Consent Forms in Ophthalmic Practice in Hindi & English

Transcription

1 Consent Forms in Ophthalmic Practice in Hindi & English EDITORS English Edition Dr. Bhavna Chawla Dr. Namrata Sharma Dr. Lalit Verma Hindi Edition Dr. P.S. Negi Dr. Y.C. Gupta Published By: Dr. Amit Khosla Secretary, DOS Room No.2225, 2nd Floor New Building Sir Ganga Ram Hospital Rajinder Nagar, New Delhi Disclaimer This manual is for educational purpose only and is not intended to constitute legal advice. Hence it should not be relied upon as a source for legal advice.

2 Contents RETINA 1. Cryosurgery Retinal Detachment Vitreo Retinal Surgery Macular Hole Surgery Avastin tm Intravitreal Injection Macugen tm Intravitreal Injection Lucentis tm Intravitreal Injection ROP Laser Laser Indirect Ophthalmoscopy Laser Photocoagulation for Diabetic Retinopathy Laser Photocoagulation for Proliferative Retinopathy Laser Photocoagulation for Maculopathy Fundus Fluorescein Angiography / Ophthalmoscopy/ Indocyanine Green Angiography Photodynamic Therapy (PDT) Trans Pupillary Thermotherapy (TTT) Intravitreal Injection for Endophthalmitis Electrophysiological Tests OCULOPLASTY & ORBIT 1. Enucleation Evisceration Orbitotomy Entropion Ectropion Ptosis Syringing and Probing Punctal Plugs Dacryocystorhinostomy (DCR) Contracted Socket OCULAR SURFACE, CORNEA & REFRACTIVE SURGERY 1. Optical Penetrating Keratoplasty Therapeutic Keratoplasty Automated Lamellar Therapeutic Keratoplasty (ALTK) Deep Anterior Lamellar Keratoplasty (DALK)

3 5. Descemet s Stripping Endothelial Keratoplasty (DSEK/DSAEK) Phototherapeutic Keratectomy (PTK) Photorefractive Keratectomy (PRK) LASIK Astigmatic Keratotomy (AK) Intacs Phakic IOL Conductive Keratoplasty Pterygium Surgery Corneal Scraping Fibrin Glue Adhesive for Corneal Perforation Symblepharon Release Amniotic Membrane Transplantation (AMT) Limbal Stem Cell Transplantation (LSCT) Osteo-odonto Keratoprosthesis (OOKP) SQUINT 1. Squint Surgery Botox (Botulinum Toxin) Injection GLAUCOMA 1. Trabeculectomy With / Without Anti-Fibroblastic Agents Diode Laser Cyclo-photocoagulation (DLCP) Argon Laser Trabeculoplasty (ALT) Laser Iridotomy CATARACT 1. Cataract Surgery With / Without Implantation of Intraocular Lens Pediatric Cataract YAG Capsulotomy MISCELLANEOUS 1. Examination Under Anesthesia (EUA) Optical Iridectomy

4 RETINA

5 Cryosurgery Bipul Baishya, Atul Kumar Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... Proposed Treatment The doctor has explained that I, (name of patient. ), have a retinal lesion in my..eye which is a risk factor for development of and Cryosurgery is proposed. Risks These are the commoner risks. There may be other unusual risks that have not been listed here. I understand there are risks associated with any anesthetic agent (in case of children). I may have side effects from any of the drugs used. The commoner side effects include light-headedness, nausea, skin rash and constipation. I understand the procedure has the following specific risks and limitations: 1. Although most retinal lesions can be treated, it is not 100% effective. In some cases, more than two sittings may be required. 2. Corneal burns 3. Retinal detachment or macular puckering that may require additional surgery 4. Inflammation 5. Pigmentary disturbances 6. Bleeding in eye Local complications of anesthesia injections around the eye include: 1. Perforation of eyeball 2. Destruction of optic nerve 3. Interference with circulation of retina 4. Possible drooping of eyelid 5. Respiratory depression 6. Hypotension Individual Risks I understand the following are possible significant risks and complications specific to my individual circumstances, that I have considered in deciding to have this operation: Declaration by Patient I acknowledge doctors from the ophthalmic team have informed me about the procedure, alternative treatments and answered my specific queries and concerns about this matter. I acknowledge that I have discussed with the surgical team any significant risks and complications specific to my individual circumstances that I have considered in deciding to have this operation. I understand that a doctor other than the specialist surgeon may perform the procedure. ( 1 )

6 I have received no guarantee the operation will be successful. I have received a copy of this form to take home with me. If a needle stick/sharps injury occurs to staff during any operation I give my permission for blood to be taken and tested for HIV and other blood borne disorders. I understand I will be advised and counselled as soon as practicable after the operation if this has been necessary. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 2 )

7 Økvks ltzjh fciqy cs';] vrqy dqekj jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... izlrkfor mipkj MkWDVj us Li"V fd;k gs fd esjh ¼jksxh dk uke½ vka[k esa jsfvuk ls tqm+k t[e gs tks fd ds fodkl ds fy, tksf[ke dk dkjd gs vksj Øk;ks ltzjh izlrkfor dh gsa tksf[ke ;s lk/kkj.k tksf[ke gsaa nwljs vlkeku; tksf[ke Hkh gks ldrs gsa ftugsa fd ;gka lwphc) ugha fd;k x;k gsa esa le>rk gwa fd fdlh Hkh laosnukgkjh dkjd ds lkfk ¼cPpksa ds ekeys esa½ tksf[ke tqm+s gksrs gsaa eq>s mi;ksx esa yk;h x;h nokvksa esa ls fdlh ds Hkh dkj.k ik'oz&izhkko mriuu gks ldrs gsaa vke ik'oz&izhkkoksa esa pddj vkuk] feryh] Ropk ij nnksjs vksj dct 'kkfey gsa esa le>rk gwa fd fpfdrldh; izfø;k ds fueufyf[kr [kkl tksf[ke vksj lhek,a gsa % 1- gkykafd jsfvuk ds vf/kdrj t[eksa dk bykt gks ldrk gs ysfdu ;g 'kr&izfr'kr izhkkoh ugha gsa dqn ekeyksa esa nks ls T;knk csbd dh t:jr im+ ldrh gsa 2- dkuhzy dk tyuk 3- jsfvuk dk vyx gksuk ;k esdqyj fldqm+u ftlds fy, vfrfjdr ltzjh dh t:jr im+ ldrh gs 4- tyu 5- jax fn[kus esa ijs'kkuh 6- vka[kksa esa jdrlzko vk[kksa ds bnzfxnz laosnukgkjh batsd'kuksa dh LFkkfud ijs'kkfu;ksa esa 'kkfey gsa % 1- vka[k dh iqryh ds Nsn 2- izdkf'kd ul dk fouk'k 3- jsfvuk ds lapj.k ds lkfk O;o/kku 4- iyd dh lahkkfor yvdu 5- 'olu ls tqm+k ncko 6- vlkeku; :i ls fueu jdrpki O;fDrxr tksf[ke esa le>rk gwa fd fo'ks"k :i ls esjh ifjflfkfr;ksa ls tqm+s lahkkfor egriw.kz tksf[ke vksj tfvyrk,a fueufyf[kr gsa] ftu ij fd es aus bl vkwijs'ku dks djokus dk fu.kz; djrs le; fopkj fd;k gs % jksxh }kjk?kks"k.kk esa bl ckr dh iqf"v djrk gwa fd us= fo'ks"kkksa dh Vhe ds MkWDVjksa us fpfdrldh; izfø;k] osdfyid mipkjksa ds ckjs esa eq>s tkudkjh iznku dh gs vksj bl ekeys esa esjs fof'k"v iz'uksa vksj fparkvksa dk tokc fn;k gsa esa bl ckr dh iqf"v djrk gwa fd esaus ltzjh djus okys MkWDVjksa dh Vhe ds lkfk fdugha egroiw.kz tksf[keksa vksj viuh O;fDrxr ifjflfkfr;ksa ds fy, [kkl tfvyrkvksa ij ppkz dh gs] ftu ij fd esaus bl vkwijs'ku dks djokrs le; fopkj fd;k gsa esa le>rk gwa fd fo'ks"kk ltzu ds vykok nwljk MkWDVj bl vkwijs'ku dks dj ldrk gsa ( 3 )

8 vkwijs'ku lqy gksxk eq>s bldh dksbz xkjavh ugha nh x;h gsa eq>s vius lkfk?kj ys tkus ds fy, bl izi= dh,d izfr izkir gqbz gsa vxj fdlh phm+&qkm+ ds nksjku LVkQ dks lqbz ;k /kkjnkj vkstkj ls pksv vkrh gs rks esa,pvkbzoh vksj jdr ls gksus okys nwljs fodkjksa ds fy, jdr ysus vksj mldk ijh{k.k djus dh vuqefr iznku djrk gwaa esa le>rk gwa fd vkwijs'ku ds ckn vko';drk im+us ij tsls gh eqefdu gksxk eq>s lykg vksj ijke'kz iznku fd;k tk,xka dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 4 )

9 Retinal Detachment Bipul Baishya, Y.R. Sharma Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... Proposed Treatment The doctor has explained that I, (name of patient.... ),have a retinal detachment in my.....eye and that is proposed: Risks These are the commoner risks. There may be other unusual risks that have not been listed here. I understand there are risks associated with any anesthetic agent. I may have side effects from any of the drugs used. The commoner side effects include light-headedness, nausea, skin rash and constipation. I understand the procedure has the following specific risks and limitations: 1. Although most retina detachments can be treated, a small proportion (5%) may be inoperable and blindness cannot be prevented. 2. Failure to accomplish intent of surgery 3. More than one surgery may be required. Like if Scleral buckling surgery fails, Vitrectomy may be required with Silicone Oil or Gas tamponade. 4. In case of Silicone Oil or Gas injection, I have to maintain position depending upon the surgery. 5. If Gas is injected, I have to restrict air travel until gas is absorbed. 6. If Silicone oil is injected, then resurgery will be required to remove the oil. 7. It may take up to 18 months before the final outcome of the surgery is known. Although many cases achieve a good result, this depends on several factors including how long the detachment had been present. 8. It may not be possible to predict before the operation which cases will do well. 9. There is a chance I may develop further retina detachments in future in the same eye or in the opposite eye. 10. In some cases, more than one operation may be required 11. Though rare, I may develop complications like vitreous hemorrhage, infection, elevated eye pressure (glaucoma), poorly healing or non-healing corneal defects, corneal clouding and scarring, cataract, which might require eventual or immediate removal of lens, double vision, eyelid droop, and loss of circulation to vital tissues in the eye, resulting in decrease or loss of vision There is an extremely small risk (1:17000 cases) that the opposite eye to the one having surgery may become inflamed, especially if complications occur after the operation. This is called sympathetic ophthalmia.although this can be treated, in some cases, eyesight may be lost. I understand some of the above risks are more likely if I smoke, am overweight, diabetic, have high blood pressure or have had previous heart disease. Individual Risks I understand the following are possible significant risks and complications specific to my individual circumstances, that I have considered in deciding to have this operation: ( 5 )

10 Declaration By Patient I acknowledge doctors from the ophthalmic team have informed me about the procedure, alternative treatments and answered my specific queries and concerns about this matter. I acknowledge that I have discussed with the surgical team any significant risks and complications specific to my individual circumstances that I have considered in deciding to have this operation. I agree to any other additional procedures considered necessary in the judgment of my surgeon during this operation. I have received no guarantee the operation will be successful. I have received a copy of this form to take home with me. If a needle stick/sharps injury occurs to staff during any operation I give my permission for blood to be taken and tested for HIV and other blood borne disorders. I understand I will be advised and counselled as soon as practicable after the operation if this has been necessary. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 6 )

11 jsfvuk dk vyxko fciqy cs';] okbz- vkj- 'kekz jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... izlrkfor mipkj MkWDVj us Li"V fd;k gs fd esjh ¼jksxh dk uke½ vka[k esa jsfvuk dk vyxko gs vksj ;g fd izlrkfor gs % tksf[ke dqn lkeku; tksf[ke gsaa nwljs vlkeku; tksf[ke Hkh gks ldrs gsa] ftugsa fd ;gka ij lwphc) ugha fd;k x;k gsa esa le>rk gwa fd fdlh Hkh laosnukgkjh dkjd ds lkfk tksf[ke tqm+s gq, gksrs gsaa eq>s mi;ksx esa yk;h x;h nokvksa esa ls fdlh ds Hkh dkj.k ik'oz&izhkko mriuu gks ldrs gsaa vke ik'oz&izhkkoksa esa pddj vkuk] feryh] Ropk ij nnksjs vksj dct 'kkfey gsa esa le>rk gwa fd fpfdrldh; izfø;k ds fueufyf[kr [kkl tksf[ke vksj lhek,a gsa % 1- gkykafd jsfvuk ds vf/kdrj vyxkoksa dk mipkj fd;k tk ldrk gs ij,d NksVk vuqikr ¼5 izfr'kr½ gks ldrk gs fd vkwijs'ku ds yk;d ugha gks vksj va/ksiu dks jksdk ugha tk ldsa 2- ltzjh ds iz;kstu dks iwjk djus esa foqyrk 3-,d ls vf/kd ltzjh dh vko';drk im+ ldrh gsa tsls fd vxj lsjy cdfyax ltzjh foqy gksrh gs rks flfydkwu vkw;y ;k xsl VSEiksusM ds lkfk fovjsdvkweh dh vko';drk im+ ldrh gsa 4- flfydkwu vkw;y ;k xsl batsd'ku dh n'kk esa ltzjh ds vk/kkj ij flfkfr dks cuk;s j[kuk gsa 5- vxj xsl dk batsd'ku fn;k tkrk gs rks eq>s ml le; rd gokbz ;k=k ls cpuk gksxh tc rd fd xsl vo'kksf"kr ugha gks tkrh- 6- vxj flfydkwu vkw;y dk batsd'ku fn;k tkrk gs rks rsy dks fudkyus ds fy, nksckjk ltzjh vko';d gksxha 7- ltjh ds vafre ifj.kke dk irk pyus esa 18 eghuksa rd dk le; yx ldrk gsa gkykafd cgqr ls ekeyksa esa vpnk ifj.kke vkrk gs ij ;g blds lesr dbz dkjdksa ij fuhkzj djrk gs fd vyxko fdrus le; ls ekstwn FkkA 8- fdu ekeyksa esa vpns ifj.kke vk,axs budk vkwijs'ku ls igys vuqeku yxkuk gks ldrk gs fd lahko ugha gksa 9- bl ckr dk [krjk gksrk gs fd eq>s Hkfo"; esa mlh vka[k esa ;k nwljh okyh esa jsfvuk dk vkxs Hkh vyxko fodflr gks tk;sa 10- dqn ekeyksa esa],d ls vf/kd vkwijs'ku dh t:jr im+ ldrh gsa 11- gkykafd eqf'dy ls gh,slk gksrk gs ysfdu esjs Hkhrj okbvfjvl jdrlzko] laøe.k] vka[k dk aåapk ncko ¼Xywdksek½] dkwuhzy dh [kjkfc;ksa ds?kko ds eqf'dy ls Hkjus ;k ugha Hkjus] dkwuhzy DykmfMax vksj LdSfjax] eksfr;kfcan] ftlds fy, ysalksa dks varr% ;k QkSju fudkyus dh t:jr im+ ldrh gs] Mcy fotu] iydksa ds yvduk vksj vka[kksa ds egroiw.kz Årdksa esa ifjlapj.k ds ugha gksus tslh tfvyrk,a fodflr gks ldrh gsa] ftlds QyLo:i utj esa deh ;k mldk [kkrek gks ldrk gsa bl ckr dk cgqr gh de tksf[ke ¼1%17000 ekeys½ gksrk gs fd ftl vka[k dh ltzjh dh x;h gs mlds cxy okyh vka[k yky gks ldrh gs] fo'ks"kdj ml le; tcfd tfvyrk,a vkwijs'ku ds ckn isnk gksrh gsaa gkykafd bldk mipkj fd;k tk ldrk gs ij dqn ekeyksa esa vka[kksa dh n`f"v tk ldrh gsa esa le>rk gwa fd Åij crk;s x;s tksf[keksa esa ls dqn ds vklkj ml le; T;knk gksrs gsa tcfd esa /kweziku djrk gwa] esjk otu T;knk gs] e/kqesg ls ihfm+r gwa] mpp jdrpki gs ;k igys fny dh chekjh gks pqdh gsa O;fDrxr tksf[ke esa le>rk gwa fd fo'ks"k :i ls esjh ifjflfkfr;ksa ls tqm+s lahkkfor egriw.kz tksf[ke vksj tfvyrk,a fueufyf[kr gsa] ftu ij fd es aus bl vkwijs'ku dks djokus dk fu.kz; djrs le; fopkj fd;k gs % ( 7 )

12 jksxh }kjk?kks"k.kk esa bl ckr dh iqf"v djrk gwa fd us= fo'ks"kkksa dh Vhe ds MkWDVjksa us fpfdrldh; izfø;k] osdfyid mipkjksa ds ckjs esa eq>s tkudkjh iznku dh gs vksj bl ekeys esa esjs fof'k"v iz'uksa vksj fparkvksa dk tokc fn;k gsa esa bl ckr dh iqf"v djrk gwa fd esaus ltzjh djus okys MkWDVjksa dh Vhe ds lkfk fdugha egroiw.kz tksf[keksa vksj viuh O;fDrxr ifjflfkfr;ksa ds fy, [kkl tfvyrkvksa ij ppkz dh gs] ftu ij fd esaus bl vkwijs'ku dks djokrs le; fopkj fd;k gsa esa,slh vu; dk;zfof/k;ksa dks viuk, tkus ij lger gwa tks fd bl vkwijs'ku ds nksjku esjs ltzu dh jk; esa vko';d gksaxha vkwijs'ku lqy gh gksxk bldh eq>s dksbz xkjavh ugha nh x;h gsa eq>s?kj ys tkus ds fy, bl izi= dh,d izfr izkir gqbz gsa vxj fdlh phm+&qkm+ ds nksjku LVkQ dks lqbz ;k /kkjnkj vkstkj ls pksv vkrh gs rks esa,pvkbzoh vksj jdr ls gksus okys nwljs fodkjksa ds fy, jdr ysus vksj mldk ijh{k.k djus dh vuqefr iznku djrk gwaa esa le>rk gwa fd vkwijs'ku ds ckn vko';drk im+us ij tsls gh eqefdu gksxk eq>s lykg vksj ijke'kz iznku fd;k tk,xka dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 8 )

13 Vitreo Retinal Surgery Bipul Baishya, R.V. Azad Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... Proposed Treatment The doctor has explained that I, (name of patient. ), have... in my... Eye and that is proposed. Risks These are the commoner risks. There may be other unusual risks that have not been listed here. I understand there are risks associated with any anesthetic agent. I may have side effects from any of the drugs used. The commoner side effects include light-headedness, nausea, skin rash and constipation. I understand the procedure has the following specific risks and limitations: 1. Failure to accomplish intent of surgery 2. Retinal detachments that may require additional surgery or may be inoperable 3. Depending upon the surgery, Silicone Oil or Gas may be required for tamponade. 4. In case of Silicone Oil or Gas injection, I have to maintain position depending upon the surgery. 5. If Gas is injected, I have to restrict air travel until gas is absorbed. 6. If Silicone oil is injected then resurgery will be required to remove the oil. 7. It may take up to 18 months before the final outcome of the surgery is known. 8. In a few cases, the underlying condition cannot be treated and blindness cannot be prevented. 9. It may not be possible to predict before the operation which cases will do well. 10. There is a chance I may develop further retina detachments in future in the same eye or in the opposite eye. 11. In some cases, more than one operation may be required 12. Though rare I may develop complications like vitreous hemorrhage, infection, elevated eye pressure (glaucoma), poorly healing or non-healing corneal defects, corneal clouding and scarring, cataract, which might require eventual or immediate removal of lens, double vision, eyelid droop, and loss of circulation to vital tissues in the eye, resulting in decrease or loss of vision There is an extremely small risk (1:17000 cases) that the opposite eye to the one having surgery may become inflamed, especially if complications occur after the operation. This is called sympathetic ophthalmia.although this can be treated, in some cases, eyesight may be lost. I understand some of the above risks are more likely if I smoke, am overweight, diabetic, have high blood pressure or have had previous heart disease. Individual Risks I understand the following are possible significant risks and complications specific to my individual circumstances, that I have considered in deciding to have this operation: ( 9 )

14 Declaration by Patient I acknowledge doctors from the ophthalmic team have informed me about the procedure, alternative treatments and answered my specific queries and concerns about this matter. I acknowledge that I have discussed with the surgical team any significant risks and complications specific to my individual circumstances that I have considered in deciding to have this operation. I agree to any other additional procedures considered necessary in the judgment of my surgeon during this operation. I agree to the disposal by the hospital authorities of any tissues that may be removed during the procedure. I understand that some tissues or samples may be kept as part of my hospital records. I have received no guarantee the operation will be successful. I have received a copy of this form to take home with me. If a needle stick/sharps injury occurs to staff during any operation I give my permission for blood to be taken and tested for HIV and other blood borne disorders. I understand I will be advised and counselled as soon as practicable after the operation if this has been necessary. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 10 )

15 fovsfjvks jsfvuy ltzjh fciqy cs';] vkj- oh- vktkn jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... izlrkfor mipkj MkWDVj us Li"V fd;k gs fd esjh ¼jksxh dk uke½ vka[k esa gs vksj ;g fd izlrkfor gs % tksf[ke dqn lkeku; tksf[ke gsaa nwljs vlkeku; tksf[ke Hkh gks ldrs gsa] ftugsa fd ;gka ij lwphc) ugha fd;k x;k gsa esa le>rk gwa fd fdlh Hkh laosnukgkjh dkjd ds lkfk tksf[ke tqm+s gq, gksrs gsaa eq>s mi;ksx esa yk;h x;h nokvksa esa ls fdlh ds Hkh dkj.k ik'oz&izhkko mriuu gks ldrs gsaa vke ik'oz&izhkkoksa esa pddj vkuk] feryh] Ropk ij nnksjs vksj dct 'kkfey gsa esa le>rk gwa fd fpfdrldh; izfø;k ds fueufyf[kr [kkl tksf[ke vksj lhek,a gsa % 1- ltzjh ds iz;kstu dks iwjk djus esa foqyrk 2- jsfvuk dk vyxko ftlds fy, vfrfjdr ltzjh dh vko';drk im+ ldrh gs ;k gks ldrk gs fd mldk vkwijs'ku gh u fd;k tk ldsa 3- ltzjh ds vk/kkj ij VSEiksusM ds fy, flfydkwu vkw;y ;k xsl dh vko';drk im+ ldrh gsa 4- flfydkwu vkw;y ;k xsl batsd'ku dh n'kk esa eq>s ltzjh ds vk/kkj ij flfkfr dks cuk;s j[kuk gsa 5- vxj xsl dk batsd'ku fn;k tkrk gs rks eq>s ml le; rd gokbz ;k=k ls cpuk gksxh tc rd fd xsl vo'kksf"kr ugha gks tkrh- 6- vxj flfydkwu vkw;y dk batsd'ku fn;k tkrk gs rks rsy dks fudkyus ds fy, nksckjk ltzjh vko';d gksxha 7- ltjh ds vafre ifj.kke dk irk pyus esa 18 eghuksa rd dk le; yx ldrk gsa 8- dqn ekeyksa esa varjfufgr n'kk dk mipkj ugha gks ldrk vksj n`f"vghurk dks jksdk ugha tk ldrka 9- fdu ekeyksa esa vpns ifj.kke vk,axs budk vkwijs'ku ls igys vuqeku yxkuk gks ldrk gs fd lahko ugha gksa 10- bl ckr dk [krjk gksrk gs fd eq>s Hkfo"; esa mlh vka[k esa ;k nwljh okyh esa jsfvuk dk vkxs Hkh vyxko fodflr gks tk;sa 11- dqn ekeyksa esa],d ls vf/kd vkwijs'ku dh t:jr im+ ldrh gsa 12- gkykafd eqf'dy ls gh,slk gksrk gs ysfdu esjs Hkhrj okbvfjvl jdrlzko] laøe.k] vka[k dk aåapk ncko ¼Xywdksek½] dkwuhzy dh [kjkfc;ksa ds?kko ds eqf'dy ls Hkjus ;k ugha Hkjus] dkwuhzy DykmfMax vksj LdSfjax] eksfr;kfcan] ftlds fy, ysalksa dks varr% ;k QkSju fudkyus dh t:jr im+ ldrh gs] Mcy fotu] iydksa ds yvduk vksj vka[kksa ds egroiw.kz Årdksa esa ifjlapj.k ds ugha gksus tslh tfvyrk,a fodflr gks ldrh gsa] ftlds QyLo:i utj esa deh ;k mldk [kkrek gks ldrk gsa bl ckr dk cgqr gh de tksf[ke ¼1%17000 ekeys½ gksrk gs fd ftl vka[k dh ltzjh dh x;h gs mlds cxy okyh vka[k yky gks ldrh gs] fo'ks"kdj ml le; tcfd tfvyrk,a vkwijs'ku ds ckn isnk gksrh gsaa bls fleisfksfvd vkfksyfe;k dgk tkrk gsa gkykafd bldk mipkj fd;k tk ldrk gs ij dqn ekeyksa esa vka[kksa dh n`f"v tk ldrh gsa esa le>rk gwa fd Åij crk;s x;s tksf[keksa esa ls dqn ds vklkj ml le; T;knk gksrs gsa tcfd esa /kweziku djrk gwa] esjk otu T;knk gs] e/kqesg ls ihfm+r gwa] mpp jdrpki gs ;k igys fny dh chekjh gks pqdh gsa O;fDrxr tksf[ke esa le>rk gwa fd fo'ks"k :i ls esjh ifjflfkfr;ksa ls tqm+s lahkkfor egriw.kz tksf[ke vksj tfvyrk,a fueufyf[kr gsa] ftu ij fd es aus bl vkwijs'ku dks djokus dk fu.kz; djrs le; fopkj fd;k gs % ( 11 )

16 jksxh }kjk?kks"k.kk esa bl ckr dh iqf"v djrk gwa fd us= fo'ks"kkksa dh Vhe ds MkWDVjksa us fpfdrldh; izfø;k] osdfyid mipkjksa ds ckjs esa eq>s tkudkjh iznku dh gs vksj bl ekeys esa esjs fof'k"v iz'uksa vksj fparkvksa dk tokc fn;k gsa esa bl ckr dh iqf"v djrk gwa fd esaus ltzjh djus okys MkWDVjksa dh Vhe ds lkfk fdugha egroiw.kz tksf[keksa vksj viuh O;fDrxr ifjflfkfr;ksa ds fy, [kkl tfvyrkvksa ij ppkz dh gs] ftu ij fd esaus bl vkwijs'ku dks djokrs le; fopkj fd;k gsa esa,slh vu; dk;zfof/k;ksa dks viuk, tkus ij lger gwa tks fd bl vkwijs'ku ds nksjku esjs ltzu dh jk; esa vko';d gksaxha esa vlirky ds vf/kdkfj;ksa }kjk,slh fdugha Hkh Årdksa ds fuivku ds fy, lger gwa ftugsa fd dk;zfof/k ds nksjku fudkyk tk ldrk gsa esa le>rk gwa fd dqn Årdksa vksj uewuksa dks vlirky ds esjs fjdkmksza ds fglls ds :i esa j[kk tk ldrk gsa vkwijs'ku lqy gh gksxk bldh eq>s dksbz xkjavh ugha nh x;h gsa eq>s?kj ys tkus ds fy, bl izi= dh,d izfr izkir gqbz gsa vxj fdlh phm+&qkm+ ds nksjku LVkQ dks lqbz ;k /kkjnkj vkstkj ls pksv vkrh gs rks esa,pvkbzoh vksj jdr ls gksus okys nwljs fodkjksa ds fy, jdr ysus vksj mldk ijh{k.k djus dh vuqefr iznku djrk gwaa esa le>rk gwa fd vkwijs'ku ds ckn vko';drk im+us ij tsls gh eqefdu gksxk eq>s lykg vksj ijke'kz iznku fd;k tk,xka dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 12 )

17 Macular Hole Surgery Ritesh Gupta Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... Indications and Benefits Your doctor has diagnosed you with macular hole and informed you that if it is left untreated, it is likely that you will have gradual central vision deterioration but you will not lose all of the vision in your eye. Your doctor has informed you that a procedure involving pars plana vitrectomy with/without internal limiting membrane removal and gas injection will be performed in your eye under local/general anesthesia. The important factors in predicting whether the hole closes as a result of surgery is the duration for which the hole has been present and the size of the hole. The success rate for holes that have been present for less than six months is about 90%. However, this reduces to around 60% for a hole which has been present for a year or more. Your doctor has told you that a successful macular hole closure does not guarantee complete visual recovery and that a 2-line improvement is usually the measure of success of the surgery. You have been told that postoperative positioning also has an important role to play for closure of macular hole and that a good majority of the failures stem from incomplete and inconsistent postoperative positioning. Complications As with any surgical procedure, there are risks associated with macular hole surgery. Not every conceivable complication can be covered in this form but the following are examples of risk encountered with macular hole surgery. These complications can occur days, weeks, months, or years later. They can result in loss of vision or blindness. Careful follow-up is required after surgery. Complications of the surgery 1. Failure to accomplish closure of the hole(10-40% depending primarily on the duration and size) 2. Retinal detachments that may require additional surgery or may be inoperable (1-2%) 3. Vitreous hemorrhage 4. Infection (0.02%-0.1%) 5. Elevated eye pressure (glaucoma) 6. Cataract, which might require eventual or immediate removal of lens 7. Poorly healing or non-healing corneal defects 8 Corneal clouding and scarring Complications of anesthesia injections around the eye 1. Perforation of eyeball 2. Needle damage to the optic nerve, which could destroy vision 3. Retrobulbar hemorrhage 4. Possible drooping of eyelid 5. Systemic effects that have the potential for life-threatening complications and death Patient Consent In spite of the risks noted above, I understand that there is more risk to my vision if I do not have the operation than if I do. I have read and understand the consent form, I have had my questions answered, and I authorize my surgeon to proceed with the operation on my... (indicate right or left eye). ( 13 )

18 Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 14 )

19 esdqyj gksy ltzjh fjrs'k xqirk jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... lq>ko vksj ykhk vkids MkWDVj dh tkap ds vuqlkj vkidh vka[k esa esdqyj Nsn gs vksj vkidks crk;k gs fd vxj bldk bykt ugha fd;k x;k rks bl ckr ds vklkj gsa fd vkidh e/;orhz utj /khjs&/khjs [kjkc gksrh tk,xh ysfdu vkidh vka[k dh iwjh jks'kuh ugha tk,xha vkids MkWDVj us vkidks crk;k gs fd csgks'kh dh flfkfr esa vkidh vka[k esa vkarfjd :i ls lhfer djus okyh f>yyh fudklh vksj xsl batsd'ku ds fcuk iklz Iykuk fovjsdvkseh ls tqm+h fø;kfof/k viuk;h tk,xha D;k ltzjh ds QyLo:i Nsn can gks tk,xk bldk iwokzuqeku yxkus esa egroiw.kz dkjd Nsn ds ekstwn jgus dh vof/k vksj Nsn dk vkdkj gsa Ng eghuksa ls de le; le; ls ekstwn jgus okys Nsnksa ds fy, lqyrk dh nj yxhkx 90 izfr'kr gsa fqj Hkh],d lky ;k vf/kd ls ekstwn jgus okys Nsn ds fy, ;g?kvdj yxhkx 60 izfr'kr gks tkrh gsa vkids MkWDVj us vkidks crk;k gs fd esdqyj Nsn dk lqyrkiwozd can gksuk n`f"v dh iw.kz:is.k HkjikbZ dh xkjavh ugha djrk vksj ;g fd 2&ykbu lq/kkj izk;% ltzjh dh lqyrk dk isekuk gksrk gsa vkidks crk;k x;k gs fd vkwijs'ku ds ckn dk LFkkiu Hkh esdqyj ds Nsn dks can djus esa egroiw.kz Hkfedk vnk djrk gs vksj foqyrkvksa ds dkqh cms+ fglls dk dkj.k vkwijs'ku ds ckn dk v/kwjk vksj vlaxr LFkkiu gksrk gsa tfvyrk,a 'ky;fø;k ls tqm+h fdlh Hkh dk;zfof/k dh Hkkafr gh esdqyj Nsn dh ltzjh ls Hkh tksf[ke tqm+s gq, gksrs gsaa bl :i esa gjsd dyiuh; tfvyrk dks 'kkfey ugha fd;k tk ldrk ysfdu esdqyj Nsn ltzjh ls tqm+s tksf[keksa ds mnkgj.k fueufyf[kr gsaa ;s tfvyrk,a fnuksa] grksa] eghuksa ;k lkyksa ckn isnk gks ldrh gsaa budh otg ls n`f"v dk pys tkuk ;k va/kkiu isnk gks ldrk gsa ltzjh ds ckn lko/kkuh Hkjs QkWyks&vi dh t:jr gksrh gsa ltzjh dh tfvyrk,a 1- Nsn dh canh dks iwjk djus esa foqyrk ¼10&40 izfr'kr eq[;r;k vof/k vksj vkdkj ij fuhkjz½ 2- jsfvuk dk vyxko ftlds fy, vfrfjdr ltzjh dh t:jr im+ ldrh gs ;k gks ldrk gs fd mldk vkwijs'ku gh u gks ik;s ¼1&2 izfr'kr½ 3- fovfjvl jdrlzko 4- laøe.k ¼0-02 izfr'kr&0-1 izfr'kr½ 5- vka[k dk c<+k gqvk ncko ¼Xywdksek½ 6- eksfr;kfcan] tks fd ysalksa dh varr% ;k QkSju fudklh dks vko';d cuk ldrk gs 7- dkwuhzy dh [kjkfc;ksa dk cgqr gh /khes Bhd gksuk ;k ugha Bhd gksuk 8- dkwuhzy DykmfMax ;k LdSfjax vka[kksa ds bnzfxnz laosnukgkjh batsd'kuksa dh tfvyrk,a 1- us=xksyd dk [ksn 2- izdkf'kd ul dks lqbz ls {kfr] tks fd n`f"v dks u"v dj nsrh gs 3- jsvªkscqyckj jdrlzko 4- iydksa dh lahko Mªwfiax 5- lokzaxh izhkko ftlesa fd thou dks [krjs esa Mkyus okyh tfvyrkvksa vksj eksr dh lahkko;rk gksrh gs jksxh dh lgefr Åij crk;s x;s tksf[keksa ds ckotwn] esa le>rk gwa fd vxj esa vkwijs'ku ugha djokrk gwa rks esjh n`f"v dks vksj Hkh vf/kd [krjk gsa esaus lgefr izi= dks i<+ vksj le> fy;k gs] esjs iz'uksa ds mùkj fn;s tk pqds gsa] vksj esa vius ltzu dks viuh ¼^^nk;ha** ;k ^^ck;ha** vka[k lq>k,a½ dk vkwijs'ku djus ds fy, vkxs c<+us gsrq vf/kñr djrk gwaa ( 15 )

20 dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %. ( 16 )

21 Avastin TM Intraivtreal Injection Zahir Abbas, Gunjan Prakash Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... Possible Benefits and Off-Label Status Avastin TM was not initially developed to treat your eye condition. Based upon the results of clinical trials that demonstrated its safety and effectiveness, Avastin TM was approved by the Food and Drug Administration (FDA) for the treatment of metastatic colorectal cancer. Once a device or medication is approved by the FDA, physicians may use it off-label for other purposes if they are well-informed about the product, base its use on firm scientific method and sound medical evidence, and maintain records of its use and effects. Ophthalmologists are using Avastin TM off-label to treat AMD and similar conditions since research indicates that VEGF is one of the causes for the growth of the abnormal vessels that cause these conditions. Some patients treated with Avastin TM had less fluid and more normal-appearing maculas, and their vision improved. Avastin TM is also used, therefore, to treat macular edema, or swelling of the macula. Recently, a medication similar in function and designed for intravitreal administration was approved by the FDA for the treatment of AMD. Possible Limitations The goal of treatment is to prevent further loss of vision. Although some patients have regained vision, the medication may not restore vision that has already been lost, and may not ultimately prevent further loss of vision caused by the disease. Alternatives You do not have to receive treatment for your condition, although without treatment, these diseases can lead to further vision loss and blindness, sometimes very quickly. Other forms of treatment are available. At present, there are three FDA-approved treatments for neovascular age-related macular degeneration. The first two are photodynamic therapy with a drug called Visudyne TM and injection into the eye of a drug called Macugen TM. The third medication, Lucentis TM is similar to Avastin TM. In addition to the FDA-approved medications, some ophthalmologists use intravitreal triamcinolone off-label to treat eye conditions like yours. Complications when Avastin TM is given to patients with cancer When Avastin TM is given to patients with metastatic colorectal cancer, some patients experienced gastrointestinal perforations or wound healing complications, hemorrhage, arterial thromboembolic events (such as stroke or heart attack), hypertension, proteinuria, and congestive heart failure. Patients who experienced these complications not only had metastatic colon cancer, but were also given 400 times the dose you will be given, at more frequent intervals, and in a way (through an intravenous infusion) that spread the drug throughout their bodies. Risk when Avastin TM is given to treat patients with eye conditions The risk of these complications for patients with eye conditions is low. Patients receiving Avastin TM for eye conditions are healthier than the cancer patients, and receive a significantly small dose, delivered only to the cavity of their eye. While there are no FDA-approved studies about the use of Avastin TM in the eye that prove it is safe and effective, Lucentis TM, a similar drug, was recently approved for AMD. One study of patients who received Avastin TM through an intravenous infusion reported only a mild elevation in blood pressure. Another study of patients treated like you will be with intravitreal Avastin TM did not have these elevations or the other serious problems seen in the patients with cancer. However, the benefits and risks of intravitreal Avastin TM for eye conditions are not yet fully known. In addition, whenever a medication is used in a large number of patients, a small number of coincidental life-threatening problems may occur that have no relationship to the treatment. For example, patients with diabetes are already at increased risk for heart attacks and strokes. If one of these patients being treated with Avastin TM suffers a heart attack or stroke, it may be caused by the diabetes and not the Avastin TM treatment. Known risks of intravitreal eye injections Your condition may not get better or may become worse. Any or all of these complications may cause decreased vision and/or have a ( 17 )

22 possibility of causing blindness. Additional procedures may be needed to treat these complications. Possible complications and side effects of the procedure and administration of Avastin TM include but are not limited to retinal detachment, cataract formation, glaucoma, hypotony (reduced pressure in the eye), damage to the retina or cornea, and bleeding. There is also the possibility of an eye infection (endophthalmitis). Any of these rare complications may lead to severe, permanent loss of vision. Patient Responsibilities I will immediately contact my doctor if any of the following signs of infection or other complications develop : pain, blurry or decreased vision, sensitivity to light, redness of the eye, or discharge from the eye. I will keep all post-injection appointments so my doctor can check for complications. Although the likelihood of serious complications affecting other organs of my body is low, I will immediately contact my physician if I experience abdominal pain associated with constipation & vomiting, abnormal bleeding, chest pain, severe headache, slurred speech, or weakness on one side of the body. As soon as possible, I will also notify the treating ophthalmologist of these problems. I will inform any other surgeon that I am on a medication that needs to be stopped before I can have surgery. Patient Consent The above explanation has been read by/to me. The nature of my eye condition has been explained to me and the proposed treatment has been described. The risks, benefits, alternatives, and limitations of the treatment have been discussed with me. All my questions have been answered. I understand that Avastin TM was approved by the FDA for the treatment of metastatic colorectal cancer, and has not been approved for the treatment of eye conditions. Nevertheless, I wish to be treated with Avastin TM, and I am willing to accept the potential risks that my physician has discussed with me. I hereby authorize the treating eye-surgeon to administer the intravitreal Avastin TM in my affected eye as needed. This consent will be valid until I revoke it or my condition changes to the point that the risks and benefits of this medication for me are significantly different. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 18 )

23 vokflvu Vh,e bavªsofvª;y btsd'ku tghj vcckl] xqatu izdk'k jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... lahkkfor ykhk vksj ^^vkq&yscy** flfkfr vokflvu Vh,e dks 'kq:&'kq: esa vkidh vka[k dh n'kk dks Bhd djus ds fy, ugha fodflr fd;k x;k FkkA bldh lqj{kk vksj izhkkfork dks iznf'kzr djus okys fpfdrldh; ijh{k.kksa ds ifj.kkeksa ds vk/kkj ij vokflvu Vh,e dks esvklvsfvd dksyksjsdvy dsalj ds mipkj ds fy, [kk,oa vks"kf/k iz'kklu ¼,QMh,½ dh eatwjh izkir gqbza,d ckj tc fdlh fmokbl ;k nok dks,qmh, dh eatwjh fey tkrh gs rks MkWDVj vxj mrikn ds ckjs esa iwjh tkudkjh j[krs gsa rks os vu; mís';ksa ds fy, mldk ^^vkq&yscy** mi;ksx dj ldrs gsa] mlds mi;ksx dks n`<+ oskkfud rjhds vksj Bksl fpfdrldh; lk{; ij vk/kkfjr dj ldrs gsa vksj mlds mi;ksx vksj izhkkoksa ds fjdkmksza dks cuk;s j[k ldrs gsaa us= fo'ks"kk,,emh vksj leku n'kkvksa ds mipkj ds fy, vokflvu Vh,e ^^vkq yscy** dk mi;ksx dj jgs gsa D;ksafd vuqla/kku crkrs gsa fd ohbzth,q vlkeku; ulksa ds fodkl ds dkj.kksa esa ls,d gs tks fd bu n'kkvksa dks mriuu djrs gsaa vokflvu Vh,e ls mipkj ikus okys jksfx;ksa esa de rjy inkfkz vksj T;knk lkeku; fn[kus okys esdqys Fks vksj mudh n`f"v lq/kjh gqbz FkhA fygktk] vokflvu Vh,e dk mi;ksx esdqyj,fmek ;k esdqyk dh lwtu dks Bhd djus ds fy, Hkh fd;k tkrk gsa gky gh esa] izdk;z esa,d leku vksj bavªkfovfj;y izca/k ds fy, rs;kj dh x;h nok dks,,emh ds mipkj ds fy,,qmh, }kjk eatwjh iznku dh x;ha lahkkfor lhek,a mipkj dk y{; n`f"v dh vksj vf/kd gkfu dks jksduk gsa gkykafd dqn jksfx;ksa us n`f"v dks fqj ls izkir fd;k gs ij gks ldrk gs fd nok ml n`f"v dks cgky ugha dj ik;s tks fd igys gh tk pqdh gs vksj chekjh ds dkj.k vkxs n`f"v ds tkus dks varr% ugha jksd ik;sa fodyi vki viuh n'kk dk mipkj ugha Hkh djok ldrs gsa] gkykafd mipkj ds fcuk ;s chekfj;ka n`f"v dh vksj Hkh gkfu vksj va/ksiu dh vksj ys tk,axh] dbz ckj cgqr gh tynha mipkj ds nwljs :i miyc/k gsaa orzeku esa] fu;ksosldwyj mez ls tqm+s esdqyj fodkj ds fy,,qmh, ls eatwjh izkir rhu mipkj gsaa izfke nks folqmkbu Vh,e uked nok ds lkfk QksVksMk;kufed mipkj vksj esdqtsu Vh,e uked nok dk vka[k esa batsd'ku gsaa rhljh nok] yqlsafvl Vh,e vokflvu Vh,e ds leku gksrh gsa,qmh, ls eatwjh izkir nokvksa ds vfrfjdr dqn us=&fo'ks"kk vkidh rjg dh vka[kksa dh n'kkvksa ds mipkj ds fy, bavªkfovfj;y fvª;kefluksyku & ^^vkq&yscy** dks mi;ksx esa ykrs gsaa dsalj ds jksfx;ksa dks vokflvu Vh,e fn;s tkus ij mriuu gksus okyh tfvyrk,a tc esvklvsfvd dksyksjsdvy dsalj okys jksfx;ksa dks vokflvu Vh,e nh x;h rks dqn jksfx;ksa us tbjkaf=; Nsnksa ;k?kko Hkjus esa ijs'kkfu;ksa] /keuh; FkzksEcks,Ecksfyd?kVukvksa ¼tSls fd nksjk ;k ân;k?kkr½] mpp jdrpki] izksvhuqfj;k vksj dkatsflvo gkvz QsY;ksj dk lkeuk fd;ka bu ijs'kkfu;ksa dks eglwl djus okys jksfx;ksa dks u dsoy esvklvsfvd dksyksu dsalj Fkk cfyd mugsa vkids eqdkcys 400 xquk [kqjkd T;knk fu;fer varjkyksa ij vksj bl izdkj ls ¼var%f'kjk esa nzo dks Mkyus ds tfj;s½ nh x;h Fkh ftlus fd muds iwjs 'kjhj esa nok dks QSyk fn;k FkkA vka[k dh chekfj;ksa okys jksfx;ksa ds mipkj ds fy, vokflvu Vh,e dks fn;s tkus ds le; ds tksf[ke vka[k dh chekjh okys jksfx;ksa ds fy, bu ijs'kkfu;ksa ds tksf[ke de gsaa vka[kksa dh chekfj;ksa ds fy, vokflvu Vh,e izkir djus okys jksxh dsalj jksfx;ksa ds eqdkcys T;knk LoLFk gksrs gsa vksj dsoy mudh vka[kksa dh dsfovh esa Mkyh tkus okyh myys[kuh; :i ls de ek=k izkir djrs gsaa tgkavka[kksa esa vokflvu Vh,e ds mi;ksx ds ckjs esa,qmh, ls eatwjh izkir,sls dksbz v/;;u ugha gsa tks fd ;g lkfcr djrs gksa fd ;g lqjf{kr vksj izhkkoh gs] ogha blh izdkj dh nok yqlsafvl Vh,e dks gky gh esa,,emh ds fy, eatwjh iznku dh x;ha ul ds vanj nzo Mkydj vokflvu Vh,e izkir djus okys jksfx;ksa ds,d v/;;u esa dsoy jdrpki esa gydh o`f) ns[kh x;ha vkidh rjg bavªkfovfj;y vokflvu Vh,e ls mipkj ikus okys jksfx;ksa ds,d nwljs v/;;u esa bu o`f);ksa ;k vu; xahkhj lel;kvksa dks ugha ns[kk x;k gs ftugsa fd dsalj ds jksfx;ksa esa ns[kk x;k FkkA fqj Hkh] vka[k dh chekfj;ksa ds fy, bavªkfovfj;y vokflvu Vh,e ds ykhkksa vksj tksf[keksa dk vhkh iwjh rjg ls irk ugha pyk gsa blds vfrfjdr] tc jksfx;ksa dh cm+h la[;k esa nok dk mi;ksx fd;k tkrk gs rks,d NksVh la[;k esa tkuysok lel;kvksa dk la;ksx isnk gks ldrk gs ftldk fd mipkj ds lkfk dksbz fj'rk ugha gksrk gsa mnkgj.k ds fy, e/kqesg dks jksfx;ksa dks fny ds nksjs ;k vk?kkr dk tksf[ke igys ls gh c<+k gqvk gksrk gsa vxj vokflvu Vh,e ls mipkj ik jgs jksfx;ksa esa ls dksbz fny ds nksjs ;k vk?kkr ls =Lr gksrk gs rks gks ldrk gs fd mldk dkj.k e/kqesg gks u fd vokflvu Vh,e ds lkfk mipkja vka[kksa ds bavªkfovfj;y batsd'kuksa ds Kkr tksf[ke vkidh chekjh esa gks ldrk gs fd lq/kkj ugha vk;s ;k og cnrj gks ldrh gsa bu ijs'kkfu;ksa esa ls dksbz ;k lhkh?kvh gqbz n`f"v vksj@;k va/kro isnk djus ( 19 )

