1 1 INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK) AND PRK FOR THE CORRECTION OF NEARSIGHTEDNESS, FARSIGHTEDNESS, AND ASTIGMATISM Introduction This information is being provided to you so that you can make an informed decision about the use of a device known as a microkeratome or femtosecond laser, combined with the use of a device known as an excimer laser, to reshape the eye to reduce or eliminate refractive errors. The content of this consent form is not intended to alarm you. Please note that serious complications are extremely rare and that the vast majority of our patients are satisfied with the results of their procedure. LASIK or PRK are 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. The first important message to understand is that it is impossible to perform any type of surgery without the patient accepting a certain degree of risk and responsibility. You should also understand that there might be other risks not known to your doctor, which may become known later. Despite the best care, complications and side effects may occur. Should this happen in your case, the result might make your vision worse. Despite all our efforts, if a complication occurs, patients sometimes feel they did not fully comprehend the risks outlined. For this reason we have put together this consent form. Many of our patients are surprised and some are upset by the extent to which we attempt to inform them of the potential for complications. It is not our intention to frighten or dissuade someone from pursuing LASIK laser surgery, as most of our patients will never encounter any complications, and the vast majority are pleased with the improvement they achieve. It is our intention, however, to accurately outline the associated risks to all candidates so that they may either elect not to accept the associated risks by declining surgery or be better prepared to deal with any unexpected complications or side effects. The only way in which a patient can avoid all surgical risks is by not proceeding with the surgery. No surgery is always 100% successful or 100% risk free.
2 2 PATIENT CONSENT In giving my permission for the use of the microkeratome or and a femtosecond laser (Flap or Smile) and an excimer laser for LASIK, I have received no disclaimers from any person, advertisement, or other educational materials that are contrary to this document and have received no guarantee as to my final outcome. I understand the following about this procedure: Alternatives to LASIK I understand that if I decide not to have LASIK, there are other methods of correcting my refractive error. These alternatives include, among others, eyeglasses, contact lenses, Photorefractive Keratectomy (PRK), Radial Keratotomy (RK), Corneal Rings, clear lensectomy, laser thermokeratoplasty, phakic implant lenses (Visian), or waiting for future improvements or new technology. CONTRAINDICATIONS: I understand that LASIK surgery may be contraindicated in patients who: are pregnant ( > 3 months) or nursing; show signs of keratoconus; have an active autoimmune disease, collagen vascular disease or an active immunodeficiency disease. I understand that it is my responsibility to ensure that PRK or LASIK has been approved for me by my commanding officer and that I will meet all the specific requirements for my military service community. WARNINGS: LASIK is sometimes not recommended in patients who have: insulindependent diabetes; severe allergies; a history of servere diseaases; a history of infectious diseases (HIV, hepatitis, TB, others); severe dry eyes; cataracts or other significant eye disease; or who have a prescription that is changing a lot. PRECAUTIONS: The safety and effectiveness of LASIK has not been established: in patients with: progressive myopia; ocular disease; corneal abnormality; previous corneal or intraocular surgery; trauma in the ablation zone; history of glaucoma; or history of keloid formation (excessive scarring); patients who are taking the medication Sumatripin (Imitrex ); in patients under 21 years of age; patients with implant lenses after cataract surgery; individuals suffering from significant depression or anxiety disorders; or patients with exceptionally high prescriptions or low prescriptions. I understand that I should notify my ophthalmologist if any of these apply to me, and that if I elect to proceed with LASIK surgery after discussion with my ophthalmologist that there may be extra risks involved, understand that the accuracy and final outcome may not be as good, and understand that there may be unknown risks or side effects that have not been adequately studied. Vision Threatening Complications I understand that the microkeratome or the excimer laser could malfunction, requiring the procedure to be stopped before completion. Depending on the type of malfunction, this may or may not be accompanied by some decrease in vision.. I understand that, in using the microkeratome, instead of making a flap, an entire portion of the central cornea could be cut off, and very rarely could be lost. If preserved, I understand
3 3 that my doctor would put this tissue back on the eye after the laser treatment and may require using sutures. It is also possible that the flap incision could result in an incomplete flap, or a flap that is too thin. If this happens, it is likely that the laser part of the procedure will have to be postponed until the cornea has a chance to heal sufficiently to try to create the flap again or to perform PRK instead of LASIK.. I understand that irregular healing of the flap could result in a distorted cornea. This would mean that glasses or contact lenses may not correct my vision to the level possible before undergoing LASIK. If this distortion in vision is severe, a partial or complete corneal transplant might be necessary to repair the cornea. I understand that the epithelium or surface skin of one or both eyes can loosen during surgery and this may delay my healing, heal irregularly, or heal inappropriately (grow under the flap). In some cases my eyes may not heal well causing blurred vision that glasses or contact lenses may not correct. This may necessitate having further procedures or wearing special contact lenses, may prevent safe treatment of the other eye, or prevent having later enhancement surgery. I understand that a possible perforation of the cornea could occur, causing significant complications, including loss of some or all of my vision. Severe problems can also be caused by an internal or external eye infection (corneal ulcers) that might not be controlled with antibiotics or other means, or by severe inflammation (diffuse lamellar keratitis or corneal melting ) that might not be controlled with eyedrops or other means. I understand that other very rare complications threatening vision include, but are not limited to: corneal swelling, corneal melting, retinal detachment, hemorrhage, venous and arterial blockage, cataract formation, total blindness and even loss of my eye I understand that further eye problems related or unrelated to the surgery may arise at a later date including but not limited to: keratoconus (irregular cornea), cataracts, retinal detachments or hemorrhages, glaucoma, epithelial ingrowth (flap problem), irregular or loose epithelium or severe dry eyes. Non-Vision Threatening Side Effects and General Information I understand that each person responds and heals after LASIK somewhat differently. I understand that because of this unpredictable variability, no guarantees as to my final vision or speed of recovery can be given. I understand that I may have a slower recovery with blurred vision or need additional treatments or visits at a later time. This can require more time off work, may cause delay in other plans, and can cause emotional stress. I understand that at night there may be a "starbursting" or halo effect around lights. I understand that this condition is common right after surgery and usually diminishes with time,
