A
Instructions Before LASIK Surgery
Your Surgery is scheduled for:
q
Wednesdayq
Thursdayq
Friday at please arrive atInstructions:
u
Bring signed consent form on the day of surgery. (The entire document is considered part of
the consent form, please do not separate the last page from the document)
u
Bring a driver with you on the day of surgery and the following morning for your first
post-operative visit. An appointment will be given to you the day of surgery.
u
Do not use cologne, perfume, makeup, or hair products such as hairspray, gel, etc., the day
of surgery (deodorant is permitted). Head bands and hair bands will need to be removed
before your procedure and cell phones and other electronics left in the waiting area.
u
If you received artificial tears at your full-dilated exam, use the drops 3-4 per day in the
operated eye(s) until surgery and once the morning of your surgery. (You may not receive
these drops until the day before surgery, depending on when your pre-operative exam is
scheduled). The three prescriptions you have filled prior to your surgery (the antibiotic drops,
steroid drops and Restoril sleep tablets) are for use AFTER your surgery. You will receive
preservative-free artificial tears in your kit the day of surgery.
D. Shawn Parker, M.D., F.A.C.S.
Custom LASIK • Corneal Surgery • Glaucoma • Cataract
573.335.3577 u 800.455.3937
B
LAS_PKT_PreOp_MK
rev 0212
Care For Your Eye After LASIK
Day of Your Procedure:
u Go directly home to relax. Try to sleep or rest with the eyes closed for at least 2 hours. You do not need to be awakened to use your drops. Sleeping medication should be taken if needed, as directed.
u Do not remove your goggles until you get up in the morning after your procedure. You do not need to wear the shield to your appointment the next day.
u No water should get in the eye for one week. You may shower, but keep your eyes closed when washing hair and rinsing so that the water runs towards the back of your head. Also, try to aim the flow of water lower than your eyes. Gently pat-wash with a clean cloth around the eyes.
u Wear no eye make-up or mascara for 1 week. After 1 week, you may wear make-up that is easily removed with soap and water.
u No motorcycling, bicycling, boating, horseback riding, swimming or tanning bed for 2 weeks.
u Avoid getting dust or dirt in the eye. This will irritate the eye as well as increase your risk of infection. If dust does get in your eye, use preservative-free artificial tears to flush out the debris.
u Wear safety glasses or sports goggles when participating in contact sports or doing work during which foreign matter may get into your eyes.
u Do not rub or push on your eye.
First Day After Your Procedure:
u The eye may be sensitive to touch, scratchy, and light sensitive; the eye may be red. This will subside as the eye heals.
u Vision may be blurry after surgery and may fluctuate. This usually improves as the eye heals over the next week. If you notice occasional blurriness, it helps to use artificial tears to keep the eye well lubricated.
These symptoms and any discomfort you might have should improve each day.
CALL IMMEDIATELY if you experience any pain after
C
Medication Instructions
CustomVue and Traditional LASIK Procedures
Sleep:
The prescription you had filled, Restoril, can be used as needed. When you get home, take one tablet and go to bed. If you are not asleep after one hour, take the second sleeping pill. If the first one is sufficient, take the second sleeping pill when you go to bed for the night.
Drops:
To start after your 2 hour nap the day of surgery:
Antibiotic Prescription 1 drop after your nap and again before you go to bed for the night
Pred Forte or Prednisolone
Acetate Prescription 1 drop after your nap and again before you go to bed for the night Preservative-Free
Artificial Tears: 1 drop after your nap and then every 2 hours until bedtime or as needed. Preservative-free artificial tears are the artificial tears you received on the day of surgery, not the bottle of drops you may have received at your pre-op exam. You can purchase more artificial tears over the counter. Please ensure they are preservative-free.
To start the first day after surgery:
Antibiotic Prescription: 1 drop 4 times a day for 6 days
Pred Forte or Prednisolone
Acetate Prescription: 1 drop 4 times a day for 6 days Preservative-Free
Artificial Tears: 1 drop at least every 2 hours while awake or as needed up to every 15 minutes. NOTE: These individual vials are good for 12 hours after opening.