24 dh lahkkouk dk dkj.k cu ldrh gsaa bu ijs'kkfu;ksa dk mipkj djus ds fy, vfrfjdr dk;zfof/k;ksa dh t:jr im+ ldrh gsa dk;zfof/k vksj vokflvu Vh,e ds lsou dh lahko ijs'kkfu;ksa vksj ik'oz&izhkkoksas esa jsfvuk dk vyx gksuk] eksfr;kfcan dk fodkl] Xywdksek] gkbiksvksuh ¼vka[kksa esa?kvk gqvk ncko½] jsfvuk ;k dkfuz;k dks {kfr vksj jdrlzko 'kkfey gsa ysfdu os bugha rd lhfer ugha gasa blds vykok vka[kksa esa laøe.k ¼,aMvkFkSyfefVl½ dh Hkh lahkkouk gksrh gsa bu fojy ijs'kkfu;ksa esa ls dksbz Hkh n`f"v dh Hkkjh] LFkk;h gkfu dks tue ns ldrh gsa jksxh dh fteesnkfj;ka vxj laøe.k ds fueufyf[kr esa ls dksbz Hkh y{k.k ;k vu; ijs'kkfu;ka fodflr gksrh gsa rks esa QkSju vius MkWDVj ls laidz d:axk % nnz] /kqa/kyh ;k?kvh gqbz n`f"v] izdk'k ds izfr laosnu'khyrk] vka[kksa dh ykyh ;k vka[kksa ls ikuh cguka esa batsd'ku ds ckn ds eqykdkr ds lhkh le; ij gkftj jgwaxk rkfd esjk MkWDVj ijs'kkfu;ksa dh tkap dj ldsa gkykafd esjs 'kjhj ds nwljs vaxksa dks izhkkfor djus okyh xahkhj ijs'kkfu;ksa dh lahkkouk de gs] ij vxj esa dct,oa myvh ls tqm+s isv nnz] vlkeku; jdrlzko] Nkrh esa nnz] cgqr vf/kd fljnnz] vkokt dk ym+[km+kuk ;k 'kjhj dh,d rjq detksjh dks eglwl djrk gwa rks QkSju vius MkWDVj ls laidz d:axka ftruh tynh lahko gks ldsxk esa viuk mipkj dj jgs us= fo'ks"kk dks bu lel;kvksa ds ckjs esa crkåaxka esa fdlh nwljs ltzu dks lwfpr d:axk fd esjh nokbz py jgh gs ftls fd jksdus dh t:jr gs rkfd esjh ltzjh gks ldsa jksxh dh lgefr mi;qzdr Li"Vhdj.k dks esjs }kjk i<+ fy;k x;k gsa esjh vka[k dh volfkk dh izñfr eq>s crk nh x;h gs vksj izlrkfor mipkj dk of.kzr dj fn;k x;k gsa esjs lkfk mipkj ds tksf[keksa] ykhkksa] fodyiksa vksj lhekvksa dh ppkz dh x;h gsa esjs lhkh iz'uksa dk mùkj ns fn;k x;k gsa esa le>rk gwa fd vokflvu Vh,e dks esvklvsfvd dksyksjsdvy dsalj ds mipkj ds fy,,qmh, }kjk eatwjh iznku dh x;h gs vksj vka[k dh chekfj;ksa ds mipkj ds fy, bls eatwj ugha fd;k x;k gsa fqj Hkh] esa vokflvu Vh,e ls mipkj ikuk pkgrk gwa vksj esa mu lahkko; tksf[keksa dks Lohdkj djus ds fy, bpnqd gwa ftudh fd esjs MkWDVj us esjs lkfk ppkz dh gsa blds }kjk esa mipkj dj jgs us= ltzu dks viuh izhkkfor vka[k esa t:jr ds vuqlkj bavªkfovfj;y vokflvu Vh,e dks mi;ksx esa ykus ds fy, vf/kñr djrk gwaa ;g vuqefr esjs }kjk bls jí fd;s tkus ;k esjh volfkkvksa ds ml gn rd ifjofrzr gksus rd os/k jgsxh tcfd esjs fy, vks"kf/k ds tksf[ke vksj ykhk myys[kuh; :i ls fhkuu u gks tk;saa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 20 )

25 Macugen TM Intravitreal Injection Aparna Gupta Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... Indications Macugen is used to treat adults with an eye problem called the wet form (neovascular) of age-related macular degeneration. Macular degeneration causes vision loss leading to blindness. Contraindications Do not use Macugen if you have an infection in or around your eye Possible Limitations The goal of treatment is to prevent further loss of vision. Although some patients have regained vision, the medication may not restore vision that has already been lost, and may not ultimately prevent further loss of vision caused by the disease. Alternatives You do not have to receive treatment for your condition, although without treatment, these diseases can lead to further vision loss and blindness, sometimes very quickly. Other forms of treatment are available. At present, there are three FDA-approved treatments for neovascular age-related macular degeneration. The first is photodynamic therapy with a drug called Visudyne TM. The other two are injection into the eye of Macugen TM. and Lucentis TM. In addition to the FDA-approved medications, some ophthalmologists use intravitreal Avastin TM and triamcinolone off-label to treat eye conditions like yours. Side Effects The most common side effects with Macugen include: 1. inflammation of the eye 2. blurred vision or changes in vision 3. cataracts 4. bleeding in the eye 5. swelling of the eye 6. eye discharge 7. irritation or discomfort of the eye 8. eye pain 9. seeing spots in your vision Patient Responsibilities I will inform my doctor if I m pregnant, planning to conceive or breast feeding. I will immediately contact my doctor if any of the following signs of infection or other complications develop:pain, blurry or decreased vision, sensitivity to light, redness of the eye, or discharge from the eye. I will keep all my post-injection appointments so that my doctor can check for complications. Although the likelihood of serious complications affecting other organs of my body is low, I will immediately contact my physician if I experience abdominal pain associated with constipation & vomiting, abnormal bleeding, chest pain, severe headache, slurred speech, or weakness on one side of the body. As soon as possible, I will also notify the treating ophthalmologist of these problems. ( 21 )

26 I will inform any other surgeon that I am on a medication that needs to be stopped before I can have surgery Patient Consent The above explanation has been read by/to me. The nature of my eye condition has been explained to me and the proposed treatment has been described. The risks, benefits, alternatives, and limitations of the treatment have been discussed with me. All my questions have been answered. I understand that Macugen TM was approved by the FDA for the treatment of metastatic colorectal cancer, and has not been approved for the treatment of eye conditions. Nevertheless, I wish to be treated with Macugen TM, and I am willing to accept the potential risks that my physician has discussed with me. I hereby authorize the treating eye-surgeon to administer the intravitreal Macugen TM in my affected eye as needed. This consent will be valid until I revoke it or my condition changes to the point that the risks and benefits of this medication for me are significantly different. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 22 )

27 esdqtsu Vh,e bavªkfovfj;y batsd'ku vi.kkz xqirk jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... lq>ko esdqtsu dk mi;ksx mez ls tqm+s esdqyj fodkj ds xhys :i ¼fu;ksoSLdqyj½ dgh tkus okyh vka[k dh lel;k okys o;ldksa ds mipkj ds fy, fd;k tkrk gsa esdqyj fodkj va/ksiu dh vksj ys tkus okyh n`f"v dh gkfu dks mriuu djrk gsa uqdlkunsg vlj vxj vkidh vka[k ;k mlds vklikl laøe.k gs rks esdqtsu dk mi;ksx ugha djsaa lahkkfor lhek,a mipkj dk y{; n`f"v dks vkxs vksj gkfu gksus ls jksduk gsa gkykafd dqn yksxksa us n`f"v iqu% izkir dh gs ij gks ldrk gs fd nokbz igys gh tk pqdh n`f"v dks fqj ls cgky ugha djs vksj ;g Hkh lahko gs fd chekjh ds dkj.k n`f"v dh vkxs dh gkfu dks Hkh varr% ugha jksd ik;sa fodyi vki viuh n'kk dk mipkj ugha Hkh djok ldrs gsa] gkykafd mipkj ds fcuk ;s chekfj;ka n`f"v dh vksj Hkh gkfu vksj va/ksiu dh vksj ys tk,axh] dbz ckj cgqr gh tynha mipkj ds nwljs :i miyc/k gsaa orzeku esa] fu;ksosldwyj mez ls tqm+s esdqyj fodkj ds fy,,qmh, ls eatwjh izkir rhu mipkj gsaa igyks folqmkbu Vh,e uked nok ds lkfk QksVksMk;kufed mipkj gsa vu; nks esdqtsu Vh,e vksj yqlsafvl Vh,e ds vka[k ds batsd'ku gsaa,qmh, ls eatwjh izkir nokvksa ds vfrfjdr dqn us=&fo'ks"kk vkidh rjg dh vka[kksa dh n'kkvksa ds mipkj ds fy, bavªkfovfj;y vokflvu Vh,e vksj fvª;kefluksyksu & ^^vkq&yscy** dks mi;ksx esa ykrs gsaa ikk'oz&izhkko esdqtsu ds lkfk lokzf/kd vke ik'oz izhkkoksa esa 'kkfey gsa % 1- vka[kksa dh tyu 2- /kqa/kyh n`f"v ;k n`f"v esa ifjorzu 3- eksfr;kfcan 4- vka[kksa esa jdrlzko 5- vka[kksa esa lwtu 6- vka[k ls ikuh cguk 7- vka[k esa tyu ;k ihm+k 8- vka[kksa dk nnz 9- vkidh n`f"v esa ^^/kccksa** dk fn[kuk jksxh dh fteesnkfj;ka vxj esa xhkzorh gwa] xhkz /kkj.k djus dh ;kstuk cuk jgh gwa ;k Lruiku djk jgh gwa rks vius MkWDVj dks lwfpr d:axha vxj laøe.k ds fueufyf[kr esa ls dksbz Hkh y{k.k ;k vu; ijs'kkfu;ka fodflr gksrh gsa rks esa QkSju vius MkWDVj ls laidz d:axk % nnz] /kqa/kyh ;k?kvh gqbz n`f"v] izdk'k ds izfr laosnu'khyrk] vka[kksa dh ykyh ;k vka[kksa ls ikuh cguka esa batsd'ku ds ckn ds eqykdkr ds lhkh le; ij gkftj jgwaxk rkfd esjk MkWDVj ijs'kkfu;ksa dh tkap dj ldsa gkykafd esjs 'kjhj ds nwljs vaxksa dks izhkkfor djus okyh xahkhj ijs'kkfu;ksa dh lahkkouk de gs] ij vxj esa dct,oa myvh ls tqm+s isv nnz] vlkeku; jdrlzko] Nkrh esa nnz] cgqr vf/kd fljnnz] vkokt dk ym+[km+kuk ;k 'kjhj dh,d rjq detksjh dks eglwl djrk gwa rks QkSju vius MkWDVj ls laidz d:axka ftruh tynh lahko gks ldsxk esa viuk mipkj dj jgs us= fo'ks"kk dks bu lel;kvksa ds ckjs esa crkåaxka ( 23 )

28 esa fdlh nwljs ltzu dks lwfpr d:axk fd esjh nokbz py jgh gs ftls fd jksdus dh t:jr gs rkfd esjh ltzjh gks ldsa jksxh dh lgefr mi;qzdr Li"Vhdj.k dks esjs }kjk i<+ fy;k x;k gsa esjh vka[k dh volfkk dh izñfr eq>s crk nh x;h gs vksj izlrkfor mipkj dk of.kzr dj fn;k x;k gsa esjs lkfk mipkj ds tksf[keksa] ykhkksa] fodyiksa vksj lhekvksa dh ppkz dh x;h gsa esjs lhkh iz'uksa dk mùkj ns fn;k x;k gsa esa le>rk gwa fd esdqtsu Vh,e dks esvklvsfvd dksyksjsdvy dsalj ds mipkj ds fy,,qmh, }kjk eatwjh iznku dh x;h gs vksj vka[k dh chekfj;ksa ds mipkj ds fy, bls eatwj ugha fd;k x;k gsa fqj Hkh] esa esdqtsu Vh,e ls mipkj ikuk pkgrk gwa vksj esa mu lahkko; tksf[keksa dks Lohdkj djus ds fy, bpnqd gwa ftudh fd esjs MkWDVj us esjs lkfk ppkz dh gsa blds }kjk esa mipkj dj jgs us= ltzu dks viuh izhkkfor vka[k esa t:jr ds vuqlkj bavªkfovfj;y esdqtsu Vh,e dks mi;ksx esa ykus ds fy, vf/kñr djrk gwaa ;g vuqefr esjs }kjk bls jí fd;s tkus ;k esjh volfkkvksa ds ml gn rd ifjofrzr gksus rd os/k jgsxh tcfd esjs fy, vks"kf/k ds tksf[ke vksj ykhk myys[kuh; :i ls fhkuu u gks tk;saa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 24 )

29 Lucentis TM Intravitreal Injection Aparna Gupta Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... Indications Lucentis is used to treat adults with an eye problem called the wet form (neovascular) of age-related macular degeneration. Macular degeneration causes vision loss leading to blindness. Contraindications Do not use Lucentis if you have an infection in or around your eye Possible Limitations The goal of treatment is to prevent further loss of vision. Although some patients have regained vision, the medication may not restore vision that has already been lost, and may not ultimately prevent further loss of vision caused by the disease. Alternatives You do not have to receive treatment for your condition, although without treatment, these diseases can lead to further vision loss and blindness, sometimes very quickly. Other forms of treatment are available. At present, there are three FDA-approved treatments for neovascular age-related macular degeneration. The first is photodynamic therapy with a drug called Visudyne TM. The other two are injection into the eye of Lucentis TM. and Macugen TM. In addition to the FDA-approved medications, some ophthalmologists use intravitreal Avastin TM and triamcinolone off-label to treat eye conditions like yours. Side Effects The most common side effects with Lucentis include: 1. Inflammation of the eye 2. Blurred vision or changes in vision 3. Cataracts 4. Bleeding in the eye 5. Swelling of the eye 6. Eye discharge 7. Irritation or discomfort of the eye 8. Eye pain 9. Seeing spots in your vision 10. The most common non eye-related side effects were high blood pressure, nose and throat infection, and headache. 11. Although uncommon, conditions associated with eye- and non eye-related blood clots (arterial thromboembolic events) may occur. Patient Responsibilities I will inform my doctor if I m pregnant, planning to conceive or breast feeding. I will immediately contact my doctor if any of the following signs of infection or other complications develops: pain, blurry or decreased vision, sensitivity to light, redness of the eye, or discharge from the eye. I will keep all my post-injection appointments so that my doctor can check for complications. Although the likelihood of serious complications affecting other organs of my body is low, I will immediately contact my ( 25 )

30 physician if I experience abdominal pain associated with constipation & vomiting, abnormal bleeding, chest pain, severe headache, slurred speech, or weakness on one side of the body. As soon as possible, I will also notify the treating ophthalmologist of these problems. I will inform any other surgeon that I am on a medication that needs to be stopped before I can have surgery Patient Consent The above explanation has been read by/to me. The nature of my eye condition has been explained to me and the proposed treatment has been described. The risks, benefits, alternatives, and limitations of the treatment have been discussed with me. All my questions have been answered. I understand that Lucentis TM was approved by the FDA for the treatment of metastatic colorectal cancer, and has not been approved for the treatment of eye conditions. Nevertheless, I wish to be treated with Lucentis TM, and I am willing to accept the potential risks that my physician has discussed with me. I hereby authorize the treating eye-surgeon to administer the intravitreal Lucentis TM in my affected eye as needed. This consent will be valid until I revoke it or my condition changes to the point that the risks and benefits of this medication for me are significantly different. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 26 )

31 yqlsafvl Vh,e bavªkfovfj;y batsd'ku vi.kkz xqirk jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... lq>ko esdqtsu yqlsafvlvh,e dk mi;ksx mez ls tqm+s esdqyj fodkj ds xhys :i ¼fu;ksoSLdqyj½ dgh tkus okyh vka[k dh lel;k okys o;ldksa ds mipkj ds fy, fd;k tkrk gsa esdqyj fodkj va/ksiu dh vksj ys tkus okyh n`f"v dh gkfu dks mriuu djrk gsa uqdlkunsg vlj vxj vkidh vka[k ;k mlds vklikl laøe.k gs rks esdqtsu dk mi;ksx ugha djsaa lahkkfor lhek,a mipkj dk y{; n`f"v dks vkxs vksj gkfu gksus ls jksduk gsa gkykafd dqn yksxksa us n`f"v iqu% izkir dh gs ij gks ldrk gs fd nokbz igys gh tk pqdh n`f"v dks fqj ls cgky ugha djs vksj ;g Hkh lahko gs fd chekjh ds dkj.k n`f"v dh vkxs dh gkfu dks Hkh varr% ugha jksd ik;sa fodyi vki viuh n'kk dk mipkj ugha Hkh djok ldrs gsa] gkykafd mipkj ds fcuk ;s chekfj;ka n`f"v dh vksj Hkh gkfu vksj va/ksiu dh vksj ys tk,axh] dbz ckj cgqr gh tynha mipkj ds nwljs :i miyc/k gsaa orzeku esa] fu;ksosldwyj mez ls tqm+s esdqyj fodkj ds fy,,qmh, ls eatwjh izkir rhu mipkj gsaa igyk folqmkbu Vh,e uked nok ds lkfk QksVksMk;kufed mipkj gsa vu; nks yqlsafvl Vh,e vksj esdqtsu Vh,e ds vka[k ds batsd'ku gsaa,qmh, ls eatwjh izkir nokvksa ds vfrfjdr dqn us=&fo'ks"kk vkidh rjg dh vka[kksa dh n'kkvksa ds mipkj ds fy, bavªkfovfj;y vokflvu Vh,e vksj fvª;kefluksyksu & ^^vkq&yscy** dks mi;ksx esa ykrs gsaa ikk'oz&izhkko yqlsafvl ds lkfk lokzf/kd vke ik'oz izhkkoksa esa 'kkfey gsa % 1- vka[kksa dh tyu 2- /kqa/kyh n`f"v ;k n`f"v esa ifjorzu 3- eksfr;kfcan 4- vka[kksa esa jdrlzko 5- vka[kksa esa lwtu 6- vka[k ls ikuh cguk 7- vka[k esa tyu ;k ihm+k 8- vka[kksa dk nnz 9- vkidh n`f"v esa ^^/kccksa** dk fn[kuk 10-,sls ik'oz&izhkkoksa esa tks fd vka[kksa ls tqm+s gq, ugha gs lokzf/kd vke ik'oz&izhkko gsa mpp jdrpki] ukd vksj xys esa laøe.k vksj fljnnza 11- gkykafd vke ugha gsa ij vka[kksa ls tqm+h gqbz n'kk,a vksj muls vlec) jdr ds FkDds ¼/keuh; FkzksEcks,Ecksfyd?kVuk,a½ isnk gks ldrh gsaa jksxh dh fteesnkfj;ka vxj esa xhkzorh gwa] xhkz /kkj.k djus dh ;kstuk cuk jgwa ;k Lruiku djk jgh gwa rks vius MkWDVj dks lwfpr d:axha vxj laøe.k ds fueufyf[kr esa ls dksbz Hkh y{k.k ;k vu; ijs'kkfu;ka fodflr gksrh gsa rks esa QkSju vius MkWDVj ls laidz d:axh % nnz] /kqa/kyh ;k?kvh gqbz n`f"v] izdk'k ds izfr laosnu'khyrk] vka[kksa dh ykyh ;k vka[kksa ls ikuh cguka esa batsd'ku ds ckn ds eqykdkr ds lhkh le; ij gkftj jgwaxh rkfd esjk MkWDVj ijs'kkfu;ksa dh tkap dj ldsa gkykafd esjs 'kjhj ds nwljs vaxksa dks izhkkfor djus okyh xahkhj ijs'kkfu;ksa dh lahkkouk de gs] ij vxj esa dct ( 27 )

32 ,oa myvh ls tqm+s isv nnz] vlkeku; jdrlzko] Nkrh esa nnz] cgqr vf/kd fljnnz] vkokt dk ym+[km+kuk ;k 'kjhj dh,d rjq detksjh dks eglwl djrh gwa rks QkSju vius MkWDVj ls laidz d:axha ftruh tynh lahko gks ldsxk esa viuk mipkj dj jgs us= fo'ks"kk dks bu lel;kvksa ds ckjs esa crkåaxha esa fdlh nwljs ltzu dks lwfpr d:axh fd esjh nokbz py jgh gs ftls fd jksdus dh t:jr gs rkfd esjh ltzjh gks ldsa jksxh dh lgefr mi;qzdr Li"Vhdj.k dks esjs }kjk i<+ fy;k x;k gsa esjh vka[k dh volfkk dh izñfr eq>s crk nh x;h gs vksj izlrkfor mipkj dk of.kzr dj fn;k x;k gsa esjs lkfk mipkj ds tksf[keksa] ykhkksa] fodyiksa vksj lhekvksa dh ppkz dh x;h gsa esjs lhkh iz'uksa dk mùkj ns fn;k x;k gsa esa le>rk gwa fd yqlsafvl Vh,e dks esvklvsfvd dksyksjsdvy dsalj ds mipkj ds fy,,qmh, }kjk eatwjh iznku dh x;h gs vksj vka[k dh chekfj;ksa ds mipkj ds fy, bls eatwj ugha fd;k x;k gsa fqj Hkh] esa yqlsafvl Vh,e ls mipkj ikuk pkgrk gwa vksj esa mu lahkko; tksf[keksa dks Lohdkj djus ds fy, bpnqd gwa ftudh fd esjs MkWDVj us esjs lkfk ppkz dh gsa blds }kjk esa mipkj dj jgs us= ltzu dks viuh izhkkfor vka[k esa t:jr ds vuqlkj bavªkfovfj;y yqlsafvl Vh,e dks mi;ksx esa ykus ds fy, vf/kñr djrk gwaa ;g vuqefr esjs }kjk bls jí fd;s tkus ;k esjh volfkkvksa ds ml gn rd ifjofrzr gksus rd os/k jgsxh tcfd esjs fy, vks"kf/k ds tksf[ke vksj ykhk myys[kuh; :i ls fhkuu u gks tk;saa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 28 )

33 ROP Laser Parijat Chandra Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been informed in my mother tongue that my child s eye(s) are affected with the disease Retinopathy of Prematurity (ROP) which urgently requires retinal laser photocoagulation treatment. I have been fully explained regarding Retinopathy of Prematurity, its vision blinding complications, and the urgent necessity for retinal laser treatment. I have been clearly explained about the laser procedure, its side effects and risks involved. I understand that depending on disease severity and treatment response, additional laser treatments may be required later. I understand that despite the best of laser treatment, sometimes the disease may progress leading to visually disabling sequelae and blindness, and later may require surgical intervention which may or may not be beneficial. I allow the attending neonatologist to administer drugs, infusions or any other treatment/ procedures as deemed necessary or desirable during the laser procedure (and in any unforeseen or emergency conditions they encounter). I certify that I have fully understood the implications of the above consent and authorise the doctors to perform retinal laser photocoagulation on my child s right / left eye. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 29 )

34 vkjvksih ystj ikfjtkr panzk jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... eq>s esjh ekr`hkk"kk esa lwfpr dj fn;k x;k gs fd esjs cpps dh vka[k¼[ksa½ jsfvuksisfkh vkq izhesp;ksfjvh ¼vkjvksih½ chekjh ls izhkkfor gsa ftlds fy, QkSju jsfvuy ystj QksVksdksvkWxqys'ku mipkj dh t:jr gsa eq>s jsfvuksisfkh vkq izhesp;ksfjvh] mldh va/kk dj nsus okyh tfvyrkvksa vksj jsfvuy ystj mipkj dh rqjar vko';drk ds ckjs esa iwjh rjg ls le>k fn;k x;k gsa eq>s ystj dh dk;zfof/k] mlds ik'oz&izhkkoksa vksj mlls tqm+s tksf[keksa ds ckjs esa Li"V :i ls le>k fn;k x;k gsa esa le>rk gwa fd chekjh dh xahkhjrk vksj mipkj ds izfrlkn ds vk/kkj ij ckn esa pydj vfrfjdr ystj mipkjksa dh vko';drk im+ ldrh gsa esa le>rk gwa fd lokszùke ystj mipkj ds ckotwn dbz ckj chekjh c<+ ldrh gs ftlls fd va/kro isnk gksxk vksj ckn esa vkwijs'ku dh t:jr im+ ldrh gs tks fd ykhknk;d gks Hkh ldrk gs vksj ugha HkhA esa mipkj dj jgs cppksa ds MkWDVj dks ystj dk;zfof/k ds nksjku nok,a nsus] batsd'ku yxkus ;k fdlh vu; dh vuqefr iznku djrk gwa ftls fd ystj dk;zfof/k ¼vkSj muds lkeus is'k vkus okyh fdlh vizr;kf'kr ;k vkikrdkyhu n'kkvksa esa½ ds nksjku vko';d ;k okafnr le>k tk;sa esa izekf.kr djrk gwa fd esaus mi;qzdr lgefr ds fufgrk'k;ksa dks iwjh rjg ls le> fy;k gs vksj MkWDVjksa dks vius cpps dh vka[k ij jsfvuy ystj QksVksdksvkxqys'ku dks leiuu djus ds fy, vf/kñr djrk gwaa dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 30 )

35 Laser Indirect Ophthalmoscopy Bhuvan Chanana Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... This document is intended to provide you with information so that you can decide whether you should have a type of laser surgery called laser indirect ophthalmoscopy or LIO. You have the right to ask any questions you might have about the procedure before agreeing to have the ophthalmologist, or eye surgeon, perform it on your eye. Indications for Laser Indirect Ophthalmoscopy The eye functions much like a camera. The front of the eye contains the structures which focus the image and regulate the amount of light that enters the eye, similar to the lens and shutter of a camera. In the back of the eye is the retina, which functions like the film in the camera. Without film, a camera cannot take a picture, and without a functioning retina, the eye cannot see. LIO is done to laser the peripheral retina. It is used to treat peripheral retinal lesions like lattice degeneration or a retinal break, which may predispose your eyes to retinal detachment. LIO is also done to delimit peripheral detached retina to prevent its further progression. LIO can also be used for augmentation of pan-retinal photocoagulation where the peripheral retina cannot be lasered by using a slit lamp machine. Possible Benefits of Laser Indirect Ophthalmoscopy Laser indirect ophthalmoscopy or LIO uses a laser to treat the peripheral retina so that it will form a strong adhesion of the retina with underlying layers, preventing the retina to detach, and avoiding a potentially blinding condition. To perform the procedure, the pupil of the eye is made bigger (dilated) with eye drops. The laser is aimed at the peripheral retina through the pupil with the help of an indirect ophthalmoscope. Since the laser treats the peripheral retina, some peripheral or side vision may be lost, and this may cause reduced night vision. This usually does not present a problem for most of the cases. Alternatives to Laser Indirect Ophthalmoscopy Cryotherapy has also been used to treat peripheral retinal lesions. Cryotherapy uses a probe placed against the outside of the eye to treat the peripheral retina by freezing it. Most ophthalmologists now treat the peripheral retina with a laser instead of cryotherapy. Risks and Complications of Laser Indirect Ophthalmoscopy When deciding whether or not to have surgery, the patient must weigh the possible risks of the surgery against the benefits the surgery is expected to produce. Laser surgery for peripheral retina has limited risks. While performing the surgery, structures of the eye can be damaged and cause complications, which may lead to loss of vision. Surgery or medications may be needed to treat these complications. In the majority of patients whose eyes were treated with LIO, the retina remained attached. While the goal of the surgery is prevent a retinal detachment and blindness, even with proper treatment, not all eyes respond to the treatment. New lesions of the retina may develop and regular retinal screening is required. For some the laser surgery may have to be repeated in order to completely treat the retinal lesion. Risks for LIO include, but are not limited to: 1. Failure to achieve the goal of surgery: even with treatment, retinal detachment may develop in few cases. 2. Bleeding in the eye (vitreous hemorrhage) 3. Elevated eye pressure (glaucoma) 4. Decreased eye pressure (hypotony) ( 31 )

36 5. Corneal burns (clear covering of the front of the eye) 6. Damage to the iris (colored portion of the eye) 7. Damage to the lens (cataract) 8. Loss of vision or loss of the eye 9. Loss of peripheral (side) vision 10. Corneal clouding or scarring 11. Decrease or loss of vision caused by loss of circulation to the vital tissues in the eye Consent for Laser Surgery for ROP The ophthalmologist has explained to me the problem with my eyes, and the risks, benefits, and alternatives to LIO surgery. Although it is impossible for the doctor to inform me of every possible complication that may occur, the doctor has answered all my questions to my satisfaction. I understand that there is no guarantee that the surgery will prevent blindness in my eye, and that the surgery may need to be repeated to effectively treat my condition. In signing this informed consent for LIO, I am stating that I have been offered a copy and I fully understand the possible risks, benefits, and complications of the laser surgery. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 32 )

37 ystj bumkw;jsdv vkwfksyeksldksih Hkqou puuk jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... bl nlrkost dk y{; vkidks og tkudkjh iznku djuk gs ftlls fd vki bl ckr dk fu.kz; dj ldsa fd vki ystj bumkw;jsdv vkwfksyeksldksih ;k,yvkbzvks uked ystj ltzjh dks djok,axs ;k ughaa us= fo'ks"kk ;k us= ltzu dks bls vkidh vka[k ij laiuu djus nsus ij lger gksus ls igys bldh dk;zfof/k ds ckjs esa dksbz Hkh iz'u iwnuk vkidk vf/kdkj gsa ystj bumkw;jsdv vkwfksyeksldksih ds fy, lq>ko vka[k dkqh dqn dsejs dh rjg ls dke djrh gsa vka[kksa ds lkeus ds fglls esa og <kapk gksrk gs tks fd Nfo ij Qksdl djrk gs vksj vka[kksa esa izos'k djus okyh izdk'k dh ek=k dks fu;fer djrk gs] tks fd dsejs dh fqye dh Hkkafr dke djrk gsa fqye ds fcuk dsejk rlohj ugha mrkj ldrk vksj dke djus okyh jsfvuk ds fcuk vka[ksa ns[k ugha ldrhaa ifj/kh; jsfvuk dks ystj djus ds fy,,yvkbzvks dh tkrh gsa bldk mi;ksx f>yfeyh ds fodkj ;k jsfvuy VwVu tsls ifj/kh; jsfvuy?kkoksa dk mipkj djus ds fy, fd;k tkrk gs] tks fd jsfvuy vyxko ds fy, vkidh vka[kksa dks igys ls gh izo`ùk dj ldrk gsa vyx gqbz ifj/kh; jsfvuk dks lhfer djus ds fy, Hkh,yvkbZvks fd;k tkrk gs rkfd mls vkxs vksj c<+us ls jksdk tk ldsa blds vykok,yvkbzvks dk mi;ksx vf[ky&jsfvuy QksVksdksvkxqys'ku dh o`f) ds fy, fd;k tk ldrk gs] tgka ij ifj/kh; jsfvuk dks flyv ysei e'khu dk mi;ksx djds ystj ls mipkfjr ugha fd;k tk ldrka ystj bumkw;jsdv vkwfksyeksldksih ds lahkkfor ykhk ystj bumkw;jsdv vkwfksyeksldksih ;k vkbz,yvks ifj/kh; jsfvuk dk mipkj djus ds fy, ystj dk mi;ksx djrh gs rkfd og varfuzfgr ijrksa ds lkfk jsfvuk ds etcwr tqm+ko dks fufezr djs] jsfvuk dks vyx gksus ls jksds vksj lahkko; :i ls va/kro dh n'kk ls cpk;sa bl dk;zfof/k dks laiuu djus ds fy, vka[kksa dh iqryh dks vkbz MªkIl ls cm+k cuk;k tkrk gs ¼QSyk;k tkrk gs½a ystj bumkw;jsdv vkfksyeksldksi dh enn ls iqryh ds tfj;s ifj/kh; jsfvuk ij yf{kr gksrh gsa pwafd ystj ifj/kh; jsfvuk dk mipkj djrh gs blfy, dqn ifj/kh; ;k ik'oz dh utj tk ldrh gs vksj bldh otg ls jkr esa de fn[kk;h im+ ldrk gsa ;g izk;% vf/kdrj ekeyksa esa lel;k ugha mriuu djrka ystj bumkw;jsdv vkwfksyeksldksih ds fodyi fø;ksfksjsih dk mi;ksx ifj/kh; jsfvuy?kkoksa ds mipkj ds fy, Hkh fd;k tkrk gsa fø;ksfksjsih ifj/kh; jsfvuk dk mipkj djus ds fy, mls cgqr gh Ba<k djds vka[k ds ckgjh fglls ds lkeus j[kh x;h lykbz dk mi;ksx djrh gsa vf/kdrj us= fo'ks"kk vc fø;ksfksjsih dh ctk; ifj/kh; jsfvuk dk mipkj ystj ls djrs gsaa ystj bumkw;jsdv vkwfksyeksldksih ds tksf[ke vksj tfvyrk,a ltzjh djokbz tk;s ;k ugha bldk fu.kz; djrs le; jksxh dks ltzjh ds ykhkksa ds cjvdl mlds lahkkfor tksf[keksa dk vkdyu vo'; djuk pkfg,a ifj/kh; jsfvuk ds fy, ystj ltzjh ds lhfer tksf[ke gsaa ltzjh djrs le; vka[k ds <kaps dks uqdlku igqap ldrk gs vksj ijs'kkfu;ka mriuu gks ldrh gsa tks fd n`f"vghurk dks tue ns ldrh gsaa bu tfvyrkvksa ds mipkj ds fy, ltzjh ;k nokb;ksa dh vko';drk im+ ldrh gsa,yvkbzvks ls mipkj ik;s vf/kdka'k jksfx;ksa esa jsfvuk layxu cuh jgha tgka ltzjh dk mís'; jsfvuk ds vyxko vksj va/ksiu dks jksduk gs ogha leqfpr mipkj ds ckn Hkh mipkj ls lhkh vka[ksa Bhd ugha gksrh gsaa jsfvuk ds u;s?kko fodflr gks ldrs gsa vksj jsfvuk dk fu;fer ijh{k.k vko';d cu tkrk gsa dqn ds fy, ystj ltzjh dks nksgjkuk im+ ldrk gs rkfd jsfvuk ls tqm+s?kko dk iwjh rjg ls mipkj fd;k tk ldsa,yvkbzvks ds fy, tksf[keksa esa 'kkfey gsa ij os bugha rd lhfer ugha gsa % 1- ltzjh ds y{; dks ikus esa foqyrk % mipkj ds ckn Hkh dqn ekeyksa esa jsfvuy vyxko fodflr gks ldrk gsa 2- vka[kksa esa jdrlzko ¼foVfjvl jdrlzko½ 3- vka[k dk c<+k gqvk ncko ¼Xywdksek½ 4- vka[k dk?kvk gqvk ncko ¼gkbiksVksuh½ ( 33 )

38 5- dkwuhzy culz ¼vka[k ds lkeus dh fdy;j dofjax½ 6- vkbfjl ¼vka[k dk jaxhu fgllk½ dks uqdlku 7- ysal dks uqdlku ¼eksfr;kfcan½ 8- n`f"v dk pys tkuk ;k vka[k dh gkfu 9- ifj/kh; ¼fdukjs dh½ n`f"v dh gkfu 10- dkwuhzy DykmfMax ;k LdSfjax 11- vka[kksa ds egroiw.kz Årdksa esa ifjlapj.k dh deh ls mriuu n`f"v esa deh ;k mldh gkfu vkjvksih gsrq ystj ltzjh ds fy, vuqefr us= fo'ks"kkksa us esjh vka[k dh lel;k vksj vkbz,yvks ltzjh ds tksf[keksa] ykhkksa vksj fodyiksa ds ckjs esa eq>s le>k fn;k gsa gkykafd MkWDVj ds fy, miflfkr gks ldus okyh gjsd lahko tfvyrk ds ckjs esa crkuk vlahko gs ij MkWDVj esjs lhkh iz'uksa dk mùkj nsdj eq>s larq"v dj fn;ka esa le>rk gwa fd bl ckr dh dksbz xkjavh ugha gs fd ltzjh esjs vka[kksa ds va/ksiu dks jksd nsxh vksj ;g fd esjh volfkk ds izhkkoh mipkj ds fy, ltzjh dks nksgjkus dh vko';drk im+ ldrh gsa,yvkbzvks ds fy, bl lwfpr lgefr ij glrk{kj djds esa dg jgk gwa fd eq>s bldh,d izfr iznku dh x;h gs vksj esa ystj ltzjh ds lahkkfor tksf[keksa] ykhkksa vksj tfvyrkvksa dks le>rk gwaa dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 34 )

39 Laser Photocoagulation for Diabetic Retinopathy Aparna Gupta Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... This document is intended to provide you with information so that you can decide whether you should have Laser photocoagulation for diabetic retinopathy You have the right to ask any questions you might have about the procedure before agreeing to have the ophthalmologist, or eye surgeon, perform it on your eye. Indications for Laser Photocoagulation for Diabetic Retinopathy The eye functions much like a camera. The front of the eye contains the structures which focus the image and regulate the amount of light that enters the eye, similar to the lens and shutter of a camera. In the back of the eye is the retina, which functions like the film in the camera. Without film, a camera cannot take a picture, and without a functioning retina, the eye cannot see. Laser photocoagulation uses the heat from a laser to seal or destroy abnormal, leaking blood vessels in the retina. One of two approaches may be used when treating diabetic retinopathy: Focal photocoagulation. Focal treatment is used to seal specific leaking blood vessels in a small area of the retina, usually near the macula. The ophthalmologist identifies individual blood vessels for treatment and makes a limited number of laser burns to seal them off. Scatter (pan-retinal) photocoagulation. Scatter treatment is used to slow the growth of new abnormal blood vessels that have developed over a wide area of the retina. The ophthalmologist may make hundreds of laser burns on the retina to stop the blood vessels from growing. The person may need two or more treatment sessions. Laser photocoagulation is not painful. The injection of anesthetic may be uncomfortable, and you may feel a slight stinging sensation or see brief flashes of light when the laser is applied to your eye. Possible Benefits of Laser Photocoagulation for Diabetic Retinopathy Laser treatment may not restore vision that has already been lost. But when performed in a timely manner, Focal photocoagulation, which targets specific blood vessels, is effective in reducing the risk of vision loss in people with macular edema. It lowers the risk of moderate vision loss by 20% in people who have mild to moderate non-proliferative retinopathy. It may also help prevent progression to more severe retinopathy. Scatter (pan-retinal) photocoagulation, which treats a wide area of the retina, reduces the risk for severe vision loss by 50% to 60% over 6 years in people with a high risk of vision loss. It reduces the risk of serious bleeding and progression of severe proliferative retinopathy and the need for surgery (vitrectomy) by 50% in people with type 2 diabetes and people age 40 and older with type 1 diabetes who already have severe non-proliferative or mild proliferative retinopathy. Studies suggest that up to 90% of cases of legal blindness caused by proliferative retinopathy could be prevented by prompt scatter photocoagulation. Risks and Complications of Laser Photocoagulation for Diabetic Retinopathy Laser photocoagulation burns and destroys part of the retina and often results in some permanent vision loss. This is usually unavoidable. Treatment may cause mild loss of central vision, reduced night vision, and decreased ability to focus. Some people may lose some of their side (peripheral) vision. However, the vision loss caused by laser treatment is mild compared with the vision loss that may be caused by untreated retinopathy. Rare complications of laser photocoagulation may cause severe vision loss. These include: Bleeding in the eye (vitreous hemorrhage). Traction retinal detachment. ( 35 )

40 Accidental laser burn of the fovea (a depression in the central macula that contains no blood vessels), resulting in severe central vision loss. Consent for Laser Photocoagulation for Diabetic Retinopathy The ophthalmologist has explained to me the problem with my eyes, and the risks, benefits, and alternatives to laser photocoagulation. Although it is impossible for the doctor to inform me of every possible complication that may occur, the doctor has answered all my questions to my satisfaction. I understand that there is no guarantee that the laser will prevent blindness in my eye, and that the laser may need to be repeated to effectively treat my condition. In signing this informed consent for laser photocoagulation, I am stating that I have been offered a copy and I fully understand the possible risks, benefits, and complications of the laser surgery. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 36 )

41 Mk;fcfVd jsfvuksfksjsih ds fy, ystj QksVksdksvkxqys'ku vi.kkz xqirk jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... bl nlrkost dk y{; vkidks og tkudkjh iznku djuk gs ftlls fd vki bl ckr dk fu.kz; dj ldsa fd vki Mk;fcfVd jsfvuksfksjsih ds fy, ystj QksVksdksvkxqys'ku djok,axs ;k ughaa us= fo'ks"kk ;k us= ltzu dks bls vkidh vka[k ij laiuu djus nsus ij lger gksus ls igys bldh dk;zfof/k ds ckjs esa dksbz Hkh iz'u iwnuk vkidk vf/kdkj gsa Mk;fcfVd jsfvuksfksjsih ds fy, ystj QksVksdksvkxqys'ku dk lq>ko vka[k dkqh dqn dsejs dh rjg ls dke djrh gsa vka[kksa ds lkeus ds fglls esa og <kapk gksrk gs tks fd Nfo ij Qksdl djrk gs vksj vka[kksa esa izos'k djus okyh izdk'k dh ek=k dks fu;fer djrk gs] tks fd dsejs dh fqye dh Hkkafr dke djrk gsa fqye ds fcuk dsejk rlohj ugha mrkj ldrk vksj dke djus okyh jsfvuk ds fcuk vka[ksa ns[k ugha ldrhaa ystj QksVksdksvkxqys'ku jsfvuk dh vlkeku;] fjlko okyh jdr okfgdkvksa dks lhy ;k u"v djus ds fy, ystj dh xjeh dk mi;ksx djrk gsa Mk;fcfVd jsfvuksfksjsih dk mipkj djrs le; nks igqapksa esa ls,d dk mi;ksx fd;k tk ldrk gs % Û Qksdy QksVksdksvkxqys'kuA Qksdy mipkj dk mi;ksx jsfvuk ds NksVs ls Hkkx izk;% esdqyk ds djhc esa fjlko djus okyh fof'k"v jdr okfgdkvksa dks can djus ds fy, fd;k tkrk gsa us=&fo'ks"kk mipkj ds fy,,d&,d jdrk okfgdkvksa dh igpku djrk gs vksj mugsa can djus ds fy, lhfer la[;k ystj culz djrk gsa Û LdSVj ¼vf[ky&jsfVuy½ QksVksdksvkxqys'kuA LdSVj mipkj dk mi;ksx u;h vlkeku; jdr okfgdkvksa dh o`f) dks /khek djus ds fy, fd;k tkrk gs tks fd jsfvuk ds cm+s fglls ds Åij fodflr gks x;h gksrh gsaa us= fo'ks"kk jdr okfgdkvksa dks c<+us ls jksdus ds fy, jsfvuk ds Åij gtkjksa ystj culz dj ldrk gsa O;fDRk dks nks ;k vf/kd mipkj l=ksa dh vko';drk im+ ldrh gsa? ystj QksVkdksvkxqys'ku nnzukd ugha gksrk gsa csgks'kh dk batsd'ku cspsu djus okyk gks ldrk gs vksj vki gydh pqhku dh lulukgv eglwl dj ldrs gsa ;k vkidh vka[kksa ij ystj ds iz;ksx ds le; izdk'k dh laf{kir ped dks ns[k ldrs gsaa Mk;fcfVd jsfvuksfksjsih ds fy, ystj QksVksdksvkxqys'ku ds lahkkfor ykhk ystj mipkj gks ldrk gs fd igys ls gh tk pqdh n`f"v dks cgky ugha dj ik;s ysfdu le;c) rjhds ls bls laiuu djus ij] Û QksVksdksvkxqys'ku] tks fd fof'k"v jdr okfgdkvksa dks yf{kr djrk gs] esdqyj,fmek okys yksxksa esa n`f"v dh gkfu ds tksf[ke dks de djus esa izhkkoh gsa ;g gydh ls ysdj e/;e rd dh xsj&izlkjh jsfvuksisfkh okys yksxksa esa n`f"v dh e/;e gkfu dks 20 izfr'kr rd de djrk gsa blds vykok ;g T;knk xahkhj jsfvuksfksjsih esa c<+r dks jksdus esa Hkh enn dj ldrk gsa Û LdSVj ¼vf[ky&jsfVuy½ QksVksdksvkxqys'ku] tks fd jsfvuk ds folr`r {ks= dk mipkj djrk gs] n`f"v dh gkfu ds mpp tksf[ke okys yksxksa esa 6 o"kksza ds nksjku n`f"v dh xahkhj gkfu dks 50 ls 60 izfr'kr rd ds tksf[ke de djrk gsa ;g Vkbi 2 Mk;fcVht okys yksxksa vksj 40 lky vksj vf/kd mez ds Vkbi 1 Mk;fcVht okys yksxksa esa] ftugsa fd igys ls gh xahkhj xsj&izlkjh ;k e/;e izlkjh jsfvuksfksjih gs] xahkhj jdrlzko ds tksf[ke vksj rhoz izlkjh jsfvuksfksjhih dh c<+r vksj ltzjh ¼foVjsDVkseh½ dh t:jr dks 50 izfr'kr rd de djrk gsa v/;;uksa ls irk pyrk gs fd izlkjh jsfvuksfksjsih ds }kjk mriuu fu;e ds vuqdwy va/ksiu ds 90 izfr'kr rd ds ekeyksa dks Rofjr LdSVj QksVkdksvkxqys'ku ds }kjk jksdk tk ldrk gsa Mk;fcfVd jsfvuksfksjsih ds fy, ystj QksVksdksvkxqys'ku ds tksf[ke vksj tfvyrk,a ystj QksVksdksvkxqys'ku jsfvuk ds fglls dks tykrk vksj u"v djrk gs vksj vdlj blds QyLo:i n`f"v dks dqn LFkk;h gksuh gks tkrh gsa ;g izk;% nqfuzokj gksrk gsa mipkj ds dkj.k e/;orhz n`f"v dks gydk uqdlku] jkr esa de fn[kk;h im+uk vksj /;ku dsafnzr djus dh {kerk esa deh vk ldrh gsa dqn yksx viuh ik'oz ¼ifj/kh;½ n`f"v dks dqn [kks ldrs gsaa fqj Hkh] fcuk mipkj okyh jsfvuksisfkh ds dkj.k mriuu gksus okyh n`f"v dh gkfu dh rqyuk esa ystj mipkj ds dkj.k gksus okyh n`f"v dh gkfu gydh gksrh gsa ystj QksVksdksvkxqys'ku dh fojy tfvyrk,a n`f"v dh xahkhj gkfu dk dkj.k cu ldrh gsaa buesa 'kkfey gsa % Û vka[kksa esa jdrlzko ¼foVfjvl jdrlzko½a Û f[kapko jsfvuy vyxkoa ( 37 )

42 Û Qksfov dk la;ksxo'k ystj cuz ¼e/;orhZ esdqyk esa ncko ftlesa esa dksbz jdr okfgdk,a ugha gksrh gsa½] blds dkj.k e/;orhz n`f"v dks xahkhj gkfu igqaprh gsa Mk;fcfVd jsfvuksfksjsih gsrq ystj QksVksdksvkxqys'ku ds fy, vuqefr us= fo'ks"kk us esjh vka[kksa dh lel;kvksa vksj ystj QksVksdksvkxqys'ku ds tksf[keksa] ykhkksa vksj fodyiksa ds ckjs esa eq>s le>k fn;k gsa gkykafd miflfkr gks ldus okyh gjsd lahko tfvyrk ds ckjs esa MkWDVj ds fy, crk ikuk vlahko gs ysfdu MkWDVj us esjs lhkh iz'uksa dk mùkj nsdj eq>s larq"v dj fn;ka esa le>rk gwa fd bl ckr dh dksbz xkjavh ugha fd ystj esjh vka[k esa va/ksiu dks jksd nsxh vksj ;g fd esjh vka[k dh volfkk ds izhkkoh mipkj ds fy, ystj dks nksgjkus dh t:jr im+ ldrh gsa ystj QksVksdksvkWxqys'ku ds fy, bl lwfpr lgefr ij glrk{kj djrs gq, esa crk jgk gwa fd eq>s bldh,d izfr izkir gqbz gs vksj esa ystj ltzjh ds lahkkfor tksf[keksa] ykhkksa vksj tfvyrkvksa dks le>rk gwaa dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 38 )

43 Laser Photocoagulation for Proliferative Retinopathy Courtesy: Shroff Eye Centre, New Delhi Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I hereby authorize Dr.... to perform upon me Laser Photocoagulation in the Right / Left eye. The aim of this treatment is to decrease the risk of severe visual loss by preventing development of or promoting regression or shrinkage of abnormal retinal blood vessels. I acknowledge that I understand that: 1. I have been diagnosed to have This treatment is usually indicated when it is likely that bleeding inside the eye from new abnormal blood vessels can occur. Sometimes laser photocoagulation may be indicated to prevent the development of new blood vessels. The intent of treatment is to reduce likelihood of hemorrhage and/or retinal detachment that could cause severe and possible permanent loss of vision. However hemorrhage and/or retinal detachment can occur despite laser treatment. 3. This treatment is not designed to improve my vision, only to stabilize it. In fact, it may make the vision somewhat worse. For example, the treatment may diminish my night vision and side vision to some extent. There is a 5% to 10% chance that it will diminish my reading vision as well. 4. No safer alternative exists to reduce the likelihood of losing vision. If treatment is not carried out. I understand that there is an increased risk of permanent vision loss from bleeding and scar tissue formation inside the eye. 5. Application of Cryo in Proliferative Vascular Retinopathy. In some cases of Diabetic Retinopathy or Eales Disease inspite of good photocoagulation, there can be neovascularization or recurrent Vitreous Hemorrhage. Hence, to ablate peripheral retina, Cryotherapy is used to avoid further problems. 6. Laser treatment may be carried out in one or several treatment sessions depending on the severity and extent of the new vessels and my tolerance for the treatment. When a peribulbar or retrobulbar Injection is given for local anesthesia, there is an extremely small chance of ocular penetration. 7. After treatment, periodic re-examination is necessary to monitor the response to treatment and detect any changes in the status of the retinopathy, especially any change that would require additional treatment. I understand that it is the patient s responsibility to maintain follow up appointments necessary after laser treatment. I acknowledge that the nature and the purpose of this procedure, the risks involved, alternatives and possible complications have been explained to me by my doctor and that all my questions have been answered to my satisfaction. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantee can be made as to the results that may be obtained. All this has been explained to me in the language I understand. I have read, or had read to me, the above information and I consent to treatment, recognizing the potential risks that are involved. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... ( 39 )

44 Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 40 )

