Download Consent Forms in Ophthalmic Practice

Consent Forms in
Ophthalmic Practice
in
Hindi & English
EDITORS
English Edition
Dr. Bhavna Chawla
Dr. Namrata Sharma
Dr. Lalit Verma
Hindi Edition
Dr. P.S. Negi
Dr. Y.C. Gupta
Published By:
Dr. Amit Khosla
Secretary, DOS
Room No.2225, 2nd Floor
New Building
Sir Ganga Ram Hospital
Rajinder Nagar, New Delhi - 110060
Disclaimer
This manual is for educational purpose only and is not intended to constitute legal
advice. Hence it should not be relied upon as a source for legal advice.
Contents
RETINA
1.
Cryosurgery------------------------------------------------------------------------------------------------------------------- 1
2.
Retinal Detachment ---------------------------------------------------------------------------------------------------------- 5
3.
Vitreo Retinal Surgery ------------------------------------------------------------------------------------------------------- 9
4.
Macular Hole Surgery ----------------------------------------------------------------------------------------------------- 13
5.
Avastintm Intravitreal Injection ------------------------------------------------------------------------------------------- 17
6.
Macugentm Intravitreal Injection ----------------------------------------------------------------------------------------- 21
7.
Lucentistm Intravitreal Injection ------------------------------------------------------------------------------------------ 25
8.
ROP Laser ------------------------------------------------------------------------------------------------------------------- 29
9.
Laser Indirect Ophthalmoscopy ----------------------------------------------------------------------------------------- 31
10.
Laser Photocoagulation for Diabetic Retinopathy -------------------------------------------------------------------- 35
11.
Laser Photocoagulation for Proliferative Retinopathy ---------------------------------------------------------------- 39
12.
Laser Photocoagulation for Maculopathy ------------------------------------------------------------------------------ 43
13.
Fundus Fluorescein Angiography / Ophthalmoscopy/ Indocyanine Green Angiography ----------------------- 47
14.
Photodynamic Therapy (PDT) ------------------------------------------------------------------------------------------ 49
15.
Trans Pupillary Thermotherapy (TTT) --------------------------------------------------------------------------------- 53
17.
Intravitreal Injection for Endophthalmitis ------------------------------------------------------------------------------ 57
16.
Electrophysiological Tests ------------------------------------------------------------------------------------------------ 59
OCULOPLASTY & ORBIT
1.
Enucleation ------------------------------------------------------------------------------------------------------------------ 63
2.
Evisceration ----------------------------------------------------------------------------------------------------------------- 67
3.
Orbitotomy ------------------------------------------------------------------------------------------------------------------ 71
4.
Entropion -------------------------------------------------------------------------------------------------------------------- 75
5.
Ectropion -------------------------------------------------------------------------------------------------------------------- 77
6.
Ptosis ------------------------------------------------------------------------------------------------------------------------- 79
7.
Syringing and Probing ----------------------------------------------------------------------------------------------------- 81
8.
Punctal Plugs --------------------------------------------------------------------------------------------------------------- 83
9.
Dacryocystorhinostomy (DCR) ----------------------------------------------------------------------------------------- 85
10.
Contracted Socket --------------------------------------------------------------------------------------------------------- 87
OCULAR SURFACE, CORNEA & REFRACTIVE SURGERY
1.
Optical Penetrating Keratoplasty ----------------------------------------------------------------------------------------- 89
2.
Therapeutic Keratoplasty ------------------------------------------------------------------------------------------------- 91
3.
Automated Lamellar Therapeutic Keratoplasty (ALTK) ------------------------------------------------------------- 95
4.
Deep Anterior Lamellar Keratoplasty (DALK) ------------------------------------------------------------------------- 97
5.
Descemet’s Stripping Endothelial Keratoplasty (DSEK/DSAEK) -------------------------------------------------- 99
6.
Phototherapeutic Keratectomy (PTK) --------------------------------------------------------------------------------- 103
7.
Photorefractive Keratectomy (PRK) ----------------------------------------------------------------------------------- 107
8.
LASIK ---------------------------------------------------------------------------------------------------------------------- 111
9.
Astigmatic Keratotomy (AK) -------------------------------------------------------------------------------------------- 115
10.
Intacs ----------------------------------------------------------------------------------------------------------------------- 119
11.
Phakic IOL ----------------------------------------------------------------------------------------------------------------- 123
12.
Conductive Keratoplasty ------------------------------------------------------------------------------------------------- 129
13.
Pterygium Surgery -------------------------------------------------------------------------------------------------------- 133
14.
Corneal Scraping ---------------------------------------------------------------------------------------------------------- 135
15.
Fibrin Glue Adhesive for Corneal Perforation ------------------------------------------------------------------------ 137
16.
Symblepharon Release --------------------------------------------------------------------------------------------------- 139
17.
Amniotic Membrane Transplantation (AMT) ------------------------------------------------------------------------- 141
18.
Limbal Stem Cell Transplantation (LSCT) ---------------------------------------------------------------------------- 143
19.
Osteo-odonto Keratoprosthesis (OOKP) ------------------------------------------------------------------------------ 145
SQUINT
1.
Squint Surgery ------------------------------------------------------------------------------------------------------------ 147
2.
Botox (Botulinum Toxin) Injection ------------------------------------------------------------------------------------- 151
GLAUCOMA
1.
Trabeculectomy With / Without Anti-Fibroblastic Agents ---------------------------------------------------------- 155
2.
Diode Laser Cyclo-photocoagulation (DLCP)------------------------------------------------------------------------ 159
3.
Argon Laser Trabeculoplasty (ALT) ----------------------------------------------------------------------------------- 163
4.
Laser Iridotomy ----------------------------------------------------------------------------------------------------------- 167
CATARACT
1.
Cataract Surgery With / Without Implantation of Intraocular Lens ----------------------------------------------- 169
2.
Pediatric Cataract --------------------------------------------------------------------------------------------------------- 175
3.
YAG Capsulotomy -------------------------------------------------------------------------------------------------------- 179
MISCELLANEOUS
1.
Examination Under Anesthesia (EUA) --------------------------------------------------------------------------------- 181
2.
Optical Iridectomy -------------------------------------------------------------------------------------------------------- 183
RETINA
Cryosurgery
Bipul Baishya, Atul Kumar
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
Proposed Treatment
The doctor has explained that I, (name of patient …………….………), have a retinal lesion in my……..eye which is a risk factor for
development of ……………… and Cryosurgery is proposed.
Risks
These are the commoner risks. There may be other unusual risks that have not been listed here.
I understand there are risks associated with any anesthetic agent (in case of children).
I may have side effects from any of the drugs used. The commoner side effects include light-headedness, nausea, skin rash and constipation.
I understand the procedure has the following specific risks and limitations:
1.
Although most retinal lesions can be treated, it is not 100% effective. In some cases, more than two sittings may be required.
2.
Corneal burns
3.
Retinal detachment or macular puckering that may require additional surgery
4.
Inflammation
5.
Pigmentary disturbances
6.
Bleeding in eye
Local complications of anesthesia injections around the eye include:
1.
Perforation of eyeball
2.
Destruction of optic nerve
3.
Interference with circulation of retina
4.
Possible drooping of eyelid
5.
Respiratory depression
6.
Hypotension
Individual Risks
I understand the following are possible significant risks and complications specific to my individual circumstances, that I have considered
in deciding to have this operation:
.......................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................
Declaration by Patient
I acknowledge doctors from the ophthalmic team have informed me about the procedure, alternative treatments and answered my
specific queries and concerns about this matter.
I acknowledge that I have discussed with the surgical team any significant risks and complications specific to my individual circumstances
that I have considered in deciding to have this operation.
I understand that a doctor other than the specialist surgeon may perform the procedure.
(1)
I have received no guarantee the operation will be successful.
I have received a copy of this form to take home with me.
If a needle stick/sharps injury occurs to staff during any operation I give my permission for blood to be taken and tested for HIV and other
blood borne disorders.
I understand I will be advised and counselled as soon as practicable after the operation if this has been necessary.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: ................................................................................................ Relationship .......................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: .............................................................................................
Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
(2)
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. ............................................................................................................................................................................................................
.............................................................................................................................................................................................................
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(3)
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(4)
Retinal Detachment
Bipul Baishya, Y.R. Sharma
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
Proposed Treatment
The doctor has explained that I, (name of patient …………….…......................……),have a retinal detachment in my…...........…..eye and
that………………………………is proposed:
Risks
These are the commoner risks. There may be other unusual risks that have not been listed here.
I understand there are risks associated with any anesthetic agent.
I may have side effects from any of the drugs used. The commoner side effects include light-headedness, nausea, skin rash and constipation.
I understand the procedure has the following specific risks and limitations:
1.
Although most retina detachments can be treated, a small proportion (5%) may be inoperable and blindness cannot be prevented.
2.
Failure to accomplish intent of surgery
3.
More than one surgery may be required. Like if Scleral buckling surgery fails, Vitrectomy may be required with Silicone Oil or Gas
tamponade.
4.
In case of Silicone Oil or Gas injection, I have to maintain position depending upon the surgery.
5.
If Gas is injected, I have to restrict air travel until gas is absorbed.
6.
If Silicone oil is injected, then resurgery will be required to remove the oil.
7.
It may take up to 18 months before the final outcome of the surgery is known. Although many cases achieve a good result, this
depends on several factors including how long the detachment had been present.
8.
It may not be possible to predict before the operation which cases will do well.
9.
There is a chance I may develop further retina detachments in future in the same eye or in the opposite eye.
10.
In some cases, more than one operation may be required
11.
Though rare, I may develop complications like vitreous hemorrhage, infection, elevated eye pressure (glaucoma), poorly healing
or non-healing corneal defects, corneal clouding and scarring, cataract, which might require eventual or immediate removal of
lens, double vision, eyelid droop, and loss of circulation to vital tissues in the eye, resulting in decrease or loss of vision
There is an extremely small risk (1:17000 cases) that the opposite eye to the one having surgery may become inflamed, especially if
complications occur after the operation. This is called sympathetic ophthalmia .Although this can be treated, in some cases, eyesight
may be lost.
I understand some of the above risks are more likely if I smoke, am overweight, diabetic, have high blood pressure or have had previous
heart disease.
Individual Risks
I understand the following are possible significant risks and complications specific to my individual circumstances, that I have considered
in deciding to have this operation:
.......................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................
(5)
Declaration By Patient
I acknowledge doctors from the ophthalmic team have informed me about the procedure, alternative treatments and answered my
specific queries and concerns about this matter.
I acknowledge that I have discussed with the surgical team any significant risks and complications specific to my individual circumstances
that I have considered in deciding to have this operation.
I agree to any other additional procedures considered necessary in the judgment of my surgeon during this operation.
I have received no guarantee the operation will be successful.
I have received a copy of this form to take home with me.
If a needle stick/sharps injury occurs to staff during any operation I give my permission for blood to be taken and tested for HIV and
other blood borne disorders.
I understand I will be advised and counselled as soon as practicable after the operation if this has been necessary.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: ................................................................................................ Relationship .......................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: .............................................................................................
Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
(6)
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. ............................................................................................................................................................................................................
.............................................................................................................................................................................................................
(7)
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irk %......................................................................................................................................................................................................
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irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
(8)
Vitreo Retinal Surgery
Bipul Baishya, R.V. Azad
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
Proposed Treatment
The doctor has explained that I, (name of patient …………….………), have …............................... in my ........................... Eye and
that………………………………is proposed.
Risks
These are the commoner risks. There may be other unusual risks that have not been listed here.
I understand there are risks associated with any anesthetic agent.
I may have side effects from any of the drugs used. The commoner side effects include light-headedness, nausea, skin rash and constipation.
I understand the procedure has the following specific risks and limitations:
1.
Failure to accomplish intent of surgery
2.
Retinal detachments that may require additional surgery or may be inoperable
3.
Depending upon the surgery, Silicone Oil or Gas may be required for tamponade.
4.
In case of Silicone Oil or Gas injection, I have to maintain position depending upon the surgery.
5.
If Gas is injected, I have to restrict air travel until gas is absorbed.
6.
If Silicone oil is injected then resurgery will be required to remove the oil.
7.
It may take up to 18 months before the final outcome of the surgery is known.
8.
In a few cases, the underlying condition cannot be treated and blindness cannot be prevented.
9.
It may not be possible to predict before the operation which cases will do well.
10.
There is a chance I may develop further retina detachments in future in the same eye or in the opposite eye.
11.
In some cases, more than one operation may be required
12.