Drop Usage
u Create a “pocket” by pulling down your lower lid and place one drop into the pocket
Do not pull on the upper lid!
u Wait 5 minutes between all drops. It does not matter which drop you use first, but shake the bottles very well before you use them.
u Refrigerating your drops helps ensure the drop actually went into the eye and not down your cheek. u The preservative-free artificial tears may be used every 15 minutes if needed.
D. Shawn Parker, M.D., F.A.C.S.
Custom LASIK • Corneal Surgery • Glaucoma • Cataract
573.335.3577 u 800.455.3937
D
LAS_PKT_PreOp_MK
rev 0212
INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK) FOR THE CORRECTION OF
HYPEROPIA (FARSIGHTEDNESS), MYOPIA (NEARSIGHTEDNESS), AND ASTIGMATISM.
This information is to help you make an informed decision about having Laser-Assisted In-Situ
Keratomileusis surgery to treat your farsightedness, nearsightedness, or astigmatism. Take as much time as you wish to make a decision about signing this form. You are encouraged to ask any questions and have them answered to your satisfaction before you give your permission for surgery. Every surgery has flaws as well as benefits and each person must evaluate this risk/benefit ratio for himself/herself in light of the information presented by your doctor and the information which follows.
Spectacles and contact lenses are the most common method of correcting nearsightedness (myopia), farsightedness (hyperopia), and astigmatism. When tolerated well, they are likely to be a good alternative to LASIK surgery. Refractive surgery is continually evolving and other refractive procedures may be available as an alternative to LASIK. You should also be aware that having any refractive
procedure could potentially disqualify you from some professions, including the military and employment with certain law enforcement.
LASIK permanently changes the shape of the cornea. The surgery is performed under a topical
anesthetic (drops in the eye). A corneal flap is created with either a microkeratome or a laser. The flap is replaced and bonds back into place without the need for stitches. The result of removing these layers of tissue causes the center of the cornea to: flatten in the case of nearsightedness; steepen in the case of farsightedness; or, become more rounded in the case of astigmatism (which changes the focusing power of the cornea). Although the goal of LASIK is to improve vision to the point of not being dependent on glasses or contact lenses, or to the point of wearing thinner (or weaker) glasses, this result is not guaranteed.
You should understand that LASIK surgery will not prevent you from developing naturally occurring eye problems such as glaucoma, retinal degeneration or detachment. After the procedure, you should avoid rubbing the eye. Your eyes may be more susceptible to traumatic injury after LASIK and protective eye wear is recommended for all contact and racquet sports where a direct blow to the eye could occur.
Also, LASIK does not correct the condition known as presbyopia (or aging of the eye) which occurs in most people around age 40 and may require them to wear reading glasses for close-up work. People over age 40 that have their nearsightedness corrected may find that they need reading glasses for
clear, close-up vision.
During pregnancy or nursing, your refractive error can fluctuate which could influence your results. If you know you are pregnant or attempting to become pregnant within the next three months, it is important you advise your doctor immediately.
LASIK 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 which 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 LASIK
If you decide not to have LASIK, there are other methods of correcting your vision. These alternatives include, among others, eyeglasses, contact lenses, and other refractive surgical procedures.
POTENTIAL RISKS OF LASIK INCLUDE:
1. LOSS OF VISION: LASIK surgery can possibly lead to loss of vision or loss of best corrected vision. This can be due to infection or irregular scarring or other causes. Unless successfully controlled with
antibiotics, steroids, or other necessary treatment, vision loss can ensue. Vision loss can also be due to the cornea healing irregularly which could result in irregular astigmatism and make wearing glasses or contact lenses necessary. Furthermore, it is possible you may not be able to successfully wear contacts after LASIK.
2. VISUAL SIDE-EFFECTS: Other complications and conditions that can occur with LASIK surgery include: a. anisometropia (difference in power between the two eyes)
b. aniseikonia (difference in image size between the two eyes) c. double vision
d. hazy vision
e. fluctuating vision during the day and from day to day
f. increased sensitivity to light which may be incapacitating for some time and may not completely go away
g. glare and halos around lights which may not completely go away
h. severe dry eye or worsening of dry eye either of which may cause decreased vision quality Some of these conditions may affect your ability to drive and judge distances and driving should only be done when you are certain your vision is adequate.