45 izksfyqjsfvo jsfvuksfksjsih ds fy, ystj QksVksdksvkxqys'ku JkWQ vkbz lsavj] u;h fnyyh ds lkstu; ls jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... esa blds }kjk MkW dks vius Åij vka[k esa ystj QksVksdksvkxqys'ku dks leiuu djus ds fy, vf/kñr djrk gwaa bl mipkj dk mís'; vlkeku; jsfvuy jdr okfgdkvksa ds fodkl dks jksd dj ;k mlds yksvko ;k fldqm+u dks c<+kok nsdj n`f"v dh xahkhj gkfu dks de djuk gsa esa Lohdkj djrk gwa fd esa le>rk gwa fd % 1- funku djds irk yxk;k x;k gs fd eq>s bl mipkj dk lq>ko izk;% ml le; fn;k tkrk gs tc bl ckr ds vklkj gksrs gsa fd u;h vlkeku; jdr okfgdkvksa ls vka[k ds vanj jdrlzko gks ldrk gsa dbz ckj ystj QksVksdksvkxqys'ku dk lq>ko u;h jdr okfgdkvksa ds fodkl dks jksdus ds fy, fn;k tk ldrk gsa mipkj dk iz;kstu jdrlzko vksj@;k jsfvuy vyxko dh lahkkouk dks de djuk gs tks fd n`f"v dks xahkhj vksj lahko gkfu igqapk ldrk gsa cgjgky] jdrlzko vksj@;k jsfvuy vyxko ystj mipkj ds ckotwn Hkh miflfkr gks ldrk gsa 3- bl mipkj dks esjh n`f"v dks lq/kkjus ds fy, ugha] flqz mls flfkj djus ds fy, rs;kj fd;k x;k gsa njvly] ;g n`f"v dks fdafpr cnrj cuk ldrk gsa mnkgj.k ds fy,] mipkj jkr esa esjh utj vksj ik'oz utj dks dqn gn rd de dj ldrk gsa bl ckr ds 5 ls 10 izfr'kr rd ds vklkj gksrs gsa fd ;g esjh i<+us dh utj esa Hkh deh yk;sa 4- n`f"v ds [kjkc gksus dh lahkkouk dks de djus ds fy, dksbz Hkh lqjf{kr fodyi ekstwn ugha gsaa vxj ugha fd;k tkrk rks esa le>rk gwa fd vka[k ds vanj jdrlzko vksj LdSj Ård fuekz.k ls n`f"v dh LFkk;h gkfu dk c<+k gqvk tksf[ke gsa 5- izksfyqjsfvo osldqyj jsfvuksisfkh esa fø;ks dk vuqiz;ksxa vpns QksVksdksvkxqys'ku ds ckotwn Mk;fcfVd jsfvuksfksjsih ;k,yl chekjh ds dqn ekeyksa esa fu;ks&osldqyjkbts'ku ;k vkorhz fovfjvl jdrlzko gks ldrk gsa fygktk] vkxs vksj lel;k ugha gksus nsus gsrq ifj/kh; jsfvuk dks dkv dj vyx djus ds fy, fø;ksfksjsih dk mi;ksx fd;k tkrk gsa 6- ystj mipkj u;h okfgdkvksa dh xahkhjrk vksj gn vksj mipkj ds fy, esjh lgu'khyrk ds vk/kkj ij,d ;k vf/kd mipkj l=ksa esa fd;k tk ldrk gsa tc yksdy,uslfkhfl;k ds fy, isfjcqyckj ;k jsvªkscqyckj batsd'ku fn;k tkrk gs rks n`f"v laca/kh Hksnu dh cgqr gh de xaqtkb'k gksrh gsa 7- mipkj ds ckn mipkj ds izfr izfrfø;k vksj jsfvuksfksjsih dh flfkfr esa fdlh cnyko] [kkldj,sls cnyko dk irk yxkus ds fy, le; ij iqu% ijh{k.k vko';d gksrk gs] ftlds fy, vfrfjdr mipkj dh t:jr gksxha esa le>rk gwa fd ;g jksxh dh fteesnkjh gs fd og ystj mipkj ds ckn vko';d QkWyksvi eqykdkrksa dks cuk;s j[ksa esa Lohdkj djrk gwa fd bl dk;zfof/k dh izñfr vksj mís';] blls tqm+s tksf[keksa] fodyiksa vksj lahkkfor tfvyrkvksa ds ckjs esa esjs MkWDVj }kjk eq>s le>k fn;k x;k gs vksj ;g fd esjs lhkh iz'uksa ds larks"ktud mùkj ns fn;s x;s gsaa esa bl ckr ls voxr gwa fd MkWDVjh vksj ltzjh lvhd fokku ugha gs vksj esa Lohdkj djrk gwa fd izkir gksus okys ifj.kkeksa ds ckjs esa dksbz Hkh xkjavh ugha nh tk ldrha bl lcdks eq>s,slh Hkk"kk esa crk fn;k x;k gs ftls fd esa le>rk gwaa mi;qzdr tkudkjh dks esaus i<+ fy;k gs ;k eq>s i<+dj lquk fn;k x;k gs vksj esa mipkj ls tqm+s lahkko; tksf[keksa dks tkurs gq, blds fy, vuqefr iznku djrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... ( 41 )

46 MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( )

47 Laser Photocoagulation for Maculopathy Courtesy: Shroff Eye Centre, New Delhi Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I hereby authorize Dr.... to perform upon me Laser Photocoagulation in the Right / Left eye for changes in the Macula (which is the vital region of the retina for clear central vision) caused by Diabetes / Age Related Macular Degeneration / Venous Blocks /... In diabetes / venous blocks the aim of treatment is to close the blood vessels and capillary abnormalities which leak fluid and cause water logging seen in this region. In age related macular degeneration the purpose is to destroy sub retinal neovascular membrane. Following photocoagulation it is possible that there may be a slight improvement and you may be able to read a line or two more on the vision test chart. Laser photocoagulation helps in maintaining your existing vision and to a certain extent prevents worsening at a later date. In some insances vision may worsen despite photocoagulation due to unpreventable changes developing in this region. In case of age - related macular degeneration, if the laser has to be applied to the centre of macula or very close to it, there can be an immediate drop of vision. In these cases, long term visual prognosis is better if laser is done. When a peribulbar or retrobulbar injection is given for local anesthesia there is an extremely small chance of ocular penetration. One or more sessions of laser may be required. During follow up, more photocoagulation may have to. be done for changes in the macula or for other changes that might have developed during this period. After treatment, periodic re-examination is necessary to monitor the response to treatment and detect any changes in the status of the retinopathy, especially any change that would require additional treatment. I understand that it is the patient s responsibility to maintain follow up appointment necessary after laser treatment. I acknowledge that the nature and the purpose of this procedure, the risks involved, alternatives and the possible complications have been explained to me by my doctor, that all my questions, if any, have been answered to my satisfaction. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantee can be made as to the results that may be obtained. All this has been explained to me in the language I understand. I have read, or had read to me, the above information and I consent to treatment, recognizing the potential risks that are involved. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... ( 43 )

48 Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 44 )

49 esdqyksisfkh ds fy, ystj QksVksdksvkxqys'ku JkWQ vkbz lsavj] u;h fnyyh ds lkstu; ls jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... esa blds }kjk MkW dks vius Åij vka[k esa ls tqm+s esdqyj a ds vo#) ls mriuu esdqyk ¼tks fd Li"V e/;orhz n`f"v ds fy, jsfvuk dk egriw.kz {ks= gs½ esa ifjorzuksa ds fy, ystj QksVksdksvkxqys'ku dks leiuu djus ds fy, vf/kñr djrk gwaa ds vojks/k esa mipkj dk mís'; jdr okfgdkvksa vksj dsfiyjh vlkeku;rkvksa dks can djuk gs tks fd nzo dk fjlko djrh gsa vksj bl {ks= esa ns[ks tkus okys ikuh ds teko dks mriuu djrh gsaa mez ls tqm+s gq, esdqyj fodkj esa mís'; mi jsfvuy fu;ksosldqyj f>yyh dks u"v djuk gksrk gsa QksVksdksvkxqys'ku ds mijkar ;g lahko gs fd fdafpr lq/kkj gks vksj vki utj ijh{k.k pkvz ij,d ;k nks ykbu vksj i<+ ldrs gsaa ystj QksVksdksvkxqys'ku vkidh orzeku n`f"v dks cuk;s j[kus esa enn djrk gs vksj,d gn rd ckn dh rkjh[k esa blds cnrj gksus dks jksdrk gsa dqn ekeyksa esa bl {ks= esa fodflr gksus okys nqfuzokj ifjorzuksa ds pyrs QksVksdksvkxqys'ku ds ckotwn n`f"v cnrj gks ldrh gsa mez ls tqm+s esdqyj fodkj ds ekeys esa vxj esdqy ds e/; esa ;k mlds cgqr gh djhc ystj dks iz;ksx esa yk;k tkuk gs rks n`f"v esa QkSju fxjkov vk ldrh gsa bu ekeyksa esa vxj ystj dk mi;ksx fd;k tkrk gs rks nwjxkeh pk{kq"k jksx funku csgrj gksrk gsa tc yksdy,uslfkhfl;k ds fy, isfjcqyckj ;k jsvªkscqyckj batsd'ku fn;k tkrk gs rks n`f"v laca/kh Hksnu dh cgqr gh de xaqtkb'k gksrh gsa ystj ds,d ;k vf/kd l=ksa dh vko';drk im+ ldrh gsa esdqyk esa ifjorzu ds fy, ;k,sls vu; ifjorzuksa ds fy, QkWyks&vi ds nksjku T;knk QksVksdksvkxqys'ku djuk im+ ldrk gs tks fd bl vof/k ds nksjku fodflr gq, gks ldrs gsaa mipkj ds ckn mipkj ds izfr izfrfø;k vksj jsfvuksfksjsih dh flfkfr esa fdlh cnyko] [kkldj,sls cnyko dk irk yxkus ds fy, le; ij iqu% ijh{k.k vko';d gksrk gs] ftlds fy, vfrfjdr mipkj dh t:jr gksxha esa le>rk gwa fd ;g jksxh dh fteesnkjh gs fd og ystj mipkj ds ckn vko';d QkWyksvi eqykdkrksa dks cuk;s j[ksa esa Lohdkj djrk gwa fd bl dk;zfof/k dh izñfr vksj mís';] blls tqm+s tksf[keksa] fodyiksa vksj lahkkfor tfvyrkvksa ds ckjs esa esjs MkWDVj }kjk eq>s le>k fn;k x;k gs vksj ;g fd esjs lhkh iz'uksa ds larks"ktud mùkj ns fn;s x;s gsaa esa bl ckr ls voxr gwa fd MkWDVjh vksj ltzjh lvhd fokku ugha gs vksj esa Lohdkj djrk gwa fd izkir gksus okys ifj.kkeksa ds ckjs esa dksbz Hkh xkjavh ugha nh tk ldrha bl lcdks eq>s,slh Hkk"kk esa crk fn;k x;k gs ftls fd esa le>rk gwaa mi;qzdr tkudkjh dks esaus i<+ fy;k gs ;k eq>s i<+dj lquk fn;k x;k gs vksj esa mipkj ls tqm+s lahkko; tksf[keksa dks tkurs gq, blds fy, vuqefr iznku djrk gwaa dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... ( 45 )

50 MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 46 )

51 Fundus Fluorescein Angiography / Ophthalmoscopy/ Indocyanine Green Angiography Courtesy: Shroff Eye Centre, New Delhi Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... This investigation procedure comprises of injection of a dye- fluorescein or Indocyanine green into one of your veins in the arm and either taking rapid serial photographs of its passage within the inner structures of the eye, the retina and choroid or examining the inside of your eye with an instrument called the indirect ophthalmoscope with appropriate filters. The information obtained from a study of this procedure aids your doctor in either making a diagnosis, planning your treatment or assessing the results of treatment particularly photocoagulation. There is no discomfort from this test apart from the needle prick and the flash of the camera which is harmless. You may have nausea (sensation of vomiting) a minute or so after the injection. This usually passes off in about 30 seconds. Remaining calm and breathing deeply helps in overcoming this difficulty. You are advised to be on an empty stomach three hours prior to this test. Your usual diet can be taken soon after the procedure. Fluorescein is a highly non toxic drug and only rarely produces a mild aleergic reaction which responds rapidly to appropriate medication. Serious life threatening reactions are exceptionally rare but can however occur. This is not different from what can occur with any other medication. The skin and urine stain yellow for about 36 hours with fluorescein and is of no consequence. You must be accompanied by an adult attendant during this test. Informed Consent The pamphlet on Fundus Fluorescein Angiography / Ophthalmoscopy / Indocyanine Green Angiography has been read by me/ out to me and having understood the content, I give my consent to the performance of this on me. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 47 )

52 QaMl bamksfl,ukbu xzhu,aft;ksxzkqh JkWQ vkbz lsavj] u;h fnyyh ds lkstu; ls jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... vuos"k.k dh bl dk;zfof/k esa ckagksa esa vkidh fdlh ul esa Mkb&ywvksjlhu ;k bamksflvukbu xzhu dk batsd'ku vfkok vka[k ds vkarfjd <kaps] jsfvuk vksj dksjksbm ds vanj mlds ekxz dh Rofjr <ax ls Øfed rlohjsa mrkjuk ;k mi;qdr fqyvjksa ds lkfk bumk;jsdv vkfksyeksldksi uked midj.k ds lkfk vkidh vka[k ds Hkhrj ijh{k.k djuk 'kkfey gksrk gsa bl izfø;k ds v/;;u ls izkir tkudkjh vkids MkWDVj dh funku djus ;k vkids mipkj dh ;kstuk cukus vfkok mipkj ds ifj.kkeksa [kkldj QksVksdksvkxqys'ku dk vkdyu djus esa enn djrh gsa lqbz dh pqhku vksj dsejs dh ped] tks fd gkfujfgr gksrh gs] ds flok; bl ijh{k.k ls dksbz vlqfo/kk ugha gksrh gsa vkidks batsd'ku ds ckn,d feuv ds vklikl feryh dh vuqhkwfr gks ldrh gsa ;g izk;% yxhkx 30 lsdsam esa [kre gks tkrh gsa 'kkar jgdj xgjh lkal ysus ls bl dfbukbz ls ikj ikus esa enn feyrh gsa vkidks lykg nh tkrh gs fd bl ijh{k.k ls igys rhu?kavksa rd isv dks [kkyh j[ksaa vki viuh jkstejkz dh [kqjkd dks izfø;k ds rqjar ys ldrs gsaa ywvksjlhu,d vr;f/kd xsj fo"kkdr nok gs vksj eqf'dy ls gh gydh,yftzd izfrfø;k mriuu djrh gs] tks fd mi;qdr nokbz ds izfr Rofjr xfr ls izfrfø;k nsrh gsa xahkhj tkuysok izfrfø;k,a eqf'dy ls gh gksrh gsa ij fqj Hkh miflfkr gks ldrh gsaa ;g mlls fhkuu ugha gs tks fd fdlh Hkh nwljh nok ds lkfk miflfkr gks ldrk gsa ywvksjlhu ds lkfk rdjhcu 36?kaVksa rd Ropk vksj is'kkc xans ihys jax dh gksrh gs vksj blls dksbz QdZ ugha im+rka bl ijh{k.k ds nksjku vkids lkfk dksbz o;ld rhekjnkj gksuk pkfg,a lwfpr lgefr QaMl xzhu,aft;ksxzsqh ij ijps dks esjs }kjk i<+ fy;k x;k i<+dj lquk fn;k x;k gs vksj esaus mldh varozlrq dks le> fy;k gs] esa vius Åij bls leiuu djus ds fy, lgefr iznku djrk gwaa dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 48 )

53 Photodynamic Therapy (PDT) Courtesy: Shroff Eye Centre, New Delhi Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I hereby authorize Dr... to perform upon me Photodynamic Therapy (PDT) in Right/Left eye for neovascular changes in the Macula (which is the vital region of the retina for clear central vision) caused by Age Related Macular Degeneration / Pathologic Mypia/other causes... Photodynamic Therapy (PDT) is a type of laser therapy designed for the treatment of subretinal new-vessel formation especially when these new vessels involve the subfoveal region. These new vessels most commonly develop in i) Aging Macular Degeneration ii) Myopia, iii) Post inflammatory and iv) Idiopathic causes. When the fovea (the vital region of the retina for fine central reading and colour vision) is not involved, these vessels can be destroyed by laser photocoagulation. However there is also simultaneous destruction of the retinal cells overlying these abnormal new vessels. This loss of function of retinal cells is usually acceptable in other areas but not at the fovea. Hence the search for alternative therapies which can destroy these abnormal vessels without destroying the overlying foveal retinal cells. The various alternatives tried for this are: 1) Surgery 2) Photodynamic Therapy (PDT) 3) TTT 4) Radiation 5) Anti-angiogenic factors. 1. Surgery : Results especially in Aging Macular Degeneration have been poor because in removing the membrane retinal pigment epithelial cells are also lost and vision usually does not improve. There is also a risk of significant vision loss if complications occur. 2. Photodynamic Therapy : Verteporfin Visudyne dye is injected into a vein in the arm and after that a contact lens is placed on the eye and laser treatment is applied to the area of neovascularization. After the treatment the entire body has to be protected from sunlight and strong light. For a few hours after treatment you will have blurred vision because of drops and the laser light exposure. Treatment results have been encouraging. Most patients have stabilization of vision. A very small number may have actual improvement in vision. Some patients may experience reduction in central vision after the treatment. PDT treatment may need to be repeated depending on the progress seen on follow up examinations and fluorescein/indocyanine green angiograms/oct results. 3. Radiation - Results have not been encouraging. 4. Anti-angiogenic factors :- Definitive results are not available so far. 5. Trans Pupillary Thermo Therapy:- Large spot of diode laser 810 nm with relatively low energy is applied to the area of new-vessels. This therapy has shown encouraging results in some cases, especially occult new-vessels. You do not have to agree to have this therapy and, if you wish, we will continue to monitor your progress even if you choose not to try Photodynamic Therapy (PDT). Post-Treatment Regime After treatment you should not bend down and lift weights, and you should sleep with head up with 2 pillows. You must not be exposed to sunlight and very bright light as mentioned earlier. After treatment, periodic re-examination is necessary to monitor the response to treatment and detect any changes in the status of the retinopathy, especially any change that would require additional treatment. I understand that it is the patient s responsibility to maintain follow up appointments necessary after laser treatment. I acknowledge that the nature and the purpose of this procedure, the risks involved, alternatives and the possible complications have been explained to me and that all my questions, if any, have been answered to my satisfaction. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantee can be made as to the results that may be obtained. All this has been explained to me in the language I understand. ( 49 )

54 I have read, or had read to me, the above information, and I consent to treatment, recognizing the potential risks that are involved. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 50 )

55 QksVksMk;ufed Fksjsih ¼ihMhVh½ JkWQ vkbz lsavj] u;h fnyyh ds lkstu; ls jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... esa blds }kjk MkW dks vius Åij vka[k esa mez ls tqm+s esdqyj dkj.kksa ls mriuu esdqyk ¼tks fd Li"V e/;orhz n`f"v ds fy, jsfvuk dk egriw.kz {ks= gs½ esa ifjorzuksa gsrq QksVksMk;ufed Fksjsih ¼ihMhVh½ dks leiuu djus ds fy, vf/kñr djrk gwaa QksVksMk;ufed Fksjsih ¼ihMhVh½ lcjsfvuy u;h&okfgdk fuekz.k ds mipkj ds fy, [kkldj ml le; tc ;s u;h okfgdk,a lcqksohy {ks= dks lec) djrh gsa] rs;kj fd;k x;k,d izdkj dk mipkj gsa ;s u;h okfgdk,a lokzf/kd vkerksj ij 1½ c<+rh mez ds esdqyj fodkj] 2½ de ns[kus dh chekjh] 3½ lwtu ds ckn vksj 4½ bfm;ksisffkd dkj.kksa esa fodflr gksrh gsaa tc Qksfovk ¼mRÑ"V e/;orhz ikbu vksj jaxksa dh n`f"v ds fy, jsfvuk dk egroiw.kz Hkkx½ lec) ugha gksrk gs rks bu okfgdkvksa dks ystj QksVksdksvkWxqys'ku ds }kjk u"v fd;k tk ldrk gsa fqj Hkh] bu vlkeku; u;h okfgdkvksa dks <adus okyh jsfvuy dksf'kdkvksa dk Hkh lkfk gh esa fouk'k gks tkrk gsa jsfvuy dksf'kdkvksa ds izdk;z dh ;g gkfu izk;% vu; {ks=ksa esa Lohdk;Z gksrh gs ysfdu Qksfovk esa ughaa fygktk] osdfyid mipkjksa dh [kkst dh x;h tks fd <adus okyh Qksfovy jsfvuy dksf'kdkvksa dks u"v fd;s fcuk bu vlkeku; okfgdkvksa dks u"v dj ldsa blds fy, vktek;s x;s fofhkuu fodyi gsa % 1½ ltzjh 2½ QksVksMk;ufed mipkj ¼ihMhVh½ 3½ VhVhVh 4½ fofdj.k 5½,aVh&,aft;kstsfud dkjda 1½ ltzjh % fo'ks"k :i ls c<+rh mez esa esdqyj fodkj esa ifj.kke [kjkc gksrs gsa D;ksafd fnyyh dks gvkus esa jsfvuy fixesav,fifksfy;y dksf'kdk,a Hkh gv tkrh gs vksj n`f"v izk;% csgrj ugha gksrh gsa blds vykok tfvyrk ds mriuu gksus ij n`f"v dh dkqh vf/kd gkfu dk Hkh tksf[k e jgrk gsa 2½ QksVksMk;ukfed mipkj % ckag dh ul esa osvsziksfqzu ^^folqmkbu** Mkb dk batsd'ku fn;k tkrk gs vksj blds ckn vka[k esa dkavsdv ysal dks Mkyk tkrk gs vksj fu;ksosldqyjkbts'ku ds fglls esa ystj mipkj dk vuqiz;ksx fd;k tkrk gsa mipkj ds ckn lewps 'kjhj dh /kwi vksj rst izdk'k ls j{kk djuh gksrh gsa mipkj ds ckn dqn?kavksa rd vkidks MªkIl vksj ystj izdk'k ds laidz esa gksus ls /kqa/kyk fn[kk;h nsxka mipkj ds ifj.kke mrlkgtud jgs gsaa vf/kdrj jksfx;ksa dh n`f"v flfkj gks tkrh gsa cgqr FkksM+h lh la[;k esa n`f"v esa oklrfod lq/kkj gks ldrk gsa dqn jksxh mipkj ds ckn e/;lfk n`f"v esa deh eglwl dj ldrs gsaa QkWyks&vi ds ijh{k.kksa vksj ywvksjlhu@bamksfl;kukbu xzhu,aft;ksxzsqh@vkslhvh ifj.kkeksa esa ns[kh x;h izxfr ds vk/kkj ij ihmhvh mipkj dks nksgjk;s tkus dh t:jr im+ ldrh gsa 3- fofdj.k & ifj.kke mrlkgtud ugha jgs gsaa 4-,aVh&,aft;kstsfud dkjd % vhkh rd fuf'pr ifj.kke miyc/k ugha gsaa 5- Vªkal&I;wiyjh FkeksZ mipkj % vis{kr;k de ÅtkZ okyk fmvksm ystj 810,u,e dk cm+k LikWV u;h okfgdkvksa ds {ks= esa iz;ksx fd;k tkrk gsa bl mipkj ds dqn ekeyksa esa] [kkldj vdyv u;h okfgdkvksa esa] mrlkgtud ifj.kke ns[ks x;s gsaa bl mipkj dks djokus ds fy, vki lgefr nsa ;g t:jh ugha vksj vxj vki pkgsaxs rks ge ml n'kk esa vkidh izxfr ij utj j[kuk tkjh j[ksaxs tcfd vki QksVksMk;ufed mipkj ¼ihMhVh½ ugha vktekus dk fodyi pqurs gsaa mipkj&ckn dh O;oLFkk mipkj ds ckn vkidks uhps ugha >qduk vksj otu mbkuk ugha pkfg, vksj vkidks nks rfd;ksa ds lkfk flj ds Åij djds lksuk pkfg,a tslk fd igys crk;k x;k gs vkidks /kwi vksj cgqr rst jks'kuh ds laidz esa ugha vkuk pkfg,a mipkj ds ckn mipkj ds izfr izfrfø;k vksj jsfvuksfksjsih dh flfkfr esa fdlh cnyko] [kkldj,sls cnyko dk irk yxkus ds fy, le; ij iqu% ijh{k.k vko';d gksrk gs] ftlds fy, vfrfjdr mipkj dh t:jr gksxha esa le>rk gwa fd ;g jksxh dh fteesnkjh gs fd og ystj mipkj ds ckn vko';d QkWyksvi eqykdkrksa dks cuk;s j[ksa esa Lohdkj djrk gwa fd bl dk;zfof/k dh izñfr vksj mís';] blls tqm+s tksf[keksa] fodyiksa vksj lahkkfor tfvyrkvksa ds ckjs esa esjs MkWDVj }kjk eq>s le>k fn;k x;k gs vksj ;g fd esjs lhkh iz'uksa ds larks"ktud mùkj ns fn;s x;s gsaa esa bl ckr ls voxr gwa fd MkWDVjh vksj ltzjh lvhd fokku ugha gs vksj esa Lohdkj djrk gwa fd izkir gksus okys ifj.kkeksa ds ckjs esa dksbz Hkh xkjavh ugha nh tk ldrha bl lcdks eq>s,slh Hkk"kk esa crk fn;k x;k gs ftls fd esa le>rk gwaa ( 51 )

56 mi;qzdr tkudkjh dks esaus i<+ fy;k gs ;k eq>s i<+dj lquk fn;k x;k gs vksj esa mipkj ls tqm+s lahkko; tksf[keksa dks tkurs gq, blds fy, vuqefr iznku djrk gwaa dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 52 )

57 Trans Pupillary Thermotherapy (TTT) Courtesy: Shroff Eye Centre, New Delhi Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I hereby authorize Dr.... to perform upon me Trans-Pupillary Thermotherapy in Right / Left eye for neovascular changes in the Macula (which is the vital region of the retina for clear central vision) caused by Age Related Macular Degeneration / Pathologic Mypia / other causes... Transpupillary thermotherapy (TTT) is a type of laser therapy designed for the treatment of sub retinal new-vessel formation especially when these new vessels involve the subfoveal region. These new vessels most commonly develop in i) Aging Macular Degeneration ii) Myopia, iii) Post inflammatory and iv) Idiopathic causes. TTT is also used in the treatment of certain tumours. When the fovea (the vital region of the retina for fine central reading and colour vision) is not involved, these vessels can be destroyed by laser photocoagulation. However there is also simultaneous destruction of the retinal cells overlying these abnormal new vessels. This loss of function of retinal cells is usually acceptable in other areas but not at the fovea. Hence the search for alternative therapies which can destroy these abnormal vessels without destroying the overlying foveal retinal cells. The various alternatives tried for this are:- 1) Surgery 2) Photodynamic therapy (PDT) 3) TTT 4) Radiation 5) Anti-angiogenic factors. 1. Surgery : Results especially in Aging Macular Degeneration have been poor because in removing the membrane retinal pigment epithelial cells are also lost and vision usually does not improve. There is also a risk of significant vision loss if complications occur. 2. Photodynamic Therapy : This is applicable only to certain specific types of new-vessels. The cost of treatment is very high because of high cost of dye. The treatment may need to be repeated depending on the progress seen on follow up examinations. 3. Radiation - Results have not been encouraging. 4. Anti-angiogenic factors :- Results have not been encouraging. 5. Trans Pupillary Thermo Therapy :- Large spot of diode laser 810 nm with relatively low energy is applied to the area of new-vessels. Treatment results have been encouraging. About two-thirds of patients have stabilization of vision. A very small number may have actual improvement in vision. Some patients may experience reduction in central vision after the treatment. TTT treatment may need to be repeated depending on the progress seen on follow up examinations and fluorescein/indocyanine green angiograms. For the laser treatment, local anaesthetic drops are put into the eye and a contact lens is used. After treatment you should not bend down, lift weight and you should sleep with head up with 2 pillows. For a few hours after the treatment, you will have some blurred vision because of the drops used to prepare your eye for the treatment. You should also wear dark sunglasses to protect your eye from the light. During this time, you must not drive any vehicles. You do not have to agree to have this therapy and, if you wish, we will continue to monitor your progress even if you choose not to try Transpupillary Thermotherapy (TTT). After treatment, periodic re-examination is necessary to monitor the response to treatment and detect any changes in the status of the retinopathy, especially any change that would require additional treatment. I understand that it is the patient s responsibility to maintain follow up appointments necessary after laser treatment. I acknowledge that the nature and the purpose of this procedure, the risks involved, alternatives and the possible complications have been explained to me and that all my questions, if any, have been answered to my satisfaction. I am aware that the practice of medicine & surgery is not an exact science, and I acknowledge that no guarantee can be made as to the results that may be obtained. All this has been explained to me in the language I understand. I have read, or had read to me, the above information, and I consent to treatment, recognizing the potential risks that are involved. ( 53 )

58 Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 54 )

59 Vªkal I;wfiyjh FkeksZFksjsih ¼VhVhVh½ JkWQ vkbz lsavj] u;h fnyyh ds lkstu; ls jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... esa blds }kjk MkW dks vius Åij vka[k esa mez ls tqm+s esdqyj dkj.kksa ls mriuu esdqyk ¼tks fd Li"V e/;orhz n`f"v ds fy, jsfvuk dk egriw.kz {ks= gs½ es a fu;ksosldqyj ifjorzuksa ds fy, esa ifjorzuksa gsrq QksVksMk;ufed Fksjsih ¼ihMhVh½ dks leiuu djus ds fy, vf/kñr djrk gwaa Vªkal I;wfiyjh FkeksZFksjsih ¼VhVhVh½ lc&jsfvuy u;h&okfgdk fuekz.k] [kkldj ml le; tcfd bu u;h okfgdkvksa ls lcqksfovy {ks= lec) gksrk gs] ds mipkj ds fy, rs;kj fd;k x;k ystj mipkj dk,d izdkj gsa ;s u;h okfgdk,a lokzf/kd vkerksj ij 1½ c<+rh mez ds esdqyj fodkj] 2½ de ns[kus dh chekjh] 3½ lwtu ds ckn vksj 4½ bfm;ksisffkd dkj.kksa esa fodflr gksrh gsaa VhVhVh dk mi;ksx dqn V~;wejksa ds mipkj esa Hkh fd;k tkrk gsa tc Qkfovk ¼mRÑ"V e/;orhz ikbu vksj jaxksa dh n`f"v ds fy, jsfvuk dk egroiw.kz Hkkx½ lec) ugha gksrk gs rks bu okfgdkvksa dks ystj QksVksdksvkWxqys'ku ds }kjk u"v fd;k tk ldrk gsa fqj Hkh] bu vlkeku; u;h okfgdkvksa dks <adus okyh jsfvuy dksf'kdkvksa dk Hkh lkfk gh esa fouk'k gks tkrk gsa jsfvuy dksf'kdkvksa ds izdk;z dh ;g gkfu izk;% vu; {ks=ksa esa Lohdk;Z gksrh gs ysfdu Qksfovk esa ughaa fygktk] osdfyid mipkjksa dh [kkst dh x;h tks fd <adus okyh Qksfovy jsfvuy dksf'kdkvksa dks u"v fd;s fcuk bu vlkeku; okfgdkvksa dks u"v dj ldsa blds fy, vktek;s x;s fofhkuu fodyi gsa % 1½ ltzjh 2½ QksVksMk;ufed mipkj ¼ihMhVh½ 3½ VhVhVh 4½ fofdj.k 5½,aVh&,aft;kstsfud dkjda 1½ ltzjh % fo'ks"k :i ls c<+rh mez esa esdqyj fodkj esa ifj.kke [kjkc gksrs gsa D;ksafd fnyyh dks gvkus esa jsfvuy fixesav,fifksfy;y dksf'kdk,a 2½ Hkh gv tkrh gs vksj n`f"v izk;% csgrj ugha gksrh gsa blds vykok tfvyrk ds mriuu gksus ij n`f"v dh dkqh vf/kd gkfu dk Hkh tksf[k e jgrk gsa QksVksMk;ukfed mipkj % ;g u;h okfgdkvksa ds dqn fof'k"v izdkjksa ij gh ykxw gksrk gsa mipkj dh ykxr Mkb dh Åath ykxr dh otg ls cgqr vf/kd gksrh gsa QkWyks&vi ds ijh{k.kksa esa ns[kh x;h izxfr ds vk/kkj ij ihmhvh mipkj dks nksgjk;s tkus dh t:jr im+ ldrh gsa 3- fofdj.k & ifj.kke mrlkgtud ugha jgs gsaa 4-,aVh&,aft;kstsfud dkjd % ifj.kke mrlkgtud ugha jgs gsaa 5- Vªkal&I;wiyjh FkeksZ mipkj % vis{kr;k de ÅtkZ okyk fmvksm ystj 810,u,e dk cm+k LikWV u;h okfgdkvksa ds {ks= esa iz;ksx fd;k tkrk gsa bl mipkj ds mrlkgtud ifj.kke ns[ks x;s gsaa yxhkx nks&frgkbz jksfx;ksa dh n`f"v flfkj gqbz gsa cgqr gh FkksM+h la[;k esa n`f"v esa oklrfod lq/kkj gks ldrk gsa mipkj ds ckn dqn jksxh e/;lfk n`f"v esa deh dk vuqhko dj ldrs gsaa QkWyks&vi ijh{k.kksa vksj ywvkslhzu@bamksflvkukbu xzhu,aft;ksxzkel esa ns[kh x;h izxfr ds vk/kkj ij VhVhVh mipkj dks nksgjk;s tkus dh vko';drk im+ ldrh gsa ystj mipkj ds fy, yksdy,uslfksfvd MªkIl dks vka[k esa Mkyk tkrk gs vksj dkavsdv ysal dk blrseky fd;k tkrk gsa mipkj ds ckn vkidks uhps >qduk] otu mbkuk ugha pkfg, vksj vkidks nks rfd;k j[kdj flj dks Åij dh vksj j[kdj lksuk pkfg,a mipkj ds ckn dqn?kavksa rd vkidh n`f"v mipkj ds fy, vkidh vka[kksa dks rs;kj djus ds fy, mi;ksx esa yk;s x;s MªkIl dh otg ls /kqa/kyh jgsxha blds vykok jks'kuh ls viuh vka[kksa dks cpkus ds fy, vkidks dkys jax dk /kwi dk p'ek iguuk pkfg,a bl le; ds nksjku vkidks dksbz okgu ugha pykuk gsa t:jh ugha fd vki bl mipkj ds fy, lgefr iznku djsa vksj vxj vki pkgsaxs rks ge ml n'kk esa Hkh vkidh izxfr dks ekwfuvj djuk tkjh j[ksaxs tcfd vkius Vªkal&I;wiyjh FkeksZ mipkj ¼VhVhVh½ dk fodyi ugha pquk gsa mipkj ds ckn mipkj ds izfr izfrfø;k vksj jsfvuksfksjsih dh flfkfr esa fdlh cnyko] [kkldj,sls cnyko dk irk yxkus ds fy, le; ij iqu% ijh{k.k vko';d gksrk gs] ftlds fy, vfrfjdr mipkj dh t:jr gksxha esa le>rk gwa fd ;g jksxh dh fteesnkjh gs fd og ystj mipkj ds ckn vko';d QkWyksvi eqykdkrksa dks cuk;s j[ksa esa Lohdkj djrk gwa fd bl dk;zfof/k dh izñfr vksj mís';] blls tqm+s tksf[keksa] fodyiksa vksj lahkkfor tfvyrkvksa ds ckjs esa esjs MkWDVj }kjk eq>s le>k fn;k x;k gs vksj ;g fd esjs lhkh iz'uksa ds larks"ktud mùkj ns fn;s x;s gsaa esa bl ckr ls voxr gwa fd MkWDVjh vksj ltzjh lvhd fokku ugha gs vksj esa Lohdkj djrk gwa fd izkir gksus okys ifj.kkeksa ds ckjs esa dksbz Hkh xkjavh ugha nh tk ldrha bl lcdks eq>s,slh Hkk"kk esa crk fn;k x;k gs ftls fd esa le>rk gwaa mi;qzdr tkudkjh dks esaus i<+ fy;k gs ;k eq>s i<+dj lquk fn;k x;k gs vksj esa mipkj ls tqm+s lahkko; tksf[keksa dks tkurs gq, blds fy, vuqefr iznku djrk gwaa ( 55 )

60 dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 56 )

61 Intravitreal Injection for Endophthalmitis Jatin Ashar, Subrata Mandal Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been explained in the language I best understand that drugs would be injected into the vitreous cavity of my eye after appropriate anesthesia to treat and limit the infection in my eye. I have been explained I may or may not regain vision after the procedure and may need a repeat injection or surgery in future. Possible complications of the procedure include retinal detachment, glaucoma, hypotony, cataract, and bleeding. I may also experience side effects such as eye pain, subconjunctival hemorrhage, swelling of the cornea and inflammation of the eye. As with any medication, there is a risk of causing allergic reactions in a small number of patients. Symptoms of allergic reactions include rash, hives, itching and shortness of breath. I also understand that my eye condition may not get better or may worsen. Any or all the complications explained to me may cause a further deterioration in vision or have a possibility of blindness. Additional procedure may be required for management of the complications. The nature of my eye condition has been explained to me and the proposed treatment has been described. The risks, benefits, alternatives, and limitations of treatment have been discussed with me. All my questions have been answered. I here by authorize the doctor to administer intravitreal antibiotics in my R/L eye. This consent is valid until I revoke it or my condition changes to a point that the risks and benefits of the injection are significantly different from this date. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 57 )

62 ,amksfksyfefvl ds fy, bavªkfovfj;y batsd'ku tfru v'kkj] lqczr eamy jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... eq>s ml Hkk"kk esa] ftls fd esa vpnh rjg le>rk gwa] HkyhHkkafr le>k fn;k x;k gs fd esjh vka[k dk mipkj djus vksj laøe.k dks lhfer djus ds fy, mi;qdr,uslfksfl;k ds ckn esjh vka[k dh fovfjvl dsfovh esa nokvksa dks batsd'ku ds tfj;s Mkyk tk,xka eq>s le>k fn;k x;k gs fd bl izfø;k ds ckn esa n`f"v dks iqu% izkir dj ldrk gwa vksj ugha Hkh dj ldrk vksj Hkfo"; esa fqj ls batsd'ku ;k ltzjh dh t:jr im+ ldrh gsa bl dk;zfof/k dh lahkkfor tfvyrkvksa esa jsfvuy vyxko] Xywdksek] gkbiksvskuh] eksfr;kfcan vksj jdrlzko 'kkfey gsa blds vykok esa vka[k esa nnz] lc datfdvoy jdrlzko] dkfuz;k dh lwtu vksj vka[kksa dh tyu dk vuqhko dj ldrk gwaa tslk fd fdlh Hkh nokbz ds lkfk gksrk gs jksfx;ksa dh FkksM+h la[;k esa,yftzd izfrfø;k,a mriuu gks ldrh gsaa,yftzd izfrfø;kvks a ds y{k.kksa esa nnksjs] gkbot] [kqtyh vksj lkalksa dk m[km+uk 'kkfey gsa esa ;g Hkh le>rk gwa fd esjh vka[k dh volfkk csgrj ugha Hkh gks ldrh ;k cnrj gks ldrh gsa eq>s le>k;h x;h dksbz ;k lhkh tfvyrk,a n`f"v ds vksj Hkh [kjkc gksus dk dkj.k cu ldrh gsa ;k mudh otg ls esa n`f"vghu gks ldrk gwaa tfvyrkvksa ds izca/ku ds fy, vfrfjdr dk;zfof/k dh vko';drk im+ ldrh gsa esjh vka[k dh volfkk dh izñfr eq>s le>k nh x;h gs vksj izlrkfor mipkj dks of.kzr dj fn;k x;k gsa mipkj ds tksf[keksa] ykhkksa] fodyiksa vksj lhekvksa dh esjs lkfk ppkz dh x;h gsa esjs lhkh iz'uksa ds mùkj fn;s x;s gsaa blds }kjk esa MkWDVj dks viuh nk;ha@ck;ha vk[ka esa bavªkfovfj;y,avhckw;ksfvdl dks Mkyus ds fy, vf/kñr djrk gwaa ;g vuqefr ml le; rd os/k gs tc rd fd esa bls jí ugha djrk ;k esjh vka[k dh volfkk ml fcanq rd cny ugha tkrh gs tgka ij batsd'ku ds tksf[ke vksj ykhk bl rkjh[k ls myys[kuh; :i ls fhkuu gksaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 58 )

63 Electrophysiological Tests Courtesy: Shroff Eye Centre, New Delhi Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... Electro-Retinogram (ERG) This investigation procedure comprises of electrodes, which are put on the cornea and on the skin with which a signal is generated from the retina in response to a flast of light. This tells us,the gross retinal function. The test takes about 45 minutes to 1 hour and includes 30 minutes of dark adaptation (sitting in a dark room) which can be a little tiring. Very rarely the contact lens electrodes can cause corneal discomfort or abrasion which can be managed by proper medication. For this test, the pupils need to be dilated after which you may not be able to drive or do near work for atleast 3-4 hours. Sometimes, in cases of very small children or uncooperative patients the test needs to be carried out under anesthesia. Visual Evoked Potential (VEP) This investigation procedure comprises of electrodes, which are put on the skin with which a signal is generated from visual pathway in response to a flash of light. This tells us the gross visual pathway function. The test takes about minutes to perform. For this test, the pupils need not be dilated. Sometimes, in cases of very small children or uncooperative patients, the test needs to be carried out under anesthesia. Electro - Oculogram (EOG) This investigation procedure comprises of electrodes which are put on the skin, with which a signal is generated from the retina in response to successive movements of the eye in opposite directions. This tells us the gross retinal function. The test takes about minutes to perform. The pupils need not be dilated for this test. Informed Consent The information on ERG/EOG/VEP has been read by me / out to me and having understood the content, I give my consent to the performance of this test on me. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... ( 59 )

64 Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 60 )

65 bysdvªksfqft;ksykwftdy ijh{k.k JkWQ vkbz lsavj] u;h fnyyh ds lkstu; ls jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... bysdvªks&jsfvuksxzke ¼bZvkjth½ tkap&im+rky dh bl dk;zfof/k esa bysdvªksm~l lekfgr gksrs gsa] ftugsa fd dkfuz;k ij vksj Ropk ij j[kk tkrk gs ftlls izdk'k dh ped dh izfrfø;k esa jsfvuk ls flxuy mriuu gksrk gsa ;g gesa laiw.kz jsfvuy izdk;z ds ckjs esa crkrk gsa ijh{k.k esa rdjhcu 45 feuv ls ysdj 1?kaVs rd dk le; yxrk gs vksj blesa va/ksjs esa vuqdwyu ¼va/ksjs dejs esa csbuk½ dk 30 feuv 'kkfey gksrk gs] tks fd FkksM+k Fkdk nsus okyk gks ldrk gsa cgqr gh fojys rksj ij bysdvªksm~l dkuhzy cspsuh ;k [kjksap dk dkj.k cu ldrs gsa] ftldk fd leqfpr nokbz ls izca/k fd;k tk ldrk gsa bl ijh{k.k ds fy, iqrfy;ksa dks QSykus dh t:jr im+rh gs] ftlds ckn de ls de 3&4?kaVksa ds fy, vki okgu ugha pyk ldrs ;k fudv dk dke ugha dj ldrs gsaa dbz ckj] cgqr gh NksVs cppksa ;k lg;ksx ugha nsus okys jksfx;ksa ds ekeyksa esa csgks'kh dh n'kk esa bl ijh{k.k dks djus dh t:jr im+ ldrh gsa fotqvy,oksdm iksvsa'ky ¼ohbZih½ tkap&im+rky dh bl dk;zfof/k esa bysdvªksm~l lekfgr gksrs gsa] ftugsa fd Ropk ij j[kk tkrk gs ftlls izdk'k dh ped dh izfrfø;k es a pk{kq"k jklrs ds izdk;z flxuy mriuu gksrk gsa ;g gesa laiw.kz pk{kq"k jklrs ds izdk;z ds ckjs esa crkrk gsa ijh{k.k esa rdjhcu 30 ls 45 feuv rd dk le; yxrk gsa bl ijh{k.k ds fy, iqrfy;ksa dks QSykus dh t:jr im+rh gsa dbz ckj] cgqr gh NksVs cppksa ;k lg;ksx ugha nsus okys jksfx;ksa ds ekeyksa esa csgks'kh dh n'kk esa bl ijh{k.k dks djus dh t:jr im+ ldrh gsa bysdvªks&vksdqyksxzke ¼bZvksth½ tkap&im+rky dh bl dk;zfof/k esa bysdvªksm~l lekfgr gksrs gsa] ftugsa fd Ropk ij j[kk tkrk gs ftlls fd foijhr fn'kkvksa esa vka[kksa dh Øfed gypy dh izfrfø;k esa jsfvuk ls flxuy mriuu gksrk gsa ;g gesa laiw.kz jsfvuy izdk;z ds ckjs esa crkrk gsa ijh{k.k esa rdjhcu 30&35 feuv rd dk le; yxrk gsa bl ijh{k.k ds fy, iqrfy;ksa dks QSykus dh ugha t:jr im+rh gsa lwfpr lgefr bzvkjth@bzvksth@ohbzih ij tkudkjh esa i<+ yh gs@eq>s i<+dj lquk nh x;h gs vksj varozlrq dks le>dj esa bl ijh{k.k dks vius Åij djus ds fy, lgefr iznku djrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... ( 61 )

66 MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 62 )

67 OCULOPLASTY & ORBIT

68 Enucleation Noornika Khuraijam Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been informed in my own language that my right/ left eye may be harboring a tumor/ disease which if not removed may result in loss of vision in the same eye and may lead to spread of the disease to other parts of the body and cause risk to my life. It has been explained to me that the exact confirmation of diagnosis can be obtained only after microscopic examination after removal of the eye. The option of removing a piece of tissue through surgery or with the help of a needle for the purpose of diagnosis and its risks involved have been explained and given to me. I understand that the entire eye along with its coverings and part of the nerve attached to it will be removed and replaced by an artificial prosthesis. I also understand that I will have to wear prosthetic eye for cosmetic purpose after the surgery. I understand that in spite of the best efforts by the operating surgeons, there may be incomplete removal which may require additional surgery or treatment. I hereby authorize..and those he/ the institute may designate as staff, associates or assistants to perform surgery for removal of my right/left eye. It has been explained to me that during the course of treatment, unforeseen conditions may be revealed or encountered which may necessitate surgical and emergency procedures in addition to or different from those contemplated at the time of initial diagnosis. I, therefore, further request and authorize the above designated staff to perform such additional surgical or other procedures as they deem necessary or desirable. I consent to the use of anesthesia and to use of anesthetics as may be deemed necessary or desirable. I further consent to the administration of such drugs, infusions, plasma or blood transfusion or any other treatment or procedures deemed necessary. I consent to the observing, photographing or televising of the procedure to be performed for medical, scientific or educational purpose provided my identity is not revealed by the pictures or by descriptive text accompanying them. I have been given the opportunity to ask all/any questions and I have also been given the option to ask for any second opinion. I am fully aware that the surgery is being performed in good faith and that no guarantee or assurance has been given as to the result that may be obtained. Any tissues or parts surgically removed may be disposed off by the institution in accordance with customary practice. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... ( 63 )

69 Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 64 )

70 ,U;wfDy,'ku uwjfudk [kqjstke jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... eq>s esjh viuh Hkk"kk esa lwfpr dj fn;k x;k gs fd esjh vka[k esa,sls isnk gks jgh gks ldrh gs ftls ugha gvk;s tkus ds QyLo:i ml vka[k dh jks'kuh tk ldrh gs vksj 'kjhj ds nwljs fgllksa esa chekjh QSy ldrh gs vksj esjh tku tk ldrh gsa eq>s ;g ckr le>k nh x;h gs fd funku dks lvhd iqf"v vka[kksa dks fudkyus ds ckn ekbøksldksfid ijh{k.k ls gh izkir fd;k tk ldrk gsa funku ds mís'; ls ltzjh ds tfj;s ;k lqbz dh enn ls Ård ds VqdM+s dk fudkyus dk fodyi vksj blls tqm+s tksf[keksa dks eq>s le>k fn;k x;k gsa esa le>rk gwa fd viuh dofjax ds lkfk&lkfk lewph vka[k vksj mlls tqm+h ul ds,d fglls dks gvk;k tk,xk vksj mldh txg ij udyh vka[k yxk nh tk,xha esa ;g Hkh le>rk gwa fd eq>s ltzjh ds ckn lqanj yxus ds fy, udyh vka[k iguuh im+sxha esa le>rk gwa fd vkwijs'ku djus okys ltzuksa ds lozjs"b iz;klksa ds ckotwn gks ldrk gs fd iwjh fudklh ugha gks ik;s ftlds fy, vfrfjdr ltzjh ;k mipkj dh vko';drk im+sa esa blds }kjk vksj mu yksxksa dks vka[k dks fudkyus ds fy, ltzjh djus gsrq vf/kñr djrk gwa] ftugsa fd us LVkQ],lksfl,V ;k lgk;d dsd :i esa fu;qdr fd;k gksa eq>s ;g ckr le>k nh x;h gs fd mipkj dh vof/k ds nksjku vizr;kf'kr n'kk,a mriuu gks ldrh gsa ;k mudk lkeuk djuk im+ ldrk gs tks fd mlls fhkuu lftzdy ;k vkikrdkyhu dk;zfof/k;ksa dh vko';drk dks mriuu djsa] ftudh fd 'kq#vkrh funku ds le; vis{kk dh x;h FkhA vr%] esa mi;qzdr fufnz"v LVkQ ls vuqjks/k djrk gwa vksj mls vf/kñr djrk gwa fd og bl izdkj dh vfrfjdr lftzdy ;k vu; dk;zfof/k;ksa dks leiuu djs tslk fd os vko';d ;k okanuh; le>rs gksaa esa,uslfksfl;k vksj,uslfksfvdl dk mi;ksx djus ds fy, lgefr iznku djrk gwa tslk fd vko';d ;k okanuh; le>k x;k gsa esa bl izdkj dh nokvksa] batsd'kuksa] IykTek ;k jdrk vk/kku ;k fdlh vu; mipkj ;k dk;zfof/k dks fd;s tkus dh Hkh vuqefr iznku djrk gwa tslk fd vko';d le>k x;k gksa esa fpfdrldh;] oskkfud ;k 'ks{kf.kd mís'; ls dk;zfof/k ds voyksdu] QksVksxzkQh ;k Vsyhfotu ij izlkfjr djus dh vuqefr iznku djrk gwa c'krsz fd rlohjksa }kjk ;k muds lkfk okys fooj.kkred ikb ds }kjk esjh igpku ugha tkfgj gksrh gksa eq>s Hkh iz'u iwnus dk volj fn;k x;k gs vksj eq>s dksbz f}rh;d iz'u iwnus dk Hkh fodyi iznku fd;k x;k gsa esa bl ckr ls iwjh rjg ls voxr gwa fd ltzjh lfnpnk ds lkfk dh tk jgh gs vksj ;g fd mu ifj.kkeksa dks ysdj dksbz xkjavh ;k oknk ugha fd;k x;k gs tks fd izkir gks ldrs gsaa ltzjh ls vyx fd;s x;s fdugha Årdksa ;k vaxksa dks pkyw ifjikvh ds vuqlkj lalfkku }kjk fulrkfjr fd;k tk ldrk gsa dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... ( 65 )