Though rare I may develop complications like vitreous hemorrhage, infection, elevated eye pressure (glaucoma), poorly healing or
non-healing corneal defects, corneal clouding and scarring, cataract, which might require eventual or immediate removal of lens,
double vision, eyelid droop, and loss of circulation to vital tissues in the eye, resulting in decrease or loss of vision
There is an extremely small risk (1:17000 cases) that the opposite eye to the one having surgery may become inflamed, especially if
complications occur after the operation. This is called sympathetic ophthalmia .Although this can be treated, in some cases, eyesight may
be lost.
I understand some of the above risks are more likely if I smoke, am overweight, diabetic, have high blood pressure or have had previous
heart disease.
Individual Risks
I understand the following are possible significant risks and complications specific to my individual circumstances, that I have considered
in deciding to have this operation:
.......................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................
(9)
Declaration by Patient
I acknowledge doctors from the ophthalmic team have informed me about the procedure, alternative treatments and answered my specific
queries and concerns about this matter.
I acknowledge that I have discussed with the surgical team any significant risks and complications specific to my individual circumstances
that I have considered in deciding to have this operation.
I agree to any other additional procedures considered necessary in the judgment of my surgeon during this operation.
I agree to the disposal by the hospital authorities of any tissues that may be removed during the procedure. I understand that some tissues
or samples may be kept as part of my hospital records.
I have received no guarantee the operation will be successful.
I have received a copy of this form to take home with me.
If a needle stick/sharps injury occurs to staff during any operation I give my permission for blood to be taken and tested for HIV and other
blood borne disorders.
I understand I will be advised and counselled as soon as practicable after the operation if this has been necessary.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: ................................................................................................ Relationship .......................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
( 10 )
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dk iq=@iq=h .........................................................................................................................................................................................
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izLrkfor mipkj
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vkSj dCt 'kkfey gSA
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ltZjh ds vk/kkj ij VSEiksuM
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flfydkWu vkW;y ;k xSl batDs 'ku dh n'kk esa eq>s ltZjh ds vk/kkj ij fLFkfr dks cuk;s j[kuk gSA
vxj xSl dk batDs 'ku fn;k tkrk gS rks eq>s ml le; rd gokbZ ;k=k ls cpuk gksxh tc rd fd xSl vo'kksf"kr ugha gks tkrhvxj flfydkWu vkW;y dk batDs 'ku fn;k tkrk gS rks rsy dks fudkyus ds fy, nksckjk ltZjh vko';d gksxhA
ltjh ds vafre ifj.kke dk irk pyus esa 18 eghuksa rd dk le; yx ldrk gSA
dqN ekeyksa esa varjfufgr n'kk dk mipkj ugha gks ldrk vkSj n`f"Vghurk dks jksdk ugha tk ldrkA
fdu ekeyksa esa vPNs ifj.kke vk,axs budk vkWijs'ku ls igys vuqeku yxkuk gks ldrk gS fd laHko ugha gksA
bl ckr dk [krjk gksrk gS fd eq>s Hkfo"; esa mlh vka[k esa ;k nwljh okyh esa jsfVuk dk vkxs Hkh vyxko fodflr gks tk;sA
dqN ekeyksa es]a ,d ls vf/kd vkWijs'ku dh t:jr iM+ ldrh gSA
gkykafd eqf'dy ls gh ,slk gksrk gS ysfdu esjs Hkhrj okbVfjvl jDrlzko] laØe.k] vka[k dk Å
a p
a k ncko ¼Xywdksek½] dkWuhZy dh [kjkfc;ksa ds ?kko
ds eqf'dy ls Hkjus ;k ugha Hkjus] dkWuhZy DykmfMax vkSj LdSfjax] eksfr;kfcan] ftlds fy, ysl
a ksa dks varr% ;k QkSju fudkyus dh t:jr iM+
ldrh gS] Mcy fotu] iydksa ds yVduk vkSj vka[kksa ds egRoiw.kZ Årdksa esa ifjlapj.k ds ugha gksus tSlh tfVyrk,a fodflr gks ldrh gS]a ftlds
QyLo:i utj esa deh ;k mldk [kkRek gks ldrk gSA
bl ckr dk cgqr gh de tksf[ke ¼1%17000 ekeys½ gksrk gS fd ftl vka[k dh ltZjh dh x;h gS mlds cxy okyh vka[k yky gks ldrh gS] fo'ks"kdj
ml le; tcfd tfVyrk,a vkWijs'ku ds ckn iSnk gksrh gSAa bls flEiSFksfVd vkFkSyfe;k dgk tkrk gSA gkykafd bldk mipkj fd;k tk ldrk gS ij
dqN ekeyksa esa vka[kksa dh n`f"V tk ldrh gSA
eSa le>rk gwa fd Åij crk;s x;s tksf[keksa esa ls dqN ds vklkj ml le; T;knk gksrs gSa tcfd eSa /kweziku djrk gw]a esjk otu T;knk gS] e/kqegs ls ihfM+r
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dk fu.kZ; djrs le; fopkj fd;k gS %
. ...........................................................................................................................................................................................................
............................................................................................................................................................................................................
( 11 )
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bl ekeys esa esjs fof'k"V iz'uksa vkSj fparkvksa dk tokc fn;k gSA
eSa bl ckr dh iqf"V djrk gwa fd eSua s ltZjh djus okys MkWDVjksa dh Vhe ds lkFk fdUgha egRoiw.kZ tksf[keksa vkSj viuh O;fDrxr ifjfLFkfr;ksa ds fy, [kkl
tfVyrkvksa ij ppkZ dh gS] ftu ij fd eSua s bl vkWijs'ku dks djokrs le; fopkj fd;k gSA
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fd dqN Årdksa vkSj uewuksa dks vLirky ds esjs fjdkMksZa ds fgLls ds :i esa j[kk tk ldrk gSA
vkWijs'ku lQy gh gksxk bldh eq>s dksbZ xkjaVh ugha nh x;h gSA
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jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
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( 12 )
Macular Hole Surgery
Ritesh Gupta
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
Indications and Benefits
Your doctor has diagnosed you with macular hole and informed you that if it is left untreated, it is likely that you will have gradual central
vision deterioration but you will not lose all of the vision in your eye.
Your doctor has informed you that a procedure involving pars plana vitrectomy with/without internal limiting membrane removal and
gas injection will be performed in your eye under local/general anesthesia. The important factors in predicting whether the hole closes
as a result of surgery is the duration for which the hole has been present and the size of the hole. The success rate for holes that have been
present for less than six months is about 90%. However, this reduces to around 60% for a hole which has been present for a year or more.
Your doctor has told you that a successful macular hole closure does not guarantee complete visual recovery and that a 2-line improvement
is usually the measure of success of the surgery. You have been told that postoperative positioning also has an important role to play for
closure of macular hole and that a good majority of the failures stem from incomplete and inconsistent postoperative positioning.
Complications
As with any surgical procedure, there are risks associated with macular hole surgery. Not every conceivable complication can be covered
in this form but the following are examples of risk encountered with macular hole surgery. These complications can occur days, weeks,
months, or years later. They can result in loss of vision or blindness. Careful follow-up is required after surgery.
Complications of the surgery
1.
Failure to accomplish closure of the hole(10-40% depending primarily on the duration and size)
2.
Retinal detachments that may require additional surgery or may be inoperable (1-2%)
3.
Vitreous hemorrhage
4.
Infection (0.02%-0.1%)
5.
Elevated eye pressure (glaucoma)
6.
Cataract, which might require eventual or immediate removal of lens
7.
Poorly healing or non-healing corneal defects
8
Corneal clouding and scarring
Complications of anesthesia injections around the eye
1.
Perforation of eyeball
2.
Needle damage to the optic nerve, which could destroy vision
3.
Retrobulbar hemorrhage
4.
Possible drooping of eyelid
5.
Systemic effects that have the potential for life-threatening complications and death
Patient Consent
In spite of the risks noted above, I understand that there is more risk to my vision if I do not have the operation than if I do. I have read and
understand the consent form, I have had my questions answered, and I authorize my surgeon to proceed with the operation on my
.................................. (indicate “right” or “left” eye).
( 13 )
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: ................................................................................................ Relationship .......................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
( 14 )
eSdqyj gksy ltZjh
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dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
lq>ko vkSj ykHk
vkids MkWDVj dh tkap ds vuqlkj vkidh vka[k esa eSdqyj Nsn gS vkSj vkidks crk;k gS fd vxj bldk bykt ugha fd;k x;k rks bl ckr ds vklkj
gSa fd vkidh e/;orhZ utj /khjs&/khjs [kjkc gksrh tk,xh ysfdu vkidh vka[k dh iwjh jks'kuh ugha tk,xhA vkids MkWDVj us vkidks crk;k gS fd
LFkkfud@iwjh csgks'kh dh fLFkfr esa vkidh vka[k esa vkarfjd :i ls lhfer djus okyh f>Yyh fudklh vkSj xSl batDs 'ku ds lkFk@ds fcuk iklZ Iykuk
foVjsDVkseh ls tqMh+ fØ;kfof/k viuk;h tk,xhA D;k ltZjh ds QyLo:i Nsn can gks tk,xk bldk iwokZuqeku yxkus esa egRoiw.kZ dkjd Nsn ds ekStnw
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dk lQyrkiwod
Z can gksuk n`f"V dh iw.kZ:is.k HkjikbZ dh xkjaVh ugha djrk vkSj ;g fd 2&ykbu lq/kkj izk;% ltZjh dh lQyrk dk iSekuk gksrk gSA vkidks
crk;k x;k gS fd vkWijs'ku ds ckn dk LFkkiu Hkh eSdqyj ds Nsn dks can djus esa egRoiw.kZ Hkfedk vnk djrk gS vkSj foQyrkvksa ds dkQh cMs+ fgLls
dk dkj.k vkWijs'ku ds ckn dk v/kwjk vkSj vlaxr LFkkiu gksrk gSA
tfVyrk,a
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ugha fd;k tk ldrk ysfdu eSdy
q j Nsn ltZjh ls tqMs+ tksf[keksa ds mnkgj.k fuEufyf[kr gSAa ;s tfVyrk,a fnuks]a grks]a eghuksa ;k lkyksa ckn iSnk gks ldrh
gSAa budh otg ls n`f"V dk pys tkuk ;k va/kkiu iSnk gks ldrk gSA ltZjh ds ckn lko/kkuh Hkjs QkWyks&vi dh t:jr gksrh gSA
ltZjh dh tfVyrk,a
1Nsn dh canh dks iwjk djus esa foQyrk ¼10&40 izfr'kr eq[;r;k vof/k vkSj vkdkj ij fuHkjZ½
2jsfVuk dk vyxko ftlds fy, vfrfjDr ltZjh dh t:jr iM+ ldrh gS ;k gks ldrk gS fd mldk vkWijs'ku gh u gks ik;s ¼1&2 izfr'kr½
3foVfjvl jDrlzko
4laØe.k ¼0-02 izfr'kr&0-1 izfr'kr½
5vka[k dk c<+k gqvk ncko ¼Xywdksek½
6eksfr;kfcan] tks fd ysl
a ksa dh varr% ;k QkSju fudklh dks vko';d cuk ldrk gS
7dkWuhZy dh [kjkfc;ksa dk cgqr gh /khes Bhd gksuk ;k ugha Bhd gksuk
8dkWuhZy DykmfMax ;k LdSfjax
vka[kksa ds bnZfxnZ laons ukgkjh batDs 'kuksa dh tfVyrk,a
1- us=xksyd dk [ksn
2- izdkf'kd ul dks lqbZ ls {kfr] tks fd n`f"V dks u"V dj nsrh gS
3- jsVªkcs qyckj jDrlzko
4- iydksa dh laHko Mªfw iax
5- lokZx
a h izHkko ftlesa fd thou dks [krjs esa Mkyus okyh tfVyrkvksa vkSj ekSr dh laHkkO;rk gksrh gS
jksxh dh lgefr
Åij crk;s x;s tksf[keksa ds ckotwn] eSa le>rk gwa fd vxj eSa vkWijs'ku ugha djokrk gwa rks esjh n`f"V dks vkSj Hkh vf/kd [krjk gSA eSua s lgefr izi=
dks i<+ vkSj le> fy;k gS] esjs iz'uksa ds mÙkj fn;s tk pqds gS]a vkSj eSa vius ltZu dks viuh ----------------------------¼^^nk;ha** ;k ^^ck;ha** vka[k lq>k,a½ dk vkWijs'ku
djus ds fy, vkxs c<+us gsrq vf/kÑr djrk gwAa
( 15 )
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
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xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
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Qksu %.