4 4 but could be permanent. I understand that my vision may not seem as sharp at night as during the day and that I may need to wear glasses at night. I understand that I should not drive until my vision is adequate both during the day and at night. I understand that conditions that increase the likelihood of night vision problems include, but are not limited to: large pupils, age less than 30, high prescriptions, high astigmatism, thin corneas, or occupations requiring a lot of night driving. 3. I understand that my eyes may be drier than usual after surgery causing some discomfort and blurred vision and requiring the use of moisturizing eye drops. I understand that this condition is common right after surgery and usually diminishes with time, but could be permanent. I understand that conditions that increase the likelihood of dry eye problems include, but are not limited to: prior problems with dry eyes, arthritis, being post-menopausal, age greater than 50 years old, medications that dry the eyes, thyroid related eye problems, or doing a lot of near work or computer work.. I understand that some occupations (e.g. pilots, police officers, military occupations, etc.) may require a certain level of vision for that occupation, and that refractive surgery may not offer that level of vision, and/or that refractive surgery may limit qualifying for some occupations. Guidelines change frequently, and you should check your particular situation before proceeding.. I understand that if I am prone to depression/anxiety, or I am prone to difficulties handling and adapting to stress, or I am very critical of my vision, that I am more likely to experience visual and emotional problems adapting to a slow recovery, visual side effects, or unexpected complications. I understand that if I am taking anti-depressants or anti-anxiety agents that I am more likely to experience dryness, fluctuating vision, and focusing difficulties possibly as a side effect of the medications. I understand that some people should elect not to pursue LASIK surgery if they feel they are at risk for handling the added stress.. For nearsightedness w/wo astigmatism: I understand that if my nearsightedness is greater than 8 diopters, or my astigmatism is greater than 2 diopters, or if my age is greater than 45 that my recovery will be longer, the ultimate accuracy may not be as good, and I am more likely to require second treatments (enhancements). For farsightedness w/wo astigmatism & mixed astigmatism: I understand that if my farsightedness is greater than 4 diopters, or my astigmatism is greater than 2 diopters, or if my age is greater than 45 that my recovery will be longer, the ultimate accuracy may not be as good, and I am more likely to require second treatments (enhancements). I understand that for all levels of farsightedness the recovery period is substantially longer, and the final clarity often not quite as good as that for equivalent amounts of nearsightedness. I understand that there may be increased sensitivity to light, glare, halos, a difference in the size of images (aniseikonia), and fluctuations in the sharpness of vision. I understand these conditions usually occur during the normal stabilization period from one to three months, but
5 5 they may also be permanent. I understand that an overcorrection or undercorrection could occur causing me to be nearsighted, farsighted, or to have astigmatism (even if I didn t have any before). This could be either permanent or treatable. I understand that overcorrections and undercorrections are more likely in people over the age of 40 years and may require the use of glasses or contacts for reading, intermediate, or for distance vision some or all of the time. I understand that I may not get a full correction from my LASIK procedure and this may require future enhancement procedures, other surgeries, or the use of glasses or contact lenses. I understand that I may not be able to achieve a full correction even with further enhancement procedures. 10. I understand that there may be a "balance" problem between my two eyes after LASIK has been performed on one eye, but not the other. I understand this could cause eyestrain and make judging distance or depth perception more difficult and may require the use of contact lenses. 11. I understand that, after LASIK, the eye may be more fragile to trauma from impact. Evidence has shown that, as with any surgery, the cornea may not be as strong as the cornea originally was. I understand that the treated eye, therefore, is somewhat more vulnerable to all varieties of injuries, at least for the first year following LASIK. I understand it would be advisable for me to wear protective eyewear when engaging in sports or other activities in which the possibility of a ball, projectile, elbow, fist or other traumatizing object contacting the eye may be high. I understand that there is a natural tendency of the eyelids to droop with age and that eye surgery may hasten this.. I understand that cataracts (clouding of the lens of the eye) occur in most people as they get older, and that my eyes will change with the formation of cataracts, affecting some of the benefit of my LASIK surgery. This may cause my vision to change, requiring a return to lens wear, and usually requires surgical correction at some point. I understand that I should tell my cataract surgeon that I have had LASIK surgery done, as the power of my implant lens used with cataract surgery will need to be modified.. I understand that there may be pain or a foreign body sensation, particularly during the first 48 hours after surgery. I understand that, following PRK, a bandage soft-contact lens will be placed on the eye where it will remain for 4-5 days, or until the epithelium has healed. I understand that this is not an FDA-approved use of the contact lens, and that it slightly increases the risks of infection. I understand the contact lens is placed to decrease postoperative discomfort and improve healing. Should the contact lens fall out of the eye, there will be an expected increase in pain.. I understand that temporary glasses either for distance or reading may be necessary while healing occurs and that more than one pair of glasses may be needed. 16. I understand that the long term effects of LASIK are not known, and that unforeseen complications or side effects could occur. LASIK has been studied for
6 6 more than ten years. I understand that visual acuity I initially gain from LASIK could regress, and that my vision may go partially or completely back to the level it was immediately prior to having the procedure. I understand that the correction which I can expect to gain from LASIK may not be perfect. I understand that it is not realistic to expect that this procedure will result in perfect vision, at all times, under all circumstances, for the rest of my life. I understand I may need glasses or contacts to refine my vision at some point later my life, and that this might occur soon after surgery or years later. I understand that nearly everyone needs reading glasses as we grow older.. I understand that I will be given medication (eye drops) in conjunction with the procedure and that my eye may be patched afterward. I understand that using these medications and following all directions are vital to achieving a good outcome. I understand that I must not drive for at least one day following the procedure and not until I am certain that my vision is adequate for driving. I understand that there may be other activity restrictions as well. 20. I understand that if I currently need reading glasses or are more than 40 years old, I will likely need reading glasses after this treatment. I understand that if I am used to taking my glasses off for reading or intermediate distance, this will not be possible after my surgery. It is possible that dependence on reading glasses may increase or that reading glasses may be required at an earlier age if I have this surgery. If I am more than 40, I understand that I may choose to have monovision done (one eye left near-sighted for upclose) and have discussed this with my ophthalmologist. I understand that some uses of equipment may not have been fully considered or evaluated by the FDA. These are known as off label uses. Advances sometimes outpace the FDA process and studies sometimes have insufficient numbers to adequately evaluate some options. Examples of this may include: treating larger zones (areas); treating higher ranges of prescription and astigmatism; treating very low ranges of prescriptions; treating patients less than 19 years old; treating patients with lesser contraindications, warnings, or precautions; or others not listed here. Even 90% clarity of vision is still slightly blurry. Repeat LASIK may result in overcorrection and undercorrection due to the variability in patient healing patterns and other surgical variables, leaving patients nearsighted, farsighted, or with astigmatism. This may or may not require patients to wear glasses or contact lenses or undergo additional surgery. Further surgery entails additional risk and is not guaranteed to provide an ideal visual outcome, although improvement is often obtained. Enhancement surgeries can be performed when vision is stable UNLESS it is unwise or unsafe. Typically, if 1.00 diopter or greater correction remains or vision is 20/40 or worse, an enhancement may be performed. If the enhancement is performed within the first six months following surgery, there generally is no need to make another cut with the microkeratome or laser. The original flap can usually be lifted with specialized
7 7 techniques. After 6 months of healing, a new LASIK incision may be required, incurring greater risk. In order to perform an enhancement surgery, there must be adequate tissue remaining. If there is inadequate tissue, it may not be possible to perform an enhancement. An assessment and consultation will be held with the surgeon at which time the benefits and risks of an enhancement surgery will be discussed.. I understand that, as with all types of surgery, there is a possibility of complications due to anesthesia, drug reactions or other factors that may involve other parts of my body. I understand that, since it is impossible to state every complication that may occur as a result of any surgery, the list of complications in this form may not be complete. Some patients develop keratoconus, a degenerative corneal disease affecting vision that occurs in approximately 1/2000 in the general population. While there are several tests that suggest which patients might be at risk, this condition can develop in patients who have normal preoperative topography (a map of the cornea obtained before surgery) and pachymetry (corneal thickness measurement). Since keratoconus may occur on its own, there is no absolute test that will ensure a patient will not develop keratoconus following laser vision correction. Severe keratoconus may need to be treated with a corneal transplant while mild keratoconus can be corrected by glasses or contact lenses. CONSENT FOR BILATERAL SIMULTANEOUS LASIK Introduction If you elect to have surgery performed on both eyes at the same time, you should understand both the possible advantages and disadvantages of your decision. The advantages of having LASIK OR PRK performed on each eye at a separate time are: Safety: You will not experience the risk of developing an infection or other severe complication in both eyes at the same time, which although very rare, could lead to significant decrease in vision in both eyes. Should this occur in both eyes at the same time, carrying out normal activities could be difficult. Ø Accuracy: The doctor can monitor the healing process and visual recovery in the first eye and may be able to make appropriate modifications to the treatment plan for the second eye, increasing the likelihood of a better outcome in the second eye. Ø Visual Recovery: Although most LASIK patients experience a rapid recovery in their vision, the recovery can at times be delayed. If the eyes are operated on separately, you can function with the fellow eye while the first eye fully recovers. This is especially true if you are able to wear a contact lens in the unoperated eye. Ø Satisfaction: You will be given the opportunity to determine whether the LASIK procedure has produced satisfactory visual results without loss of vision or other uncommon undesirable side effects such as glare, ghost images or increased light sensitivity. If you are over age 40, you will
8 8 have an opportunity to experience the change in your close vision resulting from the correction of your nearsightedness. This could influence your decision whether to fully correct your other eye to maintain some degree of close vision without the need for glasses (monovision). The disadvantages of having LASIK performed on each eye at a separate time are: Convenience: It may be inconvenient for you to have each eye treated at separate visits. This will necessitate two periods of recovery from the laser surgery and may require additional time away from work. Visual Recovery: There will be a potential period of imbalance in vision between your two eyes. This is especially important if you are unable to wear a contact lens in your unoperated eye. It is not usually possible to use the operated eye without a corrective lens along with a strong corrective lens in the unoperated eye because it produces a strong sense of imbalance, dizziness and a form of double vision. The advantages of having LASIK performed on both eyes at the same time are Convenience: It may be more convenient to have both eyes treated during the same visit and you may be able to take less time off work. Ø Visual Recovery: The balance in vision between your two eyes will usually be restored more rapidly. This is especially true if you are unable to wear a contact lens in your unoperated eye. The risks of having LASIK performed on both eyes at the same time are: Safety: The risk of infection, delayed clouding of the cornea, corneal scarring and internal bleeding or retinal damage is very rare but potentially devastating. If these serious but rare complications occur in one eye, they may also occur in the other. Should any of these complications happen, you could experience significant loss decrease in vision or even temporary or permanent legal blindness Accuracy: By correcting both eyes simultaneously, there is no opportunity to learn from the healing patterns of the first eye before treating the second eye. Therefore, if there is an overcorrection or under-correction in one eye, chances are it will happen in both eyes. If a retreatment is required in one eye, it is quite possible that your fellow eye also will require a retreatment. Visual Recovery: LASIK patients generally experience rapid visual recovery. Some patients, however, experience delayed visual recovery and symptoms such as blurred vision, night glare or ghost images. There is no way to predict how long your eyes will take to heal, and some of these side effects can result in prolonged recovery of normal vision. Blurred vision may rarely continue for several weeks in both eyes, which could make driving difficult or
9 9 dangerous and could interfere with your ability to work. The healing corneal flap is most susceptible to trauma during the first several weeks after surgery. Should both flaps become accidentally displaced, significant decrease in vision in both eyes may result Satisfaction: Both eyes tend to experience similar side effects. If you experience undesirable side effects such as glare, ghost images, increased light sensitivity or corneal haze in one eye, you will likely experience them in both eyes. These side effects may cause a decrease in vision or other negative effects, and some patients have elected to not have their second eye treated, or to wait until the side effects lessen or resolve. Implied Consent for Special Circumstances I understand that special circumstances may arise where I give my implied consent for my surgeon to act in my best interest. I understand that I will be only minimally sedated, and my ophthalmologist will attempt to explain and discuss any special circumstances with me as the situation allows, and nothing will be done against my objections. Examples of special circumstances include: A minor problem with one eye (examples include loose epithelium or other flap problems) may require judgement on whether to proceed with the second eye that day or postpone treatment. It may not be possible or safe to create a flap for LASIK (examples