71 MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 66 )

72 Evisceration Noornika Khuraijam Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been informed in my mother tongue that my right/ left eye may be harboring a disease which if not removed may result in loss of vision in the same eye and may lead to spread of the disease to other parts of the body and cause risk to my life and a painful blind eye. I understand that the total contents of the eyeball will be removed and an artificial prosthesis may have to be implanted to maintain the shape of the eye. I also understand that I will have to wear prosthetic eye for cosmetic purpose after surgery. I understand that in spite of the best efforts by the operating surgeons, there may be incomplete removal which may require additional surgery or treatment. I also understand that the other eye may be affected after surgery, which may require additional treatment. I hereby authorize..and those he/ the institute may designate as staff, associates or assistants to perform surgery for removal of my right/left eye. It has been explained to me that during the course of treatment, unforeseen conditions may be revealed or encountered which may necessitate surgical and emergency procedures in addition to or different from those contemplated at the time of initial diagnosis. I, therefore, further request and authorize the above designated staff to perform such additional surgical or other procedures as they deem necessary or desirable. I consent to the use of anesthesia and to use of anesthetics as may be deemed necessary or desirable. I further consent to the administration of such drugs, infusions, plasma or blood transfusion or any other treatment or procedures deemed necessary. I consent to the observing, photographing or televising of the procedure to be performed for medical, scientific or educational purpose provided my identity is not revealed by the pictures or by descriptive text accompanying them. I have been given the opportunity to ask all/any questions and I have also been given the option to ask for any second opinion. I am fully aware that the surgery is being performed in good faith and that no guarantee or assurance has been given as to the result that may be obtained. Any tissues or parts surgically removed may be disposed off by the institution in accordance with customary practice. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... ( 67 )

73 Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 68 )

74 ,folfljs'ku uwjfudk [kqjstke jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... eq>s esjh viuh Hkk"kk esa lwfpr dj fn;k x;k gs fd esjh vka[k esa,sls isnk gks jgh gks ldrh gs ftls ugha gvk;s tkus ds QyLo:i ml vka[k dh jks'kuh tk ldrh gs vksj 'kjhj ds nwljs fgllksa esa chekjh QSy ldrh gs vksj esjh tku tk ldrh gs vksj va/kh vka[k esa nnz jg ldrk gsa esa le>rk gwa fd us=xksyd dh lewph lkexzh dks fudkyk tk,xk vksj vka[kksa dh vkñfr dks cuk;s j[kus ds fy, udyh vka[k dks yxkuk im+ ldrk gsa esa le>rk gwa fd vkwijs'ku djus okys ltzuksa ds lozjs"b iz;klksa ds ckotwn gks ldrk gs fd iwjh fudklh ugha gks ik;s ftlds fy, vfrfjdr ltzjh ;k mipkj dh vko';drk im+sa esa ;g Hkh le>rk gwa fd ltzjh ds ckn nwljh vka[k izhkkfor gks ldrh gs] ftlds fy, vfrfjdr mipkj dh vko';drk im+ ldrh gsa esa blds }kjk vksj mu yksxksa dks vka[k dks fudkyus ds fy, ltzjh djus gsrq vf/kñr djrk gwa] ftugsa fd us LVkQ],lksfl,V ;k lgk;d ds :i esa fu;qdr fd;k gksa eq>s ;g ckr le>k nh x;h gs fd mipkj dh vof/k ds nksjku vizr;kf'kr n'kk,a mriuu gks ldrh gsa ;k mudk lkeuk djuk im+ ldrk gs tks fd mlls fhkuu lftzdy ;k vkikrdkyhu dk;zfof/k;ksa dh vko';drk dks mriuu djsa] ftudh fd 'kq#vkrh funku ds le; vis{kk dh x;h FkhA vr%] esa mi;qzdr fufnz"v LVkQ ls vuqjks/k djrk gwa vksj mls vf/kñr djrk gwa fd og bl izdkj dh vfrfjdr lftzdy ;k vu; dk;zfof/k;ksa dks leiuu djs tslk fd os vko';d ;k okanuh; le>rs gksaa esa,uslfksfl;k vksj,uslfksfvdl dk mi;ksx djus ds fy, lgefr iznku djrk gwa tslk fd vko';d ;k okanuh; le>k x;k gsa esa bl izdkj dh nokvksa] batsd'kuksa] IykTek ;k jdrk vk/kku ;k fdlh vu; mipkj ;k dk;zfof/k dks fd;s tkus dh Hkh vuqefr iznku djrk gwa tslk fd vko';d le>k x;k gksa esa fpfdrldh;] oskkfud ;k 'ks{kf.kd mís'; ls dk;zfof/k ds voyksdu] QksVksxzkQh ;k Vsyhfotu ij izlkfjr djus dh vuqefr iznku djrk gwa c'krsz fd rlohjksa }kjk ;k muds lkfk okys fooj.kkred ikb ds }kjk esjh igpku ugha tkfgj gksrh gksa eq>s Hkh iz'u iwnus dk volj fn;k x;k gs vksj eq>s dksbz f}rh;d iz'u iwnus dk Hkh fodyi iznku fd;k x;k gsa esa bl ckr ls iwjh rjg ls voxr gwa fd ltzjh lfnpnk ds lkfk dh tk jgh gs vksj ;g fd mu ifj.kkeksa dks ysdj dksbz xkjavh ;k oknk ugha fd;k x;k gs tks fd izkir gks ldrs gsaa ltzjh ls vyx fd;s x;s fdugha Årdksa ;k vaxksa dks pkyw ifjikvh ds vuqlkj lalfkku }kjk fulrkfjr fd;k tk ldrk gsa dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... ( 69 )

75 MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 70 )

76 Orbitotomy Rachna Meel Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been explained in my mother tongue that a mass has grown adjacent to my left/ right eye. The growth is causing the following: Displacement and/ protrusion of the eye ball Decrease vision (Which is due to globe distortion and/or compression of the optic nerve) Restriction of the movements of the eyeball Abnormal deviation of the eyeball Drooping of the eyelid Altered sensations in the area surrounding the eye (forehead/ nose/ cheek) Incomplete closure of the eye Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No I understand that I need to undergo orbitotomy in order to remove this mass. It is a surgical procedure that involves entering and/or opening up the orbit that is the bony compartment within which the eye is placed. The mass that is removed will then be examined by the pathologist. The histopathological diagnosis will guide further treatment that may involve no further management/ local radiotherapy/ chemotherapy. I fully understand that it may not be possible to remove the mass completely. The vision, eyeball and eyelid movements, deviation of the eyeball and the sensations around the eye may not recover completely and may even deteriorate due to surgical manipulation. The surgery has a risk of post operative bleeding and infection in the orbit that may need further treatment in the form of medication or surgery. I also understand the risks of general anesthesia under which this surgery will be done. Having clearly understood all that is stated above I hereby authorize the doctors to carry out orbitotomy on the right /left side. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... ( 71 )

77 Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 72 )

78 vksfczvksvkseh jpuk ehy jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... eq>s esjh ekr`hkk"kk esa ;g ckr le>k nh x;h gs fd esjh vka[k ds fudv ekal c<+ x;k gsa ;g o`f) fueufyf[kr dks tue ns jgh gs % us=xksyd dk folfkkiu vksj mhkkj gka@ugha?kvh gqbz n`f"v ¼tks fd Xyksc fo:i.k vksj@ gka@ugha ;k izdkf'kd ul ds laihm+u ds pyrs gs½ us=xksyd dh gypyksa dh lhek gka@ugha us=xksyd dk vlkeku; fopyu gka@ugha iydksa dh Mªwfiax gka@ugha vka[kksa ds bnzfxnz ¼eLrd] ukd] xky½ esa cnyh gqbz laosnuk gka@ugha vka[kksa dk vk/kk&v/kwjk can gksuk gka@ugha esa le>rk gwa fd eq>s bl ekal dks gvokus ds fy, vkwjfcvksvkseh djokus dh t:jr gsa ;g lftzdy dk;zfof/k gs ftlls fd vksfczv esa izos'k djuk vksj@;k [kksyuk tqm+k gqvk gksrk gs] tks fd gfì;ksa dk [kkuk gksrk gs ftlds vanj vka[k flfkr gksrh gsa gvk;s tkus okys ekal fiam dk blds ckn isfkksykwftlv }kjk ijh{k.k fd;k tk,xka fglvksisfkksykwftdy funku vkxs ds mipkj dks funszf'kr djsxk ftlls fd vkxs dk dksbz izca/ku@yksdy jsfm;ksfks jsih@dheksfksjsih tqm+h gqbz ugha gks ldrha esa iwjh rjg ls bl ckr dks le>rk gwa fd ekal ds fiam dks iwjh rjg ls fudkyuk lahko ugha Hkh gks ldrk gsa n`f"v] us=xksyd vksj iqryh dh gypyksa] us=xksyd ds fopyu vksj vka[kksa ds bnzfxnz dh laosnuk dh gks ldrk gs fd iwjh rjg ls Hkjik;h ugha gks vksj gks ldrk gs fd og ltzfdy glr{ksi ds pyrs vkxs vksj [kjkc gks tk;sa ltzjh esa vkwijs'ku ds ckn ds jdrlzko vksj vksfczv esa laøe.k dk tksf[ke gksrk gs ftlds fy, nokbz ;k ltzjh ds :i esa vkxs ds mipkj dh t:jr im+ ldrh gsa blds vykok esa lkeku; csgks'kh ds tksf[keksa dks Hkh le>rk gwa ftlds rgr ;g ltzjh dh tk,xha ml lc dks Li"V :i ls le> ysus ds ckn ftls fd Åij crk;k x;k gs esa blds }kjk MkWDVjksa dks nk;ha@ck;ha rjq vksfczvksvkseh dks leiuu djus ds fy, vf/kñr djrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... ( 73 )

79 MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 74 )

80 Entropion Prashant Yadav Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been explained in my own language the risks and complications of surgery. I have also been fully explained the surgery is being done to correct my lid deformity and there will be no improvement in my vision. The complications which may occur are enumerated below: Infection and gape of the surgical wound Suture erosion, infection and granuloma formation Lid edema and scar of the incision Risks of corneal irritation, injury and ulceration Hemorrhage and haematoma formation Excessive watering / dry eye, Damage to the lid margin Loss of eyelashes Ptosis and lid retraction. A skin graft may be required to correct the deformity. I have been explained that: a. The skin graft site maybe post auricular or the anterior forearm b. Graft rejection, infection, contracture or fibrosis may occur c. It has been explained to me that regular aseptic cleaning of the graft has to be done. It also has been explained to me that the donor site in case of a skin graft may gape or get infected and regular aseptic cleaning of the donor site is required. d. A tarsorrhaphy may have to be in place for 3-6 months to prevent contracture of the graft. Chances of under correction overcorrection and resurgery have been fully explained. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 75 )

81 ,avªksfiu iz'kkar ;kno jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... eq>s esjh viuh Hkk"kk esa ltzjh ds tksf[keksa vksj tfvyrkvksa dks le>k fn;k x;k gsa eq>s ;g ckr Hkh iwjh rjg ls le>k nh x;h gs fd esjh iiksv dh dq:irk dks Bhd djus ds fy, ltzjh dh tk jgh gs vksj esjh n`f"v esa dksbz lq/kkj ugha gksxka mriuu gks ldus okyh tfvyrkvksa dks uhps of.kzr fd;k x;k gs % Û Vkads dk {kj.k] laøe.k vksj xzsuqyksek fuekz.k Û iiksvs dk,fmek vksj phjs dk?kko Û dkuhzy [kqtyh] pksv vksj QksM+s dk tksf[ke Û jdrlzko vksj gsekvksek dk fuekz.k Û vr;f/kd iuhyh@'kq"d vka[k Û iiksvk ekftzu dks {kfr Û Û Û cjksfu;ksa dks uqdlku iksfll vksj iiksvk izr;kgkja dq:irk dks Bhd djus ds fy, fldu xzkv dh vko';drk im+ ldrh gsa eq>s le>k fn;k x;k gs fd %,- fldu xzkv dh txg ikslv vksfjdqyj ;k 'kjhj dk vxz Hkkx ;k vxzckgq gks ldrh gs ch- xzkv dk udkjk tkuk] laøe.k] vodqapu ;k Qkbczksfll mriuu gks ldrk gs lh- eq>s ;g ckr le>k nh x;h gs fd xzkv dh fu;fer dhvk.kqghu lqkbz djuh gksxha eq>s ;g Hkh le>k fn;k x;k gs fd fldu xzkv dh n'kk esa nkrk LFky [kqy ;k laøfer gks ldrk gs vksj nkrk LFky dh fu;fer dhvk.kqghu lqkbz vko';d gsa Mh- xzkv ds vodqapu dks jksdus ds fy, VklksZjgkQh dks 3&6 eghuksa ds fy, dke esa ykuk im+ ldrk gsa vamj djsd'ku] vksoj djsd'ku vksj fqj ls ltzjh dh xqatkb'kksa dks iwjh rjg ls le>k fn;k x;k gsa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 76 )

82 Ectropion Prashant Yadav Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been explained in my own language the risks and complications of surgery. I have also been fully explained the surgery is being done to correct my lid deformity and there will be no improvement in my vision. The complications which may occur are enumerated below: Infection and gape of the surgical wound Suture erosion, infection and granuloma formation Lid edema and scar of the incision Risks of corneal irritation, injury and ulceration Hemorrhage and haematoma formation Excessive watering / dry eye Damage to the lid margin Loss of eyelashes Ptosis and lid retraction A mucous membrane graft/ nasal septal/ aural cartilage maybe required to correct the deformity. Graft rejection, infection, contracture and/or fibrosis may occur. Regular aseptic cleaning of the graft site has to be done. It also has been explained to me that the donor site (buccal mucosa) of the mucous membrane graft may get infected and I have been explained the importance of regular oral hygiene Chances of undercorrection, overcorrection and resurgery have been fully explained Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 77 )

83 ,DVªksfivu iz'kkar ;kno jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... eq>s esjh viuh Hkk"kk esa ltzjh ds tksf[keksa vksj tfvyrkvksa dks le>k fn;k x;k gsa eq>s ;g ckr Hkh iwjh rjg ls le>k nh x;h gs fd esjh iiksv dh dq:irk dks Bhd djus ds fy, ltzjh dh tk jgh gs vksj esjh n`f"v esa dksbz lq/kkj ugha gksxka mriuu gks ldus okyh tfvyrkvksa dks uhps of.kzr fd;k x;k gs % Û laøe.k vksj lftzdy?kko dk [kqyk gksuk Û Vkads dk {kj.k] laøe.k vksj xzsuqyksek fuekz.k Û iiksvs dk,fmek vksj phjs dk?kko Û dkuhzy [kqtyh] pksv vksj QksM+s dk tksf[ke Û jdrlzko vksj gsekvksek dk fuekz.k Û vr;f/kd iuhyh@'kq"d vka[k Û iiksvk ekftzu dks {kfr Û cjksfu;ksa dks uqdlku Û Û Û iksfll vksj iiksvk izr;kgkja dq:irk dks Bhd djus ds fy, 'ys"ek dh f>yyh xzkv@uty lsivy@vksjy dkfvzyst dh vko';drk im+ ldrh gsa xzkv dk udkjk tkuk] laøe.k] vodqapu vksj@;k Qkbczksfll mrikuu gks ldrk gsa xzkv okyh txg dh fu;fer dhvk.kqghu djuh gksxha eq>s ;g Hkh le>k fn;k x;k gs fd 'ys"ey f>yyh xzkv dk nkrk LFky ¼cqDdy eqdkslk½ laøfer gks ldrk gs vksj eq>s fu;fer eksf[kd lkq&lqkbz ds egro dks le>k fn;k x;k gsa vamj djsd'ku] vksoj djsd'ku vksj fqj ls ltzjh dh xqatkb'kksa dks iwjh rjg ls le>k fn;k x;k gsa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 78 )

84 Ptosis Dinesh Shrey Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been explained in the language that I understand, that the surgery is being done for drooping of my Rt/ Lt/ Both eyelids under Local Anaesthesia. During the course of the surgery, there are chances of: Undercorrection / Overcorrection after surgery that may require resurgery Lid edema, lid swelling and infection Inability to fully close the eye (lagophthalmos) Lid lag during down gaze leading to scleral show Corneal exposure and keratopathy Injury to the surface of the eyeball/ globe Misdirection of the eyelashes that may point towards the eyes instead of away from it Blurred vision or double vision for one or two days postoperatively Watering of the eyes for the first few days after surgery Scarring at the incision site Knowing the above mentioned facts, I give my consent for my Rt/ Lt/ Both eyelids ptosis surgery. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 79 )

85 iksfll fnus'k Js; jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... eq>s esjs le> esa vkus okyh Hkk"kk esa ;g crk fn;k x;k gs fd yksdy,uslfkslhfl;k ds rgr esjh iydksa dh Mªwfiax ds fy, ltzjh dh tk jgh gsa ltzjh dh vof/k ds nksjku] bl ckr dh xqatkb'k gs fd % Û ltzjh ds ckn vamjdjsd'ku@vksojdjsd'ku ftlds fy, fqj ls ltzjh dh vko';drk im+ ldrh gs Û iiksv dh,fmek] iiksv dh lwtu vksj laøe.k Û vk[kksa dks iwjh rjg ls can djus esa v{ke gksuk ¼ySxvkFkSyeksl½ Û uhps utj gksus ds nksjku iiksv dk ihns jg tkuk ftlls us=xksyd dh lqsn ckgjh iyd fn[krh gs Û dkwuhzy dk vjf{kr gksuk vksj dsjsvksisfkh Û us=xksyd@xyksc dh lrg dks pksv Û cjksfu;ksa dh xyr fn'kk tks fd vka[kksa ls nwj gksus dh ctk; mldh vksj tk ldrh gs Û vkwijs'ku ds ckn,d ;k nks fnuksa ds fy, /kqa/kyh n`f"v ;k nksgjh n`f"v Û phjs okyh txg ij t[e Åij crk;s x;s rf;ksa dks tkurs gq, esa viuh nk;ha@ck;ha@nksuksa iiksvksa dh iksfll ltzjh ds fy, viuh vuqefr iznku djrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 80 )

86 Syringing and Probing Dinesh Shrey Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been explained in the language that I understand that I / my son / daughter has a block in the passage which is responsible for drainage of tears from eyes to nose. An attempt will be made to open the passage whereby a fine metal probe will be inserted so as to overcome the blockage. The procedure will be done under General Anaesthesia. Syringing and Probing is successful in 95% of cases of nasolacrimal duct blockage that are caused by a simple duct blockage. The procedure needs to be repeated sometimes if the blockage is not relieved. The tear duct may have a complicated type of obstruction or the tear duct might not have developed completely. These complications may be noticed at the time of surgery during probing. Further surgery may be required consequently. Bleeding from the nose can occur for upto three days after surgery. Lid swelling can occur due to false passage and extravasation of saline. Knowing the above mentioned facts, I give my consent for my/ my son/ daughter s surgery. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 81 )

87 fipdkjh ls lqkbz vksj tkap&im+rky fnus'k Js; jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... eq>s esjs }kjk le> esa vkus okyh Hkk"kk esa ;g crk fn;k x;k gs fd ds vk[kksa ds fudklh ds ekxz esa vojks/k gs ftldh otg ls vka[kksa ls ukd vkalw cgrk gsa fudklh ds bl ekxz dks [kksyus ds fy, iz;kl fd;k tk,xk] ftlds }kjk /kkrq dh fpduh NM+ Mkyh tk,xh rkfd fudklh ds ekxz ds vojks/k ls futkr ik;h tk ldsa ;g dk;zfof/k lkeku; csgks'kh dh n'kk esa leiuu dh tk,xha Û fipdkjh ls lqkbz vksj tkap&im+rky uslksysføey uyh vojks/k ds 95 izfr'kr ekeyksa esa lqy gs] tks fd ljy uyh vojks/k ls mriuu gk srk gsa Û vojks/k ls vxj eqfdr ugha feyrh rks dbz ckj bl dk;zfof/k dks nksgjkus dh t:jr im+rh gsa Û vkalw dh uyh esa tfvy fdle dh ck/kk gks ldrh gs vfkok vkalw dh uyh gks ldrh gs fd iwjh rjg ls fodflr ugha gqbz gksa fipdkjh ls lqkbz ds nksjku ltzjh ds le; esa ;s tfvyrk,a utj vk ldrh gsaa blds QyLo:i vkxs vksj ltzjh dh t:jr im+ ldrh gsa Û ltzjh ds ckn rhu fnuksa rd ukd ls jdrlzko gks ldrk gsa Û fudklh ds xyr ekxz vksj lsykbu dh fudklh ds pyrs iiksvs esa lwtu vk ldrh gsa Åij crk;s x;s rf;ksa dks tkurs gq, esa viuh iiksvksa dh iksfll ltzjh ds fy, viuh vuqefr iznku djrk gwaa dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 82 )

88 Punctal Plugs Prakashchand Agarwal, Bhavna Chawla Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been informed in the language I best understand that I am/ my child is suffering from dry eye syndrome due to inadequate production of tears. Blocking the tear drainage system with artificial punctal plugs may improve my symptoms by retaining more tears in the eye. This is a temporary procedure and may be reversible. I have been explained that alternative treatment options include the frequent use of artificial tears or ointment depending on severity of the condition, topical cyclosporine eyedrops or a permanent closure of the punctum and canaliculus by thermal cautery or ligation. Risks associated with this procedure include infection, excessive tearing, irritation and foreign body sensation, loss of the plug and rarely, lodging of the plug in the tear drainage pathway (canaliculus) leading to scarring. In such cases, surgery may be necessary to re-establish tear drainage. The plugs may require replacement or removal. I have been fully explained the permanent nature of the disease and that this treatment might give symptomatic relief by retaining the tears to moisten the ocular surface. This procedure will not cure the primary cause of dry eye syndrome. Regular follow up may be required to assess the ocular surface status and modify medications accordingly. I certify that I have fully understood the implications of the above consent and authorise the doctors to insert punctal plugs in my/ my child s RIGHT lower upper LEFT lower upper eyelid(s) Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 83 )

89 iadvy IyXl izdk'kpan vxzoky] Hkkouk pkoyk jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... eq>s,slh Hkk"kk esa] ftls fd esa le>rk gwa] lwfpr dj fn;k x;k gs fd cppk vkalqvksa ds de cuus ds dkj.k 'kq"d vka[k flamªkse ls =Lr gsa udyh iadvy IyXl ls vkalw fudlh ekxz dks vo#) dj nsus ls vka[kksa esa T;knk vkalw jksdus ds }kjk esjs y{k.kksa esa lq/kkj gks ldrk gsa ;g vlfkk;h dk;zfof/k gs vksj bls myvk tk ldrk gsa eq>s ;g ckr le>k nh x;h gs fd mipkj ds osdfyid fodyiksa esa udyh vkalqvksa vfkok volfkk dh xahkhjrk ds vk/kkj ij eyge] VkWfidy lkbdykstiksjkbu vkbzmªkil dk vdlj iz;ksx ;k FkeZy dksvjh ;k fyxs'ku ds }kjk iadve vksj dsukfydqyl dks ges'kk ds fy, can djuk 'kkfey gsa bl dk;zfof/k ls tqm+s tksf[keksa esa laøe.k] vr;f/kd vkalw] [kqtyh vksj ckgjh pht im+s gksus dh vuqhkwfr] Iyx dh gkfu vksj dhkh&dhkkj vkalw fudklh ds ekxz ¼dSukfydqyl½ esa Iyx dk vkuk ftlls fu'kkuk im+ tkrs gsaa bl rjg ds ekeyksa esa vkalw ds cgko ds ekxkz dks fqj ls dk;e djus ds fy, ltzjh vko';d gks ldrh gsa eq>s chekjh dh LFkk;h izñfr ds ckjs esa le>k fn;k x;k gs vksj ;g fd ;g mipkj vksdqyj lrg dks ue j[kus ds fy, vkalqvksa dks jksddj y{k.k ls jkgr iznku dj ldrk gsa ;g dk;zfof/k 'kq"d vka[kksa ds flamªkse ds izkfkfed dkj.k dks Bhd ugha djsxha vksdqyj lrg dh flfkfr dk vkdyu djus vksj mlds vuqlkj nokbz dks ifjof)zr djus ds fy, fu;fer QkWyks&vi dh vko';drk im+ ldrh gsa esa izekf.kr djrk gwa fd esaus mi;qzdrk lgefr ds fufgrk'k;ksa dks iwjh rjg ls le> fy;k gs vksj MkWDVjksa dks cpps dh nk;ha ck;ha iydksa esa iadvy Iyx Mkyus ds fy, vf/kñr djrk gwaa dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 84 )

90 Dacryocystorhinostomy (DCR) Rachna Meel Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been informed in my mother tongue that the natural passage for tear drainage from my eye (right/ left) is blocked. I understand that in order to overcome the problem of tearing in my eye because of the blockade I need to undergo dacryocystorhinostomy. This surgery involves by-passing the normal drainage system by making a direct communication between this passage and the nose. This will be done by making a bony opening in the adjacent wall of the nose, through a skin incision on the nose. A nasal pack would be kept in the nose for 24 hours post-operatively. Syringing of the passage created by the surgery may be required post-operatively. I have been explained the risks of this surgery involving: failure ( approx 10%), excessive bleeding during the surgery or postoperatively, infection at the site of surgery and a potential risk of loss of vision due to any of the above reasons. I also understand the risks of local anesthesia under which this surgery will be performed. Having completely understood the implications of the consent I hereby authorize the doctors to perform dacryocystorhinostomy on my left /right side. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 85 )

91 MSfØvksflLVksjfuksLVkseh ¼Mhlhvkj½ jpuk ehy jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... eq>s esjh ekr`hkk"kk esa lwfpr dj fn;k x;k gs fd esjh vka[k ls vkalqvksa ds cgko ds fy, LokHkkfod ekxz vo#) gsa esa le>rk gwa fd vojks/k dh otg ls esjh vka[k esa vkalw cgus dh lel;k ls futkr ikus ds Øe esa eq>s MSfØvksflLVksjfuksLVkseh djokus dh t:jr gsa bl ltzjh ls fudklh dh lkeku; O;oLFkk vksj ukd ds chp lh/kk laidz cukdj mls ckgj&ckgj ls fudkyk tkrk gsa bl dke dks ukd ij Ropk ds phjs ds tfj;s ukd ls yxh nhokj esa gfì;ksa esa lqjk[k djds fd;k tk,xka vkwijs'ku ds ckn pkschl?kavksa rd ukd esa uty isd dks j[kk tk,xka ltzjh ds }kjk rs;kj fd;s x;s cgko ekxz dh fipdkjh ls lqkbz vkwijs'ku ds ckn t:jh gks ldrh gsa eq>s bl ltzjh ls tqm+s gq, tksf[keksa ds ckjs esa le>k fn;k x;k gs % foqyrk ¼rdjhcu 10 izfr'kr½] ltzjh ds nksjku ;k vkwijs'ku ds ckn vr;f/kd jdrlzko] ltzjh dh txg ij laøe.k vksj mi;qzdr dkj.kksa esa ls fdlh ds Hkh pyrs n`f"v dh gkfua blds vykok esa yksdy,uslfksfl;k ds tksf[keksa dks Hkh le>rk gwa ftlds rgr ;g ltzjh dh tk,xha lgefr ds fufgrk'k;ksa dks iwjh rjg ls le> pqdus ds ckn esa blds }kjk MkWDVjksa dks viuh ck;ha@nk;ha rjq MSfØvksflLVksjfuksLVkseh leiuu djus ds fy, vf/kñr djrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 86 )

92 Contracted Socket Prashant Yadav Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been explained in my own language the risks and complications of surgery which is being performed to relieve my orbital socket contracture. These are enumerated below: The surgery is being done to correct my contracted socket and there will be no gain in my vision. Infection and hemorrhage and gape of the surgical wound may occur. Suture erosion, infection and granuloma formation may occur. I may require a mucous membrane graft/ amniotic membrane graft or dermis fat graft. I have been explained that: a. Graft rejection, infection, contracture or fibrosis may occur. b. It has been explained to me that regular aseptic cleaning of the graft has to be done and that the donor site in case of a mucous membrane graft is buccal mucosa. I have also been explained the importance of regular oral hygiene. c. In case of dermis fat graft, the graft site will be my gluteal region and I been fully explained the importance of donor site hygiene. I will require fornix formation sutures which will be removed after 3 weeks I will be required to wear a conformer for 2 months I will be given an artificial eye after 2 months. There is a risk of inadequate fitting of the artificial eye. There will only be minimal ocular movements. There is a high risk of failure of the socket reconstruction and I may require multiple surgeries. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 87 )

93 vodqafpr lkwdsv iz'kkar ;kno jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... eq>s esjh viuh Hkk"kk esa ltzjh ds tksf[keksa vksj tfvyrkvksa ds ckjs esa le>k fn;k x;k gs] ftls fd esjs vkfczvu lkwdsv vodqapu ls futkr fnykus ds fy, leiuu fd;k tk jgk gsa bugsa uhps fn;k x;k gs % Û esjs vodqafpr lkwdsv dks Bhd djus ds fy, ltzjh dh tk jgh gs vksj esjh n`f"v esa blls dksbz lq/kkj ugha gksxka Û laøe.k vksj jdrlzko gks ldrk gs rfkk lftzdy?kko [kqy ldrk gsa Û eq>s 'ys"ek f>yyh xzkv@,fefu;ksfvd fnyyh xzkv ;k MfeZl QSV xzkv dh t:jr im+ ldrh gsa eq>s le>k fn;k x;k gs %,- eq>s ;g ckr crk nh x;h gs fd xzkv dh fu;fer dhvk.kqghu lqkbz djuh gksxh vksj ;g fd 'ys"ek f>yyh xzkv dh n'kk esa nkrk LFky cqddy eqdkslk gsa eq>s fu;fer eksf[ke lqkbz ds egro ds ckjs esa Hkh crk fn;k x;k gsa ch- MfeZl QSV xzkv dh n'kk esa xzkv okyh txg esjk XywVhy {ks= gksxk vksj eq>s nkrk LFky dh lqkbz ds egro ds ckjs esa iwjh rjg ls le>k fn;k x;k gsa Û eq>s QksfuZDl cukus okys?kko lhus ds /kkxksa dh t:jr im+sxh ftugsa fd rhu grksa ckn fudkyk tk,xk Û eq>s nks eghuksa rd dkwuqkezj /kkj.k djus dh t:jr im+sxh Û eq>s nks eghuksa ckn udyh vka[k iznku dh tk,xha udyh vka[k dh vi;kzir fqfvax dk tksf[ke gsa dsoy U;wure vksdqyj xfrfof/k gksxha Û lkwdsv iqufuekz.k dh foqyrk dk dkqh tksf[ke gs vksj eq>s vusd ltzfj;ksa dh vko';drk im+ ldrh gsa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 88 )

94 OCULAR SURFACE, CORNEA & REFRACTIVE SURGERY

95 Optical Penetrating Keratoplasty Gaurav Prakash Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been informed in my mother tongue that I/ my child is suffering from whitening of the cornea (Corneal opacity) /other disease involving the cornea and that a surgery to remove this along with some normal cornea will be done. A donor cadaveric cornea will be used to replace this and will be placed with help of sutures. I have been fully explained regarding the permanent nature of the opacity/ lesion and that it has to be removed to enhance vision. I have been explained the risk of infection, graft rejection, suture loosening and replacement, no improvement or worsening of Best corrected visual acuity, glaucoma secondary to surgery or to medications, cataract formation and high astigmatism after surgery. There may be a need for repeat surgery which may or may not lead to improvement of vision. I have been explained the need for follow up as frequently as advised by the doctors that may span upto years, with multiple investigations at each visit. I have been explained that using medications properly is required for success of the graft. I have been explained that I will need to urgently come for follow-up to ophthalmic casualty if there is a sudden onset of redness, photophobia, foreign body sensation, pain or detoriation of vision as these may be early signs of graft infection or rejection. I understand that inspite of all efforts, there is a possibility that there may be worsening of the visual acuity or the cosmetic appearance of the eye. I certify that I have fully understood the implications of the above consent and authorise the doctors to perform Penetrating Keratoplasty on my / my child s right / left eye. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 89 )

96 vkfivdy isusvªsfvax dsjsvksiyklvh xksjo izdk'k jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... eq>s esjh ekr` Hkk"kk esa lwfpr dj fn;k x;k gs fd cppk dkfuz;k ds lqsn gksuk ¼dkWuhZy ls tqm+h vu; chekjh ls ihfm+r gs vksj ;g fd dqn lkeku; dkfuz;k ds lkfk&lkfk bl fudkyus ds fy, ltzjh dh tk,xha bls fjiysl djus ds fy, nkrk dsmkosfjd dkwfuz;k dk mi;ksx fd;k tk,xk vksj mls Vkadksa dh enn ls LFkkfir fd;k tk,xka eq>s dh LFkk;h izñfr dh ckcr iwjh rjg ls le>k fn;k x;k gs vksj ;g fd n`f"v dks c<+kus ds fy, bls fudkyuk gksxka eq>s laøe.k] xzkv ds udkj] Vkads ds <hyk im+us vksj iqu%lfkkiu] dksbz lq/kkj ugha gksus ;k lcls vpns <ax ls Bhd dh x;h pk{kq"k rh{.krk ds cnrj gksus] ltzjh ;k nokb;ksa ds ckn ds Xywdksek] eksfr;kfcan fuekz.k vksj ltzjh ds ckn mpp,lfvxesfvte ds ckjs esa le>k fn;k x;k gsa ltzjh nksgjkus dh t:jr im+ ldrh gs tks fd n`f"v dks lq/kkj dks tue ns Hkh ldrk gs vksj ugha HkhA eq>s le>k fn;k x;k gs fd MkWDVj ftruh ckj dgsxk mruh ckj QkWyks&vi foftv ds fy, vkuk gksxk vksj ;g Øe o"kksza rd py ldrk gs vksj gjsd foftv ij dbz rjg dh tkapsa dh tka,xha eq>s ;g ckr le>k nh x;h gs fd lefpr rjhds nokbz dk mi;ksx djuk xzkv dh lqyrk ds fy, vko';d gsa eq>s ;g ckr crk nh x;h gs fd vxj ykyh] QksVksQksfc;k] ckgjh d.k dh vuqhkwfr] nnz ;k n`f"v fcxm+us dh vdlekr 'kq#vkr gksrh gs rks vkikrdkyhu us= fpfdrlk ds fy, QkSju vkuk im+sxk D;ksafd ;s xzkv laøe.k ;k udkj ds 'kq#vkrh fpug gks ldrs gsaa esa le>rk gwa fd lelr iz;klksa ds ckotwn bl ckr dh lahkkouk gs fd pk{kq"k rh{.krk ;k vka[kksa dh lqanjrk cnrj gks tk;sa esa izekf.kr djrk gwa fd esaus mi;qzdr lgefr ds fufgrk'k;ksa dks iwjh rjg ls le> fy;k gs vksj MkWDVjksa dks cpps dh vka[k ij isusvªsfvax dsjsvksisfkh dks leiuu djus ds fy, vf/kñr djrk gwaa dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 90 )

97 Therapeutic Keratoplasty Anand Agarwal, Shalini Mohan Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... Therapeutic keratoplasty is an ocular surgical procedure which is carried out in patients having infections involving the transparent outer coat of the eye ie cornea. The procedure is usually undertaken in cases with impending corneal perforation or frank perforation or sometimes in cases which are not responding to conventional medical therapy and cases with infection spreading onto deeper layers of the cornea. The procedure is usually carried out under general anesthesia but can be performed under local anesthesia as well depending upon the condition of the patient s eye and systemic status of the patient. Post operative care The eye may be red, swollen and painful following the procedure for which pain relieving oral medications and some eyedrops are given to bring about relief. Out patient visits are done on first day post operatively, day three, day seven and then after every two weeks. It is very important for you to realize that the primary motive of the surgical procedure is salvaging of the eye, and prevention of spread of infection into the eye which can be devastating. Attainment of useful vision is only a secondary objective of the procedure for which additional procedures including a repeat corneal replacement may be required at a later date once the infection gets controlled. Post operative course and complications 1. Corneal wound healing problems including persistent epithelial defect 2. Secondary glaucoma 3. Graft rejection and opacification of the donor cornea 4. Suture related problems including loose, broken sutures, suture abscess 5. Recurrence of original infection in the graft 6. Endophthalmitis and shrinkage of globe- these are rare It is very important for the patient to realize that you have to be on certain topical medications in the form of antibiotics, local anti inflammatory agents, lubricants etc. for a prolonged period of time to bring about an optimal graft and visual acuity outcome. Also, the importance of regular follow up as decided by the treating physician cannot be over emphasized. Needless to say that you are actively involved in the care of the graft to ensure success. I have been made aware of the above mentioned facts and I have been counseled about the potential benefits and possible side effects of the procedure and by thoroughly going through all of the above, I give my full informed consent for the above procedure. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... ( 91 )

98 Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 92 )

99 FksjSfIVd dsjsvksiyklvh vkuan vxzoky] 'kkfyuh eksgku jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %....VsyhQksu ua %.... FksjSfIVd dsjsvksiyklvh vksdqyj lftzdy dk;zfof/k gs ftls fd mu jksfx;ksa esa leiuu fd;k tkrk gs ftugsa fd vka[k dh ckgjh ikjn'khz ijr vfkkzr dkwfuz;k ls tqm+k laøe.k gksrk gsa bl dk;zfof/k dks izk;% vkluu dkwuhzy Nsn ;k Li"V Nsn vfkok dbz ckj,sls ekeyksa] tks fd ikjaifjd fpfdrlk mipkj ls Bhd ugha gksrs] vksj dkfuz;k dh T;knk xgjh ijrksa esa QSyus okys laøe.k esa leiuu fd;k tkrk gsa bl dk;zfof/k dks lkeku;r% lkeku; csgks'kh dh gkyr esa leiuu fd;k tkrk gs ij bls jksxh dh vka[k dh volfkk vksj jksxh ds iwjs 'kjhj dh flfkfr ds vk/kkj ij yksdy,uslfksfl;k ds rgr HkhlEiUu fd;k tkrk gsa vkwijs'ku ds ckn dh ns[khkky dk;zfof/k ds ckn vka[kksa esa ykyh] lwtu vksj nnz gks ldrk gs ftlds fy, nnz fuokjd eksf[kd nokb;ka vksj dqn vkbzmªkil fn;s tk ldrs gsa rkfd vkjke igqapsa vkwijs'ku ds ckn igys fnu] rhljs fnu] lkrosa fnu vksj fqj gjsd nks grksa ij cká jksxh foftv gksrh gsa vkidks fy, ;g le>uk t:jh gs fd lftzdy dk;zfof/k dk izkfkfed mís'; vka[kksa dh j{kk djuk vksj vka[k esa laøe.k ds QSyko dks jksduk gksrk gs] tks fd fouk'kdkjh gks ldrk gsa mi;ksxh n`f"v dh izkfir dk;zfof/k dk dsoy xks.k y{; gksrk gs ftlds fy, fjihv dkwuhzy iqu%lfkkiu lesr vfrfjdr dk;zfof/k;ksa dh,d ckj laøe.k ds fu;af=r gks tkuss ij ckn esa pydj vko';drk im+ ldrh gsa vkwijs'ku ckn dk dkslz vksj tfvyrk,a 1- LFkk;h,fiFksfy;y [kjkch lesr dkwuhzy dk?kko Hkjus esa vkuh okyh lel;k,a 2- f}rh;d Xywdksxk 3- xzkv dk udkj vksj nkrk dkfuz;k dk vksisflfqds'ku 4- <hys] VwVs gq, Vkaxksa] Vkaxs ds QksM+ks lesr Vkads ls tqm+h gqbz lel;k,a 5- xzkv esa ewyhkwr laøe.k dk fqj ls gks tkuk 6- Xyksc dh,amksfksyfefvl vksj fldqm+u & ;s eqf'dy ls gh gksrk gs jksxh ds fy, bl ckr dks le>uk cgqr t:jh gs fd vki yacs le; rd,avhck;ksfvdl] lwtu jks/kh yksdy,tsavksa] yqfczøsav~l vkfn ds :i esa dqn VkWfidy nokb;ksa dk iz;ksx djsaxs rkfd vf/kdre xzkv vksj pk{kq"k rh{.krk izkir gks ldsa blds vykok] mipkj djus okys MkWDVj ds fu.kz; ds vuqlkj fu;fer QkWyksvi ds egro dks le>uk cgqr t:jh gsa dgus dh t:jr ugha fd lqyrk dks lqfuf'pr djus ds fy, vki ns[khkky ls lfø; :i ls tqm+s gq, gsaa eq>s Åij crk;s x;s rf;ksa ls HkyhHkkafr voxr djk fn;k x;k gs vksj eq>s dk;zfof/k ds lahkko; ykhkksa vksj lahkkfor ik'oz&izhkkoksa ds ckjs esa ijke'kz fn;k tk pqdk gs vksj bu lhkh ckrksa dks dk;ns ls le>&cw> dj esaus mi;qzdr dk;zfof/k ds fy, viuh iwjh lwfpr lgefr iznku dh gsa dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... ( 93 )

100 MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 94 )

101 Automated Lamellar Therapeutic Keratoplasty (ALTK) Gaurav Prakash Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been informed in my mother tongue that I/ my child is suffering from whitening of the cornea (Corneal opacity) / corneal ectasia (keratoconus) / other disease involving anterior part of the cornea (specify...) and that a surgery to remove upto anterior, middle and deep part of the cornea (epithelium, basement membrane & upto mid stroma) will be done. A part of a donor cadaveric cornea will be used to replace this and will be placed with the help of sutures. I have been fully explained regarding the permanent nature of the opacity/ lesion and that it has to be removed to enhance vision. I have been explained the risk of perforation of the host eye, leading to the need for a full thickness corneal transplant. There is risk of infection, graft rejection, suture loosening and replacement, increased blood vessels in interface possibly leading to haemorrhage, no improvement or worsening of Best corrected visual acuity, glaucoma secondary to surgery or to medications, cataract formation and high astigmatism after surgery. There may be a need for repeat surgery which may or may not lead to improvement of vision. I have been explained the need for follow up as frequently as advised by the doctors that may span upto years, with multiple investigations at each visit. I have been explained that using medications properly is required for success of the graft. I have been explained that I will need to urgently come for follow-up to ophthalmic casualty if there is sudden onset of redness, photophobia, foreign body sensation, pain or detoriation of vision as these may be early signs of graft infection or rejection. I understand that inspite of all efforts, there is a possibility that there may be worsening of the visual acuity or the cosmetic appearance of the eye. I certify that I have fully understood the implications of the above consent and authorise the doctors to perform Automated Lamellar Therapeutic Keratoplasty on my/ my child s right / left eye. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 95 )

102 vkv esvsm Y esykj F jkiqfvd dsjkv IYkkLVh ¼,,yVhds½ x jo Ádk'k jksxh dk uke %.... mez@fyax %.... jksxh dh vkbzmh %.... rkjh[k %... dk iq=@iq=h... irk %.... VsyhQksu ua %.... eq>s esjh ekr`òk"kk esa crk;k x;k gs fd esa@esjk cppk dkfuz;k ds 'osru ¼dkfuZ;k dh vikjnf'kzrk@d fuz;yk bdvsfl;k ¼dsjkV d ul½@dkfuz;k ds vxz Òkx ¼Li"V djsa ½ esa g us oky fdlh vu; j x ls ihfm+r gs v j ;g Òh fd d fuz;k ds vxz] e/; ;k fupy fglls ¼bfifFkfYk;e] cslesav esacjsu v j e/; LV ek rd½ d fudkykus ds fyk, 'ky;fø;k dh tk,xha bls ÁfrLFkkfir djus ds fyk, nkrk ds dsmsofjd dkfuz;k ds fdlh fglls dk mi; x fd;k tk,xk v j bls Vkad a dh enn ls ÁfrLFkkfir fd;k tk,xka eq>s vikjnf'kzrk@{kfr dh LFkkbZ ÁÑfr ds ckjs esa iwjh rjg le>k;k x;k gs v j ;g Òh crk;k x;k gs fd n`f"v ¼'kfä½ c<+kus ds fyk, bls fudkykk tkuk gsa eq>s gkslv dh vka[k esa fnæ g us ds t f[ke ds ckjs esa crk;k x;k gs ftlds dkj.k iwjh e VkbZ ds dkfuz;k ds ÁR;kj i.k dh t:jr im+ ldrh gsa laøe.k] fuj i ds vlohdj.k] Vkad a ds <hykk g us v j ÁfrLFkkiu] varjkqykd esa jäokfgfu; a ds c<+ tkus ls jälzko g us] n`f"v dh rh{.krk esa d bz lq/kkj u vkus ;k Bhd dh xbz lozjs"b n`f"v rh{.krk ds v j Òh [kjkc g us tkus] 'ky;fø;k ds x.k ÁÒko ds :i esa XYkkd ek g us ds t f[ke d Òh Li"V fd;k x;k gsa nqckjk 'ky; fø;k djus dh vko';drk im+ ldrh ftlls n`f"v 'kfä c<+ Òh ldrh gs v j ugè Òh c<+ ldrha eq>s ;g Òh crk;k x;k gs fd M DVj ftruh ckj cqykk,xk eq>s mruh ckj Q Yk vi ds fyk, tkuk g xk v j ÁR;sd eqykkdkr ij cgqr&lh tkapsa djkuh im+ ldrh gsaa eq>s ;g Òh Li"V fd;k x;k gs fd ;fn vka[k vpkud YkkYk g tkrh gs] Ádk'k Òhfr g rh gs vka[k esa dqn im+s g us] nnz ;k n`f"v 'kfä ds vogzkl dh vuqòwfr g rh gs r esjk rqjar us"k fpfdrlk vkikr d{k esa Q Yk vku ds fyk, vkuk vko';d g xk D; afd ;g fuj i ds laøe.k ;k vlohdj.k dk 'kq#vkrh ladsr g ldrk gsa esa le>rk gwa fd lkjh d f'k'k a ds ckotwn laòo% gs fd vka[k dh n`f"v dh rhozrk ;k vka[k dh Álk/kd okákñfr v j Òh [kjkc g tk,a esa Áekf.kr djrk gwa fd esa mi;qzä lgefr ds fufgrkfk ± d iwjh rjg le>rk gwa] v j fpfdrld a d viuh@vius cpps dh nkb±@ckb± dh vkv esvsm Y esykj F jkiqfvd dsjkv IYkkLVh djus ds fyk, Ákf/kÑr djrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 96 )

103 Deep Anterior Lamellar Keratoplasty (DALK) Gaurav Prakash Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been informed in my mother tongue that I/ my child is suffering from whitening of the cornea (Corneal opacity) / corneal ectasia (keratoconus) / other disease involving anterior part of the cornea (specify...) and that a surgery to remove upto anterior, middle and deep part of the cornea (epithelium, basement membrane & stroma upto or just before Descemets) will be done. A part of a donor cadaveric cornea will be used to replace this and will be placed with the help of sutures. I have been fully explained regarding the permanent nature of the opacity/ lesion and that it has to be removed to enhance vision. I have been explained the risk of perforation of the host eye, leading to the need for a full thickness corneal transplant. There is risk of infection, graft rejection, suture loosening and replacement, increased blood vessels in interface possibly leading to haemorrhage, no improvement or worsening of Best corrected visual acuity, glaucoma secondary to surgery or to medications, cataract formation and high astigmatism after surgery. There may be a need for repeat surgery which may or may not lead to improvement of vision. I have been explained the need for follow up as frequently as advised by the doctors that may span upto years, with multiple investigations at each visit. I have been explained that using medications properly is required for the success of the graft. I have been explained that I will need to urgently come for follow-up to ophthalmic casualty if there is a sudden onset redness, photophobia, foreign body sensation, pain or detoriation of vision as these may be early signs of graft infection or rejection. I understand that inspite of all efforts, there is a possibility that there may be worsening of the visual acuity or the cosmetic appearance of the eye. I certify that I have fully understood the implications of the above consent and authorise the doctors to perform Deep Anterior Lamellar Keratoplasty on my / my child s right / left eye. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 97 )