3. OVER CORRECTION AND UNDER CORRECTION: It may be that LASIK surgery will not give you the result you desire. Some procedures result in the eye being under corrected in which case, it may be possible or necessary to have additional surgery to fine tune or enhance the initial result. These results can not be guaranteed. It is also possible that your eye may be over corrected to the point of remaining
LASIK Consent Form Continued
…3
POTENTIAL RISKS OF LASIK…Continued:
farsighted. It is also possible that your initial results could regress over time. In some, but not all cases, retreatment could be considered.
4. OTHER RISKS: Additional reported complications include: a. corneal ulcer formation
b. epithelial healing defects c. ptosis (droopy eyelid) d. corneal swelling
e. retinal detachment and hemorrhage
Complications could also arise requiring further corrective procedures including a partial (lamellar) or full corneal transplant using a donor cornea. These complications include:
f. loss of corneal flap g. damage to the flap h. flap decentration
i. progressive corneal thinning (ectasia)
Sutures may also be required which could induce astigmatism. It is also possible that the
microkeratome or the laser could malfunction necessitating that the procedure be stopped. Since it is impossible to state all potential risks of any surgery, this form is incomplete.
5. FUTURE COMPLICATIONS: You should also be aware that there are other complications that could occur that have not been reported before the creation of this consent form as LASIK surgery has been performed only since the mid 1990s.
PATIENT CONSENT
In giving my permission for LASIK, I declare that I understand the following: The long-term risks and effects of LASIK 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:
VISION THREATENING COMPLICATIONS
1. I understand that the microkeratome or the laser could malfunction, requiring the procedure to be stopped before completion. Depending on the type of malfunction, this may or may not be accompanied by visual loss.
2. I understand that, if using the microkeratome, instead of making a flap, an entire portion of the central cornea could be cut off, and very rarely could be lost. If preserved, I understand that my doctor would put this tissue back on the eye after the laser treatment, using sutures, according to the ALK procedure method. It is also possible that the flap incision could result in an incomplete flap, or
VISION THREATENING COMPLICATIONS…Continued
a flap that is too thin. If this happens, it is likely that the laser part of the procedure will have to be postponed until the cornea has a chance to heal sufficiently to try to create the flap again.
3. I understand that irregular healing of the flap could result in a distorted cornea. This would mean that glasses or contact lenses might not correct my vision to the level possible before undergoing LASIK. If this distortion in vision is severe, a partial or complete corneal transplant might be necessary to repair the cornea.
4. 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 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.
5. I understand that other very rare complications threatening vision include, but are not limited to, corneal swelling, corneal thinning (ectasia), retinal detachment, hemorrhage, venous and arterial blockage, cataract formation, loss of best corrected vision, decrease in quality of vision, total blindness and even loss of my eye.
NON-VISION THREATENING SIDE EFFECTS
1. I understand that there may be increased sensitivity to light, glare, and fluctuations in the sharpness of vision. I understand these conditions usually occur during the normal stabilization period of from one to three months, but they may also be permanent.
2. I understand that there is an increased risk of eye irritation related to drying of the corneal
surface following the LASIK procedure. These symptoms may be temporary or, on rare occasions, permanent, and may require frequent application of artificial tears and/or closure of the tear duct openings in the eyelid.
3. I understand that at night there may be a “star bursting” or halo effect around lights. I understand that this condition usually diminishes with time, but could be 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. I understand that I should not drive until my vision is adequate both during the day and at night. 4. I understand that I may not get a full correction from my LASIK procedure and this may require future
enhancement procedures, such as more laser treatment or the use of glasses or contact lenses. 5. I understand that there may be a “balance” problem between my two eyes after LASIK has been
performed on one eye, but not the other. This phenomenon is called anisometropia. I understand that 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.
LASIK Consent Form Continued
…5
NON-VISION THREATENING SIDE EFFECTS…Continued
6. I understand that, after LASIK, the eye may be more fragile to trauma from impact. Evidence has shown that, as with any scar, the corneal incision will not be as strong as the cornea originally was at that site. I understand that the treated eye, therefore, is somewhat more vulnerable to all varieties of injuries, at least for the first year following LASIK. 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.