( 16 )
AvastinTM Intraivtreal Injection
Zahir Abbas, Gunjan Prakash
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
Possible Benefits and “Off-Label” Status
AvastinTM was not initially developed to treat your eye condition. Based upon the results of clinical trials that demonstrated its safety and
effectiveness, AvastinTM was approved by the Food and Drug Administration (FDA) for the treatment of metastatic colorectal cancer.
Once a device or medication is approved by the FDA, physicians may use it “off-label” for other purposes if they are well-informed about
the product, base its use on firm scientific method and sound medical evidence, and maintain records of its use and effects. Ophthalmologists
are using AvastinTM “off-label” to treat AMD and similar conditions since research indicates that VEGF is one of the causes for the growth
of the abnormal vessels that cause these conditions. Some patients treated with AvastinTM had less fluid and more normal-appearing
maculas, and their vision improved. AvastinTM is also used, therefore, to treat macular edema, or swelling of the macula. Recently, a
medication similar in function and designed for intravitreal administration was approved by the FDA for the treatment of AMD.
Possible Limitations
The goal of treatment is to prevent further loss of vision. Although some patients have regained vision, the medication may not restore
vision that has already been lost, and may not ultimately prevent further loss of vision caused by the disease.
Alternatives
You do not have to receive treatment for your condition, although without treatment, these diseases can lead to further vision loss and
blindness, sometimes very quickly. Other forms of treatment are available. At present, there are three FDA-approved treatments for neovascular
age-related macular degeneration. The first two are photodynamic therapy with a drug called VisudyneTM and injection into the eye of a drug
called MacugenTM. The third medication, LucentisTM is similar to AvastinTM. In addition to the FDA-approved medications, some
ophthalmologists use intravitreal triamcinolone —”off-label” to treat eye conditions like yours.
Complications when AvastinTM is given to patients with cancer
When AvastinTM is given to patients with metastatic colorectal cancer, some patients experienced gastrointestinal perforations or wound
healing complications, hemorrhage, arterial thromboembolic events (such as stroke or heart attack), hypertension, proteinuria, and
congestive heart failure. Patients who experienced these complications not only had metastatic colon cancer, but were also given 400
times the dose you will be given, at more frequent intervals, and in a way (through an intravenous infusion) that spread the drug
throughout their bodies.
Risk when AvastinTM is given to treat patients with eye conditions
The risk of these complications for patients with eye conditions is low. Patients receiving AvastinTM for eye conditions are healthier than
the cancer patients, and receive a significantly small dose, delivered only to the cavity of their eye. While there are no FDA-approved
studies about the use of AvastinTM in the eye that prove it is safe and effective, LucentisTM, a similar drug, was recently approved for AMD.
One study of patients who received AvastinTM through an intravenous infusion reported only a mild elevation in blood pressure. Another
study of patients treated like you will be with intravitreal AvastinTM did not have these elevations or the other serious problems seen in the
patients with cancer. However, the benefits and risks of intravitreal AvastinTM for eye conditions are not yet fully known. In addition,
whenever a medication is used in a large number of patients, a small number of coincidental life-threatening problems may occur that
have no relationship to the treatment. For example, patients with diabetes are already at increased risk for heart attacks and strokes. If one
of these patients being treated with AvastinTM suffers a heart attack or stroke, it may be caused by the diabetes and not the AvastinTM
treatment.
Known risks of intravitreal eye injections
Your condition may not get better or may become worse. Any or all of these complications may cause decreased vision and/or have a
( 17 )
possibility of causing blindness. Additional procedures may be needed to treat these complications. Possible complications and side
effects of the procedure and administration of AvastinTM include but are not limited to retinal detachment, cataract formation, glaucoma,
hypotony (reduced pressure in the eye), damage to the retina or cornea, and bleeding. There is also the possibility of an eye infection
(endophthalmitis). Any of these rare complications may lead to severe, permanent loss of vision.
Patient Responsibilities
I will immediately contact my doctor if any of the following signs of infection or other complications develop : pain, blurry or decreased
vision, sensitivity to light, redness of the eye, or discharge from the eye. I will keep all post-injection appointments so my doctor can check
for complications.
Although the likelihood of serious complications affecting other organs of my body is low, I will immediately contact my physician if I
experience abdominal pain associated with constipation & vomiting, abnormal bleeding, chest pain, severe headache, slurred speech, or
weakness on one side of the body. As soon as possible, I will also notify the treating ophthalmologist of these problems.
I will inform any other surgeon that I am on a medication that needs to be stopped before I can have surgery.
Patient Consent
The above explanation has been read by/to me. The nature of my eye condition has been explained to me and the proposed treatment has
been described. The risks, benefits, alternatives, and limitations of the treatment have been discussed with me. All my questions have been
answered.
I understand that AvastinTM was approved by the FDA for the treatment of metastatic colorectal cancer, and has not been approved for the
treatment of eye conditions. Nevertheless, I wish to be treated with AvastinTM, and I am willing to accept the potential risks that my
physician has discussed with me. I hereby authorize the treating eye-surgeon to administer the intravitreal AvastinTM in my affected eye as
needed. This consent will be valid until I revoke it or my condition changes to the point that the risks and benefits of this medication for
me are significantly different.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: ................................................................................................ Relationship .......................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
( 18 )
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tghj vCckl] xqatu izdk'k
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dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
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cgqr gh tYnhA mipkj ds nwljs :i miyC/k gSAa orZeku es]a fu;ksoSLdwyj mez ls tqMs+ eSdqyj fodkj ds fy, ,QMh, ls eatjw h izkIr rhu mipkj gSAa
q us Vh,e uked nok dk vka[k esa batDs 'ku gSAa rhljh nok] yqlfas VlVh,e vokfLVuVh,e
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ds leku gksrh gSA ,QMh, ls eatjw h izkIr nokvksa ds vfrfjDr dqN us=&fo'ks"kK vkidh rjg dh vka[kksa dh n'kkvksa ds mipkj ds fy, baVªkfoVfj;y
fVª;kefluksyku & ^^vkQ&yscy** dks mi;ksx esa ykrs gSAa
dSalj ds jksfx;ksa dks vokfLVu Vh,e fn;s tkus ij mRiUu gksus okyh tfVyrk,a
tc esVkLVsfVd dksyksjDs Vy dSl
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?kVukvksa ¼tSls fd nkSjk ;k ân;k?kkr½] mPp jDrpki] izkVs huqfj;k vkSj dkatfs LVo gkVZ QsY;ksj dk lkeuk fd;kA bu ijs'kkfu;ksa dks eglwl djus okys jksfx;ksa
dks u dsoy esVkLVsfVd dksyksu dSl
a j Fkk cfYd mUgsa vkids eqdkcys 400 xquk [kqjkd T;knk fu;fer varjkyksa ij vkSj bl izdkj ls ¼var%f'kjk esa nzo
dks Mkyus ds tfj;s½ nh x;h Fkh ftlus fd muds iwjs 'kjhj esa nok dks QSyk fn;k FkkA
vka[k dh chekfj;ksa okys jksfx;ksa ds mipkj ds fy, vokfLVu Vh,e dks fn;s tkus ds le; ds tksf[ke
vka[k dh chekjh okys jksfx;ksa ds fy, bu ijs'kkfu;ksa ds tksf[ke de gSAa vka[kksa dh chekfj;ksa ds fy, vokfLVuVh,e izkIr djus okys jksxh dSl
a j jksfx;ksa ds
eqdkcys T;knk LoLFk gksrs gSa vkSj dsoy mudh vka[kksa dh dsfoVh esa Mkyh tkus okyh mYys[kuh; :i ls de ek=k izkIr djrs gSAa tgka vka[kksa esa vokfLVuVh,e
ds mi;ksx ds ckjs esa ,QMh, ls eatjw h izkIr ,sls dksbZ v/;;u ugha gSa tks fd ;g lkfcr djrs gksa fd ;g lqjf{kr vkSj izHkkoh gS] ogha blh izdkj dh nok
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jDrpki esa gYdh o`f) ns[kh x;hA vkidh rjg baVªkfoVfj;y vokfLVuVh,e ls mipkj ikus okys jksfx;ksa ds ,d nwljs v/;;u esa bu o`f);ksa ;k vU; xaHkhj
leL;kvksa dks ugha ns[kk x;k gS ftUgsa fd dSl
a j ds jksfx;ksa esa ns[kk x;k FkkA fQj Hkh] vka[k dh chekfj;ksa ds fy, baVªkfoVfj;y vokfLVuVh,e ds ykHkksa vkSj
tksf[keksa dk vHkh iwjh rjg ls irk ugha pyk gSA blds vfrfjDr] tc jksfx;ksa dh cM+h la[;k esa nok dk mi;ksx fd;k tkrk gS rks ,d NksVh la[;k esa
tkuysok leL;kvksa dk la;ksx iSnk gks ldrk gS ftldk fd mipkj ds lkFk dksbZ fj'rk ugha gksrk gSA mnkgj.k ds fy, e/kqegs dks jksfx;ksa dks fny ds
nkSjs ;k vk?kkr dk tksf[ke igys ls gh c<+k gqvk gksrk gSA vxj vokfLVuVh,e ls mipkj ik jgs jksfx;ksa esa ls dksbZ fny ds nkSjs ;k vk?kkr ls =Lr gksrk
gS rks gks ldrk gS fd mldk dkj.k e/kqegs gks u fd vokfLVuVh,e ds lkFk mipkjA
vka[kksa ds baVªkfoVfj;y batsD'kuksa ds Kkr tksf[ke
vkidh chekjh esa gks ldrk gS fd lq/kkj ugha vk;s ;k og cnrj gks ldrh gSA bu ijs'kkfu;ksa esa ls dksbZ ;k lHkh ?kVh gqbZ n`f"V vkSj@;k va/kRo iSnk djus
( 19 )
dh laHkkouk dk dkj.k cu ldrh gSAa bu ijs'kkfu;ksa dk mipkj djus ds fy, vfrfjDr dk;Zfof/k;ksa dh t:jr iM+ ldrh gSA dk;Zfof/k vkSj vokfLVuVh,e
ds lsou dh laHko ijs'kkfu;ksa vkSj ik'oZ&izHkkokssa esa jsfVuk dk vyx gksuk] eksfr;kfcan dk fodkl] Xywdksek] gkbiksVksuh ¼vka[kksa esa ?kVk gqvk ncko½] jsfVuk
;k dkfuZ;k dks {kfr vkSj jDrlzko 'kkfey gSa ysfdu os bUgha rd lhfer ugha gaSA blds vykok vka[kksa esa laØe.k ¼,aMvkFkSyfefVl½ dh Hkh laHkkouk gksrh
gSA bu fojy ijs'kkfu;ksa esa ls dksbZ Hkh n`f"V dh Hkkjh] LFkk;h gkfu dks tUe ns ldrh gSA
jksxh dh ftEesnkfj;ka
vxj laØe.k ds fuEufyf[kr esa ls dksbZ Hkh y{k.k ;k vU; ijs'kkfu;ka fodflr gksrh gSa rks eSa QkSju vius MkWDVj ls laidZ d:axk % nnZ] /kq/a kyh ;k ?kVh
gqbZ n`f"V] izdk'k ds izfr laons u'khyrk] vka[kksa dh ykyh ;k vka[kksa ls ikuh cgukA eSa batDs 'ku ds ckn ds eqykdkr ds lHkh le; ij gkftj jgwx
a k rkfd
esjk MkWDVj ijs'kkfu;ksa dh tkap dj ldsA gkykafd esjs 'kjhj ds nwljs vaxksa dks izHkkfor djus okyh xaHkhj ijs'kkfu;ksa dh laHkkouk de gS] ij vxj eSa dCt
,oa mYVh ls tqMs+ isV nnZ] vlkekU; jDrlzko] Nkrh esa nnZ] cgqr vf/kd fljnnZ] vkokt dk yM+[kM+kuk ;k 'kjhj dh ,d rjQ detksjh dks eglwl djrk
gwa rks QkSju vius MkWDVj ls laidZ d:axkA ftruh tYnh laHko gks ldsxk eSa viuk mipkj dj jgs us= fo'ks"kK dks bu leL;kvksa ds ckjs esa crkÅaxkA
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jksxh dh lgefr
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eSa le>rk gwa fd vokfLVuVh,e dks esVkLVsfVd dksyksjDs Vy dSl
a j ds mipkj ds fy, ,QMh, }kjk eatjw h iznku dh x;h gS vkSj vka[k dh chekfj;ksa ds mipkj
ds fy, bls eatjw ugha fd;k x;k gSA fQj Hkh] eSa vokfLVuVh,e ls mipkj ikuk pkgrk gwa vkSj eSa mu laHkkO; tksf[keksa dks Lohdkj djus ds fy, bPNqd
gwa ftudh fd esjs MkWDVj us esjs lkFk ppkZ dh gSA blds }kjk eSa mipkj dj jgs us= ltZu dks viuh izHkkfor vka[k esa t:jr ds vuqlkj baVªkfoVfj;y
vokfLVuVh,e dks mi;ksx esa ykus ds fy, vf/kÑr djrk gwAa ;g vuqefr esjs }kjk bls jí fd;s tkus ;k esjh voLFkkvksa ds ml gn rd ifjofrZr gksus
rd oS/k jgsxh tcfd esjs fy, vkS"kf/k ds tksf[ke vkSj ykHk mYys[kuh; :i ls fHkUu u gks tk;sAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
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fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 20 )
MacugenTM Intravitreal Injection
Aparna Gupta
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
Indications
Macugen is used to treat adults with an eye problem called the wet form (neovascular) of age-related macular degeneration. Macular
degeneration causes vision loss leading to blindness.