104 Mhi,aVhfj;j Y esykj dsjkv IYkkLVh ¼Mh,,yds½ x jo Ádk'k jksxh dk uke %.... mez@fyax %.... jksxh dh vkbzmh %.... rkjh[k %... dk iq=@iq=h... irk %.... VsyhQksu ua %.... eq>s esjh ekr`òk"kk esa crk;k x;k gs fd esa@esjk cppk dkfuz;k ds 'osru ¼dkfuZ;k dh d fuz;yk bdvsfl;k ¼dsjkV d ul½/dkfuz;k ds vxz Òkx ¼Li"V djsa ½ esa g us oky fdlh vu; j x ls ihfm+r gs v j~ ;g Òh fd d fuz;k ds vxz] e/; ;k fupy fglls ¼bfifFkfYk;e] cslesav esacjsu v j e/; LVª ek rd½ d fudkykus ds fyk, 'ky;fø;k dh tk,xha bls ÁfrLFkkfir djus ds fyk, nkrk ds dsmsosfjd dkfuz;k ds fdlh fglls dk mi; x fd;k tk,xk v j bls Vkad a dh enn ls ÁfrLFkkfir fd;k tk,xka eq>s vikjnf'kzrk@{kfr dh LFkkbZ ÁÑfr ds ckjs esa iwjh rjg le>k;k x;k gs v j ;g Òh crk;k x;k gs fd n`f"v ¼'kfä½ c<+kus ds fyk, bls fudkykk tkuk gsa eq>s gkslv dh vka[k esa fnæ g us ds t f[ke ds ckjs esa crk;k x;k gs ftlds dkj.k iwjh e VkbZ ds dkfuz;k ds ÁR;kj i.k dh t:jr im+ ldrh gsa laøe.k] fuj i ds vlohdj.k] Vkad a ds <hykk g us v j ÁfrLFkkiu] varjkqykd esa jäokfgfu; a ds c<+ tkus ls jälzko g us] n`f"v dh rh{.krk esa d bz lq/kkj u vkus ;k Bhd dh xbz lozjs"b n`f"v rh{.krk ds v j Òh [kjkc g us tkus] 'ky;fø;k ds x.k ÁÒko ds :i esa XYkkd ek g us ds t f[ke d Òh Li"V fd;k x;k gsa nqckjk 'ky; fø;k djus dh vko';drk im+ ldrh ftlls n`f"v 'kfä c<+ Òh ldrh gs v j ugè Òh c<+ ldrha eq>s ;g Òh crk;k x;k gs fd M DVj ftruh ckj cqykk,xk eq>s mruh ckj Q Yk vi ds fyk, tkuk g xk v j ÁR;sd eqykkdkr ij cgqr&lh tkapsa djkuh im+ ldrh gsaa eq>s ;g Òh Li"V fd;k x;k gs fd ;fn vka[k vpkud YkkYk g tkrh gs] Ádk'k Òhfr g rh gs vka[k esa dqn im+s g us] nnz ;k n`f"v 'kfä ds vogzkl dh vuqòwfr g rh gs r esjk rqjar us"k fpfdrlk vkikr d{k esa Q Yk vku ds fyk, vkuk vko';d g xk D; afd ;g fuj i ds laøe.k ;k vlohdj.k dk 'kq#vkrh ladsr g ldrk gsa esa le>rk gwa fd lkjh d f'k'k a ds ckotwn laòo% gs fd vka[k dh n`f"v dh rhozrk ;k vka[k dh Álk/kd okákñfr v j Òh [kjkc g tk,a esa Áekf.kr djrk gwa fd esa mi;qzä lgefr ds fufgrkfk ± d iwjh rjg le>rk gwa] v j fpfdrld a d viuh@vius cpps dh nkb±@ckb± dh vkv esvsm Y esykj F jkiqfvd dsjkv IYkkLVh djus ds fyk, Ákf/kÑr djrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 98 )

105 Descemet s Stripping Endothelial Keratoplasty (DSEK/DSAEK) Bhavna Chawla Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been informed in the language I best understand that I am suffering from an ocular condition (specify such as Fuchs Corneal Dystrophy, trauma, previous intraocular surgery, failed graft) in which a critical number of endothelial cells (inner layer of the cornea) have been lost because of which the cornea has become swollen and cloudy. The remainder of the corneal layers, the stroma and the outer epithelium, are healthy. An operation known as Descemet s Stripping Endothelial Keratoplasty (DSEK/DSAEK) will be carried out in which a thin button of donor tissue containing the endothelial cell layer will be inserted onto the back surface of my eye. Advantages of DSEK over full thickness corneal transplantation are that it is faster to perform, the wound is smaller, more stable and less likely to break open from inadvertent trauma. Because the technique requires very few sutures, there is negligible postoperative astigmatism which can otherwise delay visual recovery. Since only the thin inner layer of the cornea is replaced, over 90% of the patient s own cornea remains behind contributing to greater structural integrity and a reduced incidence of rejection. Risks and complications of DSEK/DSAEK These include general risks similar to those of a full thickness corneal transplantation such as hemorrhage in the eye, infection, a retinal detachment, rejection of the transplanted tissue, chronic inflammation, double vision, loss of corneal clarity, no improvement in vision or worsening of BCVA, glaucoma secondary to surgery or to medications and cataract formation. Risks specific to DSEK include displacement of the thin button of endothelium within the first few days or weeks after surgery requiring a repeat surgery to reposition it. If the DSEK operation fails, the operation can be repeated with another button of donor endothelium. Alternatively, a traditional corneal transplant operation can also be performed. Repeat surgery may or may not lead to improvement of vision. Other complications from the local anesthesia include perforation of the eyeball, damage to the optic nerve, a droopy eyelid, interference with the circulation of the blood vessels in the retina, respiratory depression, and hypotension. I have been explained the need for follow up as frequently as advised by the doctors that may span upto years, with multiple investigations at each visit. I have been explained that using medications properly is essential for the success of the graft. I have been explained that I will need to urgently come for follow-up to ophthalmic casualty if there is a sudden onset redness, photophobia, pain or deterioration of vision as these may be early signs of graft infection or rejection. I understand that there may be other unexpected risks or complications that can occur that are not listed here. I also understand that during the course of the proposed operation, unforeseen conditions may be revealed that require the performance of additional procedures, and I authorize such procedures to be performed. I further acknowledge that no guarantees or promises have been made to me concerning the results of any procedure or treatment. This consent form has also educated me about the various options available to me. I certify that I have fully understood the implications of the above consent and authorize the doctors to perform endothelial keratoplasty on my right / left eye. ( 99 )

106 Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 100 )

107 MhLlhesV~l flvªfiax bam F fyk;yk dsjkv IYkkLVh ¼Mh,lbZds@Mh-,l-,-bZ-ds½ Òkouk pkoykk jksxh dk uke %.... mez@fyax %.... jksxh dh vkbzmh %.... rkjh[k %... dk iq=@iq=h... irk %.... VsyhQksu ua %.... eq>s ml Òk"kk esa ftls esa lcls vpnh rjg le>rk gwa lwfpr fd;k x;k gs fd esa vka[k dh fdlh volfkk ¼Li"V djsa tsls QqDl dkfuz;yk fmlvª Qh]?kko] iqjkuh var% us"kh; 'ky;fpfdrlk] vlqyk fuj i½ ls ihfm+r gwa ftlesa egroiw.kz la[;k esa dkfuz;k dh bam ffkfyk;eh d f'kdk,a u"v g xbz gsa ftlds dkj.k dkfuz;k esa lwtu vk xbz gs v j og efyku g xbz gsa dkfuz;k dh ' "k ijrsa] LVª ek v j ckgjh bfiffkfyk;eh d f'kdk,a LoLFk gsaa,d 'ky;fø;k dh tk,xh ftls fmllsesv~l flvªfiax bam ffkfyk;yk dsjsv IYkkLVh dgk tkrk gs] ftlesa bfiffkfyk;eh d f'kdkv a dh ijr ;qä nkrk ds Ård a dk,d irykk lk cvu esjh vka[k ds ihns dh lrg ds Òhrj?kqlk fn;k tk,xka iwjh e VkbZ ds dkfuz;k ds ÁR;kj i.k dh rqykuk esa Mh,lbZds dk YkkÒ ;g gs fd?kko N Vk g rk gs] ;g vf/kd fvdkå v j vlko/kkuh ls Ykxus okykh p V ls blds VwVus dk [krjk de jgrk gsa pwafd bl rduhd esa Vkads cgqr de Ykxkus im+rs gsa blfyk, 'ky;fø;k ds ckn dk n`f"vos"ke; u ds cjkcj g rk gs t vu;fkk n`f"v ds iquykkzò esa nsj dj ldrk gsa pwafd dkfuz;k dh dsoyk irykh lh Òhrjh ijr dk ÁR;kj i.k fd;k tkrk gs] blfyk, 90% ls vf/kd j fx; a dk dkfuz;k ihns cuk jgrk gs t vf/kd lajpukred v{krrk Ánku djrk gs v j vlohdj.k dh?kvukv a d de dj nsrk gsa Mh,lbZds@Mh,l,bZds ds t f[ke v j tfvykrk,a buesa vka[k esa jälzko] laøe.k] jsfvuk dk foykxko] ÁR;kj if.kr Ård a dk vlohdj.k] iqjkuk Ánkg] nqgjh n`f"v] d fuz;k dh Li"rk dk vòko] n`f"v 'kfä esa d bz lq/kkj u g uk ;k chlhoh, dk v j Òh [kjkc g tkuk] 'ky;fø;k ;k mipkj ds x.k ÁÒko ds :i esa e fr;kfcan ;k XYkkd ek ;k e fr;kfcan ds cuus tsls iwjh e VkbZ ds dkfuz;yk ÁR;kj i.k tsls lkeku; t f[ke 'kkfeyk g srs gsaa Mh,lbZds ds fof'k"v t f[ke a esa ÁkjaÒ ds dqn gh fnu a ;k gr a ds Òhrj bam ffk;e dh irykh cvu dk viuh txg ls f[kld tkuk 'kkfeyk gs ftls mldh txg ij j[kus ds fyk, nqckjk 'ky;fø;k djuh im+rh gsa ;fn Mh,lbZds ÁfØ;k vlqyk g tkrh gs r nkrk ds bam ffkfyk;e ds nwljs cvu ds lkfk nqckjk 'ky;fø;k djuh im+ ldrh gsa vu;fkk] dkfuz;k ds ÁR;kj i.k dh ijaijkxr 'ky;fø;k Òh dh tk ldrh gsa nqckjk 'ky;fø;k djus ls vka[k a dh n`f"v esa lq/kkj g Òh ldrk gs v j ugè ÒhA LFkkfud laosnukgj.k ls g us okykh vu; tfvykrkv a esa us"kx Ykd esa fnæ] n`d~ raf"kdkv a d {kfr] >qdh iykdsa] jsfvuk dh jäokfgfu; a esa jä Áokg esa O;o/kku] 'olu laca/kh volkn] v j fueu jä pki 'kkfeyk gsaa eq>s Li"V :i ls crk;k x;k gs fd eq>s fpfdrld a ds lq>k, vuqlkj ckj&ckj Q Yk vi ds fyk, vkuk g xk t o"k ± pyk ldrk gs v j ÁR;sd eqykkdkr ij cgqr&lh tkapsa djkuh g axha eq>s crk;k x;k gs fd fuj i dh lqykrk ds fyk, lgh <ax ls nokv a dk mi; x vfuok;z gsa eq>s crk;k x;k gs fd ;fn vka[k vpkud YkkYk g tkrh gs] Ádk'k Òhfr] vka[k esa dqn im+s g us] nnz ;k n`f"v 'kfä ds vogzkl dh vuqòwfr g rh gs r esjk rqjar us"k fpfdrlk vkikr~ d{k esa Q Yk vi ds fyk, vkuk vko';d g xk D; afd ;g fuj i ds laøe ;k vlohdj.k dk ÁkjafÒd Yk{k.k g ldrk gsa esa le>rk gwa fd vu; vuisf{kr t f[ke v j tfvykrk,a g ldrh gsa ftudh lwph ;gka ugè nh xbz gsa esa ;g Òh le>rk gwa fd ÁLrkfor 'ky;fø;k ds n jku vár;kf'kr volfkkv a dk irk pyk ldrk gs ftuds fyk, vfrfjä ÁfØ;k,a djus dh vko';drk im+ ldrh gs v j bl rjg dh ÁfØ;k,a djus dk vf/kdkj Ánku djrk gwaa esa ;g Òh Lohdkj djrk gwa fd eq>ls fdlh Òh ÁfØ;k ;k mipkj ds ifj.kke ds ckjs esa fdlh rjg dh xkjavh ;k okns ugè fd, x, gsaa bl lgefr Ái= us eq>s nwljs miykc/k fodyi a ds fyk, eq>s f'kf{kr fd;k gsa esa Áekf.kr djrk gwa fd esaus mi;qzä lgefr fufgrkfk ± d vpnh rjg le> fyk;k gs v j viuh nkb±@ckb± vka[k esa bam ffkfyk;eh dsjkv IYkkLVh djus dk Ákf/kdkj nsrk gwaa ( 101 )

108 dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 102 )

109 Phototherapeutic Keratectomy (PTK) Chandrashekhar Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... Patient Consent In giving my permission for excimer laser surgery, I understand the following: 1. The surgical removal of the superficial layers of my cornea using the excimer laser has been elected by me as an alternative to other forms of corneal surgery. 2. As with all surgery, I understand the results cannot by guaranteed. 3. I understand that my vision may be made worse by this procedure. Complications could include: Loss of sharp vision, increased corneal scarring, increased night glare or corneal infection. Any pre-existing viral infections may reappear with the use of postoperative drops. If the cornea has extensive scars, it is possible that a corneal perforation may occur that could produce other changes such as infections, cataracts or the need for additional surgery. I understand that I must be examined closely to ensure proper healing of the treated eye. 4. I understand Phototherapeutic Keratectomy (PTK) with the excimer laser may increase my need for glasses and may require the use of corrective lenses to achieve my best vision. 5. I understand that although sharper vision and less glare are anticipated, it is possible that glare and clarity may be made worse following this procedure. 6. I understand that for those severe corneal problems, where the surgical option for me is a corneal transplant, excimer laser PTK may not eliminate the need for a corneal transplant. 7. I understand it is impossible to state every possible complication that may occur as a result of this surgical procedure. 8. I understand that not all the beneficial effects of PTK are currently known. 9. I also understand that all the risks and complications are not known. 10. I acknowledge this disclosure of information has been made to me and that all my questions have been answered to my satisfaction. I have read this form (or it has been read to me) and I fully understand the complications, risks and benefits that can result from PTK Surgery. I realize there are no guarantees with PTK Surgery. I still however elect to have PTK laser treatment in my R/L / both eye(s). Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... ( 103 )

110 Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 104 )

111 Q V F jki;qfvd dsjkvsdv eh ¼ihVhds½ paæ' [kj jksxh dk uke %.... mez@fyax %.... jksxh dh vkbzmh %.... rkjh[k %... dk iq=@iq=h... irk %....VsyhQksu ua %.... j xh dh lgefr,dllkbej Y tj 'ky;fø;k djus dh vuqefr% 1- esaus,dllkbej Y tj dk mi; x djds viuh d fuz;k dh Åijh ir ± ds 'ky;fø;kred fu"dklu d d fuz;k dh 'ky;fø;k ds nwljs :i a ds fodyi ds :i esa pquk gsa 2- esa le>rk gwa fd nwljh lòh 'ky;fø;kv a dh rjg ifj.kke a dh xkajvh ugè nh tk ldrha 3- esa le>rk gwa fd bl ÁfØ;k ls esjh n`f"v v j Òh [kjkc g ldrh gsa tfvykrkv a esa n`f"v rh{.krk dk gzkl] of/kzr dkfuz;yk oz.kfpkug] vkof/kzr jkf"k p a/k] ;k dkfuz;k dk laøe.k 'kkfeyk gsaa 'ky;fø;k ds ckn vka[k esa VidkbZ tkus okykh nokv as ds mi; x ls igy ls e twn d bz fo"kk.kq laøe.k nqckjk mòkj dj ldrk gsa ;fn dkfuz;k esa cgqr ls oz.kfpug gsa r dkfuz;k esa fnæ g ldrk gs t laøe.k] e fr;kfcan tsls nwljs ifjorzu Ykk ldrk gs v j vfrfjä 'ky;føz;k dh vko';drk im+ ldrh gsa esa le>rk gwa fd ;g lqfuf'pr djus ds fyk, mipkfjr vka[k dk?kko,d lgh <ax ls Òjs] ckjhdh ls esjh tkap dh tkuh pkfg,a 4- esa le>rk gwa fd,dlkbe Y tj ls Q V F jki;qfvd dsjkvsdv eh ¼ihVsds½ p'es] dh esjh vko';drk c<+k ldrh gs v j esjh vf/kdre n`f"v ds fyk, lq/kkjd Y al a dh vko';drk im+ ldrh gsa 5- esa le>rk gwa fd gkykkafd vis{kkñr rh{.k n`f"v v j de p a/k visf{kr gs Y fdu ;g Òh laòo gs fd bl ÁfØ;k ds ckn p a/k v j n`f"v n u a v j Òh [kjkc g tk,aa 6- esa le>rk gwa fd dkfuz;k dh mu xaòhj lel;kv a ds fyk,] ftuds fyk, esjs fyk, dkfuz;k ds ÁR;kj i.k dk fodyi miykc/k gs],dllkbej Y tj ihdsvh dkfuz;k ds ÁR;kj i.k dh vko';drk [kre u dj ldsa 7- esa le>rk gwa fd bl 'ky;fø;kred ÁfØ;k ds QYkLo:i g us okykh ÁR;sd tfvykrk dk o.kzu dj ikuk vlaòo gsa 8- esa le>rk gwa fd ihdsvh ds lòh ykònk;d ÁÒko vòh Kkr ugè gsaa 9- esa ;g Òh le>rk gwa fd lòh t f[ke v j tfvykrk,a Kkr ugè gsaa 10- esaus ;g QkseZ i<+ fyk;k gs ¼;k bls i<+ dj eq>s lquk;k x;k gs½ v j esa ihdsvh 'ky;fø;k dh lòh tfvykrkv a] t f[ke a v j YkkÒ a d iwjh rjg le>rk gwaa esa le>rk gwa fd ihdsvh 'ky;fø;k dh d bz xkjavh ugè gsa esa fqj Òh viuh nkb±@ckb± vka[k@n u a vka[k a dh ihdsvh Y tj fpfdrlk djkus dk pquko djrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... ( 105 )

112 MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 106 )

113 Photorefractive Keratectomy (PRK) Chandrashekhar Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... In giving my permission for PRK, I understand the following: The long-term risks and effects of PRK surgery are unknown. The goal of PRK with the excimer laser is to reduce dependence upon or need for contact lenses and/or eyeglasses; however, I understand that as with all forms of treatment, the results in my case cannot be guaranteed. For example: 1. I understand that an overcorrection or undercorrection could occur, causing me to become farsighted or nearsighted or increase my astigmatism and that this could be either permanent or treatable. I understand an overcorrection or undercorrection is more likely in people over the age of 40 years and may require the use of glasses for reading or for distance vision some or all of the time. 2. If I currently need reading glasses, I will likely still need reading glasses after this treatment. It is possible that dependence on reading glasses may increase or that reading glasses may be required at an earlier age if I have PRK surgery. 3. Further treatment may be necessary, including a variety of eye drops, the wearing of eyeglasses or contact lenses (hard or soft), or additional PRK or other refractive surgery. 4. My best vision, even with glasses or contacts, may become worse. 5. There may be a difference in spectacle correction between eyes, making the wearing of glasses difficult or impossible. Fitting and wearing contact lenses may be more difficult. 6. I have been informed, and I understand, that certain complications and side effects have been reported in the post-treatment period by patients who have had PRK, including the following: A. Possible short-term effects of PRK surgery: The following have been reported in the short- term post treatment period and are associated with the normal post-treatment healing process: mild discomfort or pain (first 72 to 96 hours), corneal swelling, double vision, feeling something is in the eye, ghost images, light sensitivity, and tearing. B. Possible long-term complications of PRK surgery: Haze: Loss of perfect clarity of the cornea, usually not affecting vision, which usually resolves over time. Starbursting: After refractive surgery, a certain number of patients experience glare, a starbursting or halo effect around lights, or other low-light vision problems that may interfere with the ability to drive at night or see well in dim light. Although there are several possible causes for these difficulties, the risk may be increased in patients with large pupils or high degrees of correction. For most patients, this is a temporary condition that diminishes with time or is correctable by wearing glasses at night or taking eye drops. For some patients, however, these visual problems are 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 or take eye drops. I understand that it is not possible to predict whether I will experience these night vision or low light problems, and that I may permanently lose the ability to drive at night or function in dim light because of them. I understand that I should not drive unless my vision is adequate. These risks in relation to my particular pupil size and amount of correction have been discussed with me. LossofBestVision: A decrease in my best vision even with glasses or contacts. IOP Elevation: An increase in the inner eye pressure due to post-treatment medications, which is usually resolved by drug therapy or discontinuation of post-treatment medications. Mild or severe infection: Mild infection can usually be treated with antibiotics and usually does not lead to permanent visual loss. Severe infection, even if successfully treated with antibiotics, could lead to permanent scarring and loss of vision that may require corrective laser surgery or, if very severe, corneal transplantation. Keratoconus: 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 ( 107 )

114 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. C. Infrequent complications. The following complications have been reported infrequently by those who have had PRK surgery: itching, dryness of the eye, or foreign body feeling in the eye; double or ghost images; patient discomfort; inflammation of the cornea or iris; persistent corneal surface defect; persistent corneal scarring severe enough to affect vision; ulceration/ infection; irregular astigmatism (warped corneal surface which causes distorted images); cataract; drooping of the eyelid; loss of bandage contact lens with increased pain (usually corrected by replacing with another contact lens); and a slight increase of possible infection due to use of a bandage contact lens in the immediate post-operative period. I understand there is a remote chance of partial or complete loss of vision in the eye that has had PRK surgery. I understand that it is not possible to state every complication that may occur as a result of PRK surgery. I also understand that complications or a poor outcome may manifest weeks, months, or even years after PRK surgery. I understand this is an elective procedure and that PRK surgery is not reversible. For women only: I am not pregnant or nursing. I understand that pregnancy could adversely affect my treatment result. I have spoken with my physician, who has explained PRK, its risks and alternatives, and answered my questions about PRK surgery. I therefore consent to having PRK surgery on: Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 108 )

115 Q V fjýsfdvo dsjkvsdv eh ¼ihvkjds½ paæ'ks[kj jksxh dk uke %.... mez@fyax %.... jksxh dh vkbzmh %.... rkjh[k %... dk iq=@iq=h... irk %....VsyhQksu ua %.... ihvkjds ds fyk, viuh vuqefr nsrs le; esa fueufykf[kr d le>rk gwa% ihvkjds 'ky;fpfdrlk ds nh?kzdkfykd t f[ke v j ÁÒko vkkr gsaa,dllkbej ds lkfk ihvkjds dk Yk{; dkavsdv Y al a ;k p'es ij fuòzjrk;k vko';drk de djuk gsa cgjgkyk] esa le>rk gwa fd tslk fd lòh rjg ds mipkj a ds lkfk g rk gs] esjs ekey esa ifj.kke dh xkjavh ugè nh tk ldrha mnkgj.k ds fyk,% 1- esa le>rk gwa fd vfr la'k /ku ;k vyi la'k /ku g ldrk gs ftlesa esa fudv n`f"vn "k ;k nwj n`f"vn "k dk f'kdkj g ldrk gwa ;k esjk n`f"v os"ke; c<+ ldrk gs v j ;g Òh fd ;g vlfkk;h ;k mipkj; X; g ldrk gsa esa le>rk gwa fd 40 lkyk ls Åij ds Yk x a esa vfrla'k /ku ;k vyila'k /ku dh laòkouk vf/kd jgrh gs v j cgqr a d i<+us ds fyk, ;k dh n`f"v ds fyk, dqn le; ds fyk, ;k gj le; ds fyk, p'es dh vko';drk g rh gsa 2- ;fn bl le; eq>s i<+us ds fyk, p'es dh vko';drk gs r g ldrk gs fd eq>s mipkj ds ckn Òh p'es dh t:jr im+sa 3- laòo gs fd ;fn esa ihvkjds 'ky; fpfdrlk djkrk gwa r i<+us ds p'es ij fuòzjrk v j c<+ tk, ;k de mez esa p'es dh t:jr im+ ldrh gsa 4- esjh lozjs"b n`f"v] p'es ;k dkavsdv Y al a ds ckn Òh [kjkc g ldrh gsa 5- vka[k a ds chp p'es ds lq/kkj esa varj g ldrk gs] ftlls vka[k a dk p'ek Ykxkuk dfbu ;k vlaòo g ldrk gsa dkavsdv Y al Ykxkuk ;k iguuk vf/kd dfbu g ldrk gsa 6- eq>s lwfpr fd;k x;k gs] v j esa le>rk gwa fd ihvkjds djkus oky j fx; a esa mipkj Ùkj vof/k esa fueufykf[kr lfgr dqn tfvykrkv a v j nq"áòko a dh fji Vs± vkbz gsa%,- ihvkjds 'ky; fpfdrlk ds laòkfor vyidkykhu ÁÒko% mipkj Ùkj vof/k esa fueufykf[kr dh fji Vs± vkbz gsa v j mùkj ipkj dh lkeku; YkkÒdkjh ÁfØ;k ls tqm+h gsaa gydk d"v ;k nnz ¼igY 72 ls 96?kaVs½ dkfuz;k dh lwtu] nqgjh n`f"v] vka[k esa dqn im+s g us dh vuqòwfr] vkòklh Áfrfcac] Ádk'k ds Áfr laosnu'khykrk] v j vkalw vkuka ch- ihvkjds dh laòkfor nh?kzdkfykd tfvykrk,a%?kqa/k% d fuz;k dh iwjh Li"Vrk dk vòko] t vker j ij n`f"v d ÁÒkfor ugè djrk] v j lkeku;r;k le; ds lkfk vius&vki Bhd g tkrk gsa rkjkfolq V% viorzd 'ky; fpfdrlk ds ckn j fx; a dh,d fuf'pr rknkn p a/k] Þrkjk folq Vß ;k Ádk'k ds fxnz ÁÒkeaMYk ;k dqn j xh de j 'kuh esa ns[kus dh lel;k vuqòo djrs gsa t jkr esa okgu pykkus ;k /kqa/kykh j 'kuh esa vpnh rjg ns[k ikus dh lel;k isnk djrh gsa gkykkafd bu ijs'kkfu; a ds cgqr ls laòkfor dkj.k g ldrs gsaa Y fdu cm+h iqrfyk; a oky ;k mpp va'k a ds la'k /ku ds f'kdkj j fx; a esa t f[ke c<+ tkrk gsa vf/kdrj j fx; a ds fyk, ;g vlfkk;h volfkk g rh gs t le; ds lkfk Bhd g tkrh gs ;k p'es Ykxkuk ;k vka[k esa Vidkus okykh nok ls Bhd g ldrh gsa Y fdu dqn ejht a ds fyk, n`f"v laca/kh ;s lel;k,a LFkk;h g rh gsaa esa le>rk gwa fd g ldrk gs fd esjh utj jkr esa fnu ftruh rst ugè Árhr g v j ;g Òh fd eq>s jkr esa p'ek Ykxkus ;k vka[k esa Vidkus okykh nok Y uh im+sa esa le>rk gwa fd bldh Òfo";ok.kh djuk laòo ugè gs fd esa jkr dh ;k de j 'kuh dh ;s lel;k,a vuqòo d:axk ;k ugè] v j ;g Òh fd muds dkj.k esa jkr esa okgu pykkus ;k de j 'kuh esa dke djus dh lkef;z LFkk;h :i ls [k ldrk gwaa esa le>rk gwa fd esjh n`f"v i;kzir u g r eq>s okgu ugè pykkuk pkfg,a esjh vka[k dh iqrykh dh fo' "k eki v j lq/kkj dh ek"kk laca/kh bu t f[ke a ds ckjs esa esjs lkfk ppkz dh xbz gsa lozjs"b n`f"v dk gzkl% p'es v j dkavsdv Y al ds ckotwn esjh lozjs"b n`f"v esa deha vkbzv ih dk cguk% mipkj Ùkj nh tkus okykh nokv a ds dkj.k vka[k ds vkarfjd ncko esa o`f) g ldrh gs] t lkeku;r;k v "kf/k mipkj ;k mipkj Ùkj nokv a ds can djus ls Bhd g tkrk gsa gydk ;k xaòhj laøe.k% gyds laøe.k dk lkeku;r;k,avh c ; fvdl ls bykkt fd;k tk ldrk gs v j lkeku;r;k muls n`f"v dh dklfkk;h gzkl ugè g rka xaòhj laøe.k] pkgs,savhc ; fvdl ls lqykrkiwozd mudk mipkj g Òh tk, rc Òh LFkk;h oz.kfpug N M+ ldrs gsa v j n`f"v gzkl isnk dj ldrs gsa ftlds fyk, lqjk/kkred Y tj 'ky;fø;k dh vko';drk g rh gs] ;k cgqr xaòhj g us ij dkfuz;k ds ÁR;kj i.k dh t:jr im+ ldrh gsa dsjkv d ul% dqn j fx; a esa n`f"v d ÁÒkfor djus okykk dkfuz;k dk,d {k;dkjh j x dsjkvsd ul fodflr g tkrk gsa ;g j x vke ( 109 )

116 lh- vkcknh esa 2000 esa ls fdlh,d O;fä d g rk gsa gkykkafd dbz tkapsa gsa t crk ldrh gsa fd d u&ls j xh d bldk t f[ke g ldrk gs] Y fdu ;g volfkk mu j fx; a esa Òh fodflr g ldrh gs] 'ky;fø;k ls igy ftudh V i xzkqh ¼'kY;fØ;k ds igy rs;kj fd;k tkus okykk d fuz;k dk ud'kk½ v j isfdesvªh ¼d fuz;k dh e VkbZ dh eki½ lkeku; g rh gsa pwafd dsjkv d ul vius vki g ldrk gs] blfyk, ;g lqfuf'pr djkus okykh d bz iq[rk tkap ugè gs fd j xh esa Y tj n`f"v la'k /ku ds ckn dsjkv d ul fodflr ugè g xka xaòhj dsjkv d ul ds mipkj ds fyk, d fuz;k ds ÁR;kj i.k dh t:jr im+ ldrh gs tcfd gydk dsjkv d ul p'es ;k d VSDV Y al a ls Bhd g ldrk gsa vákf;d tfvykrk,aa ihvkjds 'ky;fø;k djkus okyk a us fueufykf[kr vákf;d tfvykrkv a dh lwpuk nh gs% [kqtykh vka[k dk lw[kkiu( ;k vka[k esa fdlh ckgjh pht ds im+s g us dh vuqòwfr( nqgjs ;k vli"v Áfrfcac] j xh d d"v( d fuz;k ;k vkbfjl dk Ánkg( dkæu;k dh lrg dh fpj LFkk;h foñfr( dkfuz;k ij n`f"v d ÁÒkfor djus ds fyk, i;kzir LFkk;h o`.k fpug(?kko@laøe.k( vfu;fer n`f"v os"ke; ¼dkfuZ;k dh <adh gqbz lrg t Áfrfcac a d fo:fir dj nsrh gs½( e fr;kfcan( iykd a dk >qdko( nnz c<+ tkus ds lkfk csamst dkavsdv Y al dh {kfr ¼t lkeku;r;k nwljk dkavsdv Y al Ykxkus ls Bhd g tkrh gs½( v j 'ky;fø;k ds ckn dh vof/k esa csamst dkavsdv Y al ds mi; x ds dkj.k laøe.k dh laòkouk esa ekewykh o`f)a esa le>rk gwa fd ftl vka[k esa ihvkjds 'ky;fø;k gqbz Fkh mlds vkaf'kd ;k iw.kz n`f"v gzkl dh gydh lh laòkouk jgrh gsa esa le>rk gwa fd ihvkjds 'ky;fø;k ds ifj.kke Lo:i g us okykh lòh tfvykrkv a dk Li"Vhdj.k laòo ugè gsa esa ;g Òh le>rk gwa fd ihvkjds 'ky;fø;k ds g r a] eghu a ;k o"k ± ckn Òh tfvykrk,a ;k [kjkc urhts lkeus vk ldrs gsaa esa le>rk gwa fd ;g fuokzfpr ÁfØ;k gs v j ihvkjds 'ky;fø;k fjozfloy ugè gsa dsoyk efgykkv a ds fyk,% esa xòzorh ugè gwa ;k Lruiku ugè djk jgh gwaa esa le>rh gwa fd xòz esjs mipkj ds ifj.kke a d ÁfrdwYk :i ls ÁÒkfor dj ldrk gsa esaus vius fpfdrld ls ckr dj Ykh gs ftlus ihvkjds] blds t f[ke a v j fodyi a d Li"V fd;k gs v j ihvkjds 'ky;fø;k laca/kh esjs Á'u a ds mùkj fn, gsaa blfyk, esa ihvkjds 'ky;fø;k djus dh lgefr nsrk gwa% jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 110 )

117 LASIK Prakashchand Agarwal, Reena Sharma Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... LASIK reshapes the cornea, it involves raising a thin flap of corneal tissue using a blade/ femtosecond laser and remodelling of corneal shape using excimer laser. During the procedure the patient is required to fix his / her gaze at the blinking light, to ensure proper centration. Clicking sound is heard and a smell similar to that of charring of hair is perceived. Expected Benefits I understand the purpose of LASIK is to reduce short sightedness, long sightedness and /or astigmatism to provide me much better unaided vision that I presently have without spectacles or/ and contact lenses. However I understand that an excellent unaided vision may not be guaranteed Alternative Treatments I understand that continuous use of spectacles and / or contact lenses can provide excellent vision and LASIK is an alternative to decrease the dependence on spectacles and / or contact lenses. Possible Side Effects, Risks and Complications Undercorrection or Over Correction I understand that calculations used in this surgery are based on previous experience on large number of patients and they use average values. Thus depending on the individual variations in response to the procedure, there might be some undercorrection or over correction. As a result, I may require some spectacles to achieve best possible vision for distance and /or near. If treatment may be required, a period of 6 months must elapse between it and the original surgery. Presbyopia I understand that as I get older (45 yrs or older), there is a likelihood of requiring spectacles for reading which is based on natural age related changes in the eye on which there is no direct bearing of the LASIK procedure. Decrease of Best Corrected Vision I understand that post-lasik, best spectacle correction may not be as good as before the procedure. Glare, Starbursts and Double Vision These may occur, more so in the first 24 hours. In most cases, they disappear in 1-4 weeks. Rare Complications Infection, inflammation, corneal oedema, loss or damage to the corneal flap. Long Term Changes There may be alteration in power requiring spectacles or contact lenses. ( 111 )

118 Technical Failure It may lead to abandoning the procedure and performing a repeat procedure at a later date. I certify that I have fully understood the implications of the above consent and authorize the doctors to perform the procedure on my R/ L Eye. I have had all the questions answered to my satisfaction. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 112 )

119 Ykkfld Ádk'kpan vxzokyk] jhuk 'kekz jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... Ykkfld d fuz;k d fqj ls x<+rh gs] blds varxzr fdlh CY M@QseV lsdam Y tj dk mi; x djds d fuz;k ds Ård a ds,d iry iís d mbk;k tkrk gs v j,dllkbej Y tj dk mi; x djds d fuz;k d fqj ls x<+k tkrk gsa mfpr,dkxzrk lqfuf'pr djus ds fyk, j xh d ÁfØ;k ds n jku j xh d tykrh&cq>rh j 'kuh ij viuh utj fvdk, j[kuh g rh gsa fvd&fvd dh vkokt vkrh gs v j ckyk a ds tykus tslh xa/k dh vuqòwfr g rh gsa visf{kr YkkÒ esa le>rk gwa fd Ykkfld dk mìs'; fcuk p'es ;k dkavsdv Y al a ds esjh orzeku n`f"v ls csgrj vleæfkr n`f"v Ánku djus ds fyk, nwjn`f"v n "k] fudv n`f"vn "k v j@;k n`f"vos"ke; d de djuk gsa cgjgkyk esa le>rk gwa fd mrñ"v vleæfkr n`f"v dh xkjavh ugè nh tk ldrha osdfyid mipkj esa le>rk gwa fd Ykxkrkj p'es v j@;k dkavsdv Y al a dk mi; x eq>s mrñ"v n`f"v Ánku dj ldrk gsa v j Ykkfld p'es ;k dkavsdv Y al a ij fuòzjrk de djus dk,d fodyi gsa laòkfor nq"áòko t f[ke v j tfvykrk,a vyi la'k /ku ;k vfr la'k /ku esa le>rk gwa fd bl 'ky;fø;k esa Á;qä g us oky vkdyku ejht a dh cm+h la[;k ds finy vuqòo a ij vk/kkfjr g rs gsa v j Yk x v lr eku a dk mi; x djrs gsaa blfyk, ÁfØ;k ds Áfr vuqfø;k esa O;fäxr fofòérkv a ds vk/kkj ij dqn vyila'k /ku ;k vfrla'k /ku g ldrs gsaa urhtru eq>s lozjs"b laòkfor nwj@;k fudv n`f"v ÁkIr djus ds fyk, dqn p'es dh t:jr im+ ldrh gsa ;fn mipkj dh vko';drk gqbz r ewyk 'ky;fø;k v j mipkj ds chp 6 eghus dk varj vo'; g uk pkfg,a çslok;ksfi;k esa le>rk gwa fd esa tsls&tsls esjh mez ¼45 lkyk ;k mlls vf/kd½ c<+rh tk;sxh] i<+us ds fyk, p'es dh vko';drk im+ ldrh gsa t vka[k esa mez ls lacaf/kr ÁkÑfrd cnykko a ij vk/kkfjr g rk gs v j ftldk Ykkfld ÁfØ;k ls d bz lh/kk laca/k ugè g rka lozjs"b la'k f/kr n`f"v esa deh esa le>rk gwa fd Ykkfld ds ckn p'es ls la'k f/kr lozjs"b n`f"v ÁfØ;k ls igy dh esjh n`f"v ls vpnh ugè Òh g ldrha p a/k] rkjk folq V v j n gjh n`f"v ;s g ldrs gsa] 'kq#vkrh 24?kaVs ds Òhrj,slk g us dh laòkouk vf/kd jgrh gsa vf/kdrj ekeyk a esa 1&4 g rs ds Òhrj [kre g tkrs gsaa nqykzò tfvykrk,a laøe.k] Ánkg] d fuz;k dh lwtu] dkfuz;k dh iíh dk {k; ;k {kfra nh?kzdkfykd ifjorzu vko';d p'es ;k dkavsdv Y al a ds ikoj esa ifjorzua ( 113 )

120 rduhdh vlqykrk bldh otg ls ÁfØ;k N M+us v j vkxs fdlh frffk ij nqckjk djus dh t:jr im+ ldrh gsa esa Áekf.kr djrk gwa fd esaus mi;qä lgefr ds fugrkfk ± d iwjh rjg le> fyk;k gs v j fpfdrld a d nkb±@ckb± vka[k ij ;g ÁfØ;k djus dk vf/kdkj nsrk gwaa eq>s esjs lòh Á'u a ds lar "ktud mùkj fn, x, gsaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 114 )

121 Astigmatic Keratotomy (AK) Asim K. Kandar Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... Introduction Astigmatic keratotomy (AK) is a surgical procedure which consists of making fine microscopic arcuate (curved) incisions, either singly or as a pair, at optical zones of either 6 or 7 mm, or relaxing incisions at the limbus, which is the junction of the clear part of the eye (cornea) with the white (sclera) of the eye. These cuts are made for the purpose of flattening the steepest part of the cornea in an attempt to obtain a more spherical cornea. AK permanently changes the shape of the cornea. Although the goal of AK is to improve vision to the point of not wearing glasses, this result is not guaranteed. AK 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 that 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. Alternatives to AK If you decide not to have AK, there are other methods of correcting your astigmatism. These alternatives include, among others, eyeglasses, contact lenses, and other refractive surgical procedures such as PRK or LASIK. Patient Consent I give my consent to my ophthalmologist to perform AK, and I declare that I have received no guarantee as to the success of my particular case. I understand that the following risks are associated with the procedure: Potential Risks and Complications 1. I understand that there is a possibility that my vision may not improve with this surgery or that the desired results of surgery may not be obtained. It is possible that I may require additional surgery at a later date or that I could still need glasses after surgery. It is possible that I may not be able to wear contact lenses after having this surgery. 2. As a result of the surgery, it is possible that I could lose vision or best-corrected vision. This could happen as a result of infection that could not be controlled with antibiotics or other means, which could even cause loss of my eye. 3. Irregular healing of incisions may cause the corneal surface to be distorted. In that case, it may be necessary for me to wear a contact lens to affect useful vision, and there is a possibility that this may not restore useful vision. 4. I understand that I may experience incapacitating light sensitivity from sunlight or other bright light sources for a varying length of time, or possibly permanently. 5. I understand that I may experience incapacitating glare or halos from oncoming headlights or other bright light sources, particularly in the evening or at nighttime, for a varying length of time or possibly permanently. I am aware that this may interfere with driving for an indefinite period both during day and night, and I understand that I am not to drive until I am certain that my vision is adequate both during day and night. 6. I understand that fluctuations or variation in vision may occur during the day during the initial stabilization period (up to three months or longer). 7. As occurs in all surgical procedures, scarring is the result of making incisions in living tissue. This particular surgery is no exception. 8. My eye will be more susceptible to a blow to the eye during the healing phase and possibly somewhat after healing as the microscopic scar tissue may not be as strong as the normal tissue. Protective eyewear is recommended for all contact and racquet sports where a direct blow to the eye could cause permanent injury to the eye. ( 115 )

122 9. Additional reported complications include corneal perforation, which could possibly require sutures; incisional inclusions, corneal vascularization, corneal ulcer formation, endothelial cell loss, epithelial healing defects, and very rarely, endophthalmitis (internal infection of the eye, which could lead to permanent loss of vision). 10. 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. Patient s Statement of Acceptance and Understanding The details of the procedure known as AK have been presented to me in detail in this document and explained to me by my ophthalmologist. My ophthalmologist has answered all my questions to my satisfaction. I have read this informed consent form (or it has been read to me), and I fully understand it and the possible risks, complications, and benefits that can result from surgery. I therefore consent to AK surgery. I wish to have AK performed on my R/L/Both eye(s). Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 116 )

123 ,flvxesfvd dsjkv V eh ¼,ds½ vkfle ds- daanj jksxh dk uke %.... mez@fyax %.... jksxh dh vkbzmh %.... rkjh[k %... dk iq=@iq=h... irk %.... VsyhQksu ua %.... ifjp;,flvxesfvd dsjkv V eh ¼,ds½,d 'ky;fø;kred ÁfØ;k gs ftlesa 6 ;k 7 feeh ds n`deamyk ij ;k r,dyk ;k t M+s esa lw{en'kê ls fn[kus oky pkikdkj ¼oؽ phjs Ykxk, tkrs gsa ;k fyeol ij f'kffkykdkjh phjs Ykxk, tkrs gsa t vka[k ds LoPN Òkx ¼dkÆu;k½ v j 'osr ivyk ¼LDYkhjk½ dh laf/k ij g rk gsa ;s phjs v j Òh x Ykkdkj dkfuz;k ÁkIr djus ds Á;kl esa dkfuz;k ds lcls <Ykoka fglls d pivk djus ds mìs'; ls Ykxk, tkrs gsaa gkykkafd,ds dk Yk{; n`f"v esa bl foanq rd lq/kkj Ykkuk gs fd p'es u Ykxkus im+sa Y fdu bl ifj.kke dh xkjavh ugè g rha,ds,d fuokzfpr ÁfØ;k gs%,slh d vkikr~ volfkk ;k nwljk dkj.k ;k vko';drk ugè g rh ftldh otg ls vkid ;g ÁfØ;k djkuh im+rh gsa vki p'ek ;k dkavsdv Y al igu dj i;kzir n`"; xfrfof/k;ka dj ldrs gsaa lòh 'ky;fø;kv a dh rjg ;g ÁfØ;k Òh dqn t f[ke isnk djrh gs ftudh lwph uhps nh xbz gsa vkid ;g Òh le>uk pkfg, fd nwljs t f[ke Òh g ldrs gsa] vkidk fpfdrld ftuds ckjs esa u tkurk g vkxs pyk dj ftudk irk pyk ldrk gsa vpnh ls vpnh ifjp;kz ds ckotwn tfvykrk,a v j nq"áòko g ldrs gsaa ;fn vkids lkfk g rk gs r ifj.kke bl gn rd ÁÒkfor g ldrs gsa fd vkidh n`f"v cn ls cnrj g tk,a,ds ds fodyi ;fn vki,ds u djkus dk fu'p; djrs gsa r Òh vkids n`f"v os"ke; d Bhd djus ds fodyi gsaa buesa vu; fodyi a ds vfrfjä p'es] dkavsdv Y al] v j vu; viorzd 'ky;fø;kred ÁfØ;k,a tsls ihvkjds ;k Ykkfld 'kkfeyk gsaa j xh dh lgefr esa vius us"k fo' "kk r,ds djus dh lgefr nsrk gwa] v j?k "k.kk djrk gwa fd eq>s esjs fo' "k ekey dh lqykrk dh d bz xkjavh ugè nh xbz gsa esa le>rk gwa fd ÁfØ;k ls fueufykf[kr t f[ke tqm+s gsa% laòkfor t f[ke v j tfvykrk,a 1- esa le>rk gwa fd bl 'ky;fø;k ls esjh n`f"v esa lq/kkj u g us dh laòkouk gs ;k ;g Òh g ldrk gs fd 'ky;fø;k ds okafnr ifj.kke u ÁkIr g aa ;g Òh laòo gsa fd vkxs fdlh fnu eq>s fdlh vfrfjä 'ky;fø;k dh vko';drk im+s ;k ;g Òh g ldrk gs fd eq>s 'ky;fø;k ds ckn p'es Ykxkus dh vko';drk im+sa ;g laòo gs fd ;g 'ky;fø;k djus ds ckn esa dkavsdv Y al u igu ldwaa 2- laòo gs fd 'ky;fø;k ds ifj.kke Lo:i esjh n`f"v ;k lozjs"b la'k f/kr n`f"v pykh tk,a ;g fdlh laøe.k ds ifj.kke Lo:i g ldrk gs ftls,afvck;kfv~dl ;k nwljs lk/ku a ls fu;af"kr u fd;k tk lds] ftldh otg ls esjh vka[k Òh tk ldrh gsa 3- dvku a ds vfu;fer :i ls Òjus ds dkj.k dkfuz;k dh lrg foñr g ldrh gsa ml flfkfr esa eq>s mi; xh n`f"v ikus ds fyk, dkavsdv Y al iguus dh vko';drk im+ ldrh gs v j ;g Òh laòo gsa fd ;g esjh mi; xh n`f"v d Yk Vk u ldsa 4- esa le>rk gwa fd esa fofòé le;kof/k; a ds fyk, ;k LFkk;h :i ls lwjt dh j 'kuh ;k rst j 'kuh ds nwljs lz r a ls v{ke cuk nsus okykh Ádk'k laosnu'khykrk vuqòo dj ldrk gwaa 5- esa le>rk gwa fd esa fofòé le;kof/k; a ;k laòor% LFkk;h :i ls 'kke ds le; ;k jkr esa vkus okykh gsmykkbv ;k rst Ádk'k ds vu; lz r a ls v{ke dj nsus okykh p a/k vuqòo dj ldrk gwaa esa tkurk gwa fd ;g vfuf'pr vof/k ds fyk, fnu v j jkr n u a le; esa esjh okgu pkyku {kerk d ÁfrdwYk :i ls ÁÒkfor dj ldrk gs] v j esa le>rk gwa fd eq>s rc rd okgu ugè pykkuk pkfg, tc rd fd esa vk'olr u g tkåa fd fnu v j jkr n u a ds n jku esjh n`f"v i;kzir gsa 6- esa le>rk gwa fd ÁkjafÒd LFkkf;Ro vof/k ds n jku fnu ds le; esjh n`f"v esa ¼rhu eghus ;k blls vf/kd le; rd½ mrkj&p<+ko vk ldr s gsaa 7- tslk fd lòh 'ky;fø;kred ÁfØ;kv a esa g rk gs] oz.k fpug thfor Ård a esa phjs Ykxkus ls curs gsaa ;g fo' "k 'ky;fø;k d bz viokn ugè gsa 8- esjh vka[k?kko Òjus dh volfkk ;k laòor%?kko Òjus ds ckn Òh vk?kkr ds Áfr vf/kd lqxzká g xh D; afd lw{en'kê oz.k Ård lkeku; Ård a ftrus n`<+ ugè g axs lòh laidz v j jsdsv ls [ Y tkus oky [ Yk a ds n jku lqj{kkred us= igukos dh lykkg nh tkrh gsa D; afd vka[k d Ykxus okykk lh/kk vk?kkr vka[k d {kfr igqapk ldrk gsa ( 117 )

124 9- vfrfjä Áfrosfnr tfvykrkv a esa dkfuz;k ds fnæ 'kkfeyk gsa ftuds fyk, laòor% Vkads Ykxkus dh vko';drk im+ ldrh gs( phjs ls lacaf/kr varosz'ku] dkfuz;k dk okfgdko/kzu] dkfuz;k esa oz.k cuus] bihffkfyk;eh d f'kdkv a dk {k;] bihffkfyk;eh?kko ds Òjus esa foñfr] v j cgqr gh fojy ekeyk a esa,am IF YkekbfVl ¼vka[k dk van:uh laøe.k ftlds dkj.k LFkk;h :i ls n`f"v tk ldrh gs½ 'kkfeyk gsaa 10- lòh 'ky;fø;kv a dh rjg blesa Òh lakkgj.k] nokv a ds ÁfrdwYk ÁÒko a ;k nwljs dkjd a ls ftlesa esjs 'kjhj ds nwljs fglls 'kkfeyk g ldrs gsa] tfvykrk,a g a ldrh gsaa esa le>rk gwa fd pwafd fdlh Òh 'ky;fø;k ds ifj.kke Lo:i g us okykh ÁR;sd tfvykrk d Lo"V djuk vlaòo gs blfyk, g ldrk gs fd bl Ái"k dh tfvykrkv a dh lwph iwjh u g A j xh dh LohÑfr v j le>nkjh dk c;ku eq>s bl nlrkost esa,ds ds uke ls tkuh tkus okykh ÁfØ;k dk folr`r fooj.k fn;k x;k gs v j esjs us= fpfdrld }kjk eq>s le>k;k x;k gsa esjs us= fpfdrld us esjs Á'u a ds lar "ktud mùkj fn, gsaa esaus ;g lwfpr lgefr Ái"k i<+ fyk;k gs ¼;k eq>s i<+ dj lquk;k x;k gs½ v j esa bls v j laòkfor t f[ke a] tfvykrkv a] v j bl 'ky;fø;k ds ifj.kke Lo:i g us oky YkkÒ a d iwjh rjg le>rk gwaa blfyk, esa,ds ltzjh dh lgefr nsrk gwaa esa nkb±@ckb± vka[k@n u a vka[k a ij,ds djkuk pkgrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 118 )

125 Intacs Rashim Mannan, J. S. Titiyal Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... Nature of the Intacs Procedure Intacs is a non-laser procedure with FDA approval for use in patients with myopia and astigmatism. Intacs are intrastromal corneal ring segments in the shape of a semi-circle which an ophthalmologist inserts into the non-seeing periphery of the cornea through a tiny incision. These segments flatten the central cornea without removing tissue to better focus light. The segments are made of the same material that s been implanted in human eyes after cataract surgery, called PMMA (polymethylmethacrylate). The procedure is performed under local anesthesia, peri-bulbar block or topical (eye drops) anesthesia. During the procedure, if performed under topical anesthesia, patient has to fix his or her gaze on the bright light of the operating microscope or as instructed by the operating ophthalmologist. Expected benefits: Intacs have the advantage of removability or exchangeability for different sized segments, and maintaining a more natural corneal shape. Intacs cannot be felt by the patient, require no maintenance, and are probably less visible than a contact lens to the naked eye. Patients who elect to have Intacs are not locked in to the procedure forever, as are patients who undergo other refractive procedures such as LASIK or PRK. Alternative treatments: I understand that continuous use of spectacles and / or contact lenses can provide good vision and Intacs is an alternative to decrease the dependence on glasses and / or contact lenses. Possible Side Effects, Risks and Complications 1. OVER/UNDER-CORRECTION: I understand that calculations used in this surgery are based on previous experience on large number of patients and these use average values. I understand that Intacs do not provide a full correction or a full reversal back to eye s normal refractive state. Rather, the goal is to reduce myopia and astigmatism and /or to alter the shape of the cornea so that contact lenses can have a better fit. Thus depending on individual variations in response to the procedure, there may be some under-correction or over-correction. 2. VISUAL ACUITY FLUCTUATION: I may have blurred vision or fluctuating vision following the procedure, this is due to modulation in the corneal tissue in response to Intacs in the corneal stroma. 3. LIGHT SENSTIVITY: I may experience glare or halos form light sources, more so during night time. These tend to disappear with time but glare may persist for a long time particularly at night. 4. INDUCED ASTIGMATISM: I understand that I may experience a temporary blurring or distortion of vision for several days after the procedure. This type of visual distortion is normal during the healing process and, in most cases, it decreases over time. However, in rare instances, it may be permanent. 5. PRESBYOPIA AND OTHER OCULAR CONDITIONS: I understand that Intacs will NOT prevent the development of naturally occurring eye problems such as glaucoma, cataracts, retinal degeneration, or detachment. Further Intacs do not correct the condition known as presbyopia (or aging of the eye), which may require reading glasses for close work at about age OTHER COMPLICATIONS: Like any other surgical procedure of the eye, insertion of Intacs can lead to trauma to corneal tissue leading to corneal edema, perforation, infection, which if severe could result in the loss of the eye or, rarely, a cataract. I understand that stromal thinning may occur due to shallow placement, which would require removal of the Intacs. Further I have been made fully aware that if there are complications or problems during the surgery, the surgeon may not be able to insert Intacs, and the surgery may have to be cancelled. There are other risks associated with any surgery. Since it is impossible to state every risk or complication that may occur as a result of any surgery, the possible risks and complications listed in this informed consent may be incomplete. There may be risks or complications associated with this surgery that are unknown because this is a relatively new procedure. ( 119 )

126 I hereby give permission to release/publish medical data and/or video/audio record/photograph the current procedure and the procedures performed in subsequent/ follow up visits for the advancement of medical knowledge. In signing this consent form for insertion of Intacs I am stating that I have read this consent form (or it has been read to me) and I fully understand the nature and the purpose of and the possible side effects, risks and complications of this procedure. Although it is impossible for the doctor to inform me of every possible complication that may occur, the doctor has answered all my questions to my satisfaction. I give permission to perform Intacs insertion on my R/L/Both eye(s). Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 120 )

127 bavsdl jkf'ke eéku] ts-,l- frfr;kyk jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... bavsdl ÁfØ;k dh ÁÑfr bavsdl ek; fi;k v j n`f"v os"ke; ds j fx; a ds mi; x ds fyk,,qmh, LohÑr,d xsj Y tj ÁfØ;k gsa bavsdl v)zo`ùkkdkj var% ihfbdh; dkfuz;k fjax flxesav g rs gsa ftugsa d bz us"k fpfdrld,d N Vs&ls phjs esa ls dkfuz;k dh u fn[kus okykh ifjf/k ds Òhrj?kqlk nsrk gsa ;s flxesav fcuk Ård fudky dkfuz;k ds e/;òkx d pivk dj nsrs gsa ftlls Ádk'k csgrj <ax ls dsafær g rk gsa ;s flxesav ih,e,e, i fykesfkkbyk&esfkkøkby V uked mlh inkfkz ls cus g srs gsa ftls e fr;kfcan ds v ijs'ku ds ckn bulku dh vka[k esa ÁR;kj fir fd;k tkrk gsa ;g ÁfØ;k Yk dyk,suslfkhfl;k] isjh cycj CYk d ;k V fidyk ¼vkbZMª i½,uslfkhfl;k ds varxzr fd;k tkrk gsa ÁfØ;k ds n jku] ;fn V fidyk,uslf fl;k ds varxzr fd;k tkrk gs r j xh d 'ky;fø;k dj jgs us=fo' "kk ds funsz'kkuqlkj v ijsfvax ekbø Ld i dh rst j 'kuh esa VdVdh Ykxk dj ns[kuk g rk gsa visf{kr YkkÒ% bavsdl ds lkfk YkkÒ ;g g rk gs fd mugsa fudkykk tk ldrk gs ;k fofòé eki ds [kam+ a ds fyk, ijlij cnykk tk ldrk gs] v j dkfuz;k dk vf/kd LokÒkfod vkdkj cuk, j[kk tk ldrk gsa j xh bavsdl dh vuqòwfr ugè dj ldrs] mudk d bz vuqj{k.k ugè djuk g rk] v j laòor% dkavsdv Y al ds eqdkcy uaxh vka[k a d de fn[krs gsaa t j xh bavsdl Ykxokus dk pquko djrs gsa mugsa Ykkfld ;k ihvkjds tslh nwljh viorzd ÁfØ;k,a djkus oky j fx; a dh rjg ges'kk ds fyk, ÁfØ;k ds lkfk ^ugè ca/ j[kuk* g rka osdfyid mipkj% esa le>rk gwa fd Ykxkrkj p'es v j@;k dkavsdv Y al dk mi; x vpnh n`f"v Ánku dj ldrk gs v j bavsdl p'es ;k dkavsdv Y al a ij fuòzjrk de djus oky fodyi gsaa laòkfor nq"ifj.kke] t f[ke v j tfvykrk,a 1- vfr@vyi la'k /ku% esa le>rk gwa fd bl 'ky;fpfdrlk esa Á; x g us oky vkdyku j fx; a dh cm+h la[;k ds vuqòo a ij vk/kkfjr g rs gsa v j os v lr eku a dk mi; x djrs gsaa esa le>rk gwa fd bavsdl iwjk la'k /ku ugè djrs ;k vka[k a dh lkeku; viorê volfkk d iwjh rjg okil ugè Y vkrsa blds ctk; budk Yk{; fudv n`f"vn "k v j n`f"v os"ke; d de djuk v j@;k dkfuz;k ds vkdkj d cnykuk g rk gs rkfd dkavsdv Y al vpnh rjg fqv g aa blfyk, ÁfØ;k ds Áfr O;fäxr vuqfø;kv a dh fofòérk ds vk/kkj ij dqn vfrla'k /ku ;k vyi la'k /ku g ldrs gs aa 2- n`f"v dh rhozrk esa mrkj&p<+ko% ÁfØ;k ds ckn esjh n`f"v /kqa/kykh g ldrh gs ;k esjh n`f"v esa mrkj&p<+ko vk ldrs gsaa ;g dkfuz;k ds LV ek esa Ykxs bavsdl dh vuqfø;k es d fuz;k ds Ård a esa e MÓwYku ds QYkLo:i g ldrk gsa 3- Ádk'k laosnu'khykrk% esa Ádk'k ds lz r ls Ykacs le; rd p a/k ;k ÁÒkeaMYk vuqòo dj ldrk gwa] jkr ds le;,slk v j Òh g ldrk gsa 4- Ásfjr n`f"vos"ke;% esa le>rk gwa fd esa ÁfØ;k ds ckn dbz fnu rd vlfkk;h :i ls /kqa/kykh ;k foñfr n`f"v dh vuqòwfr dj ldrk gwaa?kko Òjus ds n jku bl rjg dh n`f"v laca/kh foñfr lkeku; g rh gs] v j vf/kdrj ekeyk a esa le; chrus ds lkfk ;g de g rh tkrh gsa Y fdu fojy ekeyk a esa ;g LFkkbZ g ldrh gsa 5- tjk nwjn`f"v v j n`f"v laca/kh volfkk,a% esa le>rk gwa fd bavsdl XYkkd ek] e fr;kfcan] jsfvuk ds vi{k; ;k foykxko tslh lkeku; r j ij g us okykh lel;kv a d ugè j dsaxsa blds vfrfjä bavsdl Áslck; fi;k ¼;k vka[k a dk cq<+kik½ ds uke ls tkuh tkus okykh volfkk d Bhd ugè djsxk ftlesa YkxÒx 40 o"kz dh mez esa utnhd ds dke ds fyk, i<+us dk p'ek vko';d g tkrk gsa 6- vu; tfvykrk,a% vka[k dh fdlh nwljh 'ky;fø;kred ÁfØ;k dh rjg bavsdl dk lféos'k dkfuz;k ds Ård a d vk?kkr igqapk ldrk gs ftlls dkfuz;k esa lwtu vk ldrh gs] laøe.k g ldrs gsa] t ;fn xaòhj gq, r vka[k tk ldrh gs ;k fojy ekeyk a esa e fr;kfcan g ldrk gsa esa le>rk gwa fd mfky LFkkiu ds dkj.k LVª ek irykk g ldrk gs ftlls bavsdl dk fudkykuk vko';d g tkrk gsa blds vfrfjä eq>s blds ckjs esa iwjh tkudkjh nh xbz gs fd ;fn 'ky;fø;k ds n jku d bz tfvykrrk,a ;k lel;k,a isnk gqb± r g ldrk gs fd 'ky;fpfdrld bavsdl u?kqlk lds v j 'ky; fø;k jì djuh im+sa 'ky;fø;k ds lkfk v j Òh t f[ke tqm+s gsaa pwafd fdlh Òh 'ky;fø;k ds ifj.kke Lo:i g us oky ÁR;sd t f[ke ;k tfvykrk dk [kqykklk djuk vlaòo gs] blfyk, bl lgefr Ái= esa nh xbz laòkfor t f[ke a v j tfvykrkv a dh lwph viw.kz g ldrh gsa ;g Òh g ldrk gs fd bl 'ky;fø;k ls tqm+s dqn,sls t f[ke ;k tfvykrk,a g a t vòh rd vkkr g a D; afd ;g vis{kkñr ubz ÁfØ;k gsa ( 121 )

128 esa,rn}kjk fpfdrlh; Kku dh Áxfr ds fyk, orzeku ÁfØ;k v j vkxeh@q Yk vi eqykkdkr a ds n jku dh tkus okykh ÁfØ;kv a ls lacaf/kr fpfdrlh; vkadm+ a v j@;k ohfm; fjd MZ@fp"k tkjh djus@ádkf'kr djus dh vuqefr nsrk gwaa bavsdl ds lféos'k dh vuqefr nsrk gwaa bavsdl ds lféos'k dh vuqefr nsrs gq, esa?k "k.kk djrk gwa fd esaus ;g lgefr Ái= i<+ fyk;k gs ¼;k eq>s i<+ dj lquk;k x;k gs½ v j esa ÁfØ;k dh ÁÑfr v j mìs'; v j laòkfor nq"áòko a] t f[ke sa v j tfvykrkv a d le>rk gwaa gkykkafd fpfdrld ds fyk, eq>s ÁR;sd laòkofr tfvykrk ds ckjs esa lwfpr dj ikuk laòo ugè gs Y fdu fpfdrld us esjs lòh Á'u a ds lar "ktud mùkj fn, gsaa esa viuh nkb±@ckb± vka[k@n u a vka[k a esa bavsdl Ykxkus dh vuqefr nsrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 122 )

129 Phakic IOL Rashim Mannan, J. S. Titiyal Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... Nature Of The Phakic Iol Procedure Surgical implantation of a phakic intraocular lens is one of a number of alternatives for correcting nearsightedness. In phakic implant surgery, an artificial lens (such as the ICL or Verisyse phakic intraocular lens) is surgically placed inside your eye. The lens is made from material similar to the type used for intraocular lenses currently being implanted in the eye to correct vision after cataract surgery. The difference between phakic implant surgery and other intraocular lens implants is that your natural lens is not removed during phakic implant surgery. The phakic lens is inserted in addition to your natural lens. The procedure is performed under local anesthesia, peribulbar block. The surgeon will make two small holes in the colored portion of your eye (the iris) to help ensure that intraocular fluid does not build up behind the phakic lens; this procedure is called an iridotomy. It will take place either at the time of surgery by using an instrument (a surgical iridotomy) or within two weeks before the placement of the phakic implant by using a laser (YAG-laser iridotomy). Indications & Expected Benefits If you have myopia, hyperopia or astigmatism, phakic implant surgery may improve your natural vision without the use of glasses or contacts. Further they have the advantage of removability and maintaining a more natural corneal shape. Phakic IOL cannot be felt by the patient, require no maintenance, and are less visible than a contact lens to the naked eye. Patients who elect to have Phakic IOL implants are not locked in to the procedure forever, as are patients who undergo other refractive procedures such as LASIK or PRK. Alternative Treatment I understand that continuous use of spectacles and / or contact lenses can provide good vision and Phakic IOL is an alternative to decrease the dependence on glasses and / or contact lenses. Possible Side Effects, Risks And Complications Vision Threatening Complications: ANAESTHETIC COMPLICATIONS: In most cases, the surgery will be accomplished with use of an injection around the eye for anesthesia. Very rare complications from injections include damage to the eye muscles, perforation of the eye, and damage to the retina or optic nerve leading to loss of vision. INFECTION: I understand that mild or severe infection is possible. Mild infection can usually be treated with antibiotics and usually does not lead to permanent visual loss. Severe infection, even if treated with antibiotics, could lead to permanent scarring and loss of vision. IRIS ATROPHY: I understand that I could experience damage to the iris (the colored portion of the eye) leading to iris atrophy or develop a rise in the pressure in my eye (secondary glaucoma). I may require another iridotomy if this occurs or eye drops to control the pressure. RETINAL DETATCHMENT: I understand that I could develop a retinal detachment, a separation of the retina from its adhesion at the back of the eye, which usually results from a tear in the retina and could lead to vision loss. Patients with moderate to high levels of nearsightedness have a higher risk of retinal detachment when compared to the general population. This risk level may be increased with implantation of the phakic IOL. CATARACT: I understand that I may develop a cataract, or a clouding of the eye s natural lens, which impairs normal vision, and may require removal of the lens, the phakic implant, and insertion of an artificial lens. ( 123 )

130 CORNEAL INVOLVEMENT: I understand that I may develop corneal swelling (edema) and/or ongoing loss of cells lining the inner surface of my cornea (endothelial cells). These cells play a role in keeping the cornea healthy and clear. Corneal edema and loss of endothelial cells may result in a hazy and opaque appearance of the cornea, which could reduce vision and may require a corneal transplant. GLAUCOMA: I understand that I may develop glaucoma, which is an increase in the pressure of the eye caused by slowed fluid drainage. Glaucoma can lead to vision loss, and may require treatment with long-term medications or surgery. I understand that other complications could threaten my vision, including, but not limited to, iritis or inflammation of the iris (immediate and persistent), uveitis, bleeding, swelling in the retina (macular edema), and other visual complications. Though rare, certain complications may result in total loss of vision or even loss of the eye. Complications may develop days, weeks, months, or even years later. Non-vision-threatening Side Effects GLARE OR HALOS: I understand that there may be increased sensitivity to light or night glare. I also understand that at night there may be a starbursting or halo effect around lights. The risk of this side effect may be related to the size of my pupil, and larger pupils may put me at increased risk. UNDER/OVER CORRECTION: I understand that an over-correction or under-correction could occur, causing me to become farsighted, remain nearsighted, or increase my astigmatism and that this could be either permanent or treatable with either glasses, contact lenses, or additional surgery. REPEAT SURGERY: I understand that the phakic lens may need to be repositioned, removed surgically, or exchanged for another lens implant. The lens may change position (de-centration), or I may require a different size or power of lens than that of the implanted lens. Potential complications of additional surgery include all of the complications possible from the original surgery. PROTECTIVE GLASSES: I understand that, after phakic implant surgery, the eye may be more fragile to trauma from impact. I understand that the treated eye, therefore, is somewhat more vulnerable to all varieties of injuries. 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. PRESYOPIA: I understand that if I currently need reading glasses, I will still likely need reading glasses after this treatment. 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. I understand that the correction that I can expect to gain from phakic implant surgery 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 to refine my vision for some purposes requiring fine detailed vision after some point in my life, and that this might occur soon after surgery or years later. 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. I understand that because I have a phakic lens, it is important for me to be seen at all follow-up visits as felt necessary by my surgeon. I hereby give permission to release/publish medical data and/or video/audio record/photograph the current procedure and the procedures performed in subsequent/ follow up visits for the advancement if medical knowledge. In signing this consent form for insertion of Phakic IOL I am stating that I have read this consent form (or it has been read to me) and I fully understand the nature and the purpose of and the possible side effects, risks and complications of this procedure. Although it is impossible for the doctor to inform me of every possible complication that may occur, the doctor has answered all my questions to my satisfaction. I give permission to perform phakic IOL insertion on my R/L/Both eye(s). ( 124 )

131 Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 125 )

132 Q fdd vkbzv,yk jkf'ke eéku] ts,l frfr;kyk jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... Q fdd vkbzv,yk dh ÁÑfr% Q fdd bavªkv D;wYkj Y al dk 'ky;fø;kred ÁR;kj i.k fudv n`f"vn "k nwj djus ds cgqr ls fodyi a esa ls,d gsa Q fdd ÁR;kj i.k 'ky;fø;k esa vkidh vka[k esa 'ky;fø;k }kjk,d Ñf"ke Y al ¼tSls] vkbzlh,yk ;k osfjlkbls Q fdd bavªkv D;qYkj Y al½ Ykxk;k tkrk gsa ;g Y al mlh inkfkz ls cuk g rk gs ftl inkfkz ls cus Y al bu fnu sa e sfr;kfcan ds v ijs'ku ds ckn n`f"v lgh djus ds fyk, vka[k esa ÁR;kj fir fd, tkrs gsaa Q fdd ÁR;kj i.k v j nwljs b~avªkv D;qYkj Y al a ds ÁR;kj i.k 'ky;fø;k esa vkidk ÁkÑfrd Y al ugè fudkykk tkrka vkids ÁkÑfrd Y al a ds vfrfjä Qkfdd Y al?kqlk fn, tkrs gsaa ;g ÁfØ;k Yk dyk,suslfkhfl;k] isjh cycj CYk d ds varxzr dh tkrh gsa fpfdrld ;g lqfuf'pr djus ds fyk, fd Qk fdd Y al ds ihns var%us"kh; rjyk tek u g a] vkidh vka[k ds jaxhu Òkx ¼vkbfjl½ esa n N Vs fnæ djsxka bl ÁfØ;k d vkbfjm Veh dgk tkrk gsa,d midj.k ¼,d 'ky;fø;kred vkbfjv Veh½ dk mi; x djds 'ky;fø;k ds n jku fd;k tk,xk ;k,d Y tj ¼okbZ,th & Y tj vkbfjm Veh½ dk mi; x djds Qk fdd ysl ds LFkkiu ds n g ras igy fd;k tk,xka fpfdrlk lq>ko v j visf{kr YkkÒ ;fn vki ek; fi;k] gkbijv fi;k ;k n`f"vos"ke; ls ihfm+r gsa r Qkfdd ÁR;kj i.k 'ky;fø;k p'es ;k dkavsdv Y al a ds fcuk gh vkidh ÁkÑfrd n`f"v d lq/kkj ldrh gsa Åij ls mugsa fudkykk tk ldrk gs v j os dkfuz;k ds vkdkj d vf/kd ÁkÑfrd cuk, j[krs gsaa j xh Qkfdd vkbzv,yk d vuqòo ugè dj ldrk] mlds vuqj{k.k dh d bz vko';drk ugè g rh v j uaxh vka[k a ls dkavsdv Y al ds eqdkcy de fn[krs gsaa Qkfdd ÁR;kj i.k djkus oky j xh Ykkfld ;k ihvkjds tslh vu; viorzd ÁfØ;k,a djkus okykh j fx; a dh rjg ges'kk ds fyk, ÁfØ;k ls *ca/ ugè* jgrsa osdfyid mipkj esa le>rk gwa fd p'es v j@;k dkavsdv Y al a dk lrr Á; x vpnh n`f"v Ánku dj ldrk gs v j Qkfdd vkbzv,l p'es v j@;k dkavsdv Y al a dh fuòzjrk de djus dk,d fodyi gsa laòkfor nq"áòko] t f[ke v j tfvykrk,a n`f"v ds fyk, [krjukd tfvykrk,a%,suslfkhfl;k dh tfvykrk,a% vf/kdrj ekeyk a esa 'ky;fø;k laosnukgj.k ds fyk, vka[kds vkl&ikl,d lwbz Ykxk dj dh tk,xha bu lwb;ä dh vu; vr;ar fojyk tfvykrkv a esa vka[k dh isf'k; a d {kfr] vka[k esa fnæ g tkuk] v j jsfvuk ;k n`d~ raf"kdkv a d {kfr 'kkfeyk gsa ftlls n`f"v dk gzkl g ldrk gsa laøe.k% esa le>rk gwa fd gyds ;k xaòhj laøe.k laòo gsa gyds laøe.k a dk lkeku;r;k,savhc ; fvdl ls bykkt fd;k tk ldrk gs v j leku;r;k muls vlfkkbz n`f"v gzkl ugè g rka,savhc ; fvdl ls mipkj ds ckotwn xaòhj laøe.k a ls LFkk;h oz.kfpug cu ldrs gsa v j n`f"v dk {k; g ldrk gsa vkbfjl,vªksqh esa le>rk gwa fd esa vkbfjl ¼vk[ka ds jaxhu Òkx½ dk {kfr vuqòo dj ldrk gwa ftlls vkbfjl,vªksqh g ldrk gs ;k esjh vka[k esa ncko c<+ ldrk gs ¼f}rh;d XYkkd ek½ g ldrk gsa ;fn,slk g rk gs r eq>s nqckjk bfjm V eh djkuh im+ ldrh gs ;k ncko fu;af"kr djus ds fyk, vka[k esa VidkbZ tkus okykh nok dk mi; x djuk im+ ldrk gsa jsfvuk dk foykxko% esa le>rk gwa fd esa jsfvuk ds fcykxko] ;kuh vka[k ds ihns vius çkd`frd LFkku ls jsfvuk ds vykxko dk f'kdkj g ldrk gwa] t lkeku;r;k jsfvuk ds QVus ls g rk gs v j ftldh otg ls n`f"v dk {k; g ldrk gsa lkeku; vkcknh dh rqykuk esa gyds] fu;af=r fudv n`f"vrk ls ihfm+r j fx; a esa jsfvuk ds fcykxko dk t f[ke vf/kd jgrk gsa Qkfdd vkbzv,yk ds ÁR;kj i.k ls t f[ke dk ;g Lrj c<+ ldrk gsa e fr;kfcan% esa le>rk gwa fd eq>s e fr;kfcan g ldrk gs ;k vka[k ds lkeku; Y al /kqa/ky g ldrs gsa ftlls lkeku; n`f"v det j g tkrh gs] v j Y al fudky tkus] Qkfdd ÁR;kj i.k v j d`f"ke Y al Ykxkus dh vko';drk im+ ldrh gsa ( 126 )

133 dkfuz;k dk buoksyesuv esa le>rk gwa fd esjh dkfuz;k esa lwtu ¼'k Fk½ vk ldrk gs v j@;k esjh dkfuz;k dh fupykh lrg ds vlrj dh d f'kdkv a ¼baM ffkfyk;eh d f'kdkv a½ dk {k; g ldrk gsa ;s d f'kdk,a dkfuz;k d LoLFk v j LoPN j[kus esa Òwfedk fuòkrh gsaa d fuz;k esa lwtu vkus v j bam ffkfyk;eh d f'kdkv a ds {k; ls dkfuz;k /kqa/kykh v j vikjn'kê g ldrh gs ftlls n`f"v det j im+ ldrh gs v j dkfuz;k ds ÁR;kj i.k dh vko';drk im+ ldrh gsa XYkkd ek% esa le>rk gwa fd eq>s XYkkd ek g ldrk gs t rjyk ds /khes cgko ds dkj.k vka[k esa ncko c<+us ls g rk gsa XYkkd ek ls n`f"v det j im+ ldrh gs v j dkfuz;k ds ÁR;kj i.k dh vko';drk im+ ldrh gsa esa le>rk gwa fd vu; tfvykrk,a esjh n`f"v ds fyk, [krjk cu ldrh gsa] buesa vkbfjfvl ;k vkbfjl dk Ánkg ¼rkRdkfYkd v j iqjkuk½] ;wwfo;k'k Fk] jälzko] jsfvuk esa lwtu v j n`f"v laca/kh vu; tfvykrk,a 'kkfeyk gsa] Y fdu bugè rd lhfer ugè gasa gkykkafd fojy ekeyk a esa gh g rk gs Y fdu dqn tfvykrkv a ds QYkLo:i vka[k a dh j 'kuh iwjh rjg tk ldrh gs ;k vka[k gh [kjkc g ldrh gsa tfvykrk,a fnu a( g r a] eghu a ;k ;gka rd fd o"k ± ckn Òh g ldrè gsaa n`f"v ds fyk, [krjk u cuus okykh tfvykrk,a p a/k ;k ÁÒkeaMYk% esas le>rk gwa fd Ádk'k ds Áfr laosnu'khykrk ;k jkf"k p a/k c<+ ldrh gsa esa ;g Òh le>rk gwa fd jkr esa **rkjkfolq V** ;k Ádk'klz r ds vkl&ikl vkòkeamyk fn[k ldrk gsa bl nq"ifj.kke dk t f[ke esjh vka[k dh iqrfyk; a dh eki ls lacaf/kr g ldrh gs v j vis{kkñr cm+h iqrykh eq>s vf/kd t f[ke esa MkYk ldrh gsa vyi@vfr la'k /ku% esa le>rk gwa fd vfr la'k /ku ;k vyi la'k /ku g ldrk gs ftlls esa fudv n`f"vn "k ;k nwj n`f"vn "k dk f'kdkj g ldrk gwa ;k esjk n`f"vos"ke; c<+ ldrk gs v j ;g Òh fd ;g ;k r LFkk;h g ldrk gs ;k p'es] dkavsdv Y al a ;k vfrfjä 'ky;fpfdrlk ls mipkj ; X; g ldrk gsa nqckjk 'ky;fpfdrlk% esa le>rk gwa fd Qsfdd Y l a d iqulfkkzfir djuk im+ ldrk gsa 'ky;fø;k }kjk fudkykuk ;k nwljs Y al ls iqujizr;kj i.k djuk im+ ldrk gsa Y al a dh flfkfr cnyk ldrh gs ¼MhlsaVªs'ku½] ;k ÁR;kj fir Y al ds ikoj ls vykx eki v j ikoj oky Y al dh vko';drk im+ ldrh gsa vfrfjä 'ky;fpfdrlk dh laòkfor lel;kv a esa ewyk 'ky;fpfdrlk dh lòh laòkfor lel;k,a 'kkfeyk g rh gsaa lqj{kkred p'ek% esa le>rk gwa fd Qsfdd ÁR;kj i.k 'ky;fpfdrlk ds ckn esjh vka[k Vôj ls Ykxus okyks vk?kkr ds Áfr vf/kd uktqd g ldrh gsa esa le>rk gwa fd mipkfjr vka[k gj rjg dh p V a ds fyk, dqn vf/kd vk?kkr ; X; g rh gsa esa el>rk gwa fd eq>s,sls [ Yk a ;k nwljh xfrfof/k; a esa Òkx Y rs le; lqj{kkred p'es Ykxkus dh lykkg nh tk,xh ftlesa vka[k ls xsan] x Ykh] dqguh]?kwalk ;k vk?kkrdkjh nwljh olrqv a ds Vdjkus dh vk'kadk vf/kd g ldrh gsa tjk nwjn`f"v% esa le>rk gwa fd ;fn bl le; eq>s i<+us ds p'es dh vko';drk gs r g ldrk gs fd bl mipkj ds ckn Òh i<+us ds p'es dh vko';drk im+sa ;g Òh g ldrk gs fd ;fn esa ;g 'ky;fpfdrlk djkrk gwa r i<+us ds p'es ij esjh fuòzjrk v j c<+ tk, ;k de mez esa gh i<+us ds p'es dh t:jr im+ tk,a esa le>rk gwa fd esa Qsfdd vkbzvks,y ÁR;kj i.k ls ftl la'k /ku dh vis{kk djrk gwa 'ky;fpfdrlk ls og la'k /ku ÁkIr u g A esa le>rk gwa fd ;g vis{kk djuk ;FkkZFkokn ugè gs fd bl ÁfØ;k ds QYkLo:i gj le;] v j gj ifjflfkr esa ' "k thou Òj ds fyk, esjh n`f"v fcykdqyk lgh g tk,xha lw{e folr`r n`f"v dh ekax djus oky Á; tu a ds fyk, viuh n`f"v ds ifjektzu ds fyk, p'es dh t:jr im+ ldrh gs v j ;g Òh fd 'ky;fpfdrlk ds rqjar ckn ;k cjl a ckn bldh t:jr im+ ldrh gsa esa le>rk gwa fd pwafd fdlh Òh 'ky;fpfdrlk dh lòh lel;kv a d O;ä djuk laòo ugè g rk blfyk, g ldrk gs fd bl Ái"k esa of.kzr lel;kv a dh lwph iwjh u g A esa le>rk gwa fd pwafd esaus Qsfdd Y al Ykxok;k gs blfyk, esjk mu lòh QkYk vi eqykkdkr a ij tkap djkuk egroiw.kz gs ftugsa esjk'ky;fpfdrld vko';d le>rk gsa,rn}kjk esa fpfdrlh; Kku dh Áxfr ds fyk, orzeku ÁfØ;k v j vkxs pykdj@q Yk vi ds n jku dh tkus okykh ÁfØ;kv a ds vkadm+s v j@;k fm; tkjh@ádkf'kr djus dh vuqefr nsrk gwaa Qsfdd vkbzv,yk ds lféos'k ds fyk, bl lgefr Ái= ij glrk{kj djds esa?k "k.kk djrk gwa fd esaus ;g lgefr Ái= i<uk fyk;k gs ¼;k eq>s bls i<+ dj lquk;k x;k gs½ v j esaus bl ÁfØ;k dh ÁÑfr v j mìs'; v j blds laòkfor nq"áòko a] t f[ke a v j lel;kv a d le> fyk;k gsa gkykkafd fpfdrld ds fyk, ÁR;sd ÁÒkfor lel;k ds ckjs esa lwpuk ns ikuk laòo ugè gs Y fdu fpfdrld us esj lòh Á'u a ds lar "ktud mùkj fn, gsaa esa viuh nkb±@ckb± vka[k@n u a vka[k a esa Qsfdd vkbzv,yk bulvz djus dh vuqefr nsrk gwaa ( 127 )

134 dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 128 )

135 Conductive Keratoplasty Chandrashekhar Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... In giving my permission for Conductive Keratoplasty (CK) I understand the following: The long-term risks and effects of CK are unknown. I have received no guarantee as to the success of my particular case. I understand that the following risks are associated with the procedure: 1. I understand that the visual acuity I initially gain from CK could regress, and that my vision may go partially or completely back to the level it was immediately prior to having the procedure 2. I understand that it is possible that damage to my cornea could also be caused by scarring, ulceration, or an eye infection that could not be controlled with antibiotics or other means 3. I understand that I may not get a full correction from my CK procedure and this may require future enhancement procedures or the use of glasses or contact lenses. This procedure may also cause an increase in my astigmatism, which may cause blurred vision 4. I understand that an over-correction could occur, causing me to become nearsighted, and that this nearsightedness could be either permanent or treatable 5. I understand that the correction that I can expect to gain from CK may not be perfect and 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 to refine my vision for some purposes requiring fine detailed vision after some point in my life, and that this might occur soon after surgery or years later 6. I understand that there may be pain, scratchiness, a foreign body sensation, or slight dryness in my eye, particularly during the first 48 hours after surgery 7. I understand that there may be increased sensitivity to light. I understand this condition usually resolves within the first few weeks following treatment, but it may also be permanent 8. I understand that there may be a balance problem between my two eyes after CK has been performed on one eye, but not the other. This phenomenon is called anisometropia. I understand this would cause eyestrain and make judging distance or depth perception more difficult. I understand that my first eye may take longer to heal than is usual, prolonging the time I could experience anisometropia 9. I understand I may temporarily experience corneal haze, small round hazy areas where the cornea was heated during the CK treatment. This haze will usually fade over time and may only be visible with a microscope within 3 months following surgery 10. I understand that if I currently need reading glasses, I will still likely need reading glasses after this treatment 11. Even 90% clarity of vision is still slightly blurry. Enhancement surgeries can be performed when vision is stable UNLESS it is unwise or unsafe. An assessment and consultation will be held with the surgeon at which time the benefits and risks of an enhancement surgery will be discussed 12. I understand that there is a natural tendency of the eyelids to droop with age and that eye surgery may hasten this process. 13. I understand that the follow-up effects of CK are unknown and that CK has not been in use long enough to measure long-term effects (those occurring after 10 years or more) following the procedures, and that unforeseen complications or side effects could occur 14. I understand that I may be given medication in conjunction with the procedure. 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 15. 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 ( 129 )

136 The details of the procedure known as CK have been presented to me in detail and explained to me by my ophthalmologist. My ophthalmologist has answered all my questions to my satisfaction. I therefore consent to CK surgery my R/L eye. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 130 )

137 damfdvo dsjkv IYkkLVh paæ' [kj jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... damfdvo dsjkv IYkkLVh ¼lhds½ ds fyk, vuqefr nsrs gq, esa fueufykf[kr d le>rk gwa% lhds ds nh?kzdkfykd t f[ke v j ÁÒko vkkr gsaa eq>s vius fo' "k ekey dh lqykrk dh d bz xkjavh ugè feykh gsa esa le>rk gwa fd ÁfØ;k ds lkfk fueufykf[kr t f[ke tqm+s gsa% 1- esa le>rk gwa fd lhds ls ÁkjaÒ esa eq>s t n`f"v laca/kh xfrfof/k ÁkIr g xh og i'pxeu dj ldrh gs v j vkaf'kd :i ls ;k iwjh rjg ls ÁfØ;k djkus ls Bhd igy ds Lrj ij okil tk ldrh gs 2- esa le>rk gwa fd laòo gs fd oz.k fpug] oz.k] ;k vka[k ds fdlh laøe.k ds dkj.k esjs dkfuz;k d {kfr igqap ldrh gs] ftls,savhck; fvdl ;k nwljs lk/ku a ls duvªksy ugè fd;k tk ldrk 3- esa le>rk gwa fd g ldrk gs fd viuh lhds ÁfØ;k ls eq>s iwjk la'k /ku u ÁkIr g v j g ldrk gs fd Òfo"; esa lao`f) ÁfØ;k dh vko';drk im+sa ;g ÁfØ;k esjs n`f"v os"ke; d c<+k ldrh gs] t /kqa/kykh n`f"v dk dkj.k cu ldrk gs 4- esa le>rk gwa fd vfrla'k /ku g ldrk gs t eq>s fudv n`f"voku cuk ldrk gs v j ;g fudvn`f"voùkk ;k r LFkk;h ;k mipkj ; X; g ldrh gsa 5- esa le>rk gwa fd esa lhds ls t la'k s/ku ÁkIr djus dh vis{kk djrk gwa og iwjh rjg lgh ugè g ldrk v j ;g vis{kk djuk ;FkkFkZokn ugè g xk fd bl ÁfØ;k ds QYkLo:i esjh n`f"v ' "kthou Òj ds fyk, gj le;] gj ifjflfkfr esa iwjh rjg lgh g tk,xha esa le>rk gwa fd vius thou ds fdlh eqdke ij dqn Á; tu a ds fyk, t lw{e folr`r n`f"v dh ekax djrs gsa] eq>s viuh n`f"v ds ifjektzu ds fyk, p'es dh vko';drk im+ ldrh gs] v j 'ky;fpfdrlk ds rqjar ckn ;k o"k ± ckn,slk g ldrk gs 6- esa le>rk gwa fd esjh vka[k a esa nnz] fdjfdjkgv] dqn im+s g us ;k gyds ls lw[ iu dh vuqòwfr g ldrh gs] fo' "kr;k 'ky;fpfdrlk ds igy 48?kaVs ds n jku 7- esa le>rk gwa fd Ádk'k ds Áfr laosnu'khykrk esa o`f) g ldrh gsa esa el>rk gwa fd mipkj ds 'kq#vkrh dqn g r a ds n jku ;g j x Bhd g tkrk gs Y fdu ;g LFkk;h Òh g ldrk gsa 8- esa le>rk gwa fd esjh n u a vka[k a esa ugè] cfyd,d vka[k esa lhds g us ds ckn esjh n u a vka[k a ds chp larqyku dh lel;k isnk g ldrh gsa bl x pj rf; d n`f"v fo"kerk dgk tkrk gsa esa le>rk gwa fd blls vka[k ij ruko im+sxk v j nwjh dk vuqeku Ykxkus v j xgjkbz d le>us esa dfbukbz g ldrh gsa esa le>rk gwa fd esjh igykh vka[k dk?kko Òjus esa lkeku; ls vf/kd le; Ykx ldrk gsa bl le; ds Ykack f[kapus ls esa n`f"v fo"kerk vuqòo dj ldrk gwa 9- esa le>rk gwa fd esa vlfkk;h :i ls dkfuz;k dk /kqa/kykkiu vuqòo dj ldrk gwa] N Vs&N Vs /kqa/ky fglls tgka ij lhds mipkj ds n Sjku dkfuz;k xez dh xbz FkhA ;g /kqa/kykkiu le; ds chrus ij lkeku;r;k [kre g tk,xk v j 'ky;fpfdrlk ds rhu eghus ds Òhrj dsoyk lw{en'kê ls ns[kk tk ldsxka 10- esa le>rk gwa fd ;fn eq>s bl le; i<+us dk p'ek Ykxrk gs r bl mipkj ds ckn Òh eq>s p'es dh t:jr im+ ldrh gsa 11- olrqr% n`f"v dh 90% Li"Vrk vòh rd dqn /kqa/kykh gsa n`f"v ds flfkj g tkus ds ckn lao`f) 'ky;fpfdrlk dh tk ldrh gs] c'krsz fd ;g vfoosdiw.kz v j vlqjf{kr u g A 'ky;fpfdrld ds lkfk ewy;kadu v j ijke'kz fd;k tk,xk v j mlh le; lao`f) 'ky;fpfdrlk ds YkkÒ a v j t f[ke a ij ppkz dh tk,xh 12- esa le>rk gwa fd iykd a dh LokÒkfod Áo`fÙk g rh gs fd mez c<+us ds lkfk os >qdrh tkrh gsa v j ;g Òh fd vka[k dh 'ky;fpfdrlk bl ÁfØ;k d rst dj ldrh gs 13- esa le>rk gwa fd lhds ds QkYk vi ÁÒko vkkr gsa v j lhds brus Ykacs le; ls pyku esa ugè gs fd ÁfØ;kv sa ds ckn ds nh?kzdkfykd ÁÒko ekis tk ldsa ¼,sls ÁÒko t 10 o"kz ;k blls Òh vf/kd le; ckhn fn[krs gsa½ v j ml rjg dh vuisf{kr lel;k,a ;k nq"áòko g ldrs gsa 14- esa le>rk gwa fd eq>s ÁfØ;k ds lkfk&lkfk nok,a Òh nh tk ldrh gsaa esa le>rk gwa fd eq>s ÁfØ;k ds de ls de,d fnu ckn rd okgu ugè pykkuk pkfg, v j rc rd ugè pykkuk pkfg, tc rd fd esa vk'olr u g tkåa fd esjh n`f"v okgu pykkus ds fyk, i;kzir gs 15- esa le>rk gwa fd tslk fd lòh rjg dh 'ky;fpfdrlkv a ds lkfk g rk gs] laosnukgj.k] nokv a ds ÁfrdwYk ÁÒko a] ;k esjs 'kjhj ds nwljs fgll a ls tqm+s vu; dkjd a ds dkj.k lel;k,a isnk g ldrh gsaa esa le>rk gwa fd fpfdrld ds fyk, fdlh Òh 'ky;fpfdrlk dh lòh laòkfor lel;kv a dk O; jk ns ikuk vlaòo g rk gs blfyk, g ldrk gs fd bl Ái= esa nh xbz lel;kv a dh lwph iwjh u g A ( 131 )

138 eq>s esjs us"k fo' "kk }kjk lhds ds uke ls tkuh tkus okykh ÁfØ;k dk folr`r O; jk fn;k x;k gsa esjs us"kfpfdrld us esjs lòh Á'u a ds lar "ktud mùkj fn, gsaa blfyk, esa viuh nkb±@ckb± vka[k esa lhds 'ky;fpfdrlk djus dh vuqefr nsrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 132 )

139 Pterygium Surgery Saurbhi Khurana Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been explained in the language that I understand that I have a fold of conjunctiva enroaching upon the cornea in my R/L eye, which is to be surgically removed. The following has been explained to me: Corneal opacity would persist after surgery Risk of recurrence of fold and need for repeat surgery Visual prognosis remains guarded in view of persisting astigmatism, hence vision may / may not improve after removal of the lesion A piece of conjunctiva from the same / other eye may be required to prevent recurrence of the fold if an autoconjunctival graft is planned after excision If Mitomycin C is applied after excision to decrease the incidence of recurrence, risk of scleral thinning has been explained Redness, irritation, watering may persist for a few days after surgery In case of autograft, sutures will be applied and may lead to irritation. Risk of infection of the graft has been explained Additional laser procedure may be required for removal of corneal opacity after surgery Surgery would be done under local infiltration/ anesthetic drops After knowing all this, I give my free and voluntary consent to undergo pterygium excision i.e. removal of conjunctival fold from my eye. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 133 )

140 Vsfjft;e 'ky;fpfdrlk l jfò [kqjkuk jksxh dk uke %.... mez@fyax %.... jksxh dh vkbzmh %.... rkjh[k %... dk iq=@iq=h... irk %.... VsyhQksu ua %.... esa t Òk"kk le>rk gwa ml Òk"kk esa eq>s le>k x;k gs fd esjh dutadvªkbzok dh,d ijr esjh dkfuz;k ij vfrøe.k dj jgh gs ftls 'ky;fpfdrld }kjk gvk;k tkuk gs- eq>s fueufykf[kr ckrsa le>kbz xbz gsa% Û 'ky;fpfdrlk ds ckn Òh dkfuz;k dh vikjnf'kzrk cuh jg ldrh gs Û ijr ds nqckjk cu tkus dk t f[ke jgsxk v j nqckjk mldh 'ky;fpfdrlk dh vko';drk im+ ldrh gs Û ozreku n`f"vos"ke; ds eìsutj n`"; iwzokuqeku lqjf{kr jgrk gs blfyk,?kko d fudkyk fn, tkus ds ckn n`f"v esa lq/kkj g Òh ldrk gs v j ugè Òh Û ijr ds nqckjk vkus ls j dus ds fyk, mlh vka[k@nwljh vka[k ls dutadvªkbzok ds,d VqdM+s dh t:jr g xh] ;fn?kko fudkykus ds ckn viuh gh dutadvªkbzok ds mij i.k dh ; tuk ckukbz tkrh gs r Û ;fn nqckjk ijr d vkus ls j dus ds fyk,?kko fudky tkus ds ckn ekbv flu&lh Ykxk;k tkrk gs r LDY jk ds iry g us ds t f[ke dkli"vhdj.k fd;k tk pqdk gs Û YkYkkbZ] Ánkg] v j ikuh dk vkuk 'ky;fpfälk ds dqn fnu ckn rd cuk jg ldrk gs Û viuh gh vka[k ds 'Y "ek ds mij i.k ds ekey esa Vkads Ykxk, tka,xs v j mudh otg ls {k Ò g ldrk gsa mij i.k esa laøe ds t f[ke d Li"V fd;k tk pqdk gs Û 'ky;fpfdrlk ds ckn dkfuz;k dh vikjnf'kzrk d fudkykus ds fyk, vfrfjä Y tj ÁfØ;k dh vko';drk g xh Û 'ky;fpfdrlk LFkkuh; var%lj.k@laosnuk gj.k Mª Il MkYk dj dh tk,xh ;g lc tkuus ds ckn essa Vsfjft;e,Dlfltu] ;kuh viuh vka[k ls 'Y "ek dh ijr d fudkykus dh Lora"k v j LosZfPNd vuqefr nsrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 134 )

141 Corneal Scraping Saurbhi Khurana Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been explained in my own language thah I am suffering from an ocular infection i.e. a corneal ulcer in my R/L eye. I am to undergo a diagnostic procedure in the form of a corneal scraping for the same. The following has been explained to me: After topical anaesthesia, material would be taken from the ulcerated area with the help of a needle and sent for investigations. The procedure is being done to isolate the organisms responsible for the infection in order to start appropriate treatment for the same. This is not a therapeutic procedure and will not lead to improvement in symptoms/ healing of the lesion or in visual recovery. There is a risk of corneal perforation during the procedure for which surgical intervention may be required. This procedure may/ may not isolate the organism responsible for the infection and accordingly may have to be repeated. After knowing all this, I give my free and voluntary consent to undergo corneal scraping from my R/L eye. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 135 )

142 dkfuz;y LØsfix lqjfò [kqjkuk jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %....VsyhQksu ua %.... eq>s esjh Òk"kk esa le>k;k x;k gs fd esa us"k ds,d laøe.k] ;kuh viuh vka[k dh dkfuz;y vylj ls ihfm+r gwaa eq>s blds funku ds fyk, dkfuz;y LØsfix ds :i esa,d usnkfud ÁfØ;k djkuh gsa eq>s fueufykf[kr ds ckjs esa crk;k x;k gs% Û LFkkfud laosnukgj.k ds oz.k Q M+s okykh txg ls,d lwbz dh lgk;rk ds dqn æo; fudkykk tk,xk v j mls tkap ds fyk, Òstk tk,xka Û ;g ÁfØ;k ml laøe.k ds fyk, fteesnkj tho dk irk Ykxkus ds fyk, dh tk jgh gs rkfd mlds fyk, mi;qä mipkj 'kq: fd;k tk ldsa Û ;g mipkjkred ÁfØ;k ugè gs v j blls Yk{k.k a esa lq/kkj ugè g xk@?kko ugè Òjsxk ;k n`f"v dh fjdojh ugè g xha Û ÁfØ;k ds n jku dkfuz;k esa fnæ g us dk t f[ke gs ftlds fyk, glr{ i dh vko';drk im+ ldrh gsa Û g ldrk gs fd ÁfØ;k ls laøe.k ds fyk, fteesnkj tho u fey v j bls fqj ls djuk im+sa ;g lc tkuus ds ckn esa viuh nkb±@ckb± vka[k ds dkfuz;k ls [kqjpu fudkykus dh Lora"k v j LosZfPNd lgefr nsrk gwa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 136 )

143 Fibrin Glue Adhesive for Corneal Perforation Kiran G. Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been clearly explained in the language I best understand that in view of my (diagnosis-corneal perforation), application of fibrin glue will be attempted to seal the defect. I have also been informed of the fact that this procedure is being attempted because the tissue defect in my cornea is less than 2 mm in diameter. I am fully aware of the risk of failure of the procedure which may necessitate reapplication of the glue or alternate treatment modalities like corneal patch grafting. I am also aware of the fact that glue may produce inflammation of varying intensities in the eye and that the risk of endophthalmitis is greater with this procedure than a patch graft. Nevertheless, I wish to have the procedure performed in my R/L eye and I am willing to accept the potential risks that my doctor has discussed with me. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 137 )

