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

---

Photorefractive Keratectomy (PRK)

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 with all forms of treatment, the result in my case cannot be guaranteed.

1. I understand that an overcorrection or undercorrection could occur, causing me to become farsighted or nearsighted or increasing my astigmatism. This may be permanent or treatable.
2. If I currently need reading glasses, I will likely still need reading glasses after treatment. Dependence on reading glasses may increase or may be required at an earlier age.
3. Further treatment may be necessary, including eye drops, eyeglasses, contact lenses, additional PRK, or other refractive surgery.
4. My best vision, even with glasses or contact lenses, may become worse.
5. There may be a difference in spectacle correction between eyes, making the wearing of glasses difficult or impossible.
6. I understand that certain complications and side effects have been reported after PRK surgery.

The following have been reported in the short-term post-treatment period and are associated with the normal healing process:

• Mild discomfort or pain (first 72–96 hours)
• Corneal swelling
• Double vision
• Foreign body sensation
• Ghost images
• Light sensitivity
• Tearing

Haze: Loss of perfect clarity of the cornea, usually not affecting vision and often resolving over time.

Starbursting / Halos / Glare: Some patients experience glare, halos around lights, starburst effects, or low-light vision problems that may interfere with driving at night or seeing in dim light. These symptoms may be temporary or permanent.

I understand that it is not possible to predict whether I will experience these night vision problems and that I may permanently lose the ability to drive at night or function in dim light because of them.

Loss of Best Vision: A decrease in best corrected vision even with glasses or contact lenses.

IOP Elevation: Increase in eye pressure due to medications used after treatment, usually controlled with medication changes.

Infection: Mild infections can usually be treated successfully. Severe infections may lead to corneal scarring, loss of vision, corrective surgery, or corneal transplantation.

Keratoconus: Some patients may develop keratoconus, a degenerative corneal disease affecting vision. Severe keratoconus may require corneal transplantation.

The following complications have been reported infrequently:

• Dry eyes
• Itching
• Foreign body sensation
• Double or ghost images
• Corneal inflammation
• Iris inflammation
• Persistent corneal defects
• Corneal scarring affecting vision
• Ulceration or infection
• Irregular astigmatism
• Cataract
• Drooping eyelid
• Loss of bandage contact lens with increased pain
• Slight increase in infection risk due to bandage contact lens use

I understand there is a remote chance of partial or complete loss of vision in the eye that has undergone PRK surgery.

I understand that it is not possible to state every complication that may occur as a result of PRK surgery and that complications may appear weeks, months, or years after surgery.

I understand that PRK is an elective procedure and is not reversible.

For Women Only: I am not pregnant or nursing. I understand that pregnancy may adversely affect my treatment result.

I have spoken with my physician, who has explained PRK, its risks, alternatives, and answered all my questions.

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 full authority to my treating doctor to take any necessary decision for my wellbeing.

Further, I consent to the observing, using medical records, photographing, or televising of the procedure for medical, scientific, research, educational purposes and publication in scientific journals provided my identity is not revealed.

I hereby give permission to release/publish medical data and/or video/audio recordings/photographs of the current procedure and future follow-up visits for advancement of medical knowledge.

I have read and understood this consent form, all my queries have been answered, and I authorize my surgeon to proceed with the operation on my __________________________ (indicate "Right" or "Left" eye).