include inability to fit the suction ring, epithelial problems, or others) and you may want to consider having PRK (laser vision correction done by removing the epithelium instead of creating a flap) done that day instead. An unexpected problem may need other procedures done immediately for repair (for example suturing, others). For PRK and Epilasik Mitomycin-C: All patients who elect to undergo PRK on their eye(s) have been informed that they are at some risk for scar (haze) development and that the risk is proportional to the depth of corneal tissue ablation and therefore to the degree of nearsightedness and astigmatism treated. In other words, the higher the amount of preoperative nearsightedness without astigmatism, the higher risk of developing significant post-operative haze.. Scar or haze may also be more likely if there are pre-existing corneal scars or if the eye has had previous trauma or surgery. The use of prophylactic Mitomycin-C in an effort to prevent or minimize the formation of haze may be recommended by my surgeon to decrease the risk of haze formation. Though considered an off-label use, Mitomycin-C has been used for decades in Ophthalmology surgeries with very positive outcomes. There are potential well-known, though very rare, visually-significant sideeffects and complications that may take years to develop. These have been felt to be due to late ischemic affects (damage to blood vessels) to the sclera and the conjunctiva and have resulted in delayed healing, scleral melts, and perforations. Possible complications of using Mitomycin-C for PRK include delayed healing and corneal thinning or melting. However,
10 10 these complications are extremely rare in PRK, as a very dilute solution of Mitomycin-C is used and it is in contact with the cornea (which contains no blood vessels) for only a short period of time. The use of Mitomycin-C does not guarantee that haze will not develop. Other circumstances not listed here might also arise. Care Commitment, Financial Consent, & Comanagement I understand that my fees for surgery include my measurements of my eye(s) and reporting done for outcome analysis, my surgery, and my post-operative exams with my co-managing doctor (if any) or us for one year from the date of your surgery. Additionally, any LASIK enhancements I may need within the first year will be done at no additional charge. Items NOT covered in my fees include, but are not limited to: initial eye exam, prescription medications, artificial tear drops, material costs for glasses or contact lenses, fees for second opinions or surgeries, extra fees for wavefront treatments, fees for other surgeries other than LASIK enhancements within the first year, travel expenses, missed work expenses, and any other expenses not specifically included above. I may optionally choose, by initialing here, to have some part of my post-operative care done with my own eye doctor if it is more convenient for me (e.g. travel, office hours, and familiarity). My LASIK surgeon will perform my surgery and see me the first few visits, afterwards I can see my own optometrist/ophthalmologist for some of the post-operative visits. There is NO extra charge to do this, and payment can be forwarded directly to your own optometrist/ophthalmologist by our office by giving your permission here. I give my permission to forward medical and health information to my comanaging doctor. Even though my other eye doctor may provide some of my post-operative care, I understand that my LASIK surgeon will continue to be available to me if I should develop a complication or have any questions about my care. I understand that my LASIK surgeon cannot, however, assume any risk or liability involved in my choosing to see my own eye doctor for some portion of my post-operative care PATIENT S STATEMENT OF ACCEPTANCE AND UNDERSTANDING The details of the procedure known as LASIK have been presented to me in detail in this document, explained to me by my ophthalmologist, and I have reviewed the advantages, disadvantages, possible risks, and alternatives at my leisure. Although it is impossible for the doctor to inform me of every possible complication that may occur, my ophthalmologist has answered all my questions to my satisfaction. I have received no disclaimers from any person, advertisement, or other educational materials that are contrary to this document and have received no guarantee as to my final outcome. I therefore consent to LASIK surgery. I give permission for my ophthalmologist to record my procedure and use data about my procedure for purposes of education, research or training of other health care professionals. I understand that my
11 11 name will remain confidential, unless I give subsequent written permission for it to be disclosed outside my ophthalmologist s office or the office where my LASIK procedure will be performed. In signing this document, I do so knowingly, voluntarily and intelligently. Key points : LASIK OR PRK are surgery, there are risks and possible complications. Millions of people have had LASIK, many very successfully, but it s not for everyone. LASIK may not give you perfect vision. The American Academy of Ophthalmology (AAO) reports that nine out of 10 patients achieve somewhere between 20/20 and 20/40 vision, but 20/40 vision may not be sharp enough for certain work or leisure activities. Even 20/20 does not always mean perfect vision. Detailed, precise vision may be slightly diminished. Even with LASIK or PRK to correct your distance vision, you are likely to need reading glasses in your mid-40s. LASIK surgery cannot correct or prevent presbyopia, the agerelated loss of focusing power for seeing near objects. If you are nearsighted and don't yet need reading glasses, having LASIK may mean you will need reading glasses earlier than if you had not had the surgery. The benefits of the LASIK procedure may diminish over time. More than 10 percent of LASIK patients in the U.S. require a second surgery, called retreatment, to restore the desired vision correction. At the Clinique de la Vision the percentage is 3-5 % This is more likely for people who were more nearsighted or farsighted, or had higher astigmatism before LASIK. Most insurance plans don t cover the surgery. I give permission for my ophthalmologist to record on video or photographic equipment my procedure, for purpose of education, research, or training of other health care professionals. I also give permission for my ophthalmologist to use data about my procedure and subsequent treatment to further understand LASIK. I understand that my name will remain confidential,
12 12 unless I give subsequent written permission for it to be disclosed outside my ophthalmologist s office or the center where my LASIK procedure will be performed. Patient signature Date Witness signature Date ( the patient has confirmed to me that they have read and understand this consent ) I have been offered a copy of this consent form (patient initials) Glossary Ablate - in surgery, is to remove. Ablation zone - the area of tissue that is removed during laser surgery. Accommodation - the ability of the eye to change its focus from distant objects to near objects. Acuity - clearness, or sharpness of vision. All-Laser LASIK - (also known as Bladeless LASIK ) a laser keratome device is used to cut a corneal flap for LASIK surgery. Astigmatism - a distortion of the image on the retina caused by irregularities in the cornea or lens. Cornea - the clear, front part of the eye. The cornea is the first part of the eye that bends (or refracts) the light and provides most of the focusing power. Diopter - the measurement of refractive error. A negative diopter value signifies an eye with myopia and positive diopter value signifies an eye with hyperopia. Dry Eye Syndrome - a common condition that occurs when the eyes do not produce enough tears to keep the eye moist and comfortable. Common symptoms of dry eye include pain, stinging, burning, scratchiness, and intermittent blurring of vision. Endothelium - the inner layer of cells on the inside surface of the cornea. Epithelium - the outermost layer of cells of the cornea and the eye's first defense against infection.
13 13 Excimer laser - an ultraviolet laser used in refractive surgery to remove corneal tissue. Farsightedness - the common term for hyperopia. FDA - the abbreviation for the Food and Drug Administration. It is the United States governmental agency responsible for the evaluation and approval of medical devices. Ghost Image - a fainter second image of the object you are viewing. Glare - scatter from bright light that decreases vision. Halos are rings around lights due to optical imperfections in or in front of the eye. Haze - corneal clouding that causes the sensation of looking through smoke or fog. Higher order aberrations refractive errors, other than nearsightedness, farsightedness, and astigmatism, that cannot be corrected with glasses or contacts. Hyperopia - the inability to see near objects as clearly as distant objects, and the need for accommodation to see distant objects clearly. Inflammation - the body's reaction to trauma, infection, or a foreign substance, often associated with pain, heat, redness, swelling, and/or loss of function. Informed Consent Form a document disclosing the risks, benefits, and alternatives to a procedure. In Situ a Latin term meaning "in place" or not removed. Iris - the colored ring of tissue suspended behind the cornea and immediately in front of the lens. Keratectomy - the surgical removal of corneal tissue. Keratotomy - a surgical incision (cut) of the cornea. Keratitis - inflammation of the cornea. Kerato - prefix indicating relationship to the cornea. Keratoconus a disorder characterized by an irregular corneal surface (cone-shaped) resulting in blurred and distorted images. Keratomileusis - carving of the cornea to reshape it. Laser - the acronym for light amplification by stimulated emission of radiation. A laser is an instrument that produces a powerful beam of light that can vaporize tissue. Laser Keratome - a laser device used to create a corneal flap LASIK - the acronym for laser assisted in situ keratomileusis which refers to creating a flap in the cornea with a microkeratome and using a laser to reshape the underlying cornea.
14 14 Lens - a part of the eye that provides some focusing power. The lens is able to change shape allowing the eye to focus at different distances. Microkeratome - a mechanical surgical device that is affixed to the eye by use of a vacuum ring. When secured, a very sharp blade cuts a layer of the cornea at a predetermined depth. Monovision - the purposeful adjustment of one eye for near vision and the other eye fordistance vision. Myopia - the inability to see distant objects as clearly as near objects. Nearsightedness - the common term for myopia. Ophthalmologist - a medical doctor specializing in the diagnosis and medical or surgical treatment of visual disorders and eye disease. Optician - an expert in the art and science of making and fitting glasses and may also sell contact lenses. Optometrist - a primary eye care provider who diagnoses, manages, and treats disorders of the visual system and eye diseases. NOT IN FRANCE Overcorrection - a complication of refractive surgery where the achieved amount of correction is more than desired. PRK - the acronym for photorefractive keratectomy which is a procedure involving the removal of the surface layer of the cornea (epithelium) by gentle scraping and use of a computer-controlled excimer laser to reshape the stroma. Presbyopia - the inability to maintain a clear image (focus) as objects are moved closer. Presbyopia is due to reduced elasticity of the lens with increasing age. Pupil - a hole in the center of the iris that changes size in response to changes in lighting. It gets larger in dim lighting conditions and gets smaller in brighter lighting conditions. Radial Keratotomy - commonly referred to as RK; a surgical procedure designed to correct myopia (nearsightedness) by flattening the cornea using radial cuts. Refraction - a test to determine the refractive power of the eye; also, the bending of light as it passes from one medium into another. Refractive Errors - imperfections in the focusing power of the eye, for example, hyperopia, myopia, and astigmatism. Refractive Power - the ability of an object, such as the eye, to bend light as light passes through it. Retina - a layer of fine sensory tissue that lines the inside wall of the eye. The retina acts like the film in a camera to capture images, transforms the images into electrical signals, and sends the signals to the brain.
15 15 Sclera - the tough, white, outer layer (coat) of the eyeball that, along with the cornea, protects the eyeball. SMILE Small incision lenticular extraction lasik method with only femtosecond laser Snellen Visual Acuity Chart - one of many charts used to measure vision. Stroma - the middle, thickest layer of tissue in the cornea. Undercorrection - a complication of refractive surgery where the achieved amount of correction is less than desired. Visual Acuity - the clearness of vision; the ability to distinguish details and shapes. Vitreous Humor - the transparent, colorless mass of gel that lies behind the lens and in front of the retina and fills the center of the eyeball. Wavefront - a measure of the total refractive errors of the eye, including nearsightedness, farsightedness, astigmatism, and other refractive errors that cannot be corrected with glasses or contacts.
Lasik Center 2445 Broadway Quincy, IL 62301 217-222-8800 INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK) INTRODUCTION This information is being provided to you so that you can make an informed
EYE PHYSICIANS OF NORTH HOUSTON 845 FM 1960 WEST, SUITE 101, Houston, TX 77090 Office: 281 893 1760 Fax: 281 893 4037 INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK) INTRODUCTION This information
Left Eye Right Eye INFORMED CONSENT FOR PHOTOREFRACTIVE KERATECTOMY (PRK) FOR THE CORRECTION OF NEARSIGHTEDNESS, FARSIGHTEDNESS, AND ASTIGMATISM WITH OR WITHOUT MITOMYCIN ** Please don t sign this until
No surgery is without risks and possible complications and LASIK is no different in that respect. At Trusted LASIK Surgeons, we believe patients can minimize these risks by selecting a highly qualified
Left Eye Right Eye INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK) FOR THE CORRECTION OF NEARSIGHTEDNESS, FARSIGHTEDNESS, AND ASTIGMATISM ** Please don t sign this until you are asked to by our
Consent for Bilateral Simultaneous Refractive Surgery Please sign and return Patient Copy While many patients choose to have both eyes treated at the same surgical setting, there may be risks associated
INFORMED CONSENT FOR LASER ASSISTED SUBEPITHELIAL KERATOMILEUSIS (LASEK)/PHOTO-REFRACTIVE KERATECTOMY (PRK) Please read the following consent form very carefully. Please initial each page where indicated.
Drs. Fine, Hoffman and Packer, LLC PHYSICIANS AND SURGEONS, EyeMDs OPHTHALMOLOGY I. Howard Fine, M.D. Richard S. Hoffman, M.D. Mark Packer, M.D. 1550 Oak Street, Suite 5 www.finemd.com Eugene, OR 97401-7701
INFORMED CONSENT FOR PHOTOREFRACTIVE KERATECTOMY (PRK) This information and the Patient Information booklet must be reviewed so you can make an informed decision regarding Photorefractive Keratectomy (PRK)
CONSENT FOR INTRALASIK CORRECTION OF NEARSIGHTEDNESS, FARSIGHTEDNESS, AND ASTIGMATISM USING INTRALASE TM TECHNOLOGY BY AMJAD KHOKHAR, M.D. INDICATIONS AND PROCEDURE This information is being provided to
MEDICATIONS VIGAMOX (OCUFLOX) PURPOSE PREVENTS INFECTION DOSAGE USE 1 DROP 4 TIMES DAILY STARTING 1 DAY PRIOR TO SURGERY VALIUM (Diltiazem 5 mg) AMBIEN (ZOLPIDEM) RESTASIS (if prescribed) Provides relaxation
A Center for VisionCare 4418 Vineland Avenue, Suite 106 North Hollywood, CA 91607 818/762-0647 Alan I. Mandelberg, M.D. Donald I. Goldstein, M.D. Glossary of Refractive Surgery Terms Aberration: An irregularity
1550 Oak St., Suite 5 1515 Oak St., St Eugene, OR 97401 Eugene, OR 97401 (541) 687-2110 (541) 344-2010 INFORMED CONSENT FOR PHOTOREFRACTIVE KERATECTOMY (PRK) This information is to help you make an informed
Consent for Bilateral Simultaneous Refractive Surgery PRK Please sign and return Patient Copy While many patients choose to have both eyes treated at the same surgical setting, there may be risks associated
Consent for LASIK (Laser In Situ Keratomileusis) Retreatment Please read the following consent form very carefully. Please initial at the bottom of each page where indicated. Do not sign this form unless
1 BoydVision TABLE OF CONTENTS: LASER EYE SURGERY CONSENT FORM Risks and Side Effects... 2 Risks Specific to PRK... 3 Risks Specific to LASIK... 4 Patient Statement of Consent... 5 Consent for Laser Eye
INFORMED CONSENT FOR PHAKIC IMPLANT SURGERY INTRODUCTION This information is being provided to you so that you can make an informed decision about having eye surgery to reduce or eliminate your nearsightedness.
LASER CENTER LASIK PATIENT PACKET PLEASE BRING BACK WITH YOU THE DAY OF YOUR SURGERY PRE-OPERATIVE INSTRUCTIONS PLEASE REVIEW CAREFULLY WHAT TO EXPECT THE DAY OF YOUR SURGERY POST-OPERATIVE INSTRUCTIONS
INFORMED CONSENT FOR PHOTOREFRACTIVE KERATECTOMY (PRK) AND ADVANCE SURFACE ABLATION (ASA) This information and the Patient Information booklet must be reviewed so you can make an informed decision regarding
INTRODUCTION: You have been diagnosed with myopia (nearsightedness) or hyperopia (farsightedness) with or without astigmatism, or astigmatism alone. Myopia is a result of light entering the eye and focusing
A Division of Scott & Christie and Associates INFORMED CONSENT TO HAVE LASIK This information is to help you make an informed decision about having Laser Assisted Intrastromal Keratomileusis (LASIK), an
Drs. Fine, Hoffman & Packer, LLC 1550 Oak Street, Suite #5 Eugene, OR 97401 541-687-2110 From Drs. Fine, Hoffman, & Packer Risks and Limitations of LASIK Procedure Infection, serious injury, or even death,
2014 2015 LASIK What is LASIK? LASIK (laser in situ keratomileusis) is a type of refractive surgery. This kind of surgery uses a laser to treat vision problems caused by refractive errors. You have a refractive
Shawn R. Klein, MD Klein & Scannapiego MD PA Patient Authorization for Laser Vision Correction Surgery 1. General information The following information is intended to help you make an informed decision
Informed Consent Cataract Surgery with Intraocular Lens Implant Please initial below indicating that you have read and understand each section Introduction The internal lens of the eye can become cloudy
Dear Valued Patient, Thank you for choosing Shady Grove Ophthalmology for your laser vision correction procedure. Our excellent staff is committed to offering you the highest quality eye care using state
2305 GENOA BUSINESS PARK DR. SUITE 250, BRIGHTON, MI 48114 (810) 494-2020 (OFFICE), (810) 494-0127 (FAX) LASIK Consent Form 1. General Information The following information is intended to help you make
INTRODUCTION INFORMED CONSENT FOR PHAKIC LENS IMPLANT SURGERY This information is being provided to you so that you can make an informed decision about having eye surgery to reduce or eliminate your nearsightedness.
