NABH & ISO CERTIFIED V.M.V  Road, Rathi Nagar, Amravati  Ph.: 0721-2664880 Mob.: 9370109617

Dr. Neeta Vyawahare MBBS DO (Opth) Regd. No 070595 Dr. Pravin Vyawahare MBBS MS (Opth) Regd. No 65374

Laser-assisted in Situ Keratomileusis (LASIK)

Procedure: This information is being provided to you so that you can make an informed decision about the procedure you are about to undergo.

LASIK reshapes the cornea. It involves raising a thin flap of corneal tissue using femtosecond laser or microkeratome and remodeling of corneal shape using excimer laser. The word LASIK includes all laser vision procedures done under a flap of corneal tissue like Contoura Vision, Bladeless Lasik, SBK, Aspheric Lasik, C-Lasik and Standard Lasik.

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 than I presently have without spectacles and/or contact lenses.

Alternative Treatments: I understand that continuous use of spectacles and/or contact lenses can provide excellent vision and LASIK is an alternative to decrease dependence on spectacles and/or contact lenses.

Possible Side Effects, Risks and Complications: This presentation of the possible risks and complications of LASIK is given to improve your understanding of the medical limitations and to initiate an open channel of communication between you and your doctor.

In giving my permission for surgery, I declare that I understand the following information:

1. I understand that the result of surgery is highly predictable but cannot be guaranteed.
2. I understand that the goal of LASIK surgery is to improve vision to the point of not being dependent on glasses or contact lenses, or to the point of wearing thinner/weaker glasses, but this result is not guaranteed.
3. I understand that calculations used in this surgery are based on previous experience on a large number of patients and average values. Individual variations may cause under-correction or over-correction.
4. I understand that if there is a residual number requiring glasses, I may opt for further treatment after at least three months from the original surgery.
5. I understand that the cornea may be thinned to such an extent that further treatment may not be safe or advisable.
6. I understand that in high numbers or thin corneas, a residual number may intentionally be left behind for safety reasons.
7. I understand that associated eye diseases such as corneal pathology, retinal pathology or amblyopia may limit vision improvement after LASIK.
8. I understand that my vision may become worse due to infection or irregular healing and, in rare cases, useful vision may not be restored.
9. I understand the possibility of glare, halos, light sensitivity and fluctuating vision which may be temporary or permanent.
10. I understand that age-related reading glasses may still be required after age 45 and LASIK does not prevent this.
11. I understand that if I presently wear bifocals or reading glasses, I may still need them after surgery.
12. I understand that rare complications such as infection, inflammation, corneal edema, keratectasia, flap damage or loss may occur.
13. I understand that LASIK does not change the anatomical structure of my eye and conditions such as retinal detachment may still occur.
14. I understand that future power changes may require spectacles.
15. I understand that anesthesia, medications or other factors may cause complications affecting other parts of my body.
16. I understand that it is impossible to list every possible complication.
17. I understand that if any serious health problem occurs, I may be shifted to another hospital where suitable treatment facilities are available.

I certify that this informed consent has been read and explained to me in my mother tongue. I fully understand the implications of this consent and authorize the doctors to perform the procedure on my right / left / both eye(s).

I have had all my questions answered to my satisfaction.

I declare that I am not suffering from any undisclosed systemic disease, pregnancy, lactation, allergy, cardiac, respiratory, connective tissue disorder, diabetes or hypertension that has not been discussed with my eye care professional.

I consent to the administration of anesthesia and drugs or infusions deemed necessary by the medical staff.

I consent to the observation, photography, videography and use of medical records for medical, scientific, educational and research purposes provided my identity remains confidential.

I consent that all disputes arising out of the above procedure are subject to arbitration in __________________ jurisdiction only.

The advantages and disadvantages, risks and possible complications of the present surgery and alternative treatments have been explained to me by my ophthalmologist. In any emergency situation during surgery, I authorize my treating doctor to take necessary decisions for my wellbeing.

I have read and understood the consent form and all my questions have been answered.

I authorize my surgeon to proceed with the operation on my ___________________________ (indicate "Right", "Left" or "Both" eye).