144 Qk;fczu XYkw v<sflo Q j dkfuz;yk iq Zjs'ku fdju thjksxh dk uke %.... mez@fyax %.... jksxh dh vkbzmh %.... rkjh[k %... dk iq=@iq=h... irk %.... VsyhQksu ua %.... eq>s ml Òk"kk esa ftls esa lcls vpnh rjg le>rk gwa] Li"V :i ls le>k;k x;k gs fd esjs ¼funku&dkfuZ;k ds fnæ½ d ns[krs gq, bl [kkeh d can djus ds fyk, Qk;fczu XYkw Ykxkus Ykxkus dk Á;kl fd;k tk,xka eq>s bl rf; ls Òh voxr djk;k x;k gs fd bl ÁfØ;k dk Á;kl blfyk, fd;k tk jgk gs fd esjh dkfuz;k dh Ård foñfr dk O;kl 2 feeh ls degsa esa ÁfØ;k dh ukdkeh ds t f[ke ls Òh iwjh rjg voxr gwa ftlds fyk, XYkw ;k dkfuz;k ds VqdM+s ds j i.k tslh osdfyid mipkj dh vko';drk g xha esa bl rf; ls Òh voxr gwa fd XYkw vka[k esa vykx&vykx rhczrkv a ds Ánkg isnk dj ldrk gs v j ;g Òh fd bl ÁfØ;k ds lkfk bam IF YekbfVl dk t f[ke VqdM+s ds j i.k ls vf/kd g rk gsa fqj Òh esa viuh nkb±@ckb± vka[k esa ;g ÁfØ;k djkus dk bpnqd gwa v j esa mu laòkfor t f[ke a d Lohdkj djus d rs;kj gwa ftuds ckjs esa fpfdrld us esjs lkfk ppkz dh gsa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 138 )

145 Symblepharon Release Reena Sharma Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been informed in my mother tongue that I/ my child is suffering from adhesion of ocular surface and lids (Symblepharon) due to disease involving the conjunctiva and cornea and that a surgery to remove this will be done. An amniotic membrane graft (human placental tissue) or mucous membrane graft may be applied to the ocular surface with the help of sutures. Bandage contact lens will be applied after the surgery. I have been fully explained regarding the permanent nature of the lesion and that it has to be released to improve the ocular surface. This procedure primarily will not improve vision. I have been explained the risk of inadvertent perforation of the eye during the surgery, infection, inadequate release or reformation of adhesions. There may be a need for repeat surgery which may or may not lead to improvement of vision. I have been explained the need for follow up as frequently as advised by the doctors that may span upto years, with multiple investigations at each visit. I have been explained that proper use of medications is required for success of the treatment. I understand that inspite of all efforts, there is a possibility that there may be no improvement or worsening of the visual acuity or the cosmetic appearance of the eye. I certify that I have fully understood the implications of the above consent and authorise the doctors to perform symblepharon release with/ without AMT on my/ my child s right / left eye. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 139 )

146 flacy Qsj u fjykht jhuk 'kekz jksxh dk uke %.... mez@fyax %.... jksxh dh vkbzmh %.... rkjh[k %... dk iq=@iq=h... irk %.... VsyhQksu ua %.... eq>s esjh ekr`òk"kk esa crk;k x;k gs esa@esjk cppk datafdvok v j dkfuz;k ls lac) j x ds dkj.k vkdqyj ljqsl v j iykd ds fpidkyk ¼flaCY Qsj u½ ls ihfm+r gs v j ;g Òh fd bls Bhd djus ds fyk, 'ky;fpfdrlk dh tk,xha Vkad a dh enn ls vkdqyj ljqsl ij,feuv fvd esacjsu ¼ekuo IY lsavds Ård½ ;k 'Y "ek dykk dk j i.k Ykxk;k tk,xka 'ky;fpfdrlk ds ckn csamst dkavsdv Y al Ykxk;k tk,xka eq>s?kko dh LFkkbZ ÁÑfr ds ckjs esa iwjh rjg le>k;k x;k gs v j ;g Òh fd vkdqyj ljqsl d lq/kkjus ds fyk, bls [k Ykuk gsa ;g ÁfØ;k ewykr% n`f"v ugè lq/kkjsxha eq>s 'ky;fpfdrlk ds n jku vlko/kkuh o'k vka[k esa fnæ] laøe.k] vi;kzir eqfä] ;k vklatu a ds iqufuzeku dh vk'kadk ds ckjs esa crk;k x;k gsa nqckjk fpfdrlk dh vko';drk im+ ldrh gs ftlls n`f"v esa lq/kkj g ldrk gs ;k ugè Òh g ldrka eq>s le>k;k x;k gs fd fpfdrld ds lq>k, vuqlkj eq>s ckj&ckj Q Yk vi ds fyk, vkuk g xk t cjl a pyk ldrk gs v j ÁR;sd eqykkdkr ij vusd tkapsa dh tk ldrh gsaa eq>s le>k x;k gs fd bykkt dh lqykrk ds fyk, nokv a dk Á; x vko';d gsa esa le>rk gwa fd lòh Á;kl a ds ckotwn laòkouk gs fd n`f"v dh rh{.krk ;k vka[k dh Álk/kd cká vkñfr esa d bz lq/kkj u g ;k v j Òh [kjkc g tk,a esa Áekf.kr djrk gwa fd esaus mi;qzä lgefr ds fufgrkfk ± d iwjh rjg le> fyk;k gs v j fpfdrld d,,evh ds lkfk@mlds fcuk viuh@vius cpps dh nkb±@ckb± vka[k dh flacy Qsj u fjykht djus ds fyk, vf/kñr djrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 140 )

147 Amniotic Membrane Transplantation (AMT) Asim K. Kaudar Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been informed in my mother tongue that I/ my child is suffering from a disease involving the ocular surface (specify...) and that a surgery will be performed in which an amniotic membrane (covering of the foetal sac) will be used to cover the ocular surface. The amniotic membrane will be sutured into place with circumferential interrupted sutures with 10-0 monofilament nylon sutures and the peripheral edge of the membrane will be sutured to the conjunctiva with 8-0 polyglactin interrupted sutures. The excess membrane will be trimmed and a bandage contact lens will be put after surgery. I have been fully explained regarding the permanent nature of the opacity/ lesion. I have been explained the risk of perforation of the host eye, leading to the need for a full thickness corneal transplant. There is risk of infection, suture loosening and replacement, increased blood vessels in interface possibly leading to haemorrhage, no improvement or worsening of best corrected visual acuity and pain, glaucoma secondary to surgery or to medications after surgery. The membrane may shed off prematurely leading to repeat surgery which may or may not lead to improvement of vision. I have been explained the need for follow up as frequently as advised by the doctors that may span upto years, with multiple investigations at each visit. I have been explained that use of medications properly is required for success of the surgery. There is chance of falling of the bandage contact lens and it may require replacement. I have been explained that I will need to urgently come for follow-up to ophthalmic casualty if there is sudden onset redness, photophobia, pain or detoriation of vision as these may be early signs of amniotic membrane infection. I understand that inspite of all efforts, there is a possibility that there may be worsening of the visual acuity or the cosmetic appearance of the eye. I certify that I have fully understood the implications of the above consent and authorise the doctors to perform Amniotic Membrane Transplantation on my right / left eye. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 141 )

148 ,feuv fvd esaczsu VªkalIYkkaVs'ku ¼,,eVh½ vklhe ds- danj jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... eq>s esjh ekr`òk"kk esa lwfpr fd;k xk;k gs fd CkPpk vkdqyj ljqsl ls lac) j x ¼Li"V djsa ½ ls ihfm+r gs v j ;g Òh,d 'ky;fpfdrlk dh tk,xh ftlesa vkdqyj ljqsl d <adus ds fyk,,d,feuv fvd esacjsu ¼Òzw.kh; F Ykh ds vkoj.k½ dk mi; x fd;k tk,xka,feuv fvd esacjsu d 10&0 e u fqykkesav uk;yk u Vkad a dh enn ls ÒXuØe ifj/kh; Vkad a ls flykk tk,xk v j esaczsu ds ifj/kh; fdukjs d ÒXuØe 8&0 i fykxy fdvu Vkad a dh enn ls datafdvuk ds lkfk flykk tk,xka vfrfjä esaczsu d rjk'k fn;k tk,xk v j 'ky;fpfdrlk ds ckn csamst dkavsdv Y al Ykxk;k tk,xka eq>s vikjnf'kzrk@?kko dh LFkkbZ ÁÑfr ds ckjs esa iwjh rjg le>k;k x;k gsa eq>s nkrk dh vka[k esa fnæ g us ds t f[k.k ds ckjs esa crk;k x;k gsa ftldh otgls iwjh e VkbZ dh dkfuz;k ds ÁR;kj i.k dh vko';drk im+ ldrh gsa laøe.k] Vkads ds <hykk im+ tkus v j ÁfrLFkkiu] varjkqykd esa jäokfgfu; a ds c<+ tkus v j laòor% mldh otg ls jälzko g us] lozjs"v la'k f/kr n`'; xfrfof/k; a esa d bz lq/kkj u g us ;k v j Òh [kjkc g tkus] v j nzn] ltzjh ;k nokv a ds x.k ÁÒko ds :i esa XYkkd eke g tkus dk t f[ke gsa esaczsu le; ls igy fxj ldrh gs ftlds dkj.k nqckjk ltzjh djuh im+ ldrh gs ftlls n`f"v esa lq/kkj g Òh ldrk gs v j ugè ÒhA eq>s crk;k x;k gs fd fpfdrld ds lq>k, vuqlkj esjk ckj&ckj QkYk vi ds fyk, vkuk vko';d g xk t cjl a pyk ldrk gs v j ÁR;sd QkYk vi ds le; dbz tkapsa dh tk ldrh gsaa eq>s crk;k x;k gs fd ltzjh dh lqykrk ds fyk, mfpr vks kf/k ds Á; x vko';d gsa csamst dkavsdv Y al ds fxjus dh Òh laòkouk gs v j mlds ÁfrLFkkiu dh vko';drk im+ ldrh gsa eq>s crk;k x;k gs fd ;fn esjh vka[k esa vpkud YkYkkbZ vk tkrh gs] Ádk'k Òhfr] nnz g us Ykxrh gs ;k n`f"v v j Òh [kjkc g us Ykxrh gs r eq>s rqjar us=fpfdrld vkikr d{k esa Q Yk vi ds fyk, vkuk g xk D; afd ;g,feuv fvd esacjsu esa laøe.k dk ÁkjafÒd ladsr g ldrk gsa esa le>rk gwa fd lòh Á;kl a ds ckotwn laòo gs fd n`'; xfrfof/k ;k vka[k dh Álk/kd oká vkñfr v j Òh [kjkc g tk,a esa Áekf.kr djrk gwa fd esaus mi;qzä vuqá; x a ds fufgrkkfk ± d iwjh rjg le> fyk;k gs v j fpfdrldd a d viuh nkb±@ckb± vka[k esa,feuv fvd esaczsu ÁR;kj i.k dk vf/kdkj Ánku djrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 142 )

149 Limbal Stem Cell Transplantation (LSCT) Asim K. Kaudar, Bhavna Chawla Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been informed in the language I best understand that I/ my child is suffering from an ocular surface disease with conjunctivalization of the cornea (specify...) and that a surgery to improve the ocular surface will be done along with removal of the superficial part of the cornea depending upon depth of involvement. A part (limbal tissue) of a donor cadaveric cornea / from opposite normal eye / from live related donor will be used either directly or after expansion in tissue culture media to replace the diseased tissue with the help of sutures. I have been fully explained regarding the permanent nature of the disease and that this treatment is intended to improve the ocular surface. I have been explained the risk of perforation of the host eye, leading to full thickness corneal transplant. There is a risk of infection, graft rejection, suture loosening and replacement, increased blood vessels possibly leading to haemorrhage, no improvement or worsening of best corrected visual acuity. The opacity may increase after the surgery. There may be a need for repeat surgery which may or may not lead to improvement of vision. I have been explained the need for follow up as frequently as advised by the doctors that may span upto years, with multiple investigations at each visit. I have been explained that using medications properly is required for success of the graft. I have been explained that I will need to urgently come for follow-up to ophthalmic casualty if there is a sudden onset of redness, photophobia, foreign body sensation, pain or detoriation of vision as these may be early signs of infection or rejection. I understand that inspite of all efforts, there is a possibility that there may be worsening of the visual acuity or the cosmetic appearance of the eye. I certify that I have fully understood the implications of the above consent and authorise the doctors to perform Limbal Stem Cell Transplantation on my right / left eye. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 143 )

150 fykacyk LVse lsyk VªkalIYkkaVs'ku ¼,y,llhVh½ vlhe ds- danj] Òkouk pkoykk jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... eq>s ml Òk"kk esa ftls esa lcls vpnh rjg le>rk gwa le>k;k x;k gs fd cppk dkfuz;k esa datafdvoykkbts'ku ¼Li"V :i ls O; jk nsa ½ ds lkfk vkd;wykj lqszl fmtht ls ihfm+r gs v j ;g Òh fd tfvykrk dh xgjkbz ds vk/kkj ij dkfuz;k ds Åijh fglls d fudkykus ds lkfk&lkfk us= dh lrg d lq/kkjus ds fyk,,d 'ky;fpfdrlk dh tk,xha nkrk ds dsmkosfjd dkfuz;k nwljh lkeku; vka[k@fj'rs ds thfor nkrk ds dkfuz;k ds,d Òkx ¼fYkacYk Ård½ dk lh/ ;k Ård lao/kzu ek/;e esa folrkj ds ckn Vkad a dh lgk;rk ls j xh Ård a d ÁfrLFkkfir djus ds fyk, mi; x fd;k tk,xka eq>s j x dh LFkk;h ÁÑfr ds ckjs esa iwjh rjg crk;k x;k gs v j ;g Òh fd bykkt dk mns'; us= dh lrg d lq/kkjuk gsa eq>s nkrk dh vka[k esa fnæ g tkus ds t f[ke ds ckjs esa Òh crk;k x;k gs ftldh otg ls iwjh e VkbZ ds dkfuz;k dk ÁR;kj i.k djuk im+ ldrk gsa laøe.k] fuj i dh vlohñfr] Vkads ds <hykk g us v j ÁfrLFkkiuk] jä okfgfu; a dh la[;k ds c<+ tkus v j QYkLo:i jälzko] lozjs"b n`f"v rh{.krk esa d bz lq/kkj u g us ;k mlds v j Òh [kjkc g tkus dk t f[ke gsa nqckjk 'ky;fpfdrlk djus dh vko';drk im+ ldrh gs ftlls esa lq/kkj g ldrk gs ;k ugè Òh g ldrka eq>s fpfdrld dh lykkg ds vuqlkj ckj&ckj Q Yk vi ds fyk, vkus dh vko';drk ds ckjs esa crk;k x;k gs t cjl a pyk ldrk gs v j ÁR;sd eqykkdkr ij dbz tkapsa dh tk ldrh gsaa vpkud YkYkkbZ vk tkus] Ádk'k Òhfr g us d bz pht im+s g us dh vuqòwfr g us] nnz gs ;k n`f"v v j [kjkc g tkus ij eq>s rqjar us"kfpfälk vkikr d{k esa Q Yk vi ds fyk, vkus dh t:jr ds ckjs esa crk;k x;k gs D; afd ;s laøe.k ;k vlohñfr ds ÁkjafÒd Yk{k.k g ldrs gsaa esa le>rk gwa fd lòh Á;kl a ds ckotwn laòkouk gs fd vka[k dh n`'; rh{k.rk ;k Álk/kd okáñfr v j Òh [kjkc g ldrh gsa esa Áekf.kr djrk gwa fd esaus mi;qzä lgefr ds fufgrkfk ± d iwjh rjg le> fyk;k gs v j fpfdrld a d viuh nkb±@ckb± vka[k esa fykacyk LVse lsyk VªkalIYkkaVs'ku dsjus dk vf/kdkj Ánku djrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 144 )

151 Osteo-odonto Keratoprosthesis (OOKP) Noopur Gupta, Radhika Tandon Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been informed in my mother tongue that I will need a specially designed keratoprosthesis where the artificial cornea is embedded in a biological frame made of the canine tooth to enhance support and long-term stability of the visual aid to treat my blind eye/eyes as this is the last option of restoring vision in my present condition and no other surgical procedure e.g. keratoplasty will be successful as I have severe dry eyes also. I understand that Keratoprosthesis will replace my opaque, white cornea and act like a telescope, so that the light rays can go in the eye and reach the retina (back of the eye which is the seeing machinery of the eye) and I will be able to see. I have been fully explained that for osteo-odonto-keratoprosthesis (OOKP), one of my healthy canine tooth/teeth will be harvested for the surgery and a layer of the inner lining of the cheek will also be taken to cover the surface of the eye. The surgery will be done in two stages which will be two months apart, so it may take a long time to gain vision after the first stage of the surgery. I have been explained the potential benefits and risks of the procedure and that there is a possibility of no visual gain after surgery. There may be potential complications like extrusion or necrosis of the OOKP lamina, infection in the eye and increased pressure in the eye. There may be need of further surgeries if tissue grows over the OOKP cylinder or a membrane forms behind the cylinder, both of which will need to be removed. I certify that I have fully understood the implications of the above consent and authorize the doctors to perform OOKP surgery in my right/ left eye. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 145 )

152 vk flvvks&v M av dsjkv Á LF fll ¼vksvksdsih½ uwiqj xqirk] jkf/kdk VaMu jksxh dk uke %.... mez@fyax %.... jksxh dh vkbzmh %.... rkjh[k %... dk iq=@iq=h... irk %.... VsyhQksu ua %.... eq>s esjh ekr`òk"kk esa crk;k x;k gs fd eq>s fo' "k :i ls fmtkbu fd, x,,d dsjkv Á LF fll dh vko';drk g xh] ftlesa esjh va/kh vka[k@vka[k a dk bykkt djus ds fyk, n`'; lgkjs ds lefkzu v j nh?kz dkfykd LFkkf;Ro d c<+kus ds fyk, jnu ds nar ds tho oskkfud <kaps esa Ñf"ke dkfuz;k tm+h tkrh gs] D; afd esjh orzeku volfkk esa esjh n`f"v cpkus dk vafre fodyi ;gh gs v j dsjkv IYkkLVh lqyk ugè g axh D; afd esjh vka[ a xa Òhj :i ls lw[kh Òh gsaa esa le>rk gwa fd dsjkv Á LF fll esjs vikjn'kê lqsn dkfuz;k d ÁfrLFkkfir dj nsxk v j fdlh nwjn'kê dh rjg dke djsxk rkfd Ádk'k dh fdj. a lh/ esjh vka[k esa tk,a v j esjh vka[k dh jsfvuk ¼vka[k dk finykk fgllk t vka[k dh ns[kus okykh e'khujh gs½ rd igqapsa v j es a ns[kus esa l{ke g ldwaa eq>s iwjh rjg le>k;k x;k gs fd vk flvvks&v M av dsj V Á LF fll ¼v v dsih½ ds fyk, esjk,d LoLFk jnud nar fudkykk tk,xk v j esjh vka[k dh lrg d <adus ds fyk, xkyk dh van:uh ijr dk,d irykk vlrj Òh fyk;k tk,xka 'ky;fpfdrlk n pj.k a esa dh tk,xh t n eghus ds varj ij g axsa blfyk, 'ky;fpfdrlk ds igy pj.k ds ckn esjh n`f"v ds okil vkus esa Ykack le; Ykx ldrk gsa eq>s laòkfor YkkÒ a v j t f[ke a ds ckjs esa crk;k x;k gs v j laòkouk ;g Òh gs fd 'ky;fpfdrlk ds ckn d bz n`"; YkkÒ u g A v v dsih Y feuk ds ofgosz/ku] ;k foxyku] vka[k esa laøe.k v j vka[k esa ncko c<+us tslh laòkfor lel;k,a Òh g ldrh gsaa ;fn v v dsih flfyamj ij Ård c<+ vkrs gsa ;k flfyamj ds ihns esecjsu cu tkrh gs r n u a d fudkykuk g xka esa Áekf.kr djrk gwa fd esaus mi;qzä lgefr ds fufgrkfk ± d iwjh rjg le> fyk;k gs v j fpfdrld a d viuh nkb±@ckb± vka[k esa v v dsih djus dk vf/kdkj nsrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 146 )

153 SQUINT

154 Squint Surgery Shailesh G.M, Rohit Saxena Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... Information about Squint Adults & children of any age with eye deviation may benefit from eye muscle surgery to make both eyes look straight. This will help maximizing the chance of binocular fusion (3-D vision/depth perception) and normalizing the field of vision. Apart from making them look cosmetically better, squint surgery may also allow patients to see more comfortably with a relaxed head position. Events during surgery General anesthesia is given in children & some special squint cases. Local anesthesia in the form of injections around the eye is given in adults. During surgery, one eye or both eye muscles are either tightened or loosened & the positions of the eye muscles are changed to make eyes look straight. Risks associated with Squint surgery While we are unable to list every possible complication, the following are some potential risks. Major risks 1) Due to anesthesia (both general & local) includes breathing difficulties, vomiting, sore throat, or even risk of heart attack or death. Local complications of anesthesia injections around the eye can be in the form of perforation of eyeball, destruction of optic nerve, interference with circulation of retina, drooping of eyelid, hypotension & respiratory depression. 2) Need for reoperation Over- and under-correction after surgery is common. A reoperation may be necessary because a totally predictable response is not possible in every case. Need for reoperation may be high in cases where prior surgery has been performed, when the squint is complicated, in cases of a slipped or lost muscle, excessive hemorrhage, or fat exposure. Reoperation in some cases may be needed in the other (normal) eye also later to fine tune the surgical results. 3) Loss of vision is quite rare but can be associated with anesthesia or other causes like hemorrhage, retinal detachment (after needle perforation), infection, or change in blood supply to the eye. Minor risks: include inflammation of the eye (conjunctivitis), reaction to the sutures, pain, temporary double vision, temporary blurry vision, alteration of the eyelid position and scar tissue formation including implantation cysts. General information Discomfort of eyes, redness & swollen eyelids for the first few days after surgery is common. If child wears glasses, they will likely continue to wear glasses after the surgery. Eyes are not patched after surgery & usually there is no permanent scar. Eye drops are given 3 to 6 times a day for up to 1 month after surgery. Temporary double vision after surgery is common. Absorbable sutures are used & need not be removed after surgery. Additional comments: I have read & understand the consent form including potential risks & benefits of the squint surgery. I have discussed with my treating eye ( 147 )

155 surgeons & am satisfied with the explanation provided & I authorize them to proceed with my/child s surgery. Occasionally a different, unsuspected condition may arise at the time of surgery requiring immediate attention, and I authorize my surgeon to do what he/she deems necessary. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 148 )

156 fldfouv ltzjh ' Y 'k th,e] j fgr ldlsuk jksxh dk uke %.... mez@fyax %.... jksxh dh vkbzmh %.... rkjh[k %... dk iq=@iq=h... irk %....VsyhQksu ua %.... fldfouv ds ckjs esa tkudkjh folkeku;rk xzlr fdlh Òh mez ds o;ld v j cpps n u a vka[k a ds lh/kk fn[kus ds fyk, dh tkus okykh vka[k dh is'kh dh 'ky;fpfdrlk ls YkkÒkfUor g ldrs gsaa ;g f}us=h; lesdu ¼3&Mh n`f"v@xgjkbz dk Kku½ dh laòkoukv a d vf/kdre djus esa enn djsxh v j n`f"v d lkeku; djsxha vka[k a d Álk/kd okáñfr dh n`f"v ls fn[kus esa csgrj cukus ds vykkok fldfouv 'ky;fpfdrlk flj dh f'kffkyk volfkk esa j xh d vf/kd vkjke ls ns[kus dh Òh lgwfyk;r ns ldrh gsa ltzjh ds n jku dh?kvuk,a Û cpp a v j fldfouv ds dqn fo' "k ekeyk a esa lkeku;,suslfkhfl;k nh tkrh gsa Û o;ld a esa vka[k ds vkl&ikl lwbz Ykxk dj LFkkuh;,susLFkhfl;k nh tkrh gsa Û 'ky;fpfdrlk ds n jku,d vka[k ;k n u a vka[k a dh isf'k; a d ;k r dlk ;k <hykk fd;k tkrk gs v j vka[k dh isf'k; a dh flfkfr cnykh tkrh gs rkfd vka[ a lh/kh fn[ aa fldfouv ltzjh ls tqm+s t f[ke gkykkafd ge ÁR;sd laòkfor tfvykrk dh lwph nsus esa v{ke gsa Y fdu dqn laòkfor t f[ke fueufykf[kr gsa Áeq[k t f[ke 1½,susLFkhfl;k ds dkj.k ¼lkekU; v j LFkkuh; n u a ½ buesa 'kkfeyk gsa% lkal Y us esa dfbukbz] xy esa Ánkg ;k fnyk dk n jk im+uk ;k e`r;q g tkuka vka[k ds vkl&ikl YkxkbZ tkus okykh,suslfkhfl;k dh lwbz dh LFkkuh; tfvykrk,a us= x Ykd esa fnæ g sus] n`'; raf"kdk ds /oal] jsfvuk ds jälapkj esa cka/kk] vka[k dh iykd a ds >qd tkus] mppjäpki v j 'olu laca/kh volkn ds :i esa lkeus vk ldrh gsaa 2½ iqu% 'ky;fø;k dh vko';drk&'ky;fpfdrlk ds ckn vfr@vyi la'k /ku lkeku; g rk gsa iqu% 'ky;fpfdrlk vko';d g ldrh gs D; afd ÁR;sd ekey esa iwjh rjg iwokzuqekus; vuqfø;k laòo ugè g rha mu ekeyk a esa iqu% 'ky;fpfdrlk dh vko';drk g ldrh gs] igy Òh ftudh 'ky;fpfdrlk g pqdh g rh gs] tc fldfouv tfvyk g rk gs] isf'k; a ds f[kld tkus ;k is'kh; {k; ds ekeyk a esasa] vr;f/kd jälzko ;k o'kk dk [kqyk tkuka dqn ekeyk a esa 'ky;fpfdrlk ifj.kke a d lw{e la kks/ku djus ds fyk, iqu% 'ky;fpfdrlk dh vko';drk im+ ldrh gsa 3½ n`f"v dk {k;& cgqr gh fojy ekeyk a esa g rk gs Y fdu,suslfkhfl;k ;k jälzko] jsfuuk dk foykxko] ¼lwbZ ls fnæ g tkus ds ckn½ ;k vka[k dh jä vkiwfrz esa cnykko tsls nwljs dkj.k a ls tqm+k g ldrk gsa N Vs t f[ke% esa 'kkfeyk gsa vka[k dk Ánkg ¼datfDVovkbfVl½] Vkad a ds Áfr ÁfrfØ;k] nnz] vlfkkbz nqgjh n`f"v] vlfkkbz /kqa/kykh n`f"v] vka[k dh iykd dh flfkfr esa cnykko] ÁR;kj i.k fllv cuus lfgr oz.kfpug Ård a dk cuuka lkeku; tkudkfj;ka Û 'ky;fpfdrlk ds ckn ds dqn ÁkjafÒd fnu a ds fyk, vk[k a dh rdykhq] YkYkkbZ] v j lwth gqbz iykdsaa Û ;fn cppk p'ek Ykxkrk gs r og 'ky; fpfdrlk ds ckn Òh p'ek Ykxkuk tkjh j[k ldrk gsa Û 'ky;fpfdrlk ds ckn vka[k a esa t M+ ugè Ykxk;k tkrk v j lkeku;r;k d bz fu'kku ugè im+rka Û 'ky;fpfdrlk ds ckn 1 eghus rd fnu esa 3 ls 6 ckj vkbz Mª Il MkY a tkrs gsaa Û 'ky;fpfdrlk ds ckn vlfkkbz nqgjh n`f"v lkeku; gsa Û vo'k "; Vkads Ykxk, tkrs gsa v j 'ky;fpfdrlk ds ckn fudkykus dh vko';drk ugè im+rha vfrfjä fviif.k;ka% esaus laòkfor t f[ke a v j YkkÒ a lfgr lgefr Ái= d i<+ v j le> fyk;k gsa esaus viuk bykkt dj jgs us"k 'ky;fpfdrld ls ppkz dh gs v j fn, ( 149 )

157 x, Li"Vhdj.k a ls larq"v gwa v j mugsa viuh@vius cpps dh 'ky;fpfdrlk djus dk vf/kdkj nsrk gwaa dòh dòkj 'ky;fpfdrlk ds le;,d vykx] vuisf{kr volfkk,a mòj dj lkeus vk ldrh gsa t vfoykac /;ku nsus dh ekax dj ldrh gsa v j esa vius 'ky;fpfdrld d og djus dk vf/kdkj nsrk gwa t og vko';d lerk@le>rh gsa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 150 )

158 Botox (Botulinum Toxin) Injection Shailesh G.M, Rohit Saxena Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I... have discussed my illness with my treating eye surgeon and I consent to having Botox treatment carried out upon myself for the improvement of... Botox is injected with a small needle into the skin/muscle, with the aim of inhibiting the underlying muscle contraction, therefore improving my underlying muscle spasms/illness. In squint cases, the injection will weaken the overacting muscle & help in making the eye look straight. Botox injection also gives additional information about squint and can be used instead of performing surgery. I have been informed about the indications, treatment procedure, expected results & possible side effects. I understand that I may experience swelling, redness, tenderness, flu-like syndrome, temporary muscle aching, as well as paralysis of a nearby muscle (which can cause droopy eyelids, double vision, droopy mouth, or neck weakness), slight headache, pain and/or bruising that may occur for several days after my treatment, however these symptoms will resolve. Although the results are usually dramatic, I have been informed that the practice of medicine is not an exact science and that no guarantees can be made concerning the expected results in my case. The injection will take 3-4 days to start acting & will usually last for up to 3 months. Repeated injections may be required as the effect starts decreasing from 3-months onwards. I understand that I am required to have a follow-up consultation at 2 weeks, and that I am required to have photographs taken before, during and after treatment for my medical records. Contraindications You should not have Botox if you are pregnant; nursing; allergic to albumin; have an infection, skin condition, or muscle weakness at the site of the injection; or have Eaton-Lambert syndrome, Lou Gehrig s disease, or myasthenia gravis. Botox contains human-derived albumin and carries a theoretical risk of virus transmission. I understand that whilst every precaution will be taken to prevent complications and that whilst complications from this procedure are rare, they can and sometimes do occur. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... ( 151 )

159 Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 152 )

160 c V Dl ¼c VqfYkue V fdlu½ batsd'ku ' Y 'k th,e] j fgr ldlsuk jksxh dk uke %.... mez@fyax %.... jksxh dh vkbzmh %.... rkjh[k %... dk iq=@iq=h... irk %.... VsyhQksu ua %.... esaus viuk bykkt dj jgs 'ky;fpfdrld ls ppkz dh gs v j ds lq/kkj ds fyk, vius Åij c V Dl fpfdrlk djkus ds fyk, lger gwaa vk/kkjòwr is'kh ladqpu ds voj /ku] blfyk, esjh vk/kkjòwr is'kh esa vkdqapu@chekjh esa lq/kkj Ykkus ds mìs'; ls,d N Vh lh lwbz ls Ropk@is'kh esa c V Dl dh lwbz YkxkbZ tkrh gsa fldfouv ds ekeyk a esa lwbz vfr lfø; isf'k; a d det j djsxh v j vka[k ds s lh/kk fn[kus esa enn djsxha c V Dl dk batsd'ku fldfouv ds ckjs esa vfrfjä tkudkjh nsrk gs v j 'ky;fpfdrlk djus dh txg Á; x fd;k tk ldrk gsa eq>s fpfdrlk l>ko a] fpfdrlk ÁfØ;k] visf{kr ifj.kke a v j laòkfor nq"ifj.kke a ds ckjs esa lwpuk nh xbz gsa esa le>rk gwa fd es a lwtu] YkYkkbZ] laosnu'khykrk] Ykw tsls flamª e] vlfkkbz is'kh; nnz ds lkfk&lkfk vkl&ikl dh isf'k; a dk Ykdok ¼t >qdh iykd a] nqgjh n`f"v] >qds eqag ;k xnzu dh det jh dk dkj.k curk gs½] gydk ljnnz] nnz ;k xwem+ vuqòo dj ldrk gwa t bykkt ds dbz fnu ckn rd g ldrk gsa cgjgkyk ;s Yk{k.k [kre g tk,axsa gkykkafd urhts vker j ij ukvdh; g rs gsa] Y fdu eq>sa crk;k x;k gs fd fpfdrlk dk is'kk lvhd fokku ugè gs v j ;g Òh fd fdlh Òh ekey esa visf{kr ifj.kke dh d bz xkjavh ugè nh tk ldrha batsd'ku ds dke djuk 'kq: djus esa 3&4 fnu Ykxsaxs v j rhu eghus rd dke djrs jgs axsa rhu eghus ckn tc mudk ÁÒko de g us Ykxsxk r fqj ls batsd'ku Ykx ldrs gsaa esa le>rk gwa fd eq>s 2 g rksa ij ijke'kznkrk fpfdrld ls Q Yk vi ds fyk, feykuk g xk v j eq>s vius fpfdrlh; vfòy [k ds fyk, bykkt ls igy ] mlds n jku v j mlds ckn vius Q V f[kapokus g axsa duvªkbafmds ku ;fn vki xòzorh gsa( Lruiku djkrh gsa(,ycqfeu dh,yktê gs( d bz laøe.k gqvk gs( Ropk dk d bz j x gs( ;k batsd'ku dh txg ij is'kh; det jh gs( ;k bzv u&ywxsfjl fmthu j x] ;k ek;klf fu;k xzsfol gsa r vkid c V Dl ugè Y uk pkfg,a c V Dl esa ekuo O;wRié,Ycqfeu g rh gs v j fo"kk.kq Álkj.k ds ls)kafrd [krjs dk okgd g rh gsa esa le>rk gwa fd gkykkafd tfvykrkv a d j dus ds fyk, gj lko/kkuh cjrh tk,xh] v j gkykkafd bl ÁfØ;k ls cgqr de tfvykrk,a isnk g rh gs] fqj Òh os g ldrh gsa v j dòh&dòkj g tkrh gsaa esa Áekf.kr djrk gwa fd esaus mi;qzä isjs i<+ v j iwjh rjg le> fyk, gsa v j eq>s ppkz djus v j d bz Á'u mbus ij muds mùkj ikus dk i;kzir volj feykk gsa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... ( 153 )

161 MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 154 )

162 GLAUCOMA

163 Trabeculectomy With / Without Anti-Fibroblastic Agents Munish Dhawan, Ramanjit Sihota Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... Indications, Benefits, and Alternatives I have been informed by my treating doctor that I have been diagnosed with glaucoma and if it is left untreated, it is very likely that I will experience loss of vision which could end up in blindness. Glaucoma means rise in pressure of the eye which can sometimes be treated successfully with medications, or if medications are not effective, laser and other surgical procedures may be of value in controlling the pressure and preventing further vision loss. My doctor has informed me that an operation called trabeculectomy is necessary to help control the pressure in my eye(s) because prolonged rise of this pressure can damage my optic nerve leading to loss of vision and eventual blindness. When successful, this procedure will lower the pressure in my eye, minimizing the risk of further vision loss from glaucoma. The purpose of the operation is to control the pressure and preserve my vision; any vision lost to glaucoma cannot be restored. Complications As with any surgical procedure, there are risks associated with glaucoma drainage surgery. For example, there is always the possibility that the surgery cannot control my eye pressure, for which medications or more procedures may be needed after surgery. Not every possible complication can be covered in this form but the following are examples of risk encountered with glaucoma drainage surgery. These complications can occur days, weeks, months, or years later. They can result in loss of vision or blindness. So frequent follow-up is mandatory after surgery. After complete healing also, regular eye examination is necessary to monitor eye pressure and to look for other problems. Complications of the surgery 1. Failure to control eye pressure, with the need for another operation (early or late) 2. Generally vision might decrease for 2 months or so. There may be development of cataract which can reduce vision but it can be treated with cataract surgery 3. There might be too high or too low pressure after glaucoma surgery for which other necessary treatment or operation might be needed. 4. Bleeding in the eye 5. Pronged redness and mild pain resulting in chronic inflammation 6. Irritation or discomfort in the eye that may persist 7. In spite of surgery, vision could become worse from continuing degenerative changes in the eye 8. Infection resulting in pain, redness and decrease in vision which can occur early or much later 9. In rare cases, there could be total loss of vision Operation will be done under local or general anesthesia which also includes complications of anesthesia. Complications of anesthesia injections around the eye 10. Perforation of eyeball 11. Needle damage to the optic nerve, which could destroy vision 12. Interference with circulation of the retina 13. Possible drooping of eyelid 14. Systemic effects that have the potential for life-threatening complications and death ( 155 )

164 Patient Consent There may arise unwanted situation during surgery. In that situation I give my full authority to my treating doctor to take any necessary decision. In spite of the risks noted above, I understand that there is more risk to my vision if I do not have the operation than if I do. I have read and understood the consent form, and all my queries have been answered, and I authorize my surgeon to proceed with the operation on my... (indicate right or left eye). Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 156 )

165 ,savh&qkbcz CYkkfLVd,tsaV a ds lkfk@muds fcuk VªscsdqY DV eh equh'k /kou je.kthr flg Vk jksxh dk uke %.... mez@fyax %.... jksxh dh vkbzmh %.... rkjh[k %... dk iq=@iq=h... irk %.... VsyhQksu ua %.... fpfdrlk lq>ko] YkkÒ] v j fodyi esjk bykkt dj jgs fpfdrld us eq>s crk;k gs fd funku gqvk gs fd eq>s XYkkd ek gsa cgqr laòo gs fd esa n`f"v gzkl dk vuqòo d:a] g ldrk gs bldk lekiu va/ iu esa g A XYkkd ek dk vfkz gs vka[k ds ncko esa o`f)a dòh&dòh nokv as ls lqykrkiwozd bldk bykkt fd;k tk ldrk gs] ;fn nok,a ÁÒkoh u g a r ncko fu;af=r djus v j vf/kd n`f"v gzkl d j dus ds fyk, Y tj ;k vu; 'ky;fpfdrlk ÁfØ;k,a mi; xh g ldrh gsaa esjs fpfdrld us eq>s crk;k gs fd esjh vka[k ¼vka[k a½ dk ncko fu;af=r djus ds fyk, Vªscs dqy DV eh uke dk,d v ijs'ku vko';d gs D; afd bl ncko ds Ykacs le; rd c<+rs tkus ls n`f"v gzkl g rk gs v j varr% va/kkiu vk tkrk gsa lqyk g us ij ;g v ijs'ku esjh vka[k dk ncko de dj nsxk v j XYkkd ek ds dkj.k v j n`f"v gzkl d de djsxka bl v ijs'ku dk mìs'; ncko fu;af"kr djuk] v j esjh n`f"v d v{kq..k j[kuk gs] XYkkd ek dh otg ls [k bz n`f"v Yk VkbZ ugè tk ldrha lel;k,a tslk fd fdlh Òh 'ky;fpfälh; ÁfØ;k ds lkfk g rk gs] XYkkd ek Mªsust ltzjh ds lkfk Òh t f[ke tqm+s gsaa mnkgj.k ds fyk, bldh laòkouk ges'kk jgrh gs fd 'ky;fpfdrlk esjh vka[k ds ncko d fu;af=r u dj lds] ftlds fyk, 'ky;fpfdrlk ds ckn nokv a ;k v j ÁfØ;kv a dh vko';drk im+ ldrh gsa bl Ái= esa laòkfor lòh lel;kv a d 'kkfeyk djuk laòo ugè gs Y fdu XYkkd ek Mªsust ltzjh djus ij lkeus vkus okykh lel;kv a ds mnkgj.k fueufykf[kr gsa- ;s lel;k,a fnu a] g r a] eghu a v j o"k ± ckn g ldrh gsaa os n`f"v dk gzkl ;k va/kkiu isnk dj ldrh gsaa blfyk, 'ky;fpfdrlk ds ckn Ák;% Q Yk vi ds fyk, tkuk vfuok;z g rk gsa?kko ds iwjh rjg Òj tkus ds ckn Òh vka[k a ds ncko dh fuxjkuh djus v j nwljh lel;kv a dk irk Ykxkus ds fyk, vka[k a dh fu;fer tkap vko';d gsa 'ky;fpfdrlk dh lel;k,a 1- ¼tYnh ;k nsj ls½ nwljs v ijs'ku dh vko';drk ds lkfk vka[k dk ncko fu;af=r djus esa vlqykrk] 2- lkeku;r;k n eghus ds fyk, n`f"v de g ldrh gs] e fr;kfcan g ldrk gs t n`f"v de dj ldrk gs Y fdu dvsjsdv ltzjh ls mldk bykkt fd;k tk ldrk gs 3- XYkkd ek ltzjh ds ckn ncko cgqr de ;k cgqr vf/kd g ldrk gs ftlds fyk, nwljs vko';d bykkt a ;k v ijs'ku a dh t:jr im+ ldrh gs 4- vka[k esa jälzko 5- Ykacs le; rd YkYkkbZ v j gydk nnz ftlds QYkLo:i nh?kzdkfykd Ánkg g ldrk gs 6- vka[k esa bfjvs ku ;k fmldeqzv t cuk jg ldrk gs 7- 'ky;fpfdrlk ds ckotwn vka[k esa tkjh vigzklh ifjorzu a ds dkj.k n`f"v v j [kjkc g ldrh gs 8- laøe.k] ftuds dkj.k YkYkkbZ vk ldrh gs] n`f"v de g ldrh gs t tynh ;k dkqh nsj ls Òh g ldrk gs 9- fojy ekeyk a esa iwjh rjg ls n`f"v dk gzkl g ldrk gs v ijs'ku Yk dyk ;k tujyk&,suslfkhfl;k nsdj fd;k tk,xk] ftlesa,suslfkhfl;k dh lel;k,a Òh 'kkfeyk g ldrh gsaa vka[k ds vkl&ikl,suslfkhfl;k dh lwbz Ykxkus dh lel;k,a 10- us=x Ykd esa fnæ g tkuk 11- lwbz ls n`'; raf=dk d {kfr igqapuk t n`f"v d u"v dj ldrk gs 12- jsfvuk esa jä lapkj esa ck/kk 13- laòkfor iykd Mwfiax 14- fllvesfvd ÁÒko t tkuy ok lel;k,a isnk dj ldrs gsa ;k e`r;q dk dkj.k cu ldrs gsa ( 157 )

166 j xh dh lgefr 'ky;fpfdrlk ds n jku vokafnr flfkfr;ka isnk g ldrh gsaa ml flfkfr esa viuk bykkt dj jgs fpfdrld d d bz Òh vko';d fu.kz; Y us dk iwjk vf/kdkj nsrk gwaa mi;qzä t f[ke a ds ckotwn esa le>rk gwa fd ;fn esa vkijs'ku ugè djkrk r esjh n`f"v d v ijs'ku djkus ls dgè vf/kd [krjk jgsxka esaus lgefr Ái= d i<+ v j le> fyk;k gs v j esjs lòh Á'u a ds mùkj fn, x, gsa v j esa vius 'ky;fpfdrld d viuh ¼**nkb±** ;k **ckb±** vka[k dk fufnz"v djsa½ v ijs'ku djus dk vf/kdkj nsrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 158 )

167 Diode Laser Cyclo-photocoagulation (DLCP) Anand Agarwal, Shalini Mohan Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... DLCP is an ocular surgical procedure which is usually carried out in people with advanced, recalcitrant glaucoma who have uncontrolled high intra ocular pressures (IOPs) inspite of use of medications and repeated glaucoma filtration surgeries and used of glaucoma drainage devices (GDDs). This procedure is effective in bringing down IOPs and relieving ocular pain if the cause of pain is high IOP. The procedure is usually carried out under local peribulbar anesthesia and sometimes more than one sitting needs to be given ie the procedure may have to be repeated to bring about clinical success. Post operative care The eye may be red, swollen and painful following the procedure for which pain relieving oral medications and some drops are given to bring about relief. Out patient visits are done on first day post operatively, day seven and then after every two weeks. The need for repeat procedure is decided by the treating physician after evaluating patient s symptoms and IOP. The usual side effects encountered are: 1. Ocular pain 2. Redness 3. Peri ocular swelling 4. Need for repeat treatments 5. The procedure may be able to bring down the need for IOP lowering medications although some of them may be required to maintain optimal IOP 5. Rarely the eye may become smaller i.e. progress to atrophic bulbi IT IS VERY IMPORTANT FOR THE PATIENT TO UNDERSTAND THAT THE PROCEDURE IS NOT MEANT TO IMPROVE THE VISION OVER & ABOVE WHAT HE/SHE HAS ALREADY GOT. I have been made aware of the above mentioned facts and I have been counseled about the potential benefits and possible side effects of the procedure and by thoroughly going through all of the above, I give my full informed consent for the above procedure. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... ( 159 )

168 Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 160 )

169 Mk; M Y tj lkbdyk &Q V d xqy 'ku ¼Mh,y lh ih½ vkuan vxzokyk] 'kkfykuh e gu jksxh dk uke %.... mez@fyax %.... jksxh dh vkbzmh %.... rkjh[k %... dk iq=@iq=h... irk %.... VsyhQksu ua %.... Mh,Yklhih,d us= 'ky;fpfdrlk ÁfØ;k gs t mér] nqnze; XYkkd ek ls ihfm+r mu Yk x a ij dh tkrh gs ftuds mpp var% usf=; nkc ¼vkbZv ih½ nokv a v j ckj&ckj XYkkd ek fqyvjs'ku ltzjh djus v j XYkkd ek Mªsust Msokbl a ¼thMhMh½ ds mi; x ds ckn Òh fu;af=r ugè g rsa ;g ÁfØ;k var% usf=; nkc ¼vkbZv ih½ de djus v j vka[k ds nnz ls jkgr fnykkus esa ÁÒkoh g rh gs] c'krsz fd nnz mpp vkbzv ih ds dkj.k g jgk g A lkeku;r;k ;g ÁfØ;k isjhcycj,suslfkhfl;k nsdj dh tkrh gs v j dòh&dòh,d ls vf/kd ckj djuh im+rh gs] ;kuh fpfdrlh; lqykrk ds fyk, ÁfØ;k nqgjkuh im+ ldrh gsa 'ky;fpfdrl Ùkj ifjp;kz ÁfØ;k ds ckn vka[k YkkYk g ldrh gs] lwtu ;k ldrh gs ;k nnz g ldrk gs] ftlls jkgr fnykkus ds fyk, [kkus v j vka[k esa Vidkus dh nok,a nh tk ldrh gsaa cfgjax j xh foòkx esa v ijs'ku ds ckn igy v j~ lkrosa fnu v j mlds ckn gj n g rksa ij eqykkdkrsa dh tkrh gsaa nqckjk ÁfØ;k djus dh vko';drk j xh ds Yk{k.k a v j vkbzv ih tkapus ds ckn bykkt djus okykk fpfdrld r; djrk gsa lkeku;r% lkeus vkus oky nq"áòko gsa% 1- vka[k esa nnz 2- YkYkkbZ 3- isfjvk dwyj lwtu 4- iqu% fpfdrlk dh vko';drk 5- ÁfØ;k vkbzv ih de djus okykh nokv a dh vko';drk de dj ldrh gs gkykkafd ;F "V vkbzv ih cuk, j[kus ds fyk, dqn nokv a dh t:jr im+ ldrh gsa 5- fojy ekeyk a esa vka[k N Vh g ldrh gs] ;kuh,vªksfqd oyokbz j xh ds fyk, ;g le>uk cgqr egroiw.kz gs fd ÁfØ;k dk mìs'; mldh orzeku n`f"v esa lq/kkj Ykkdj mlls vf/kd ;k mlls Åij dh n`f"v Ánku djuk ugè gs eq>s mi;qzä rf; a ls voxr djk;k x;k gs v j eq>s ÁfØ;k ls j xh d g us oky YkkÒ a v j laòkfor nq"áòko a ds ckjs esa lykkg nh xbz gs v j mi;qzä lkjh ckr a d xaòhjrk ls i<+us ds ckn esa miq;zä ÁfØ;k ds fyk, viuh iwjh lwfpr lgefr nsrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... ( 161 )

170 MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 162 )

171 Argon Laser Trabeculoplasty (ALT) Manoj Gupta Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... The argon laser causes photocoagulation of tissue. Thermal disruption of structural molecules, especially protein denaturation, results in tissue changes that are observed such as contraction, condensation, and separation. Formation of amorphous gels as well as clot formation can also occur. Higher temperatures result in non-selective coagulation necrosis of the target tissue and will lead to the burning of tissue. Argon Laser Trabeculoplasty Laser trabeculoplasy (LTP) is indicated for the treatment of open-angle glaucomas and is particularly effective in the treatment of pigmentary and pseudoexfoliation glaucomas. LTP causes alteration of the TM by photocoagulation and a greater effect is seen with more heavily pigmented TM. The precise mechanism of action is unknown but it relates to the change in conformation of the TM by collagen shrinkage leading to the opening of meshwork in adjacent, nontreated regions. Procedure A slit lamp-mounted argon laser is usually used with the laser beam focused at the outflow angle with a contact lens such as a Goldmann three-mirror lens. The laser settings are typically 800 mw to 1200 mw for 0.1 second and a 50-µm spot size. The laser is focused on the TM and the power adjusted to cause a slight focal bubble or blanching of the TM. The TM is treated for 180º to 360º with a total of 50 to 100 spots. Treatment complications include elevation of IOP, inflammation, inadvertent treatment of the cornea or ciliary body, hemorrhage, and pain. Antiglaucoma Medication History I have been explained about the procedure and the risk involved in the procedure in my own language. I have been explained that there might be decrease in vision, corneal burn, raised IOP, and IOP may not decrease to desired level. Knowing all these inadvertent complications, I am willing to undergo the above procedure and I give my consent for the procedure. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... ( 163 )