IMPORTANT: READ EVERY WORD! This information is to help you make an informed decision about having laser assisted in-situ keratomileusis (LASIK) surgery to treat your nearsightedness, farsightedness and/or
2305 GENOA BUSINESS PARK DR. SUITE 250, BRIGHTON, MI 48114 (810) 494-2020 (OFFICE), (810) 494-0127 (FAX) LASEK / PRK Consent Form 1. General Information The following information is intended to help you
What is LASIK? The eye and vision errors The cornea is a part of the eye that helps focus light to create an image on the retina. It works in much the same way that the lens of a camera focuses light to
1 WAKE FOREST BAPTIST HEALTH EYE CENTER LASIK Consent Form 1. GENERAL INFORMATION The following information is intended to help you make an informed decision about having Laser In-Situ Keratomileusis (LASIK).
LASIK What is LASIK? Laser assisted in situ keratomileusis, or LASIK, is an outpatient surgical procedure used to treat myopia (nearsightedness), hyperopia (farsightedness), and astigmatism. With LASIK,
Vision Correction Surgery Patient Information Anatomy of the eye: The eye is a complex organ composed of many parts, and normal vision requires these parts to work together. When a person looks at an object,
Associated Eye Surgeons 45 Resnik Road, Suite 301 Plymouth, MA 02360 Henry J Kriegstein MD, FACS Board Certified Lois M. Townshend, MD, FRCSC Board Certified Kristin S. Kenney, OD LASIK CONSENT FORM I.
LASIK Introduction LASIK surgery is a procedure that improves vision and can decrease or eliminate the need for eyeglasses or contact lenses. If you and your doctor decide that LASIK surgery is right for
Tucson Eye Care, PC Informed Consent for Cataract Surgery And/Or Implantation of an Intraocular Lens INTRODUCTION This information is provided so that you may make an informed decision about having eye
ALABAMA VISION CENTER PRICE M. KLOESS, M.D. ANDREW J. VELAZQUEZ, M.D. 790 Montclair Road Suite 100 Birmingham, Alabama 35213 P. 205.592.3911 www.alabamavisioncenter.com PHOTOREFRACTIVE KERATECTOMY PRE-OPERATIVE
Daniel F. Goodman, M.D. 2211 Bush Street, 2nd Floor San Francisco, CA 94115 Phone: 415-474-3333 Fax: 415-474-3939 INFORMED CONSENT FOR LASIK (LASER IN SITU KERATOMILEUSIS) and PRK (PHOTOREFRACTIVE KERATECTOMY)
ROCKWALL EYE ASSOCIATES Edward P. Hurst, M.D. Claire Y. Chu, M.D. PHOTO-REFRACTIVE KERATOMILEUSIS (PRK) SECTION 1: GENERAL INFORMATION It is our intention to fully inform you concerning side effects, limitations,
Edward C. Wade, M. D Christopher D. Allee, O. D. Ting Fang-Suarez, M. D. Jill Autry, O. D. Mark L. Mayo, M. D. Amanda Bachman, O. D. Randall N. Reichle, O. D. Julie Ngo, O. D. 6565 West Loop South Suite
4089 TAMIAMI TRAIL NORTH SUITE A103 NAPLES, FL 34103 TELEPHONE (239) 262-2020 FAX (239) 435-1084 DOES THE PATIENT NEED OR WANT A TRANSLATOR, INTERPRETOR OR READER? YES NO TO THE PATIENT: You have the right,
1700 Whitehorse-Hamilton Square Rd, Hamilton Sq., NJ 08690 INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK) AND LASIK ENHANCEMENTS Please read the following pages carefully and initial and sign
LASIK EPILASIK FEMTOSECOND LASER Advantages There are many advantages to having laser vision correction. Laser vision correction gives most patients the freedom to enjoy their normal daily activities without
We've developed this handbook to help our patients become better informed about the entire process of laser vision correction. We hope you find it helpful and informative. Dr. Booth received his medical
The LASIK experience I WHO CAN HAVE LASIK? To be eligible for LASIK you should be at least 21 years of age, have healthy eyes and be in good general health. Your vision should not have deteriorated significantly
INFORMED CONSENT FOR PRK SURGERY Please read the following consent form carefully. Please initial each page where indicated. Do not sign this from unless you read and understand each page. Patient s Name:
Edward C. Wade, M. D Christopher D. Allee, O. D. Ting Fang-Suarez, M. D. Jill Autry, O. D. Mark L. Mayo, M. D. Amanda Bachman, O. D. Randall N. Reichle, O. D Julie Ngo, O. D. 6565 West Loop South Suite
1700 Whitehorse-Hamilton Square Rd, Hamilton Sq., NJ 08690 INFORMED CONSENT FOR REFRACTIVE SURGERY INCLUDING LASER IN-SITU KERATOMILEUSIS (LASIK), PHOTOREFRACTIVE KERATECTOMY (PRK), AND ENHANCEMENTS AND
CATARACT AND LASER CENTER, LLC Patient Information Date: Patient Name: M F Address: Street City State Zip Home Phone: Work Phone: Cell Phone: E-Mail : Referred by: Medical Doctor: Who is your regular eye
Wang Vision Institute 1801 West End Avenue Nashville, TN 37203 615/321-8881 The purpose of this consent for is to educate you on the Phototherapeutic Keratectomy (PTK) and Photorefractive Keratectomy (PRK)
Is LASIK for Me? A Patient s Guide to Refractive Surgery October 2008 Is LASIK for Me? A Patient s Guide to Refractive Surgery Table of Contents LASIK: A COMPREHENSIVE GUIDE... 2 Introduction... 2 What
LASIK & Refractive Surgery LASIK PRK ICL RLE Monovision + + + For over 30 years, The Eye Institute of Utah has been giving people vision for life... The Eye Institute of Utah was the first medical facility
PLACE LETTERHEAD HERE AND REMOVE NOTE 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
FACTS YOU NEED TO KNOW ABOUT LASER IN SITU KERATOMILEUSIS (LASIK) SURGERY FOR THE CORRECTION OF -1.00 TO -7.00 DIOPTERS OF NEARSIGHTEDNESS AND LESS THAN 3.00 DIOPTERS OF ASTIGMATISM WITH THE BAUSCH AND
Excimer Laser Eye Surgery This booklet contains general information that is not specific to you. If you have any questions after reading this, ask your own physician or health care worker. They know you
1801 West End Avenue Suite 1150 Nashville, TN 37203, USA Office: 615.321.8881 Fax: 615.321.8874 T he purpose of this consent form is to educate you on the bladeless (Intralase) LASIK procedure. It is not
Bladeless LASIK and PRK Bladeless LASIK and PRK The specialists at North Shore-LIJ Laser Vision Correction understand how valuable your sight is to you, which is why we use the safest, most advanced technology
Refractive Surgery Education and Informed Consent Tripler Army Medical Center Refractive Surgery Center Warfighter Refractive Eye Surgery Program (WRESP) Goals of this Briefing To explain the Warfighter
Alexandria s Guide to LASIK A Community Service Project sponsored by: Wallace Laser Center Your Guide To A Successful LASIK Procedure The word LASIK is actually an acronym for Laser Assisted In-Situ Keratomileusis.
