Download 7.2.10 Cataracts Surgery with Lens Implant Consent Form

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Cataract Surgery with Lens Implant Consent Form
Please take time to read and understand this form thoroughly before signing it.
This form is a legal document that requires your signature before you can be accepted for
treatment. It is signed by you and the treating doctor, and is witnessed at the clinic on the day
of the procedure. This form gives the doctor the right to treat you and it will cover all subsequent
treatments. This form is given to you at least 24 hours prior the treatment so you have ample
time to reconsider your procedure.
I declare that I am fully informed about the procedure and its risks and complications.
Procedure to be performed under Local / Topical Anesthesia is:
[insert name and laterality of procedure]
____________________________________________________________________________
My doctor informed me about the procedure, the risks and complications and the expected
outcomes. Also I was informed about the post -operative management.
Surgery:
Cataract surgery involves removing the cloudy lens and replacing it with an artificial lens. It is
performed as a day surgery under local anesthesia, so you are awake, but your eye will not feel
any pain. You will not be able to see properly during the surgery, but you may notice bright
Code: SJH-EC-CL/frm 003 v1.0
Date: May 2016
Saint James Hospital-Eye Clinic
lights or colors. You will need to lie relatively still during the operation; if you need to cough or
adjust your position, please warn your surgeon.
A small incision in the side of your eye will be made and an ultrasound probe technique called
‘phacoemulsification’ to remove your cataract will be used. Then the crystalline lens will be
replaced by an artificial lens. This is made of a special kind of material and stays in your eyes
forever, only rarely needing replacement. Measurements taken before the operation help us
decide which lens is best for you.
Risks and Complications
Cataract surgery is usually very successful, with over 95 out of 100 noticing an improvement in
their vision after the surgery if there are no other pre-existing eye conditions. However, it is
important to realize that there is always a risk of complications associated with any operation,
some of the complications that may occur during the operation include:
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Internal bleeding
Damage to other structures of the eye including the capsule surrounding the lens
Incomplete removal of the cataract
Part of the cataract falling into the back of the eye
Some of these complications can be dealt with at the time of the surgery or just after surgery.
Rare potential complications occurring after the operation include:
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Severe infection
Fluid accumulating at the back of the eye (in the retina, the light-sensitive layer at the
back of the eye)
Detachment of the retina
Clouding of the membrane behind the lens
These complications can sometimes occur even if the operation itself is carried out perfectly.
Many of these complications are manageable, although it may mean that other treatments may
be required and the recovery period may be longer than usual. This may include the need for
additional surgery. The most serious consequence of all the complications is the risk of loss of
vision in extreme rare cases.
Even though accurate biometry is taken, there is still a slight possibility that you might need
glasses both for near or distance vision. I understand that there is a slight risk that the outcome
of the visual acuity will not be as expected.
If the membrane behind the artificial lens becomes cloudy, this will make your vision blurry
again. If this happens, laser treatment may be needed some time after the surgery, restoring
back your clear vision.
Code: SJH-EC-CL/frm 003 v1.0
Date: May 2016
Saint James Hospital-Eye Clinic
We would like to remind you that these risks are not common and that all necessary precautions
will be taken by our professional staff to ensure that you have an uneventful procedure.
Precautions after the Surgery:
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Do not wash your hair for 1 week after the surgery
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Do not rub your eye for 1 week after the surgery
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Do not stay near pets for 1 week after the surgery
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Do not let any tap water come into your eye for the first week after the surgery
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Avoid dirty environment
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Always wash your hands before you put in the drops – see our hand washing guidelines
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Keep the drops in a clean place
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Wear sunglasses even inside for the 1st week after the surgery
Please contact us if there are any problems or any concerns. It is important to contact us if you
have any of the following:
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Severe pain after the surgery
Increasing redness, pain and blurring of the vision in the days or weeks after surgery
Worsening vision – especially if you find that your vision initially improves after surgery
but then starts to decline
Patient’s Declaration
I have been advised that I should take as long as I wish before consenting to the procedure and
I am not under any pressure by either the doctors or Saint James Eye Clinic to have this
treatment. The choice to go ahead is mine based on the benefits and drawbacks, as explained
to me both in verbal and written form.
I have also been informed that I can withdraw my consent at any time during the process and
that the doctors will act in my best interest.
I understand that a sedative may be given to me 30mins before the treatment commences. On
signing this form I am not under the influence of any drugs / medication and have not yet had
any eye drops administered.
Code: SJH-EC-CL/frm 003 v1.0
Date: May 2016
Saint James Hospital-Eye Clinic
I have informed my doctor about all my illnesses that I am aware of, the medications that I
currently take, including herbal supplements and also of any allergies that I have.
In the case of a Premium Lens Implant
I was informed that in some cases, halos will be present after the surgery. These are more
evident at night around bright lights and can disturb my night vision even when driving. It can
also be possible that I can experience flashes that can disturb my vision. I understand that I can
get used to these haloes and flashes in due time, in a few weeks time. This is a matter of the
brain adjusting to the new vision given by this particular type of lens.
I am satisfied that all of the above has been fully explained and is understood.
Patient’s Signature:
Patient’s Name in Block:
Date:
Time:
Legal Guardian/Representative/Parent
Signature:
Legal
Guardian/Representative/Parent
Name in Block:
Relationship to the Patient:
Date:
Time:
Second Witness Signature:
Second Witness Name in Block:
Relationship to the Patient:
Date:
Time:
Code: SJH-EC-CL/frm 003 v1.0
Date: May 2016
Saint James Hospital-Eye Clinic
Interpreter’s Statement
I have interpreted the information to the best of my ability, and in a way in which I believe the
patient can understand:
Interpreter’s Signature:
Interpreter’s Name in Block:
Date:
Time:
Treating Doctor’s Declaration
I have discussed the contents of this form with the patient and I am satisfied that they
understand the meaning of the technical terms which it contains, the nature and purpose of the
procedure and the side effects and possible complications that are described. I agree to accept
this patient on the above terms and provide treatment as set out above.
Treating Doctor’s Signature:
Treating Doctor’s Name in Block:
Date:
Time:
Withdrawal of Patient Consent:
If the patient has withdrawn consent please ask the patient to sign here
Patient’s Signature:
Name of Patient in Block:
Treating Doctor’s Signature:
Name of Doctor in Block:
Date:
Time:
Code: SJH-EC-CL/frm 003 v1.0
Date: May 2016
Saint James Hospital-Eye Clinic