172 Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 164 )

173 vkxzu Y tj VªscsdqYk IYkkLVh ¼,,yVh½ eu t xqirk jksxh dk uke %.... mez@fyax %.... jksxh dh vkbzmh %.... rkjh[k %... dk iq=@iq=h... irk %.... VsyhQksu ua %.... vkxzu Y tj Ård a ds Q V dkxqy 'ku dk dkj.k curk gsa lajpukred v.kqv a dk rkih; fo?kvu] [kkl dj Á Vhu foñfrdj.k ds dkj.k Ård ifjorzu g rs gsa t ladqpu] la?kuu] v j vykxko ds :i esa lkeus vkrs gsaa vfølvykh; tsyk ;k Fkôk Òh cu ldrk gsa Åaps rkieku ds dkj.k vfòykf{kr Ård a dk vp;fur Ldanu foxyku g rk gs v j Ård tyk tkrs gsaa vkxzu Y tj VªscsdqYk IYkkLVh Y tj VªscsdqYk IYkkLVh dk lq>ko vksiu,saxy ds XYkkd ek ds bykkt ds fyk, fn;k tkrk gs v j fixesavjh v j L;wM,DlQ fyk,'ku XYkkd ek ds bykkt esa ÁÒkoh gsa,ykvhih Q V dkxqy 'ku }kjk Vh,e dk,dkarj.k djrh gsa bl fø;k dh lvhd ;kaf=dh vkkr gs Y fdu ;g dky tu ds ladqpu ls Vh,e dh jpuk esa cnykko ls lacaf/kr gs ftlls ikl ds vuqipkfjr es kodz dh tkykh [kqyk tkrh gsa ÁfØ;k lkeku; :i ls Y tj fdj.k ds lkfk flyv Y ai ij LFkkfir vkxzu Y tj d x YMeSu Fkzh fejwj Y al tsls dkavsdvy al ds lkfk oká Áokg d.k ij dsafær fd;k tkrk gsa Y tj dh Áokg fn'kk Á:ih r j ij 0-1 lsdam ds fyk, 800,eMCY;w ls 1200,eMCY;w v j 50 E;w,l ds fcanqeki ij g rh gsa Y tj d Vh,e ij dsafær fd;k tkrk gs v j gydk&lk ukòh; cqykcqykk mrié djus ds fyk, ikoj leaftr fd;k tkrk gsa 180 ls 360 rd dqyk 50 ls 100 fcanqv a ij Vh,e dk mipkj fd;k tkrk gsa bykkt dh lel;kv sa esa vkbzv ih dk c<+uk] Ánkg] dkfuz;k ;k flfyk;jh c Mh dk vufòásr mipkj] jälzko v j nnz 'kkfeyk g ldrs gsaa,savhxykkd ek ds v "kf/ká; x dk bfrgkl eq>s esjh viuh Òk"kk esa ÁfØ;k v j ÁfØ;k ds lkfk tqm+s t f[ke a ds ckjs esa le>k;k x;k gsa eq>s crk;k x;k gs fd g ldrk gs fd n`f"v de g tk,] dfuz;k tyk tk,] vkbzv ih c<+ tk, v j vkbzv ih okafnr Lrj rd de u g A bu lòh vufòásr lel;kv a ds ckotwn esa mi;qzä ÁfØ;k djkuk pkgrk gwa v j ÁfØ;k ds fyk, viuh lgefr nsrk gwajksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... ( 165 )

174 MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 166 )

175 Laser Iridotomy Deepankur Mahajan Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... Laser iridotomy is a procedure used for patients with narrow angle glaucoma in which a laser is used to make a small hole in the iris (colored part of the eye) to allow free movement of fluid from posterior to anterior chamber of the eye which might help to control the intraocular pressure and hopefully prevent scar formation between the iris and cornea which can check progression of the glaucoma. Risks associated with this procedure include transient blurring of vision, post laser IOP spike, anterior uveitis, pupillary distortion, corneal epithelial defects and corneal burns, bleeding/hyphema, cataract, diplopia, late iridotomy closure, retinal/macular burns, malignant glaucoma, sterile hypopyon, cystoid macular edema and pupillary pseudomembrane. Additional medical or surgical intervention might be required for these complications. The procedure may require more than on sitting for completion in some cases. Some individuals respond only partially or not at all to the procedure and may require additional medication/surgical intervention to check progression of glaucoma. Post procedure topical medication including glaucoma medication might have to be continued/ changed. I,... have been fully explained in the best understood language (...) that I have RE/LE... and have to undergo right/left eye laser iridotomy for the same. The details of the procedure, alternatives and their risks and benefits have been explained to my satisfaction. I hereby give my full, free and voluntary informed consent for right/left eye laser iridotomy. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 167 )

176 Y tj vkbfjm V eh nhiadj egktu jksxh dk uke %.... mez@fyax %.... jksxh dh vkbzmh %.... rkjh[k %... dk iq=@iq=h... irk %.... VsyhQksu ua %.... Y tj vkbfjm V eh,d ÁfØ;k gs t ladh.kz d.k XYkkd ek ds j fx; a esa Á;qä g rh gs] ftlesa vka[k ds finy Ád "B ls vxy Ád "B es a eqä :i ls rjyk ds Áokg dh lqfo/kk nsus ds fyk, vkbfjl ¼vka[k ds jaxhu Òkx½ esa,d N Vk&lk fnæ djus ds fyk, Y tj dk Á; x fd;k tkrk gs] t var%usf=; ncko fu;af=r djus esa enn dj ldrk gs v j meehn dh tkrh gs fd vkbfjl v j dkfuz;k ds chp LdkWj cuus ls j d ldrh gs t XYkkd ek ds fodkl d j d ldrk gsa bl ÁfØ;k ls tqm+s t f[ke a esa 'kkfeyk gsa n`f"v dk vlfkk;h /kqa/kykkiu] Y tj ds ckn vkbzv ih Likbd],saVsfj;j ;wfo;kl Fk] I;wiykjh dk fo:i.k] dkfuz;k ds bfiffk;e dh foñfr] dkfuz;k dk tyk tkuk] jälzko@gkbqsek] e fr;kçcan] fmiyk fi;k] vkbfjm V eh dk nsj ls can g uk] jsfvuyk@esdqyj cuz] dsaljh XYkkd ek] thok.kqjfgr gkbi ik; u] fllv ;M ekdqykj,fmek v j I;wfiYkjh L;wM esaczsua bu lel;kv a ds fyk, vfrfjä fpfdrlh;@'ky;fpfdrlh; glr{ i dh t:jr im+ ldrh gsa dqn ekeyk a esa g ldrk gs fd ÁfØ;k,d ls vf/kd ckj esa iwjh g A dqn O;fä ÁfØ;k ds Áfr vkaf'kd vuqfø;k nsrs gsa ;k fljs ls vuqfø;k ugè nsrs v j muds fyk, XYkkd ek d c<+us ls j dus ds fyk, vfrfjä v "kf/k Á; x@'ky;fpfdrlh; glr{ i dh vko';drk im+ ldrh gsa v ijs'ku ds ckn dh LFkkfud nok,a] XYkkd ek dh nokv a lfgr] tkjh j[kuh@cnykuh im+ ldrh gsaa eq>s] t Òk"kk lcls vpnh rjg le> esa vkrh gs ml Òk"kk ¼ ½ esa le>k;k x;k gs fd eq>s nkbz vk [k@ckbz vk [k v j eq>s mlds fyk, nkb±@ckb± vk[k dk Y tj vkbfjm V eh djkuk gsa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 168 )

177 CATARACT

178 Cataract Surgery With / Without Implantation of Intraocular Lens Courtesy: Shroff Eye Centre, New Delhi Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... Introduction : A cataract is opacity of the lens. Cataract operation is indicated only when you cannot function adequately due to poor sight produced by the cataract. Maturity of cataract is no longer a criterion for surgery. The natural lens within your eye with a slight cataract, although not perfect, has distinct advantages over an artificial lens. In giving permission for cataract extraction with / without implantation of an intraocular lens in my eye, I declare that I understand the following information 1. Alternative Treatments : There are three methods of restoring vision after cataract surgery a) Cataract Spectacles b) Contact Lens c) Intraocular Lens Cataract spectacles increase image size by 30%. They cannot be used if there is cataract in only one eye (the other is normal) because they may cause double vision. A contact lens increases image size by 8%. However, it is difficult to handle and may not be tolerated by everyone. Intraocular lens does not increase image size. It is surgically placed inside the eye permanently 2. An intraocular lens is implanted by surgery (not by laser). The implanted lens will be left in the eye permanently. At the time of surgery the doctor may decide not to implant an intraocular lens in the eye, if for any reason he feels that the lens implantation is not indicated or may prove deleterious to the well being of the eye, even though permission may have been given to do so 3. Though the intraocular implant power is calculated by utilizing a computerised Biometer (A-scan), a small correction in the spectacles is to be considered inevitable postoperatively and this may be more in specific cases. An astigmatism (number with axis) which may reduce with time, is to be taken as inevitable and normal. Therefore, a small power is to be expected in the spectacles for distance and near for clear vision after the operation. In any case, the aim of cataract surgery is to remove the cloudy lens from the eye and replace it with a plastic lens and not to rid the patient of his spectacles 4. The calibre of vision obtained after a successful cataract surgery/lens implantation depends upon the retina behind. In an advanced cataract even with the most sophisticated instruments (Ultrasound Scan etc.), it is not possible to be certain that the retina inside is normal. Removal of cataract is like opening a door to a room. If the retina is normal, you will see well, but it is not possible in a majority of advanced cataract cases to ascertain the visual status of the retina before operation 5. With modern instrumentation and micro surgical techniques, the rate of complications in cataract surgery with/without intraocular lens implantation is very low. Complications can usually be managed by medical and/or surgical treatment. The chances of total loss of vision are less than 0.5%. However, the following complications can occur and are mentioned in standard text books of cataract and lens implantation surgery a) It is possible that vision may drop after surgery due to thickening/opacification of the posterior capsule. This is not a complication but a sequelae to Extra Capsular Cataract Extraction. The condition is treated with the Yag Laser b) Complications may include haemorrhage (bleeding), posterior capsule rupture, nucleus drop, vitreous loss, wound leakage, uveitis, cornea! decompensation, glaucoma, cystoid macular oedema or retinal detachment. In addition lens implantation may be complicated by severe reaction to the lens (Toxic Lens Syndrome) or dislocation of the lens. The implanted lens may have to be repositioned or removed surgically if it is likely to damage the eye. Though every effort is made to minimize the chances of infection, it cannot be eliminated altogether. Loss of vision is a risk common to any intraocular surgery c) Although you may have opted for phacoemulsification surgery and the same may have been planned by your surgeon after ( 169 )

179 pre operative examination, if during surgery phacoemulsification is found to be unsafe or not feasible. your surgeon will have the liberty to perform surgery by the conventional technique in the interest of patient safety d) Complications of surgery in general:- As the procedure is generally done under local anaesthesia the risk to life is less than 0.5%. Risk is greater in patients with Diabetes, Hypertension, Cardiac ailments and other systemic disorders & when surgery is performed under general anaesthesia. There is a possibility of drug reaction, brain damage or risk to life Since it is impossible to state every complication that may occur as a result of surgery, the list of complications in this form is not exhaustive. Consent for Operation 1. I hereby authorize Dr.... and those whom he may designate as associates or assistants to perform cataract operation with an intraocular lens / without an intraocular lens / as a secondary procedure on my left / right eye It has been explained to me that during the course of operation/ procedure, unforeseen conditions may be revealed or encountered which necessitate surgical or other procedures in addition to or different from those contemplated. I, therefore, further request and authorize the above named Physician/Surgeon or his designates to perform such additional surgical or other procedures as he or they deem necessary or desirable 2. The nature and purpose of the operation, the necessity thereof, the possible alternative methods of treatment of my condition have been fully explained to me and I understand the same 3. I am fully aware that the surgery is being performed in good faith and that no guarantee or assurance has been given as to the result that may be obtained 4. I consent to the administration of anesthesia and to the use of such anesthetics as may be deemed necessary or desirable 5. I further consent to the administration of such drugs or infusions deemed necessary in the judgement of the medical staff 6. I consent to the observing, photographing or televising of the procedure to be performed for medical, scientific or education purpose provided my identity is not revealed by the pictures or by descriptive text accompanying them 7. Any tissues or parts surgically removed may be disposed off by the institution in accordance with customary practice Informed Consent for Operation on Patients With Guarded / Poor Visual Prognosis I have been explained by the attending surgeon/designated Assistant prior to the operation that visual prognosis after surgery is guarded/uncertain/poor/very poor. The reasons for this have been explained to me. The reasons are: (to be signed by the patient / person authorised to consent for the patient.) Trauma / Diabetic Retinopathy / Myopia / Glaucoma / Uveitis /Age Related Macular Degeneration / PVR / Complex Traction Retinal Detachment/Combined tractional rhegmatogenous retinal detachment /Dislocated lens or IOL / Endophthalmitis (Severe eye infection) Signature of patient / person authorised to consent for patient:... I THE UNDERSIGNED (THE PATIENT OR NEAREST RELATIVE) HEREBY GIVE MY CONSENT FOR THE OPERATION OF LEFT EYE / RIGHT EYE WITH THE FULL KNOWLEDGE OF POSSIBLE COMPLICATIONS AND GUARDED / POOR VISUAL PROGNOSIS. I CERTIFY THAT I HAVE READ THIS INFORMED CONSENT / IT HAS BEEN READ OVER TO ME AND EXPLAINED TO ME IN MY MOTHER TONGUE AND ALL BLANKS OR STATEMENTS REQUIRING INSERTION OR COMPLETION WERE FILLED IN AND ANY INAPPLICABLE PARAGRAPHS STRICKEN OFF BEFORE I SIGNED. THE DOCTOR HAS ANSWERED ALL MY QUESTIONS TO MY SATISFACTION. ( 170 )

180 Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 171 )

181 bavªkvkd;wykj Y al a ds lkfk@muds fcuk dsvjsdv ltzjh lkòkj%: J Q vkbz lsavj] u;h fnyykh jksxh dk uke %.... mez@fyax %.... jksxh dh vkbzmh %.... rkjh[k %... dk iq=@iq=h... irk %.... VsyhQksu ua %.... ifjp;% dsvjsdv Y al dh vikjnf'kzrk gsa dsvjsdv ds v ijs'ku dk lq>ko ròh fn;k tkrk gs tc vki e fr;kfcan tu; [kjkc n`f"v ds dkj.k ;F "kzv :i ls dke ugè dj ikrsa e fr;kfcan dk id tkuk vc 'ky;fpfdrlk dh dl Vh ugè gsa gyds e fr;kfcan ds lkfk vka[k esa vka[k ds ÁkÑfrd Y al ds Ñf"ke Y al ds jgus ds eqdkcy vusd YkkÒ gsaa viuh vka[k esa bavªkv D;wYkj Y al ds lkfk@;k mlds fcuk e fr;kfcan ds fu"d"kz.k dh vuqefr nsrs gq, esa?k "k.kk djrk gwa fd fueu esa lwpukv a d le>k gwa 1- osdfyid fpfdrlk,a% dsvjsdv ltzjh ds ckn n`f"v dh okilh d rhu fof/k;ka gsa v½ dsvjsdv p'ek c½ dkavsdvy al l½ bavªkvkd;wykj Y al dsvjsdv p'ek fp= d 30% c<+k nsrk gsa ;fn dsoyk,[k vka[k esa e fr;kfcan g r p'ek ugè iguk tk ldrk D; afd og nqgjh n`f"v isnk dj ldrk gsa dkavsdv Y al fp= dk vkdkj 8% c<+krk gsa Y fdu mldk j[k&j[kko dfbu g rk gs v j gj fdlh ls lgu ugè g rka bavªkvkd;wykj Y al fp"k dk vkdkj ugè c<+krka 'ky;fpfdrlk ls bls LFkkbZ :i ls vka[k ds Òhrj Ykxk;k tkrk gsa 2- d bz var% us=h; Y al 'ky;fpfdrlk }kjk ¼Y tj }kjk ugè½ vka[k esa Ykxk;k tkrk gsa ÁR;kj fir Y al d LFkkbZ :i ls vka[k esa N M+ fn;k tkrk gsa 'ky;fpfdrlk ds le; fpfdrld var% us=h; Y al u Ykxkus dk QSlYkk dj ldrs gs]a c'krsz fd fdlh dkj.ko'k mls Ykxrk gs fd ÁR;kj i.k ugè fd;k tk ldrk ;k vka[k ds LokLF; ds fyk, gkfudkjd lkfcr g ldrk gs] pkgs mls,slk djus dh vuqefr feykh g rc ÒhA 3- gkykkafd var% us=h; ÁR;kj i.k ds ikoj dk vkdyku dai;wvjhñr ck; ehvj ¼,&LdSu½ dk mi; x djds fd;k tkrk gs] Y fdu v ijs'ku ds ckn p'es esa ekewykh la'k /ku d vifjgk;z le>k tkrk gs v j fo' "k ekeyk a esa ;g vf/kd Òh g ldrk gsa n`f"vos"ke; ¼,fDll ds lkfk uacj½ d vo';aòkoh v j lkeku; ekuk tk ldrk gsa blfyk, v ijs'ku ds ckn nwj v j utnhd ds fyk, p'es esa Fk M+k lk ikoj g us dh vis{kk dh tk ldrh gsa t Òh g dsvjsdv ltzjh dk mìs'; vka[k ls /kqa/kykk Y al fudkyk dj mldh txg IYkkfLVd dk Y al Ykxkuk g rk gs] j xh d p'es ls futkr fnykkuk ugèa 4- lqyk dsvjsdv ltzjjh@y al ds ÁR;kj i.k ds ckn ÁkIr n`f"v dh {kerk ihns dh jsfvuk ij fuòzj djrk gsa c<+ pqds e fr;k fcan esa] vk/kqfudre midj.k a ¼vYVªklkmaM LdSu br;kfn½ ds lkfk Òh fuf'pr :i ls dguk laòo ugè gs g rk fd Òhrj jsfvuk lkeku; gsa e fr;kfcan dk fudkykuk fdlh dejs dk njoktk [k Ykus tslk gsa ;fn jsfvuk lkeku; gs r vki vpnh rjg ns[ axs Y fdu e fr;kfcan dh c<+h volfkk esa v ijs'ku ls igy jsfvuk dh n`'; flfkfr dk r; g ikuk laòo ugè g rka 5- vk/kqfud midj.k a v j lw{e 'ky;fpfdrlh; rduhd ds lkfk var%us=h; Y al ds ÁR;kj i.k ds lkfk@mlds fcuk e fr;kfcan dh 'ky;fpfdrlk esa tfvykrkv a dh nj cgqr de g rh gsa tfvykrkv a d fpfdrlh; v j@;k 'ky;fpfdrlh; bykkt ls fu;af=r fd;k tk ldrk gsa iwjh rjg n`f"v gzkl dh laòkouk,a 0-5% ls Hkh de jgrh gsaa Y fdu fueufykf[kr tfvykrk,a isnk g ldrh gsa v j e fr;kfcan v j Y al ÁR;kj i.k laca/kh ekud iqlrd a esa mudk myy [k fd;k x;k gsa,½ laòo gs fd 'ky;fpfdrlk ds ckn i'p dsilwyk ds e Vk g us@vikjn'kê g us ds dkj.k n`f"v det j im+ tk,a ;g tfvykrk ugè] cfyd,dlvªk dsilqykj dsvjsdv,dlvªsd'ku dk ifj.kke gsa bl volfkk dk bykkt **okbz,th Y tj** ls fd;k tkrk gs ch½ tfvykrkv a esa 'kkfeyk gs] gsejst ¼jälzko½] i LVsfj;j dsilwyk dk QV tkuk] U;wfDYk;l Mª i] ikslvhfj;j dsilyw dk VwVuk]?kko dk fjluk] ;wfo;k'k Fk dkfuz;k! dk fmdweisals'ku] XYkkd ek] fllv ;M ekd;wykj,fmek ;k jsfvuk dk foykxkoa blds vfrfjä Y al ds Áfr xaòhj ÁfrfØ;k ¼V fdld Y al flamª e½ ls Y al ÁR;kj i.k tfvyk g ldrk gsa ÁR;kj fir Y al d iqu% LFkkfir djuk im+ ldrk gs ;k ;fn mlds vka[k d {kfr igqapkus dh vk'kadk g r mls 'ky;fpfdrlk ls fudkykuk im+ ldrk gsa gkykkafd laøe.k de djus ds lòh Á;kl fd, tkrs gsa Y fdu mldh laòkouk d iwjh rjg [kre ugè fd;k tk ldrka lh½ gkykkafd g ldrk gs fd vkius Qkd bey'ku ltzjh ilan dh g v j 'ky;fpfdrlk ls igsyk dh xbz tkap ds ckn vkids 'ky;fpfdrld ( 172 )

182 us ogh djus dh ; tuk cukbz g xh Y fdu ;fn Qkd bey'ku ltzjh vlqjf{kr ;k vo;kogkfjd ikbz tkbz gs r vkidk 'ky;fpfdrld j xh ds fgr esa ijaijkxr rduhd ls 'ky;fpfdrlk djus ds fyk, Lora= g xk Mh½ 'ky;fpfdrlk dh lkeku; tfvykrk,a] pwafd ÁfØ;k lkeku;r;k Yk dyk,suslfkhfl;k nsdj dh tkrh gs blfyk, tku dk t f[ke 0-5% ls de jgrk gsa tc 'ky;fpfdrlk tujyk,suslfkhfl;k nsdj dh tkrh gs r Mk;kfcVht] mppjäpki] fnyk ds j x a] v j nwljs nsfgd fodkj a ds j fx; a d t f[ke vf/kd jgrk gsa nok dh ÁfrfØ;k] eflr"d {kfr ;k tku t f[ke dh Òh laòkouk jgrh gsa pwafd 'ky;fpfdrlk ds QYkLo:i g us okykh ÁR;sd tfvykrk ds ckjs esa crkuk vlaòo gs blfyk, bl Ái= esa nh xbz tfvykrkv a dh lwph laiw.kz ugè g ldrha v ijs'ku ds fyk, lgefr 1- esa,rn~ }kjk M v j mugsa ftud og vius lg; fx; a ;k lgk;d a ds :i esa fu;qä djrs gsa] viuh ckb±@nkb± vka[k esa bavªkv D;wYkj Y al ds lkfk@bavªkv D;wYkj Y al ds fcuk dsvjsdv v ijs'ku djus dk vf/kdkj nsrk gwa eq>s le>k;k x;k gs fd v ijs'ku@áfø;k ds n jku vuisf{kr volfkkv a dk irk pyk ldkr gs ;k lkeus vk ldrh gsa t visf{kr v ijs'ku ls vfrfjä ;k vykx nwljh 'ky;fpfdrlh; ;k vu; ÁfØ;kv a d vko';d cuk ldrh gsaa blfyk, esa mi;qzä uke ds vfrfjä 'ky;fpfdrlk ;k nwljh ÁfØ;k,a djus dk vuqj /k djrk v j vf/kdkj Ánku djrk gwa ftugsa og ;k os vko';d ;k okafnr le>rs g a 2- v ijs'ku dh ÁÑfr v j mìs';] mldh vko';drk] esjh volfkk ds bykkt ds vu; laòkfor rjhd a ds ckjs esa eq>s iwjh rjg crk;k xk;k gs v j esa mugsa le>rk ga 3- esa iwjh rjg voxr gwa fd 'ky;fø;k usduh;rh ls dh tk jgh gs v j ÁkIr g ldus oky ifj.kke a ds ckjs esa d bz xkjavh ;k vk'oklu ugè fn;k xk; gs 4- esa,suslf fl;k v j,sls,uslf fvdl ds mi; x ls lger gwa ftls vko';d okafnr le>k tk, 5- esa fpfdrlh; dfez; a dh utj esa vko';d v j okafnr nokv as v j bu ;wtu fn, tkus ls lger gwa 6- esa fpfdrlh;] oskkfud ;k ' {kf.kd mìs'; ls ÁfØ;k ds voyk du] Q V mrkjus ;k VsfYkfotu ls Álkfjr djus dh lgefr nsrk gwa c'krsz fd fp= ;k muds lkfk fn, tkus oky o.kzukred ikb ls esjk ifjp; ÁdV u g A 7- 'ky;fpfdrlk }kjk fudky x, d bz Òh Ård ;k vax a d lalfkku ijaijkxr pyku ds vuq:i fbdkus Ykxk ldrk gs jf{kr@[kjkc n`'; iwokzuqeku oky j fx; a ds v ijs'ku ds fyk, lwfpr lgefr eq>s ifjp;kz djus oky ltzu@ukfer lgk;d }kjk v ijs'ku ls igy crk;k x;k gs fd 'ky;fpfdrlk ds ckn n`'; iwokzuqeku jf{kr@vfuf'pr@cgqr [kjkc gsa eq>s blds dkj.k crk, x, gsaa dkj.k gsa% ¼j xh@j xh ds fyk, lgefr nsus ds fyk, Ákf/kÑr O;fä }kjk glrk{kj djus ds fyk,a½ vk?kkr] Mk;kcsfVd jsfvu isfkh] ek; fi;k@xykkd ek@;wfo;k'k Fk@mez laca/kh us"kh; {k;@ihohvkj@daiy Dl VªSD'ku jsfvuyk fmvspesav@dackbam VªSD'kuYk jsxesv tsul jsfvuyk fmvspesava LFkkarfjr Y al ;k vkbzv,yk@,am IF YkekbfVl ¼vka[k dk xaòhj laøe.k½ j xh@j xh ds fyk, lgefr ds fyk, Ákf/kÑr O;fä ds glrk{kj esa v/k glrk{kj drkz ¼j xh ;k fudvre laca/kh½,rn~}kjk laòkfor tfvykrkv a v j lajf{kr@[kjkc n`f"v ds iwokzuqeku ds ckjs esa iwjh tkudkjh ds lkfk viuh ckb±@nkb± vka[ka ds v ijs'ku dh lgefr nsrk gwaa esa Áekf.kr djrk gwa fd esaus ;g lwfpr lgefr i<+ Ykh gs ;g eq>s i<+ dj lqukbz xbz gs v j esjh ekr`òk"kk esa eq>s le>kbz xbz gsa v j lkjh [kkykh txgsa ;k fuos'ku ;k iwfrz dh ekax djus okyks lòh dfku esjs glrk{kj djus ls igy Òjs x, F v j Ykkxw u g us oky isjs dkv fn, x, F A fpfdrld us esjs lòh Á'u a ds lar "ktud mùkj fn, gsaa ( 173 )

183 dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 174 )

184 Pediatric Cataract Shalini Mohan, Anand Aggarwal Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... Pediatric cataract may affect one or both eyes of children in any age group. Some children have cataract at birth where as some can get it during their developing years. The need for surgery is undertaken on the discretion of the ophthalmologist after a thorough assessment of child s visual behaviour. If the cataract is visually significant, then early surgery is the best option for improving visual outcome and giving the child binocular vision. The surgery is performed under general anesthesia and whether or not the intra ocular lens is placed at the time of primary surgery, depends on the age of the child and the laterality of cataract whether unilateral or bilateral. If both the eyes need to be operated, then two separate requirements for anesthesia are needed and the time for second eye is decided by the ophthalmologist after seeing the response of the first eye. It is very critical that clear ocular media is ensured so that the child can develop full visual potential. Post operative care The eye may be red, swollen and painful following the procedure for which pain relieving oral medications and some eyedrops are given to bring about relief. The medications may need to be used for a prolonged period after the procedure to ensure maximal efficacy of the procedure. Itisveryim portantforthechild sparents/legalguardianstounderstandtha theirroleintheoptim alvisualoutcom eisas param ountastheophthalm icphysician.theyneedtoensureregularfollow upofthechild,to makenoteofabnorm alvisualbehaviour, the need for regular examinations under anesthesia due to the changing refractive errors as the pediatric eye grows over time. Sometimes children may have other associated ocular and systemic abnormalities accompanying their cataract which might need additional surgical interventions/ systemic pediatric evaluation. Post operative course & complications 1. After cataract and membrane formation: The incidence has decreased in recent years with the availability of modern techniques of surgery but can still occur especially in small children under the age of one year. 2. Changing refractive errors and the frequent need of glasses: Periodic assessment of child s refractive status is a must for which repeated examinations under anesthesia are needed to ensure proper refraction. It is also important for the parents/ legal guardians to realize that they ensure that the proper refractive correction in the form of glasses/ contact lenses is worn by the child during waking hours. 3. Amblyopia (lazy eye) treatment: This is the single most important factor in the success of unilateral cataract cases. The parents/ legal guardians need to ensure that the child is on proper occlusion therapy, the frequency of which is decided by the treating ophthalmologist. 4. Glaucoma: This is the single most important cause of late onset visual loss after successful pediatric cataract surgery. The rate of this complication varies widely. To ensure safety, it is very important for the parents / legal guardians to ensure that periodic Intra ocular pressure of the child s eye is monitored so that early detection is possible and remedial measures can be undertaken. 5. Retinal detachment/ endophthalmitis: These are rare complications. 6. Strabismus (squint) and nystagmus: These may sometimes be present at the time of presentation. Both of these require separate surgical intervention usually at a later date. It is very important for you to realize that meticulous regular life long follow up is very important on your part so that the treating physician is able to assess your child s visual function and early detection of any complication as listed above is possible. I have been made aware of the above mentioned facts and I have been counseled about the potential benefits and possible side effects of the procedure and by thoroughly going through all of the above, I give my full informed consent for the above procedure on my child. ( 175 )

185 Signature / Thumb Impression of Patient/ Parent / Guardian:... Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 176 )

186 ihfm,sfvªd dsvjsdv 'kkfykuh e gu] vkuan vxzokyk jksxh dk uke %.... mez@fyax %.... jksxh dh vkbzmh %.... rkjh[k %... dk iq=@iq=h... irk %.... VsyhQksu ua %.... ihfm,sfvªd dsvjsdv lòh vk;qox ± ds cpp a dh,d ;k n u a vka[k a d ÁÒkfor dj ldrk gsa dqn cpp a d tue ls gh e fr;kfcan jgrk gs v j dqn d mudh c<+us dh mez ds n jku dòh Òh g ldrk gsa us= fo' "kk cpps ds n`'; vkpj.k ds xgu vkdyku ds ckn vius foosd ls 'ky;fpfdrlk dk fu.kz; Y rk gsa ;fn e fr;kfcan ns[kus esa myy [kuh; gs r n`'; ifj.kke lq/kkjus v j cpps d f}us=h; n`f"v Ánku djus ds fyk, ;Fkk le; 'ky;fpfdrlk lcls vpnk fodyi g rh gsa 'ky;fpfdrlk csg 'k djds dh tkrh gs v j 'ky;fpfdrlk ds le; var%us=h; Y al Ykxk;k tk,xk ;k ugè] bldk QSlYkk cpps dh mez v j e fr;kfcan dh ik'oê;rk ij fuòzj djrk gs] ;kuh bl ij fd e fr;kfcan,d vka[k esa gs ;k n u a vka[k a esaa ;fn n u a vka[k a ds v ijs'ku dh vko';drk g rh gs n vykx&vykx ckj csg 'k djus dh t:jr im+rh gs D; afd v j nwljh vka[k ds v ijs'ku dk le; us"kfpfdrld igykh vka[k dh vuqfø;k ns[kus ds ckn r; djrk gsa ;g cgqr egroiw.kz gs fd Li"V us=h; ehfm;k lqfuf'pr fd;k tk, rkfd cppk iw.kz n`f"v {kerk fodflr dj ldsa 'ky;fpfdrl Ùkj ifjp;kz ÁfØ;k ds ckn vka[k YkkYk] lwth gqbz g ldrh gs v j mlesa nnz g ldrk gs ftlds fyk, dqn [kkus dh nnz fuokjd nok,a v j jkgr nsus ds fyk, vka[k esa VidkbZ tkus okykh nok,a nh tkrh gsaa ÁfØ;k dh vf/kdre ÁÒkodkfjrk lqfuf'pr djus ds fyk, ÁfØ;k ds ckn Ykach vof/k rd nokv a dk Á; x fd;k tkrk gsa cpps ds ekrk&firk@dkuwuh vfòòkod a dk ;g le>uk cgqr egroiw.kz gs fd n`f"v laca/kh ;F "Vre ifj.kke esa mudh Òwfedk us"kfo' "kka fpfdrld ftruh gh vge g rh gsa muds fu;fer :i ls cpps dk Q Yk vi lqfuf'pr djus] vlkeku; n`'; crkzo ij /;ku nsus dh t:jr g rh gs],suslfkhfl;k nsdj cnykrh viorzukred [kkfe; a ds fyk, fu;fer :i ls tkap dh vko';drk g rh gs D; afd cpp a dh vka[ksa le; ds lkfk c<+rh jgrh gsaa dòh&dòh cpp a d muds e fr;kfcan ds lkfk vka[k dh nwljh ;k nsfgd foñfr;ka g ldrh gsa t vfrfjä 'ky;fpfdrlh; gl{ i@nsfgd fcekfj;ksa ds bosy;w ku dh t:jr im+ ldrh gsa 'ky;fpfdrl Ùkj dk;zfof/k v j tfvykrk,a 1- vkqvj dsvjsdv o eseojsu Qkjes ku 'ky;fpfdrlk dh vk/kqfud rduhd a dh miykc/krk ds lkfk bl rjg dh?kvuk,a de g us Ykxh gsa Y fdu vc Òh g ldrh gsa] fo' "kdj,d lkyk ls de mez ds cpp a esaa 2- cnykrh viorzukred [kkfe;ka v j p'esa dh Ákf;d vko';drk% cpps dh viorzukred flfkfr dk fu;rdkfykd ewy;kadu vfuok;z g rk gs] ftlds fyk,,susflfkhfl;k nsdj mi;qzä viorzu lqfuf'pr djus ds fyk, ckj&ckj tkap djus dh vko';drk g rh gsa ekrk&firk@dkuwuh vfòokod a ds fyk, ;g Òh egroiw.kz g rk gs fd os lqfuf'pr djsa fd cppk tkxrs le; p'es@dkavsdv Y al a ds :i esa mi;qä viorzukred la'k /ku igusa 3-,Eoyk;ksfi;k ¼lqLr vka[k½ dk bykkt% ;g,d vka[k ds e fr;kfcan ds ekeyk a esa lqykrk dk vdsykk lcls egroiw.kz dkjd gsa ekrk&firk@dkuwuh vfòòkod a dk ;g lqfuf'pr djkuk vko';d gs fd cpps d mi;qä voj /k fpfälk feyk jgh gs] ftldh vko`fùk bykkt djus okykk us=fpfdrld r; djrk gsa 4- XYkkd ek% lqyk ckyk e fr;kçcn v ijs'ku ds ckn nsj ls n`f"v gzkl ds ÁkjaÒ dk ;g vdsykk lcls egroiw.kz dkj.k gsa bl tfvykrk dh nj esa O;kid fofòérk gsa lqj{kk lqfuf'pr djus ds fyk, ekrk&firk@dkuwuh vfòòkod a dk ;g lqfuf'pr djuk cgqr egroiw.kz gs fd fu;r le;karjkyk ij cpps dh vka[k ds var%us=h; ncko dh fuxjkuh dh tk, rkfd le; jgrs irk Ykx lds v j mipkjkred mik; fd, tk ldsaa 5- jsfvuk dk foykxko@,am IF YkekbfVl% ;s fcjyk tfvykrk,a gsaa 6- HkSaxkiu ¼HkSaxk½ v j fulvsxel ¼vf{kn Yku½% dòh&dòh ;s tfvykrk,a ÁLrqfrdj.k ds le; e twn g ldrh gsaa buesa ls n u a lek;u;r% vkxs dh fdlh frffk ij vykx ls 'ky;fpfdrlh; glr{ i dh ekax djrh gasa vkids fyk, ;g vuqòo djuk egroiw.kz gs fd thou Òj vr;ar lko/kkuh ds Q Yk vi djuk cgqr egroiw.kz g rk gs rkfd bykkt djus okykk fpfdrld vkids cpps ds n`'; dk; ± dk ewy;kadu dj lds v j mi;qzä tfvykrkv a esa fdlh tfvykrk dk le; jgrs irk Ykx ldsa eq>s mi;qzä rf; a ls voxr djk;k x;k gs v j ÁfØ;k ls laòkfor YkkÒ a v j nq"áòko a ds ckjs esa eq>s lykkg nh xbz gs v j mi;qzä lòh pht a d iwjh rjg i<+ Y us ds ckn esa vius cpps ij mi;qzä ÁfØ;k djus dh iw.kz lwfpr lgefr nsrk gwaa ( 177 )

187 dk dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 178 )

188 YAG Capsulotomy Deepankur Mahajan Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... Posterior capsular opacification (PCO) is a condition which develops due to clouding of back membrane of the lens left behind following modern cataract surgery to support the intraocular lens. Such a membrane causes blurring and dimunition of vision and occasionally streaks or haloes around light. Laser capsulotomy involves using Nd-Yag laser to make a central hole within the PCO when it is causing significant complaints to the patient thereby providing a clear central visual axis to the patient. Complications of the procedure include: Damage to IOL optic, IOL pitting, IOL subluxation, IOL dislocation, postoperative intraocular pressure elevation, new floaters/ spots, cystoid macular edema, retinal swelling, retinal detachment and exacerbation of localized endophthalmitis. Additional medical/surgical intervention may be required for these Alternative treatment options include surgical posterior capsulotomy whereby eye has to be opened to remove opacified posterior capsule. I,... have been fully explained in the best understood language (...) that I have RE/LE posterior capsular opacification and have to undergo right/left eye Yag laser posterior capsulotomy for the same. The details of the procedure and alternate treatments and their risks and benefits have been explained to my satisfaction. I hereby give my full, free and voluntary informed consent for a posterior capsulotomy in my right/left eye with the YAG laser. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 179 )

189 okbz,th dsilwyk V eh nhiadj egktu jksxh dk uke %.... mez@fyax %.... jksxh dh vkbzmh %.... rkjh[k %... dk iq=@iq=h... irk %.... VsyhQksu ua %.... i LVsfj;j dsilwykj v ikflfqds'ku ¼ihlhv ½,d volfkk gs t var% us=h; Y al d lefkzu nsus ds fyk, vk/kqfud dsvjsdv ltzjh ds ckn N M+h xbz Y al dh dykk ds /kqa/kykh g tkus ls g rh gsa eseojsu dk bl rjg dk /kqa/kkykkiu] n`f"v gzkl v j Ádk'k ds bnz&fxnz ÁÒkeaMYk ;k /kfj;k isnk djrk gsa Y tj dsilwyk V eh ds varxzr ml le;,umh okbz,th Y tj dk mi; x djds ihlhv ds Òhrj,d dsaæh; fnæ fd;k tkrk gs] tc og j xh d myÿ[kuh; d"v nsus Ykxrh gs v j bl rjg j xh d us= dk Li"V dsaæh; v{k Ánku fd;k tkrk gsa ÁfØ;k dh tfvykrkv a esa 'kkfeyk gsa% vkbzv,yk v fivd d {kfr] vkbzv,yk dk fifvax] vkbzv,yk dk folfkkiu] 'ky;fpfdrl Ùkj var%us=h; ncko esa o`f)] u, yksvlz@/kccs] fllv ;M ekd;wykj,fmek] jsfvuk dh lwtu] jsfvuk dk foykxko v j LFkkfud,aM IF YkekbfVl dk vr;f/kd c<+ tkuk buds fyk, vfrfjä nokbz ls mipkj@'ky;fpfdrlh; glr{ i dh vko';drk im+ ldrh gsa bykkt ds osdfyid fodyi a esa lftzdyk i LVsfj;j dsilwyk V eh 'kkfeyk gs ftlds varxzr vikjn'kê g pqds i LVsfj;j dsilwyk d fudkykus ds fyk, vka[k [k Ykuh im+rh gsa eq>s] ml Òk"kk esa ftls esa lcls vpnh rjg le>rk gwa iwjh rjg le>k;k x;k gs fd esjh nkb± vka[k@ckb± vka[k esa i LVsfj;j dsilwykj v ikflfqds'ku gs v j mlds fyk, esjk nkb±@ckb± vka[k dh okbz,thy tj i LVsfj;j dsilwyk V eh dh tkuh gsa ÁfØ;k ds O; js v j osdfyid bykkt a v j muds t f[ke a v j YkkÒ a dk eq>s lar "ktud fooj.k fn;k x;k gsa,rn~}kjk esa viuh nkb±@ckb± vka[k esa okbz,th Y tj i LVsfj;j dsilwyk V eh djus ds fyk, viuh iwjh] Lora"k] v j LoSfPNd lwfpr lgefr nsrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 180 )

190 MISCELLANEOUS

191 Examination Under Anesthesia (EUA) Chaitali Basu Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been informed in the language I understand best, that my daughter/son/.. is to undergo Examination Under Anaesthesia ( EUA), and that : The procedure is being done to thoroughly examine the patient who is not otherwise co-operative for normal examination. During examination, if any need for an intervention is felt by my doctor, I give my consent for performing any procedure as may be deemed advisable. I hereby certify that I have fully understood the reasons why the above procedure is considered necessary, its advantages and possible alternative modes of treatment. I also hereby certify that no guarantee or assurance has been made as to the result that may be obtained. The procedure carries all the inherent risks of General Anaesthesia. The risk of complication with serious after effects and/or death, though small is always present. Knowing this I give my full, free and voluntary consent. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 181 )

192 ,sfulfkhfl;k nsdj tkap ¼b;w,½ psrkykh clq jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... eq>s ml Òk"kk esa ftls esa lcls vpph rjg le>rk gwa] lwfpr fd;k x;k gs fd esjh dh,suslfkhfl;k nsdj ¼bZ;w,½ tkap dh tkuh gs] v j ;g Òh fd% Û ;g ÁfØ;k j xh dh vpnh rjg tkap djus ds fyk, dh tk jgh gs t vu;fkk lkeku; tkap esa lg; x ugè dj jgk gsa Û tkap ds n jku ;fn fpfdrld fdlh glr{ i dh t:jr vuqòo djsxk r og ftl fdlh Òh ÁfØ;k d mfpr le>sxk mls djus dh viuh lgefr nsrk gwaa esa,rn~}kjk Áekf.kr djrk gwa fd esa mi;qzä ÁfØ;k d vko';d le>us ds dkj.k a] blds YkkÒ a v j bykkt dh laòo osdfyid fof/k; a d iwjh rjg le>rk gwaa esa,rn~}kjk ;g Òh Áekf.kr djrk gwa fd ÁkIr g ldus oky ifj.kke ds ckjs esa eq>s d bz vk'oklu ;k xkjavh ugè nh xbz gsa Û ÁfØ;k ds lkfk tujyk,suslfkhfl;k ds lòh varfuzfgr t f[ke tqm+s gsaa xaòhj mùkj ÁÒko v j@;k e`r;q ds lkfk tfvykrkv a ds t f[ke] gkykkafd de] Y fdu ges'kk e twn jgrs gsaa ;g tkurs gq, esa viuh iwjh] Lora= v j LoSfPNd lgefr nsrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 182 )

193 Optical Iridectomy Asim K. Kandar Name of Patient... Age/Sex... Patient ID... Date... Son / Daughter of... Address... Tel... I have been informed in my mother tongue that I/ my child is suffering from whitening of the cornea (Corneal opacity) with some clear area remaining (specify...) and that a surgery will be performed to enhance the passage of light through the clear area. A part of the iris (diaphragm of the eye) will be excised during the surgical procedure. I have been fully explained regarding the permanent nature of the opacity/ lesion and that it may increase after the surgery and corneal transplant may be required. I have been explained the risk of development of cataract, leading to cataract surgery and lens implantation. There is risk of infection, hyphema due to haemorrhage from iris vessels leading to secondary rise of intraocular pressure. There is chance of no improvement or worsening of best corrected visual acuity, glaucoma secondary to surgery or to medications, and high astigmatism after surgery. There may be a need for repeat surgery which may or may not lead to improvement of vision. I have been explained the need for follow up as frequently as advised by the doctors that may span upto years, with multiple investigations at each visit. I have been explained that using medications properly is required for success of the procedure. I have been explained that I will need to urgently come for follow-up to ophthalmic casualty if there is sudden onset of redness, photophobia, pain or detoriation of vision as these may be signs of endophthalmitis. I understand that inspite of all efforts, there is a possibility that there may be worsening of the visual acuity or the cosmetic appearance of the eye. I certify that I have fully understood the implications of the above consent and authorise the doctors to perform Optical Iridectomy on my/ my child s right / left eye. Signature / Thumb Impression of Patient/ Parent / Guardian:... Name:... Relationship... Date... Address:... Phone (Off)... (Res)... (Mob)... Declaration by Doctor I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly concern the patient. I have given the patient an opportunity to ask questions and I have answered these. Doctor s signature Doctor s name Date Witness 1 Witness 2 Signature:... Signature:... Name:... Name:... Address:... Address:... Tel:... Tel:... ( 183 )

194 v fivdyk bfjmsv eh vkfle ds- danj jksxh dk uke %.... %.... jksxh dh vkbzmh %.... rkjh[k %... dk irk %.... VsyhQksu ua %.... eq>s esjh ekr`òk"kk esa lwfpr fd;k x;k gs fd cppk dkfuz;k ds 'osru ¼dkfuZ;k dh vikjnf'kzrk½ ls ihfm+r gs( dqn LoPN fglls ds cps g us ds lkfk ¼Li"V myy [k djsa ½ v j LoPN fglls ls g dj Ádk'k ds ikjxeu d c<+kus ds fyk,,d 'ky;fpfdrlk dh tk,xha 'ky;fpfdrlh; ÁfØ;k ds n jku vkbfjl ¼vka[k ds Mk;kÝke½ dk,d Òkx dkv fn;k tk,xka eq>s vikjnf'kzrk {kfr dh LFkkbZ ÁÑfr ds ckjs esa iwjh rjg le>k;k x;k gs v j ;g Òh fd 'ky;fpfdrlk ds ckn ;g c<+ ldrh gs v j dkfuz;k ds ÁR;kj i.k dh vko';drk im+ ldrh gsa eq>s e fr;kçcn g us ds t f[ke ds ckjs esa Òh crk;k x;k gs ftlds fyk, dsvjsdv 'ky;fø;k djuh im+ ldrh gsa laøe.k] vkbfjl dh jäokfgfu; a ls jälzko ds dkj.k gk;qsek dk Òh t f[ke gs ftlds dkj.k 'ky;fpfdrlk ds ckn var%us=h; ncko esa f}rh;d o`f) g ldrh gsa lozjs"b la'k f/kr n`f"v xfrfof/k esa d bz lq/kkj u g us ;k v j Òh [kjkc g tkus] 'ky;fpfdrlk ;k nokv a ds ÁÒko ls f}rh;d XYkkd ek] v j mpp n`f"v os"ke; dh Òh laòkouk gsa nqckjk 'ky;fpfdrlk dh vko';drk im+ ldrh gs ftlls n`f"v esa lq/kkj g ldrk gs v j ugè ÒhA eq>s crk;k x;k gs fd fpfdrld ds lq>k, vuqlkj eq>s ckj&ckj Q Yk vi ds fyk, vkuk g xk t o"k ± pyk ldrk gsa v j ÁR;sd eqykkdkr ij dbz tkapsa dh tk ldrh gsaa eq>s crk;k x;k gs fd vka[k ds vpkud YkkYk g tkus] Ádk'kÒhfr vuqòo djus] nnz ;k n`f"v ds v j Òh foñfr g tkus ij eq>s rqjar us=fpfdrlk vkikrd{k esa Q Yk vi ds fyk, vkuk g xk D; afd ;s,umvkifksyekbfvl ds ÁkjafÒd Yk{k.k g ldrs gsaa esa le>rk gwa fd vka[k dh fotqvy,sdohvh@us=fpfdrlk ;k Álk/kd okáñfr ds v j Òh [kjkc g tkus dh laòkouk gsa esa Áekf.kr djrk gwa fd esa mi;zqä lgefr ds fufgrkfk ± d iwjh rjg le>rk gwa v j viuh vius cpps dh nkb±@ckb± vka[k esa v fivdyk vkbfjnzksvkseh djus ds fyk, fpfdrld a d vf/kñr djrk gwaa jksxh@vfhkhkkod dk glrk{kj@vaxwbs dk fu'kku %... uke %.... fj'rk %... rkjh[k %.... irk %... Qksu % ¼vkfQl½.... ¼/kj½.... eksckby%.... MkWDVj }kjk?kks"k.kk esa?kks"k.kk djrk gwa fd esaus laiuu dh tkus okyh dk;zfof/k dh izñfr vksj mlds ifj.kkeksa dks le>k fn;k gs vksj mu tksf[keksa dh ppkz dh gs tks fd fo'ks"k :i ls jksxh ls lacaf/kr gsa esaus jksxh dks iz'u iwnus dk volj iznku fd;k gs vksj mudk mùkj fn;k gsa MkWDVj dk glrk{kj % MkWDVj dk uke % rkjh[k % xokg 1 xokg 2 glrk{kj %.... glrk{kj %... uke %.... uke %.... irk %... irk %.... Qksu %.... Qksu %.... ( 184 )