Seeing Beyond the Symptoms Cataracts are one of the leading causes of vision impairment in the United States. 1 However, because cataracts form slowly and over a long period of time, many people suffer
2011-2012 refractive surgery a closer look How the eye works Light rays enter the eye through the clear cornea, pupil and lens. These light rays are focused directly onto the retina, the light-sensitive
At LASIK MD, we strongly believe that you should have all of the necessary information on-hand in order to make an informed decision about your procedure. The content of this consent form is not intended
GENERAL INFORMATION Long Island Vision Experts 2 Lincoln Avenue, Suite 401 Rockville Centre, NY 11570 (516) 763-4106 INTACS INFORMED CONSENT Intacs (Keratoconus) The following information is intended to
Clear Advantage Vision Correction Center INFORMED CONSENT FOR PRK PLEASE READ THE FOLLOWING PAGES CAREFULLY AND INITIAL AND SIGN WHERE INDICATED. PLEASE DO NOT SIGN ANY SECTION THAT YOU HAVE NOT READ OR
Consumer s Guide to LASIK A Community Service Project brought to you by Price Vision Group Your Guide To A Successful LASIK Procedure The purpose of this educational guide is to help prospective patients
LASIK INFORMED CONSENT INITIAL TREATMENT PLEASE READ THE FOLLOWING PAGES CAREFULLY AND INITIAL AND SIGN WHERE INDICATED. PLEASE DO NOT SIGN ANY SECTION THAT YOU HAVE NOT READ OR DO NOT UNDERSTAND. SECTION
PRK Wavefront Guided idesign Photorefractive Keratectomy What is PRK? PRK (photorefractive keratectomy) is the same laser procedure as LASIK. Like LASIK it involves the use of the cool energy of an Excimer
BEACH EYE MEDICAL GROUP INFORMED CONSENT FOR LASER VISION CORRECTION (LVC) PLEASE READ THE FOLLOWING PAGES CAREFULLY AND INITIAL AND SIGN WHERE INDICATED. PLEASE DO NOT SIGN ANY SECTION THAT YOU HAVE NOT
Introduction REFRACTIVE ERROR AND SURGERIES IN THE UNITED STATES 150 million wear eyeglasses or contact lenses 2.3 million refractive surgeries performed between 1995 and 2001 Introduction REFRACTIVE SURGERY:
Informed Consent for Refractive Lens Exchange (Clear Lens Extraction) This form is designed to ensure that you have all the information you need to make a decision about whether or not you wish to undergo
LASIK Eye Surgery Report LASIK eye surgery can be a liberating experience for people hoping to reduce or eliminate their dependence on glasses and contact lenses. Most patients do not realize how evolved
INFORMED CONSENT FOR CATARACT AND LENS IMPLANT SURGERY 1. GENERAL INFORMATION This information is given to you to help you make an informed decision about having cataract and/or lens implant surgery. Once
Pre-Operative Laser Surgery Information Contact 1800 10 20 20 Our Facility The Canberra Eye Laser Centre has always been at the forefront of refractive technology employing the most up to date equipment
Conductive Keratoplasty Conductive Keratoplasty Until recently, if you were one of the millions of people with a refractive error, eyeglasses and contact lenses were the only options for correcting vision.
Bruce H. Brumm, MD, PC 6751 North 72 nd Street, Ste 105 Omaha, NE 68122 (402) 572-2020 800-775-5909 www.brummeye.com Informed Consent for Cataract Surgery and/or Implantation of an Intraocular Lens (IOL)
TLC The Laser Center (Northeast) Inc. TLC Laser Eye Centers (Charlotte) TLC LASER EYE CENTERS VISION CORRECTION SURGERY INFORMED CONSENT Informed Consent. The purpose of this Informed Consent is to help
Olympia HSA Medical Series Laser Eye Surgery A COMPLETE GUIDE FOR CANADIANS 1 Optimal Healthcare and Life Benefits Olympia s All-in-one Benefits Program HEALTH SPENDING ACCOUNTS Optimize your Health Benefits
PATIENT CONSENT FORM ADVANCED SURFACE ABLATION (ASA) PRK / LASEK I. Introduction Advanced Surface Ablation, or ASA, is a permanent vision correction procedure in which tissue is removed from the surface
ReLEx smile Minimally invasive vision correction Information for patients Seeing is living Our eyes are our most important sensory organ. The human brain obtains over 80 % of its information via the sense
Informed Consent for Cataract Surgery or Clear Lens Extraction with Implantation of an Intraocular Lens Please read the following pages carefully, and initial and sign where indicated. Please do not sign