Contraindications
Do not use Macugen if you have an infection in or around your eye
Possible Limitations
The goal of treatment is to prevent further loss of vision. Although some patients have regained vision, the medication may not restore
vision that has already been lost, and may not ultimately prevent further loss of vision caused by the disease.
Alternatives
You do not have to receive treatment for your condition, although without treatment, these diseases can lead to further vision loss and
blindness, sometimes very quickly. Other forms of treatment are available. At present, there are three FDA-approved treatments for
neovascular age-related macular degeneration. The first is photodynamic therapy with a drug called VisudyneTM. The other two are
injection into the eye of MacugenTM. and LucentisTM . In addition to the FDA-approved medications, some ophthalmologists use intravitreal
AvastinTM and triamcinolone —”off-label” to treat eye conditions like yours.
Side Effects
The most common side effects with Macugen include:
1.
inflammation of the eye
2.
blurred vision or changes in vision
3.
cataracts
4.
bleeding in the eye
5.
swelling of the eye
6.
eye discharge
7.
irritation or discomfort of the eye
8.
eye pain
9.
seeing “spots” in your vision
Patient Responsibilities
I will inform my doctor if I’m pregnant, planning to conceive or breast feeding.
I will immediately contact my doctor if any of the following signs of infection or other complications develop:pain, blurry or decreased
vision, sensitivity to light, redness of the eye, or discharge from the eye. I will keep all my post-injection appointments so that my doctor
can check for complications.
Although the likelihood of serious complications affecting other organs of my body is low, I will immediately contact my physician if I
experience abdominal pain associated with constipation & vomiting, abnormal bleeding, chest pain, severe headache, slurred speech, or
weakness on one side of the body. As soon as possible, I will also notify the treating ophthalmologist of these problems.
( 21 )
I will inform any other surgeon that I am on a medication that needs to be stopped before I can have surgery
Patient Consent
The above explanation has been read by/to me. The nature of my eye condition has been explained to me and the proposed treatment has
been described. The risks, benefits, alternatives, and limitations of the treatment have been discussed with me. All my questions have been
answered.
I understand that Macugen TM was approved by the FDA for the treatment of metastatic colorectal cancer, and has not been approved for
the treatment of eye conditions. Nevertheless, I wish to be treated with Macugen TM, and I am willing to accept the potential risks that my
physician has discussed with me. I hereby authorize the treating eye-surgeon to administer the intravitreal Macugen TM in my affected eye
as needed. This consent will be valid until I revoke it or my condition changes to the point that the risks and benefits of this medication
for me are significantly different.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: ................................................................................................ Relationship .......................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
( 22 )
eSdqtsuVh,e baVªkfoVfj;y batsD'ku
vi.kkZ xqIrk
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
lq>ko
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gSA eSdqyj fodkj va/ksiu dh vksj ys tkus okyh n`f"V dh gkfu dks mRiUu djrk gSA
uqdlkunsg vlj
vxj vkidh vka[k ;k mlds vklikl laØe.k gS rks eSdqtus dk mi;ksx ugha djsAa
laHkkfor lhek,a
mipkj dk y{; n`f"V dks vkxs vkSj gkfu gksus ls jksduk gSA gkykafd dqN yksxksa us n`f"V iqu% izkIr dh gS ij gks ldrk gS fd nokbZ igys gh tk pqdh
n`f"V dks fQj ls cgky ugha djs vkSj ;g Hkh laHko gS fd chekjh ds dkj.k n`f"V dh vkxs dh gkfu dks Hkh vara r% ugha jksd ik;sA
fodYi
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cgqr gh tYnhA mipkj ds nwljs :i miyC/k gSAa orZeku es]a fu;ksoSLdwyj mez ls tqMs+ eSdqyj fodkj ds fy, ,QMh, ls eatjw h izkIr rhu mipkj gSAa
igyks folqMkbuVh,e uked nok ds lkFk QksVksMk;kufed mipkj gSA vU; nks eSdqtus Vh,e vkSj yqlfas VlVh,e ds vka[k ds batDs 'ku gSAa ,QMh, ls eatjw h izkIr
nokvksa ds vfrfjDr dqN us=&fo'ks"kK vkidh rjg dh vka[kksa dh n'kkvksa ds mipkj ds fy, baVªkfoVfj;y vokfLVuVh,e vkSj fVª;kefluksyksu &
^^vkQ&yscy** dks mi;ksx esa ykrs gSAa
ikk'oZ&izHkko
eSdqtus ds lkFk lokZf/kd vke ik'oZ izHkkoksa esa 'kkfey gSa %
1vka[kksa dh tyu
2/kq/a kyh n`f"V ;k n`f"V esa ifjorZu
3eksfr;kfcan
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5vka[kksa esa lwtu
6vka[k ls ikuh cguk
7vka[k esa tyu ;k ihM+k
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jksxh dh ftEesnkfj;ka
vxj eSa xHkZorh gw]a xHkZ /kkj.k djus dh ;kstuk cuk jgh gwa ;k Lruiku djk jgh gwa rks vius MkWDVj dks lwfpr d:axhA
vxj laØe.k ds fuEufyf[kr esa ls dksbZ Hkh y{k.k ;k vU; ijs'kkfu;ka fodflr gksrh gSa rks eSa QkSju vius MkWDVj ls laidZ d:axk % nnZ] /kq/a kyh ;k ?kVh
gqbZ n`f"V] izdk'k ds izfr laons u'khyrk] vka[kksa dh ykyh ;k vka[kksa ls ikuh cgukA eSa batDs 'ku ds ckn ds eqykdkr ds lHkh le; ij gkftj jgwx
a k rkfd
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( 23 )
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( 24 )
LucentisTM Intravitreal Injection
Aparna Gupta
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
Indications
Lucentis is used to treat adults with an eye problem called the wet form (neovascular) of age-related macular degeneration. Macular
degeneration causes vision loss leading to blindness.
Contraindications
Do not use Lucentis if you have an infection in or around your eye
Possible Limitations
The goal of treatment is to prevent further loss of vision. Although some patients have regained vision, the medication may not restore
vision that has already been lost, and may not ultimately prevent further loss of vision caused by the disease.
Alternatives
You do not have to receive treatment for your condition, although without treatment, these diseases can lead to further vision loss and
blindness, sometimes very quickly. Other forms of treatment are available. At present, there are three FDA-approved treatments for
neovascular age-related macular degeneration. The first is photodynamic therapy with a drug called VisudyneTM. The other two are
injection into the eye of LucentisTM. and MacugenTM. In addition to the FDA-approved medications, some ophthalmologists use intravitreal
AvastinTM and triamcinolone —”off-label” to treat eye conditions like yours.
Side Effects
The most common side effects with Lucentis include:
1.
Inflammation of the eye
2.
Blurred vision or changes in vision
3.
Cataracts
4.
Bleeding in the eye
5.
Swelling of the eye
6.
Eye discharge
7.
Irritation or discomfort of the eye
8.
Eye pain
9.
Seeing “spots” in your vision
10.
The most common non–eye-related side effects were high blood pressure, nose and throat infection, and headache.
11.
Although uncommon, conditions associated with eye- and non–eye-related blood clots (arterial thromboembolic events) may
occur.
Patient Responsibilities
I will inform my doctor if I’m pregnant, planning to conceive or breast feeding.
I will immediately contact my doctor if any of the following signs of infection or other complications develops: pain, blurry or decreased
vision, sensitivity to light, redness of the eye, or discharge from the eye. I will keep all my post-injection appointments so that my doctor
can check for complications.
Although the likelihood of serious complications affecting other organs of my body is low, I will immediately contact my
( 25 )
physician if I experience abdominal pain associated with constipation & vomiting, abnormal bleeding, chest pain, severe headache,
slurred speech, or weakness on one side of the body. As soon as possible, I will also notify the treating ophthalmologist of these problems.
I will inform any other surgeon that I am on a medication that needs to be stopped before I can have surgery
Patient Consent
The above explanation has been read by/to me. The nature of my eye condition has been explained to me and the proposed treatment has
been described. The risks, benefits, alternatives, and limitations of the treatment have been discussed with me. All my questions have been
answered.
I understand that LucentisTM was approved by the FDA for the treatment of metastatic colorectal cancer, and has not been approved for the
treatment of eye conditions. Nevertheless, I wish to be treated with LucentisTM, and I am willing to accept the potential risks that my
physician has discussed with me. I hereby authorize the treating eye-surgeon to administer the intravitreal LucentisTM in my affected eye
as needed. This consent will be valid until I revoke it or my condition changes to the point that the risks and benefits of this medication
for me are significantly different.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: ................................................................................................ Relationship .......................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
( 26 )
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( 27 )
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( 28 )
ROP Laser
Parijat Chandra
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been informed in my mother tongue that my child’s eye(s) are affected with the disease Retinopathy of Prematurity (ROP) which
urgently requires retinal laser photocoagulation treatment.
I have been fully explained regarding Retinopathy of Prematurity, its vision blinding complications, and the urgent necessity for retinal
laser treatment. I have been clearly explained about the laser procedure, its side effects and risks involved. I understand that depending on
disease severity and treatment response, additional laser treatments may be required later. I understand that despite the best of laser
treatment, sometimes the disease may progress leading to visually disabling sequelae and blindness, and later may require surgical
intervention which may or may not be beneficial.
I allow the attending neonatologist to administer drugs, infusions or any other treatment/ procedures as deemed necessary or desirable
during the laser procedure (and in any unforeseen or emergency conditions they encounter).
I certify that I have fully understood the implications of the above consent and authorise the doctors to perform retinal laser photocoagulation
on my child’s right / left eye.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: ................................................................................................ Relationship .......................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
( 29 )
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ldrk gS vkSj ugha HkhA
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( 30 )
Laser Indirect Ophthalmoscopy
Bhuvan Chanana
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
This document is intended to provide you with information so that you can decide whether you should have a type of laser surgery called
laser indirect ophthalmoscopy or LIO. You have the right to ask any questions you might have about the procedure before agreeing to have
the ophthalmologist, or eye surgeon, perform it on your eye.
Indications for Laser Indirect Ophthalmoscopy
The eye functions much like a camera. The front of the eye contains the structures which focus the image and regulate the amount of light
that enters the eye, similar to the lens and shutter of a camera. In the back of the eye is the retina, which functions like the film in the
camera. Without film, a camera cannot take a picture, and without a functioning retina, the eye cannot see.
LIO is done to laser the peripheral retina. It is used to treat peripheral retinal lesions like lattice degeneration or a retinal break, which may
predispose your eyes to retinal detachment. LIO is also done to delimit peripheral detached retina to prevent its further progression. LIO
can also be used for augmentation of pan-retinal photocoagulation where the peripheral retina cannot be lasered by using a slit lamp
machine.
Possible Benefits of Laser Indirect Ophthalmoscopy
Laser indirect ophthalmoscopy or LIO uses a laser to treat the peripheral retina so that it will form a strong adhesion of the retina with
underlying layers, preventing the retina to detach, and avoiding a potentially blinding condition.
To perform the procedure, the pupil of the eye is made bigger (dilated) with eye drops. The laser is aimed at the peripheral retina through
the pupil with the help of an indirect ophthalmoscope. Since the laser treats the peripheral retina, some peripheral or side vision may be
lost, and this may cause reduced night vision. This usually does not present a problem for most of the cases.
