosed with late-stage AMD?

Yes

Not yet, but my doctor thinks I may have late-stage AMD

In the last year, have you seen an eye care specialist?

Yes

Have you been told by an eye care specialist that you are legally blind in both eyes (around 20/200 or worse)?

Yes

I am not sure

Do you currently have blind spots in the center of your vision in both eyes?

Yes

Have you been told by an eye doctor that you have a cataract in at least one eye?

Yes

I am not sure

Do you have enough side vision (peripheral vision) in one eye to help you move around?

Yes

Do you have a history of rubbing your eyes frequently or an eye condition that could cause you to rub your eyes often?

Yes

Have you ever been diagnosed with any of the following conditions? Check all that apply.

Stargardt disease

Diabetic retinopathy

Retinal tears or detachment

Retinal blood vessel disease

Optic nerve disease

Tumors in the eye

Retinitis pigmentosa

Corneal stromal or endothelial dystrophies, including guttata

I am not sure/none of the above

Do you have glaucoma or high eye pressure that is not controlled?

Yes

I am not sure

Have you ever been told you are allergic to any eye drops or medications used after surgery?

Yes

Have you had previous intraocular or corneal surgery, including any type of surgery for refractive or therapeutic purposes?

Yes

This study is for those living with stable (non-active neovascularization), bilateral central scotomas (blind spots) due to late-stage AMD and fovea-involving geographic atrophy or disciform scar to receive a SING IMT™ in one eye. The SING IMT™ is an investigational telescope implant designed to improve visual acuity and quality of life for patients with late-stage AMD. It is implanted during typical, out-patient cataract surgery. Part of the study involves using a special external telescope simulator with a low-vision specialist before surgery, and attending followup visits after the surgery. Qualified participants receive the procedure at no cost to themselves or their insurance, and may earn a stipend for their time and effort.

Based on the information you have today, how interested would you be in learning more?

Very interested

Somewhat interested

Not sure

Somewhat disinterested

Very disinterested

If we are unable to identify a location near you that performs this procedure, would you be willing to travel to a participating study location if travel costs, including accommodations, were covered by the study?

Yes, I am willing to travel

I am not sure

No, I am not willing to travel

What is your biological sex?

Male

Female

Prefer not to say

Which of the following best describes you?

Asian or Pacific Islander

Black or African American

Hispanic or Latino

Native American or Alaskan Native

White or Caucasian

Multiracial or Biracial

A race/ethnicity not listed here

Prefer not to say

How old are you?

Contact Information

First Name

Last Name

Phone

Zip

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