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.Your decision whether or not to have LASIK performed on your eye(s) at this time should be based on the information given here as well as the conversation with your doctor and staff and additional risks and complications given in this form.

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 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. Sometimes there may be residual number left for which I may need to use glasses
3. 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 under correction or over correction.
4. Further, if there is residual number for which I am required to use glasses then at a later date, I may opt for further treatment, which should be at least three months after the original surgery. This further treatment may fully correct my vision or should bring me closer to target is mild variations may still occur
5. I understand that as a result of primary treatment, the cornea may be thinned to such an extent that, further treatment of cornea for correction of residual number may not be safe and advisable
6. I understand that in high numbers/thin cornea a residual number may be left behind on purpose, for the safety of my eye, for which I may need to wear glasses for good vision
7. I understand that if my eye has any associated pathology e.g. corneal or retinal pathology etc or my eye has less than normal capacity to see even with best corrected glasses (Amblyopia or lazy eye) as recorded on Snellens chart, my vision would not improve beyond that level even after Lasik surgery and the same has been explained to me
8. I understand as a result of the surgery, it is possible that my vision may be made worse. This could happen as a result of infection that not be controlled with antibiotics or other means in which case it may be possible that the eye would be lost. This could also be due to irregular healing such that the corneal surface is distorted. I understand in that case, it may be necessary to wear a contact lens to attain useful vision and that there is a possibility that this may not restore useful vision
9. I understand that there is possibility of conditions such as sensitivity to light, glare and halo’s around light, and variations of vision which may be temporary or permanent as a result of surgery
10. I understand that as I get older (45 years 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
11. I understand that if I presently wear bifocals or reading glasses, I may still need a reading prescription after this surgical procedure
12. I understand that it is possible to incur rare unforeseen complications such as Infections, inflammation, corneal oedema, corneal bulging (Kerectasia) or loss or damage to the corneal flap etc., causing varying degree of loss of vision.
13. I understand that while this surgery may improve my vision, it will not alter the anatomical state of my eye. If I am myopic, my eye is such difficulties as retinal detachment and other incidents not related in any way to this type of surgery.
14. I understand that as part of long term changes, there may be alteration in power requiring spectacles or not related in any way to this type of surgery
15. I understand that as with all surgeries there is a possibility of other complications due to anesthesia, drug reaction or other factors, which may affect other parts of my body
16. I understand that since it is impossible to state every complication that may occure as result of any surgery, this is list of complications is incomplete
17. I understand that if any untoward health problem happens, I will be shifted to hospital where the facility to treat my condition is available

I clarify that I have read this informed consent/has been read to me and explained to me in my mother tongue and all blanks or statements requiring insertion or complication were filled in and any inapplicable paragraphs stricken off before I signed. I fully understood the implications of the above consent and authorize the doctors to perform the procedure on my right/left/both Eye(s).

I have had all the questions answered to my satisfaction

I declare that I am not suffering from any systemic ailment (Diabetes, hypertension/any cardiac/ respiratory and connective tissue disorder, nor physiological condition (Pregnancy, lactation) or allergies that I have not previously discussed with my eye care professional and I have not hidden any medical information from my doctor to the best of my knowledge

I consent to the administration of anesthesia and to the use of anesthesia as may be deemed necessary or desirable.

I further consent to the administration of drug or infusions deemed necessary in the judgment of the medical staff

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. I also give permission for medical data concerning my operation and subsequent treatment to be released to investigators, physicians and responsible authorities demonstrating a need for such information without disclosing my identity. I give my permission to allow the attendance of observers while under my doctor care.

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