Alternatives to Laser Indirect Ophthalmoscopy
Cryotherapy has also been used to treat peripheral retinal lesions. Cryotherapy uses a probe placed against the outside of the eye to treat
the peripheral retina by freezing it. Most ophthalmologists now treat the peripheral retina with a laser instead of cryotherapy.
Risks and Complications of Laser Indirect Ophthalmoscopy
When deciding whether or not to have surgery, the patient must weigh the possible risks of the surgery against the benefits the surgery is
expected to produce. Laser surgery for peripheral retina has limited risks. While performing the surgery, structures of the eye can be
damaged and cause complications, which may lead to loss of vision. Surgery or medications may be needed to treat these complications.
In the majority of patients whose eyes were treated with LIO, the retina remained attached. While the goal of the surgery is prevent a retinal
detachment and blindness, even with proper treatment, not all eyes respond to the treatment. New lesions of the retina may develop and
regular retinal screening is required. For some the laser surgery may have to be repeated in order to completely treat the retinal lesion.
Risks for LIO include, but are not limited to:
1.
Failure to achieve the goal of surgery: even with treatment, retinal detachment may develop in few cases.
2.
Bleeding in the eye (vitreous hemorrhage)
3.
Elevated eye pressure (glaucoma)
4.
Decreased eye pressure (hypotony)
( 31 )
5.
Corneal burns (clear covering of the front of the eye)
6.
Damage to the iris (colored portion of the eye)
7.
Damage to the lens (cataract)
8.
Loss of vision or loss of the eye
9.
Loss of peripheral (side) vision
10.
Corneal clouding or scarring
11.
Decrease or loss of vision caused by loss of circulation to the vital tissues in the eye
Consent for Laser Surgery for ROP
The ophthalmologist has explained to me the problem with my eyes, and the risks, benefits, and alternatives to LIO surgery. Although it
is impossible for the doctor to inform me of every possible complication that may occur, the doctor has answered all my questions to my
satisfaction. I understand that there is no guarantee that the surgery will prevent blindness in my eye, and that the surgery may need to be
repeated to effectively treat my condition.
In signing this informed consent for LIO, I am stating that I have been offered a copy and I fully understand the possible risks, benefits,
and complications of the laser surgery.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: ................................................................................................ Relationship .......................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
( 32 )
ystj buMkW;jsDV vkWFkSyeksLdksih
Hkqou pUuk
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
bl nLrkost dk y{; vkidks og tkudkjh iznku djuk gS ftlls fd vki bl ckr dk fu.kZ; dj ldsa fd vki ystj buMkW;jsDV vkWFkSyeksLdksih ;k
,yvkbZvks uked ystj ltZjh dks djok,axs ;k ughaA us= fo'ks"kK ;k us= ltZu dks bls vkidh vka[k ij laiUu djus nsus ij lger gksus ls igys bldh
dk;Zfof/k ds ckjs esa dksbZ Hkh iz'u iwNuk vkidk vf/kdkj gSA
ystj buMkW;jsDV vkWFkSyeksLdksih ds fy, lq>ko
vka[k dkQh dqN dSejs dh rjg ls dke djrh gSA vka[kksa ds lkeus ds fgLls esa og <kapk gksrk gS tks fd Nfo ij Qksdl djrk gS vkSj vka[kksa esa izo's k
djus okyh izdk'k dh ek=k dks fu;fer djrk gS] tks fd dSejs dh fQYe dh Hkkafr dke djrk gSA fQYe ds fcuk dSejk rLohj ugha mrkj ldrk vkSj
dke djus okyh jsfVuk ds fcuk vka[ksa ns[k ugha ldrhaA
ifj/kh; jsfVuk dks ystj djus ds fy, ,yvkbZvks dh tkrh gSA bldk mi;ksx f>yfeyh ds fodkj ;k jsfVuy VwVu tSls ifj/kh; jsfVuy ?kkoksa dk mipkj
djus ds fy, fd;k tkrk gS] tks fd jsfVuy vyxko ds fy, vkidh vka[kksa dks igys ls gh izo`Ùk dj ldrk gSA
vyx gqbZ ifj/kh; jsfVuk dks lhfer djus ds fy, Hkh ,yvkbZvks fd;k tkrk gS rkfd mls vkxs vkSj c<+us ls jksdk tk ldsA blds vykok ,yvkbZvks dk
mi;ksx vf[ky&jsfVuy QksVksdksvkxqy's ku dh o`f) ds fy, fd;k tk ldrk gS] tgka ij ifj/kh; jsfVuk dks fLyV ySEi e'khu dk mi;ksx djds ystj
ls mipkfjr ugha fd;k tk ldrkA
ystj buMkW;jsDV vkWFkSyeksLdksih ds laHkkfor ykHk
ystj buMkW;jsDV vkWFkSyeksLdksih ;k vkbZ,yvks ifj/kh; jsfVuk dk mipkj djus ds fy, ystj dk mi;ksx djrh gS rkfd og varfuZfgr ijrksa ds lkFk
jsfVuk ds etcwr tqMk+ o dks fufeZr djs] jsfVuk dks vyx gksus ls jksds vkSj laHkkO; :i ls va/kRo dh n'kk ls cpk;sA
bl dk;Zfof/k dks laiUu djus ds fy, vka[kksa dh iqryh dks vkbZ MªkIl ls cM+k cuk;k tkrk gS ¼QSyk;k tkrk gS½A ystj buMkW;jsDV vkFkSyeksLdksi dh
enn ls iqryh ds tfj;s ifj/kh; jsfVuk ij yf{kr gksrh gSA pwfa d ystj ifj/kh; jsfVuk dk mipkj djrh gS blfy, dqN ifj/kh; ;k ik'oZ dh utj tk
ldrh gS vkSj bldh otg ls jkr esa de fn[kk;h iM+ ldrk gSA ;g izk;% vf/kdrj ekeyksa esa leL;k ugha mRiUu djrkA
ystj buMkW;jsDV vkWFkSyeksLdksih ds fodYi
fØ;ksFksjis h dk mi;ksx ifj/kh; jsfVuy ?kkoksa ds mipkj ds fy, Hkh fd;k tkrk gSA fØ;ksFksjis h ifj/kh; jsfVuk dk mipkj djus ds fy, mls cgqr gh Ba<k
djds vka[k ds ckgjh fgLls ds lkeus j[kh x;h lykbZ dk mi;ksx djrh gSA vf/kdrj us= fo'ks"kK vc fØ;ksFksjis h dh ctk; ifj/kh; jsfVuk dk mipkj
ystj ls djrs gSAa
ystj buMkW;jsDV vkWFkSyeksLdksih ds tksf[ke vkSj tfVyrk,a
ltZjh djokbZ tk;s ;k ugha bldk fu.kZ; djrs le; jksxh dks ltZjh ds ykHkksa ds cjvDl mlds laHkkfor tksf[keksa dk vkdyu vo'; djuk pkfg,A
ifj/kh; jsfVuk ds fy, ystj ltZjh ds lhfer tksf[ke gSAa ltZjh djrs le; vka[k ds <kaps dks uqdlku igqp
a ldrk gS vkSj ijs'kkfu;ka mRiUu gks ldrh
gSa tks fd n`f"Vghurk dks tUe ns ldrh gSAa bu tfVyrkvksa ds mipkj ds fy, ltZjh ;k nokb;ksa dh vko';drk iM+ ldrh gSA
,yvkbZvks ls mipkj ik;s vf/kdka'k jksfx;ksa esa jsfVuk layXu cuh jghA tgka ltZjh dk mís'; jsfVuk ds vyxko vkSj va/ksiu dks jksduk gS ogha leqfpr
mipkj ds ckn Hkh mipkj ls lHkh vka[ksa Bhd ugha gksrh gSAa jsfVuk ds u;s ?kko fodflr gks ldrs gSa vkSj jsfVuk dk fu;fer ijh{k.k vko';d cu tkrk
gSA dqN ds fy, ystj ltZjh dks nksgjkuk iM+ ldrk gS rkfd jsfVuk ls tqMs+ ?kko dk iwjh rjg ls mipkj fd;k tk ldsA
,yvkbZvks ds fy, tksf[keksa esa 'kkfey gSa ij os bUgha rd lhfer ugha gSa %
1ltZjh ds y{; dks ikus esa foQyrk % mipkj ds ckn Hkh dqN ekeyksa esa jsfVuy vyxko fodflr gks ldrk gSA
2vka[kksa esa jDrlzko ¼foVfjvl jDrlzko½
3vka[k dk c<+k gqvk ncko ¼Xywdksek½
4vka[k dk ?kVk gqvk ncko ¼gkbiksVksuh½
( 33 )
567891011-
dkWuhZy cUlZ ¼vka[k ds lkeus dh fDy;j dofjax½
vkbfjl ¼vka[k dk jaxhu fgLlk½ dks uqdlku
ysl
a dks uqdlku ¼eksfr;kfcan½
n`f"V dk pys tkuk ;k vka[k dh gkfu
ifj/kh; ¼fdukjs dh½ n`f"V dh gkfu
dkWuhZy DykmfMax ;k LdSfjax
vka[kksa ds egRoiw.kZ Årdksa esa ifjlapj.k dh deh ls mRiUu n`f"V esa deh ;k mldh gkfu
vkjvksih gsrq ystj ltZjh ds fy, vuqefr
us= fo'ks"kKksa us esjh vka[k dh leL;k vkSj vkbZ,yvks ltZjh ds tksf[keks]a ykHkksa vkSj fodYiksa ds ckjs esa eq>s le>k fn;k gSA gkykafd MkWDVj ds fy, mifLFkr
gks ldus okyh gjsd laHko tfVyrk ds ckjs esa crkuk vlaHko gS ij MkWDVj esjs lHkh iz'uksa dk mÙkj nsdj eq>s larq"V dj fn;kA eSa le>rk gwa fd bl
ckr dh dksbZ xkjaVh ugha gS fd ltZjh esjs vka[kksa ds va/ksiu dks jksd nsxh vkSj ;g fd esjh voLFkk ds izHkkoh mipkj ds fy, ltZjh dks nksgjkus dh vko';drk
iM+ ldrh gSA
,yvkbZvks ds fy, bl lwfpr lgefr ij gLrk{kj djds eSa dg jgk gwa fd eq>s bldh ,d izfr iznku dh x;h gS vkSj eSa ystj ltZjh ds laHkkfor tksf[keks]a
ykHkksa vkSj tfVyrkvksa dks le>rk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 34 )
Laser Photocoagulation for Diabetic Retinopathy
Aparna Gupta
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
This document is intended to provide you with information so that you can decide whether you should have Laser photocoagulation for
diabetic retinopathy
You have the right to ask any questions you might have about the procedure before agreeing to have the ophthalmologist, or eye surgeon,
perform it on your eye.
Indications for Laser Photocoagulation for Diabetic Retinopathy
The eye functions much like a camera. The front of the eye contains the structures which focus the image and regulate the amount of light
that enters the eye, similar to the lens and shutter of a camera. In the back of the eye is the retina, which functions like the film in the
camera. Without film, a camera cannot take a picture, and without a functioning retina, the eye cannot see.
Laser photocoagulation uses the heat from a laser to seal or destroy abnormal, leaking blood vessels in the retina. One of two approaches
may be used when treating diabetic retinopathy:
•
Focal photocoagulation. Focal treatment is used to seal specific leaking blood vessels in a small area of the retina, usually near the
macula. The ophthalmologist identifies individual blood vessels for treatment and makes a limited number of laser burns to seal
them off.
•
Scatter (pan-retinal) photocoagulation. Scatter treatment is used to slow the growth of new abnormal blood vessels that have
developed over a wide area of the retina. The ophthalmologist may make hundreds of laser burns on the retina to stop the blood
vessels from growing. The person may need two or more treatment sessions.
Laser photocoagulation is not painful. The injection of anesthetic may be uncomfortable, and you may feel a slight stinging sensation or
see brief flashes of light when the laser is applied to your eye.
Possible Benefits of Laser Photocoagulation for Diabetic Retinopathy
Laser treatment may not restore vision that has already been lost. But when performed in a timely manner,
•
Focal photocoagulation, which targets specific blood vessels, is effective in reducing the risk of vision loss in people with macular
edema. It lowers the risk of moderate vision loss by 20% in people who have mild to moderate non-proliferative retinopathy. It may
also help prevent progression to more severe retinopathy.