7. I understand that there is a natural tendency of the eyelids to droop with age and that the eye surgery may hasten this process.
8. I understand that there may be pain or foreign body sensation, particularly during the first 48 hours after surgery.
9. I understand that temporary glasses either for distance or reading may be necessary while healing occurs and that more than one pair of glasses may be needed.
10. I understand that the long-term effects of LASIK are unknown and that unforeseen complications or side effects could possibly occur.
11. I understand that visual acuity I initially gain from LASIK could regress, and that my vision may go partially back to a level that may require glasses or contacts lens use to see clearly.
12. I understand that the correction that I can expect to gain from LASIK 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.
13. I understand that I may be given medication in conjunction with the procedure and that my eye may be patched afterward. I, therefore, understand that I must not drive the day of surgery and not until I am certain that my vision is adequate for driving.
14. 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 if I have this surgery.
15. I understand that even 90% clarity of vision is still slightly blurry. Enhancement surgeries can be performed when vision is stable UNLESS it is unwise or unsafe. If the enhancement is performed, there generally is no need to make another cut. The original flap can usually be lifted with
specialized techniques, although I understand a new flap may need to be made or surface treatment performed. In order to perform an enhancement surgery, there must be adequate tissue remaining. If there is inadequate tissue, it may not be possible to perform an enhancement. An
Non-NON-VISION THREATENING SIDE EFFECTS…Continued
assessment and consultation will be held with the surgeon at which time the benefits and risks of an enhancement surgery will be discussed.
16. 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.
POST-OPERATIVE INSTRUCTIONS
With this consent, you have been given medications and written instructions to help prevent infection and control healing. It is imperative that you follow all instructions exactly as they are given to you. It is also imperative that all follow-up visits be kept as directed. Failure to follow-up as indicated can result in visual loss.
In signing this form, you are stating that you have read this consent form, and you have had the opportunity to ask questions and have had them answered to your satisfaction. Please answer the following questions:
q
Trueq
False I may need to wear glasses or contact lenses after the procedure to achieve my best potential vision. I may completely lose my vision or experience a decrease in my quality of vision.q
Trueq
False I may have glare or other visually impairing symptoms in the evening which may make it difficult for me to function at night.q
Trueq
False I may not be able to have 20/20 vision after the procedure even with glasses or contact lenses.q
Trueq
False I may need further surgery if certain complications arise.q
Trueq
False LASIK does not eliminate the need for reading glasses if they are normally needed with presbyopia.LASIK Consent Form Continued
…7
PATIENT’S STATEMENT OF ACCEPTANCE AND UNDERSTANDING
The details of the procedure known as LASIK 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, therefore, consent to LASIK surgery.
I give permission for my ophthalmologist to record on video or photographic equipment my procedure, for purposes of education, research or training of other health care professionals. I also give my permission for my ophthalmologist to use data about my procedure and subsequent treatment to further understand LASIK. I understand that my name will remain confidential, unless I give subsequent written permission for it to be disclosed outside my ophthalmologist’s office or other center where my LASIK procedure will be performed.
I am making an informed decision in giving my permission to have LASIK utilizing the following technology:
❍ iLASIK surgery using the FDA approved Advanced CustomVue WaveScans, FS60 IntraLase Laser and the VISX™ Star S4 Active Trak excimer laser performed on my:
q
Right Eyeq
Left Eyeq
Both Eyes.This option includes post-operative visits for 1 year and a 2-year retreatment period
❍ Advanced CustomVue LASIK surgery using the FDA approved Advanced CustomVue WaveScans, the Bausch and Lomb Hansatome Microkeratome and the VISX™ Star S4 Active Trak excimer laser performed on my:
q
Right Eyeq
Left Eyeq
Both Eyes.This option includes post-operative visits for 1 year and a 1-year retreatment period
❍ Traditional LASIK surgery using the FDA approved Bausch and Lomb Hansatome Microkeratome and the VISX™ Star S4 Active Trak excimer laser performed on my:
q
Right Eyeq
Left Eyeq
Both Eyes.This option includes post-operative visits for 1 year and a 1-year retreatment period
Signature of Patient: Date: Signature of Witness: Date:
