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Collagen Cross Linking
I have been informed in my mother tongue that I / my child is suffering from corneal ectasia (keratoconus) / other disease involving anterior part of the cornea (specify ____________________). I have been explained that the disease is progressive and can lead to thinning and perforation of my cornea.
I have been explained that I have to undergo the process of CXL, wherein the epithelium (anterior most covering of the eye) will be scraped under topical anesthesia. Riboflavin will then be put on the eye for 20 minutes, following this the eye will be exposed to UV-A radiation for 6 minutes. At the end of the procedure bandage contact lens will be put.
I have also been explained that the procedure done will not reverse or cure the disease. The procedure done will only stabilize the current condition, thus helping to prevent its progression. Therefore I will have to follow up every 3 months or as advised by the doctor. Also, in spite of the procedure there is a possibility of disease progression, for which surgery could be needed.
The risks and complications in the procedure are those of infection, persistent epithelial defect, corneal haze and blurred vision.
I certify that I have fully understood the implications of the above consent and authorize the doctors to perform Corneal Cross Linking on my / my child’s right / left eye.
The advantages and disadvantages, risks, and possible complications of the present surgery and alternative treatments have been explained to me by my ophthalmologist. There may arise unwanted emergency situations during surgery. In that situation I give my full authority to my treating doctor to take any necessary decision for me / my patient’s wellbeing.
Although it is impossible for the doctor to inform me about every possible complication that may occur, the doctor has answered all my questions to my satisfaction. In signing this informed valid consent for operation, I am stating that I have been offered a copy of this consent.
Further, I consent to the observing, using medical record, photographing or televising of the procedure to be performed for medical, scientific, research, education purpose and publication in scientific journals provided my identity is not revealed by the picture or by descriptive text accompanying them.
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.
I have read and understood the consent form, and all my queries have been answered. I authorize my surgeon to proceed with the operation on my ________________________ (indicate "right" or "left" eye).