•
Scatter (pan-retinal) photocoagulation, which treats a wide area of the retina, reduces the risk for severe vision loss by 50% to 60%
over 6 years in people with a high risk of vision loss. It reduces the risk of serious bleeding and progression of severe proliferative
retinopathy and the need for surgery (vitrectomy) by 50% in people with type 2 diabetes and people age 40 and older with type 1
diabetes who already have severe non-proliferative or mild proliferative retinopathy. Studies suggest that up to 90% of cases of legal
blindness caused by proliferative retinopathy could be prevented by prompt scatter photocoagulation.
Risks and Complications of Laser Photocoagulation for Diabetic Retinopathy
Laser photocoagulation burns and destroys part of the retina and often results in some permanent vision loss. This is usually unavoidable.
Treatment may cause mild loss of central vision, reduced night vision, and decreased ability to focus. Some people may lose some of their
side (peripheral) vision. However, the vision loss caused by laser treatment is mild compared with the vision loss that may be caused by
untreated retinopathy.
Rare complications of laser photocoagulation may cause severe vision loss. These include:
•
Bleeding in the eye (vitreous hemorrhage).
•
Traction retinal detachment.
( 35 )
•
Accidental laser burn of the fovea (a depression in the central macula that contains no blood vessels), resulting in severe central
vision loss.
Consent for Laser Photocoagulation for Diabetic Retinopathy
The ophthalmologist has explained to me the problem with my eyes, and the risks, benefits, and alternatives to laser photocoagulation.
Although it is impossible for the doctor to inform me of every possible complication that may occur, the doctor has answered all my
questions to my satisfaction. I understand that there is no guarantee that the laser will prevent blindness in my eye, and that the laser may
need to be repeated to effectively treat my condition.
In signing this informed consent for laser photocoagulation, I am stating that I have been offered a copy and I fully understand the
possible risks, benefits, and complications of the laser surgery.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
( 36 )
Mk;fcfVd jsfVuksFksjsih ds fy, ystj QksVksdksvkxqys'ku
vi.kkZ xqIrk
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
bl nLrkost dk y{; vkidks og tkudkjh iznku djuk gS ftlls fd vki bl ckr dk fu.kZ; dj ldsa fd vki Mk;fcfVd jsfVuksFksjis h ds fy, ystj
QksVksdksvkxqy's ku djok,axs ;k ughaA us= fo'ks"kK ;k us= ltZu dks bls vkidh vka[k ij laiUu djus nsus ij lger gksus ls igys bldh dk;Zfof/k ds
ckjs esa dksbZ Hkh iz'u iwNuk vkidk vf/kdkj gSA
Mk;fcfVd jsfVuksFksjsih ds fy, ystj QksVksdksvkxqys'ku dk lq>ko
vka[k dkQh dqN dSejs dh rjg ls dke djrh gSA vka[kksa ds lkeus ds fgLls esa og <kapk gksrk gS tks fd Nfo ij Qksdl djrk gS vkSj vka[kksa esa izo's k
djus okyh izdk'k dh ek=k dks fu;fer djrk gS] tks fd dSejs dh fQYe dh Hkkafr dke djrk gSA fQYe ds fcuk dSejk rLohj ugha mrkj ldrk vkSj
dke djus okyh jsfVuk ds fcuk vka[ksa ns[k ugha ldrhaA
ystj QksVksdksvkxqy's ku jsfVuk dh vlkekU;] fjlko okyh jDr okfgdkvksa dks lhy ;k u"V djus ds fy, ystj dh xjeh dk mi;ksx djrk gSA Mk;fcfVd
jsfVuksFksjis h dk mipkj djrs le; nks igqp
a ksa esa ls ,d dk mi;ksx fd;k tk ldrk gS %
Û
Qksdy QksVksdksvkxqys'kuA Qksdy mipkj dk mi;ksx jsfVuk ds NksVs ls Hkkx izk;% eSdqyk ds djhc esa fjlko djus okyh fof'k"V jDr okfgdkvksa
dks can djus ds fy, fd;k tkrk gSA us=&fo'ks"kK mipkj ds fy, ,d&,d jDRk okfgdkvksa dh igpku djrk gS vkSj mUgsa can djus ds fy, lhfer
la[;k ystj cUlZ djrk gSA
Û
LdSVj ¼vf[ky&jsfVuy½ QksVksdksvkxqys'kuA LdSVj mipkj dk mi;ksx u;h vlkekU; jDr okfgdkvksa dh o`f) dks /khek djus ds fy, fd;k
tkrk gS tks fd jsfVuk ds cM+s fgLls ds Åij fodflr gks x;h gksrh gSAa us= fo'ks"kK jDr okfgdkvksa dks c<+us ls jksdus ds fy, jsfVuk ds Åij
gtkjksa ystj cUlZ dj ldrk gSA O;fDRk dks nks ;k vf/kd mipkj l=ksa dh vko';drk iM+ ldrh gSA ?
ystj QksVkdksvkxqy's ku nnZukd ugha gksrk gSA csgks'kh dk batDs 'ku cspSu djus okyk gks ldrk gS vkSj vki gYdh pqHku dh lulukgV eglwl dj ldrs
gSa ;k vkidh vka[kksa ij ystj ds iz;ksx ds le; izdk'k dh laf{kIr ped dks ns[k ldrs gSAa
Mk;fcfVd jsfVuksFksjsih ds fy, ystj QksVksdksvkxqys'ku ds laHkkfor ykHk
ystj mipkj gks ldrk gS fd igys ls gh tk pqdh n`f"V dks cgky ugha dj ik;s ysfdu le;c) rjhds ls bls laiUu djus ij]
Û
QksVksdksvkxqy's ku] tks fd fof'k"V jDr okfgdkvksa dks yf{kr djrk gS] eSdqyj ,fMek okys yksxksa esa n`f"V dh gkfu ds tksf[ke dks de djus esa
izHkkoh gSA ;g gYdh ls ysdj e/;e rd dh xSj&izlkjh jsfVuksiSFkh okys yksxksa esa n`f"V dh e/;e gkfu dks 20 izfr'kr rd de djrk gSA blds
vykok ;g T;knk xaHkhj jsfVuksFksjis h esa c<+r dks jksdus esa Hkh enn dj ldrk gSA
Û
LdSVj ¼vf[ky&jsfVuy½ QksVksdksvkxqy's ku] tks fd jsfVuk ds foLr`r {ks= dk mipkj djrk gS] n`f"V dh gkfu ds mPp tksf[ke okys yksxksa esa 6
o"kksZa ds nkSjku n`f"V dh xaHkhj gkfu dks 50 ls 60 izfr'kr rd ds tksf[ke de djrk gSA ;g Vkbi 2 Mk;fcVht okys yksxksa vkSj 40 lky vkSj
vf/kd mez ds Vkbi 1 Mk;fcVht okys yksxksa es]a ftUgsa fd igys ls gh xaHkhj xSj&izlkjh ;k e/;e izlkjh jsfVuksFksjih gS] xaHkhj jDrlzko ds tksf[ke
vkSj rhoz izlkjh jsfVuksFksjhih dh c<+r vkSj ltZjh ¼foVjsDVkseh½ dh t:jr dks 50 izfr'kr rd de djrk gSA v/;;uksa ls irk pyrk gS fd izlkjh
jsfVuksFksjis h ds }kjk mRiUu fu;e ds vuqdy
w va/ksiu ds 90 izfr'kr rd ds ekeyksa dks Rofjr LdSVj QksVkdksvkxqy's ku ds }kjk jksdk tk ldrk
gSA
Mk;fcfVd jsfVuksFksjsih ds fy, ystj QksVksdksvkxqys'ku ds tksf[ke vkSj tfVyrk,a
ystj QksVksdksvkxqy's ku jsfVuk ds fgLls dks tykrk vkSj u"V djrk gS vkSj vDlj blds QyLo:i n`f"V dks dqN LFkk;h gksuh gks tkrh gSA ;g izk;%
nqfuZokj gksrk gSA mipkj ds dkj.k e/;orhZ n`f"V dks gYdk uqdlku] jkr esa de fn[kk;h iM+uk vkSj /;ku dsfa nzr djus dh {kerk esa deh vk ldrh gSA
dqN yksx viuh ik'oZ ¼ifj/kh;½ n`f"V dks dqN [kks ldrs gSAa fQj Hkh] fcuk mipkj okyh jsfVuksiSFkh ds dkj.k mRiUu gksus okyh n`f"V dh gkfu dh rqyuk
esa ystj mipkj ds dkj.k gksus okyh n`f"V dh gkfu gYdh gksrh gSA
ystj QksVksdksvkxqy's ku dh fojy tfVyrk,a n`f"V dh xaHkhj gkfu dk dkj.k cu ldrh gSAa buesa 'kkfey gSa %
Û
vka[kksa esa jDrlzko ¼foVfjvl jDrlzko½A
Û
f[kapko jsfVuy vyxkoA
( 37 )
Û
Qksfov dk la;ksxo'k ystj cuZ ¼e/;orhZ eSdqyk esa ncko ftlesa esa dksbZ jDr okfgdk,a ugha gksrh gS½a ] blds dkj.k e/;orhZ n`f"V dks xaHkhj gkfu
igqp
a rh gSA
Mk;fcfVd jsfVuksFksjsih gsrq ystj QksVksdksvkxqys'ku ds fy, vuqefr
us= fo'ks"kK us esjh vka[kksa dh leL;kvksa vkSj ystj QksVksdksvkxqy's ku ds tksf[keks]a ykHkksa vkSj fodYiksa ds ckjs esa eq>s le>k fn;k gSA gkykafd mifLFkr
gks ldus okyh gjsd laHko tfVyrk ds ckjs esa MkWDVj ds fy, crk ikuk vlaHko gS ysfdu MkWDVj us esjs lHkh iz'uksa dk mÙkj nsdj eq>s larq"V dj fn;kA
eSa le>rk gwa fd bl ckr dh dksbZ xkjaVh ugha fd ystj esjh vka[k esa va/ksiu dks jksd nsxh vkSj ;g fd esjh vka[k dh voLFkk ds izHkkoh mipkj ds fy,
ystj dks nksgjkus dh t:jr iM+ ldrh gSA
ystj QksVksdksvkWxqy's ku ds fy, bl lwfpr lgefr ij gLrk{kj djrs gq, eSa crk jgk gwa fd eq>s bldh ,d izfr izkIr gqbZ gS vkSj eSa ystj ltZjh ds
laHkkfor tksf[keks]a ykHkksa vkSj tfVyrkvksa dks le>rk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 38 )
Laser Photocoagulation for Proliferative Retinopathy
Courtesy: Shroff Eye Centre, New Delhi
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I hereby authorize Dr. ......................................................... to perform upon me Laser Photocoagulation in the Right / Left eye. The aim of this
treatment is to decrease the risk of severe visual loss by preventing development of or promoting regression or shrinkage of abnormal
retinal blood vessels.
I acknowledge that I understand that:
1.
I have been diagnosed to have ............................................................
2.
This treatment is usually indicated when it is likely that bleeding inside the eye from new abnormal blood vessels can occur.
Sometimes laser photocoagulation may be indicated to prevent the development of new blood vessels. The intent of treatment is to
reduce likelihood of hemorrhage and/or retinal detachment that could cause severe and possible permanent loss of vision. However
hemorrhage and/or retinal detachment can occur despite laser treatment.
3.
This treatment is not designed to improve my vision, only to stabilize it. In fact, it may make the vision somewhat worse. For
example, the treatment may diminish my night vision and side vision to some extent. There is a 5% to 10% chance that it will
diminish my reading vision as well.
4.
No safer alternative exists to reduce the likelihood of losing vision. If treatment is not carried out. I understand that there is an
increased risk of permanent vision loss from bleeding and scar tissue formation inside the eye.
5.
Application of Cryo in Proliferative Vascular Retinopathy. In some cases of Diabetic Retinopathy or Eales Disease inspite of good
photocoagulation, there can be neovascularization or recurrent Vitreous Hemorrhage. Hence, to ablate peripheral retina, Cryotherapy
is used to avoid further problems.
6.
Laser treatment may be carried out in one or several treatment sessions depending on the severity and extent of the new vessels and
my tolerance for the treatment. When a peribulbar or retrobulbar Injection is given for local anesthesia, there is an extremely
small chance of ocular penetration.
7.
After treatment, periodic re-examination is necessary to monitor the response to treatment and detect any changes in the status of
the retinopathy, especially any change that would require additional treatment. I understand that it is the patient’s responsibility to
maintain follow up appointments necessary after laser treatment.
I acknowledge that the nature and the purpose of this procedure, the risks involved, alternatives and possible complications have been
explained to me by my doctor and that all my questions have been answered to my satisfaction. I am aware that the practice of medicine
and surgery is not an exact science, and I acknowledge that no guarantee can be made as to the results that may be obtained. All this has
been explained to me in the language I understand.
I have read, or had read to me, the above information and I consent to treatment, recognizing the potential risks that are involved.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
( 39 )
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
( 40 )
izksfyQjsfVo jsfVuksFksjsih ds fy, ystj QksVksdksvkxqys'ku
JkWQ vkbZ lsaVj] u;h fnYyh ds lkStU; ls
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eSa blds }kjk MkW- ----------------------------------------------------dks vius Åij nk;h@ck;ha vka[k esa ystj QksVksdksvkxqy's ku dks lEiUu djus ds fy, vf/kÑr djrk
gwAa bl mipkj dk mís'; vlkekU; jsfVuy jDr okfgdkvksa ds fodkl dks jksd dj ;k mlds ykSVko ;k fldqMu+ dks c<+kok nsdj n`f"V dh xaHkhj gkfu
dks de djuk gSA
eSa Lohdkj djrk gwa fd eSa le>rk gwa fd %
1funku djds irk yxk;k x;k gS fd eq>s ----------------------------------------------2bl mipkj dk lq>ko izk;% ml le; fn;k tkrk gS tc bl ckr ds vklkj gksrs gSa fd u;h vlkekU; jDr okfgdkvksa ls vka[k ds vanj jDrlzko
gks ldrk gSA dbZ ckj ystj QksVksdksvkxqy's ku dk lq>ko u;h jDr okfgdkvksa ds fodkl dks jksdus ds fy, fn;k tk ldrk gSA mipkj dk iz;kstu
jDrlzko vkSj@;k jsfVuy vyxko dh laHkkouk dks de djuk gS tks fd n`f"V dks xaHkhj vkSj laHko gkfu igqp
a k ldrk gSA cgjgky] jDrlzko vkSj@;k
jsfVuy vyxko ystj mipkj ds ckotwn Hkh mifLFkr gks ldrk gSA
3bl mipkj dks esjh n`f"V dks lq/kkjus ds fy, ugha] flQZ mls fLFkj djus ds fy, rS;kj fd;k x;k gSA njvly] ;g n`f"V dks fdafpr cnrj cuk
ldrk gSA mnkgj.k ds fy,] mipkj jkr esa esjh utj vkSj ik'oZ utj dks dqN gn rd de dj ldrk gSA bl ckr ds 5 ls 10 izfr'kr rd
ds vklkj gksrs gSa fd ;g esjh i<+us dh utj esa Hkh deh yk;sA
4n`f"V ds [kjkc gksus dh laHkkouk dks de djus ds fy, dksbZ Hkh lqjf{kr fodYi ekStnw ugha gSAa vxj ugha fd;k tkrk rks eSa le>rk gwa fd vka[k
ds vanj jDrlzko vkSj LdSj Ård fuekZ.k ls n`f"V dh LFkk;h gkfu dk c<+k gqvk tksf[ke gSA
5izkfs yQjsfVo oSLdqyj jsfVuksiSFkh esa fØ;ks dk vuqiz;ksxA vPNs QksVksdksvkxqy's ku ds ckotwn Mk;fcfVd jsfVuksFksjis h ;k ,Yl chekjh ds dqN ekeyksa
esa fu;ks&oSLdqyjkbts'ku ;k vkorhZ foVfjvl jDrlzko gks ldrk gSA fygktk] vkxs vkSj leL;k ugha gksus nsus gsrq ifj/kh; jsfVuk dks dkV dj
vyx djus ds fy, fØ;ksFksjis h dk mi;ksx fd;k tkrk gSA
6ystj mipkj u;h okfgdkvksa dh xaHkhjrk vkSj gn vkSj mipkj ds fy, esjh lgu'khyrk ds vk/kkj ij ,d ;k vf/kd mipkj l=ksa esa fd;k tk
ldrk gSA tc yksdy ,usLFkhfl;k ds fy, isfjcqyckj ;k jsVªkcs qyckj batDs 'ku fn;k tkrk gS rks n`f"V lac/a kh Hksnu dh cgqr gh de xat
q kb'k gksrh
gSA
7mipkj ds ckn mipkj ds izfr izfrfØ;k vkSj jsfVuksFksjis h dh fLFkfr esa fdlh cnyko] [kkldj ,sls cnyko dk irk yxkus ds fy, le;&le;
ij iqu% ijh{k.k vko';d gksrk gS] ftlds fy, vfrfjDr mipkj dh t:jr gksxhA eSa le>rk gwa fd ;g jksxh dh ftEesnkjh gS fd og ystj mipkj
ds ckn vko';d QkWyksvi eqykdkrksa dks cuk;s j[ksA
eSa Lohdkj djrk gwa fd bl dk;Zfof/k dh izÑfr vkSj mís';] blls tqMs+ tksf[keks]a fodYiksa vkSj laHkkfor tfVyrkvksa ds ckjs esa esjs MkWDVj }kjk eq>s le>k
fn;k x;k gS vkSj ;g fd esjs lHkh iz'uksa ds larks"ktud mÙkj ns fn;s x;s gSAa eSa bl ckr ls voxr gwa fd MkWDVjh vkSj ltZjh lVhd foKku ugha gS vkSj
eSa Lohdkj djrk gwa fd izkIr gksus okys ifj.kkeksa ds ckjs esa dksbZ Hkh xkjaVh ugha nh tk ldrhA bl lcdks eq>s ,slh Hkk"kk esa crk fn;k x;k gS ftls fd
eSa le>rk gwAa
mi;qZDr tkudkjh dks eSua s i<+ fy;k gS ;k eq>s i<+dj lquk fn;k x;k gS vkSj eSa mipkj ls tqMs+ laHkkO; tksf[keksa dks tkurs gq, blds fy, vuqefr iznku
djrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
( 41 )
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
(( 42
11 ))
Laser Photocoagulation for Maculopathy
Courtesy: Shroff Eye Centre, New Delhi
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I hereby authorize Dr. ......................................................... to perform upon me Laser Photocoagulation in the Right / Left eye for changes in
the Macula (which is the vital region of the retina for clear central vision) caused by Diabetes / Age Related Macular Degeneration /
Venous Blocks / ......................................................................................
In diabetes / venous blocks the aim of treatment is to close the blood vessels and capillary abnormalities which leak fluid and cause water
logging seen in this region. In age related macular degeneration the purpose is to destroy sub retinal neovascular membrane.
Following photocoagulation it is possible that there may be a slight improvement and you may be able to read a line or two more on the
vision test chart. Laser photocoagulation helps in maintaining your existing vision and to a certain extent prevents worsening at a later
date. In some insances vision may worsen despite photocoagulation due to unpreventable changes developing in this region.
In case of age - related macular degeneration, if the laser has to be applied to the centre of macula or very close to it, there can be an
immediate drop of vision. In these cases, long term visual prognosis is better if laser is done. When a peribulbar or retrobulbar injection
is given for local anesthesia there is an extremely small chance of ocular penetration.
One or more sessions of laser may be required. During follow up, more photocoagulation may have to. be done for changes in the macula
or for other changes that might have developed during this period.
After treatment, periodic re-examination is necessary to monitor the response to treatment and detect any changes in the status of the
retinopathy, especially any change that would require additional treatment. I understand that it is the patient’s responsibility to maintain
follow up appointment necessary after laser treatment. I acknowledge that the nature and the purpose of this procedure, the risks involved,
alternatives and the possible complications have been explained to me by my doctor, that all my questions, if any, have been answered to
my satisfaction. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantee can be
made as to the results that may be obtained. All this has been explained to me in the language I understand.
I have read, or had read to me, the above information and I consent to treatment, recognizing the potential risks that are involved.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
( 43 )
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
( 44 )
eSdqyksiSFkh ds fy, ystj QksVksdksvkxqys'ku
JkWQ vkbZ lsaVj] u;h fnYyh ds lkStU; ls
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eSa blds }kjk MkW- ------------------------------------dks vius Åij nk;h@ck;ha vka[k esa e/kqegs @mez ls tqMs+ eSdqyj fodkj@ulksa ds vo#) gksu@
s ---------------------------------- ls mRiUu eSdqyk ¼tks fd Li"V e/;orhZ n`f"V ds fy, jsfVuk dk egRiw.kZ {ks= gS½ esa ifjorZuksa ds fy, ystj QksVksdksvkxqy's ku dks lEiUu djus
ds fy, vf/kÑr djrk gwAa
e/kqegs @ulksa ds vojks/k esa mipkj dk mís'; jDr okfgdkvksa vkSj dSfiyjh vlkekU;rkvksa dks can djuk gS tks fd nzo dk fjlko djrh gSa vkSj bl {ks=
esa ns[ks tkus okys ikuh ds teko dks mRiUu djrh gSAa mez ls tqMs+ gq, eSdqyj fodkj esa mís'; mi jsfVuy fu;ksoSLdqyj f>Yyh dks u"V djuk gksrk
gSA
QksVksdksvkxqy's ku ds mijkar ;g laHko gS fd fdafpr lq/kkj gks vkSj vki utj ijh{k.k pkVZ ij ,d ;k nks ykbu vkSj i<+ ldrs gSAa ystj QksVksdksvkxqy's ku
vkidh orZeku n`f"V dks cuk;s j[kus esa enn djrk gS vkSj ,d gn rd ckn dh rkjh[k esa blds cnrj gksus dks jksdrk gSA dqN ekeyksa esa bl {ks=
esa fodflr gksus okys nqfuZokj ifjorZuksa ds pyrs QksVksdksvkxqy's ku ds ckotwn n`f"V cnrj gks ldrh gSA
mez ls tqMs+ eSdqyj fodkj ds ekeys esa vxj eSdqy ds e/; esa ;k mlds cgqr gh djhc ystj dks iz;ksx esa yk;k tkuk gS rks n`f"V esa QkSju fxjkoV
vk ldrh gSA bu ekeyksa esa vxj ystj dk mi;ksx fd;k tkrk gS rks nwjxkeh pk{kq"k jksx funku csgrj gksrk gSA tc yksdy ,usLFkhfl;k ds fy,
isfjcqyckj ;k jsVªkscqyckj batsD'ku fn;k tkrk gS rks n`f"V laca/kh Hksnu dh cgqr gh de xaqtkb'k gksrh gSA
ystj ds ,d ;k vf/kd l=ksa dh vko';drk iM+ ldrh gSA eSdqyk esa ifjorZu ds fy, ;k ,sls vU; ifjorZuksa ds fy, QkWyks&vi ds nkSjku T;knk
QksVksdksvkxqy's ku djuk iM+ ldrk gS tks fd bl vof/k ds nkSjku fodflr gq, gks ldrs gSAa
mipkj ds ckn mipkj ds izfr izfrfØ;k vkSj jsfVuksFksjis h dh fLFkfr esa fdlh cnyko] [kkldj ,sls cnyko dk irk yxkus ds fy, le;&le; ij iqu%
ijh{k.k vko';d gksrk gS] ftlds fy, vfrfjDr mipkj dh t:jr gksxhA eSa le>rk gwa fd ;g jksxh dh ftEesnkjh gS fd og ystj mipkj ds ckn vko';d
QkWyksvi eqykdkrksa dks cuk;s j[ksA eSa Lohdkj djrk gwa fd bl dk;Zfof/k dh izÑfr vkSj mís';] blls tqMs+ tksf[keks]a fodYiksa vkSj laHkkfor tfVyrkvksa
ds ckjs esa esjs MkWDVj }kjk eq>s le>k fn;k x;k gS vkSj ;g fd esjs lHkh iz'uksa ds larks"ktud mÙkj ns fn;s x;s gSAa eSa bl ckr ls voxr gwa fd MkWDVjh
vkSj ltZjh lVhd foKku ugha gS vkSj eSa Lohdkj djrk gwa fd izkIr gksus okys ifj.kkeksa ds ckjs esa dksbZ Hkh xkjaVh ugha nh tk ldrhA bl lcdks eq>s ,slh
Hkk"kk esa crk fn;k x;k gS ftls fd eSa le>rk gwAa
mi;qZDr tkudkjh dks eSua s i<+ fy;k gS ;k eq>s i<+dj lquk fn;k x;k gS vkSj eSa mipkj ls tqMs+ laHkkO; tksf[keksa dks tkurs gq, blds fy, vuqefr iznku
djrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
( 45 )
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 46 )
Fundus Fluorescein Angiography / Ophthalmoscopy/
Indocyanine Green Angiography
Courtesy: Shroff Eye Centre, New Delhi
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
This investigation procedure comprises of injection of a dye- fluorescein or Indocyanine green into one of your veins in the arm and
either taking rapid serial photographs of its passage within the inner structures of the eye, the retina and choroid or examining the inside
of your eye with an instrument called the indirect ophthalmoscope with appropriate filters. The information obtained from a study of this
procedure aids your doctor in either making a diagnosis, planning your treatment or assessing the results of treatment particularly
photocoagulation. There is no discomfort from this test apart from the needle prick and the flash of the camera which is harmless. You may
have nausea (sensation of vomiting) a minute or so after the injection. This usually passes off in about 30 seconds. Remaining calm and
breathing deeply helps in overcoming this difficulty. You are advised to be on an empty stomach three hours prior to this test. Your usual
diet can be taken soon after the procedure. Fluorescein is a highly non toxic drug and only rarely produces a mild aleergic reaction which
responds rapidly to appropriate medication. Serious life threatening reactions are exceptionally rare but can however occur. This is not
different from what can occur with any other medication. The skin and urine stain yellow for about 36 hours with fluorescein and is of no
consequence. You must be accompanied by an adult attendant during this test.
Informed Consent
The pamphlet on Fundus Fluorescein Angiography / Ophthalmoscopy / Indocyanine Green Angiography has been read by me/ out to me
and having understood the content, I give my consent to the performance of this on me.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
( 47 )
QaMl yqvksjlhu ,aft;ksxzkQh@vkFkSyeksLdksih
baMksfl,ukbu xzhu ,aft;ksxzkQh
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dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
vUos"k.k dh bl dk;Zfof/k esa ckagksa esa vkidh fdlh ul esa Mkb&ywvksjlhu ;k baMksflvukbu xzhu dk batDs 'ku vFkok vka[k ds vkarfjd <kap]s jsfVuk vkSj
dksjksbM ds vanj mlds ekxZ dh Rofjr <ax ls Øfed rLohjsa mrkjuk ;k mi;qDr fQYVjksa ds lkFk buMk;jsDV vkFkSyeksLdksi uked midj.k ds lkFk
vkidh vka[k ds Hkhrj ijh{k.k djuk 'kkfey gksrk gSA bl izfØ;k ds v/;;u ls izkIr tkudkjh vkids MkWDVj dh funku djus ;k vkids mipkj dh ;kstuk
cukus vFkok mipkj ds ifj.kkeksa [kkldj QksVksdksvkxqy's ku dk vkdyu djus esa enn djrh gSA lqbZ dh pqHku vkSj dSejs dh ped] tks fd gkfujfgr
gksrh gS] ds flok; bl ijh{k.k ls dksbZ vlqfo/kk ugha gksrh gSA vkidks batDs 'ku ds ckn ,d feuV ds vklikl feryh dh vuqHkwfr gks ldrh gSA ;g izk;%
yxHkx 30 lsdM
as esa [kRe gks tkrh gSA 'kkar jgdj xgjh lkal ysus ls bl dfBukbZ ls ikj ikus esa enn feyrh gSA vkidks lykg nh tkrh gS fd bl
ijh{k.k ls igys rhu ?kaVksa rd isV dks [kkyh j[ksAa vki viuh jkstejkZ dh [kqjkd dks izfØ;k ds rqjra ys ldrs gSAa ywvksjlhu ,d vR;f/kd xSj fo"kkDr
nok gS vkSj eqf'dy ls gh gYdh ,yftZd izfrfØ;k mRiUu djrh gS] tks fd mi;qDr nokbZ ds izfr Rofjr xfr ls izfrfØ;k nsrh gSA xaHkhj tkuysok izfrfØ;k,a
eqf'dy ls gh gksrh gSa ij fQj Hkh mifLFkr gks ldrh gSAa ;g mlls fHkUu ugha gS tks fd fdlh Hkh nwljh nok ds lkFk mifLFkr gks ldrk gSA ywvksjlhu
ds lkFk rdjhcu 36 ?kaVksa rd Ropk vkSj is'kkc xans ihys jax dh gksrh gS vkSj blls dksbZ QdZ ugha iM+rkA bl ijh{k.k ds nkSjku vkids lkFk dksbZ o;Ld
rhekjnkj gksuk pkfg,A
lwfpr lgefr
QaMl ywvksjlhu ,aft;ksxSQ
z h@vkFkSyeksLdksih@baMksfl;kukbu xzhu ,aft;ksxSQ
z h ij ijps dks esjs }kjk i<+ fy;k x;k gS@eq>s i<+dj lquk fn;k x;k gS vkSj
eSua s mldh varoZLrq dks le> fy;k gS] eSa vius Åij bls lEiUu djus ds fy, lgefr iznku djrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
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( 48 )
Photodynamic Therapy (PDT)
Courtesy: Shroff Eye Centre, New Delhi
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I hereby authorize Dr................................................................. to perform upon me Photodynamic Therapy (PDT) in Right/Left eye for neovascular
changes in the Macula (which is the vital region of the retina for clear central vision) caused by Age Related Macular Degeneration /
Pathologic Mypia/other causes..........................................................................................................................
Photodynamic Therapy (PDT) is a type of laser therapy designed for the treatment of subretinal new-vessel formation especially when
these new vessels involve the subfoveal region. These new vessels most commonly develop in i) Aging Macular Degeneration ii) Myopia,
iii) Post inflammatory and iv) Idiopathic causes. When the fovea (the vital region of the retina for fine central reading and colour vision)
is not involved, these vessels can be destroyed by laser photocoagulation. However there is also simultaneous destruction of the retinal
cells overlying these abnormal new vessels. This loss of function of retinal cells is usually acceptable in other areas but not at the fovea.
Hence the search for alternative therapies which can destroy these abnormal vessels without destroying the overlying foveal retinal cells.
The various alternatives tried for this are:
1) Surgery 2) Photodynamic Therapy (PDT) 3) TTT 4) Radiation 5) Anti-angiogenic factors.
1.
Surgery : Results especially in Aging Macular Degeneration have been poor because in removing the membrane retinal pigment
epithelial cells are also lost and vision usually does not improve. There is also a risk of significant vision loss if complications occur.
2.
Photodynamic Therapy : Verteporfin “Visudyne” dye is injected into a vein in the arm and after that a contact lens is placed on the
eye and laser treatment is applied to the area of neovascularization. After the treatment the entire body has to be protected from
sunlight and strong light. For a few hours after treatment you will have blurred vision because of drops and the laser light exposure.
Treatment results have been encouraging.
Most patients have stabilization of vision. A very small number may have actual improvement in vision. Some patients may experience
reduction in central vision after the treatment. PDT treatment may need to be repeated depending on the progress seen on follow up
examinations and fluorescein/indocyanine green angiograms/OCT results.
3.
Radiation - Results have not been encouraging.
4.
Anti-angiogenic factors :- Definitive results are not available so far.
5.
Trans Pupillary Thermo Therapy:- Large spot of diode laser 810 nm with relatively low energy is applied to the area of new-vessels.
This therapy has shown encouraging results in some cases, especially occult new-vessels.
You do not have to agree to have this therapy and, if you wish, we will continue to monitor your progress even if you choose not to try
Photodynamic Therapy (PDT).
Post-Treatment Regime
After treatment you should not bend down and lift weights, and you should sleep with head up with 2 pillows. You must not be exposed
to sunlight and very bright light as mentioned earlier.
After treatment, periodic re-examination is necessary to monitor the response to treatment and detect any changes in the status of the
retinopathy, especially any change that would require additional treatment. I understand that it is the patient’s responsibility to maintain
follow up appointments necessary after laser treatment. I acknowledge that the nature and the purpose of
this procedure, the risks involved, alternatives and the possible complications have been explained to me and that all my questions, if any,
have been answered to my satisfaction. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge
that no guarantee can be made as to the results that may be obtained. All this has been explained to me in the language I understand.
( 49 )
I have read, or had read to me, the above information, and I consent to treatment, recognizing the potential risks that are involved.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
( 50 )
QksVksMk;ufed Fksjsih ¼ihMhVh½
JkWQ vkbZ lsaVj] u;h fnYyh ds lkStU; ls
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eSa blds }kjk MkW- ------------------------------------dks vius Åij nk;h@ck;ha vka[k esa mez ls tqMs+ eSdqyj fodkj@iSFkksykWftd ekbfivk@vU; dkj.kksa --------------------------------- ls mRiUu eSdqyk ¼tks fd Li"V e/;orhZ n`f"V ds fy, jsfVuk dk egRiw.kZ {ks= gS½ esa ifjorZuksa gsrq QksVksMk;ufed Fksjis h ¼ihMhVh½ dks lEiUu
djus ds fy, vf/kÑr djrk gwAa
QksVksMk;ufed Fksjis h ¼ihMhVh½ lcjsfVuy u;h&okfgdk fuekZ.k ds mipkj ds fy, [kkldj ml le; tc ;s u;h okfgdk,a lcQksohy {ks= dks lEc)
djrh gS]a rS;kj fd;k x;k ,d izdkj dk mipkj gSA ;s u;h okfgdk,a lokZf/kd vkerkSj ij 1½ c<+rh mez ds eSdqyj fodkj] 2½ de ns[kus dh chekjh]
3½ lwtu ds ckn vkSj 4½ bfM;ksiSfFkd dkj.kksa esa fodflr gksrh gSAa tc Qksfovk ¼mRÑ"V e/;orhZ ikBu vkSj jaxksa dh n`f"V ds fy, jsfVuk dk egRoiw.kZ
Hkkx½ lEc) ugha gksrk gS rks bu okfgdkvksa dks ystj QksVksdksvkWxqy's ku ds }kjk u"V fd;k tk ldrk gSA fQj Hkh] bu vlkekU; u;h okfgdkvksa dks <adus
okyh jsfVuy dksf'kdkvksa dk Hkh lkFk gh esa fouk'k gks tkrk gSA jsfVuy dksf'kdkvksa ds izdk;Z dh ;g gkfu izk;% vU; {ks=ksa esa Lohdk;Z gksrh gS ysfdu Qksfovk
esa ughaA fygktk] oSdfYid mipkjksa dh [kkst dh x;h tks fd <adus okyh Qksfovy jsfVuy dksf'kdkvksa dks u"V fd;s fcuk bu vlkekU; okfgdkvksa dks
u"V dj ldsA blds fy, vktek;s x;s fofHkUu fodYi gSa %
1½ ltZjh 2½ QksVksMk;ufed mipkj ¼ihMhVh½ 3½ VhVhVh 4½ fofdj.k 5½ ,aVh&,aft;kstfs ud dkjdA
1½
ltZjh % fo'ks"k :i ls c<+rh mez esa eSdqyj fodkj esa ifj.kke [kjkc gksrs gSa D;ksfa d fNYyh dks gVkus esa jsfVuy fixesVa ,fiFksfy;y dksf'kdk,a
Hkh gV tkrh gS vkSj n`f"V izk;% csgrj ugha gksrh gSA blds vykok tfVyrk ds mRiUu gksus ij n`f"V dh dkQh vf/kd gkfu dk Hkh tksf[ke jgrk gSA
2½
QksVksMk;ukfed mipkj % ckag dh ul esa osVZis ksfQZu ^^folqMkbu** Mkb dk batDs 'ku fn;k tkrk gS vkSj blds ckn vka[k esa dkaVSDV ysl
a dks Mkyk
tkrk gS vkSj fu;ksoSLdqyjkbts'ku ds fgLls esa ystj mipkj dk vuqiz;ksx fd;k tkrk gSA mipkj ds ckn lewps 'kjhj dh /kwi vkSj rst izdk'k
ls j{kk djuh gksrh gSA mipkj ds ckn dqN ?kaVksa rd vkidks MªkIl vkSj ystj izdk'k ds laidZ esa gksus ls /kq/a kyk fn[kk;h nsxkA mipkj ds ifj.kke
mRlkgtud jgs gSAa
vf/kdrj jksfx;ksa dh n`f"V fLFkj gks tkrh gSA cgqr FkksMh+ lh la[;k esa n`f"V esa okLrfod lq/kkj gks ldrk gSA dqN jksxh mipkj ds ckn e/;LFk n`f"V esa
deh eglwl dj ldrs gSAa QkWyks&vi ds ijh{k.kksa vkSj ywvksjlhu@baMksfl;kukbu xzhu ,aft;ksxzSQh@vkslhVh ifj.kkeksa esa ns[kh x;h izxfr ds vk/kkj ij
ihMhVh mipkj dks nksgjk;s tkus dh t:jr iM+ ldrh gSA
3fofdj.k & ifj.kke mRlkgtud ugha jgs gSAa
4,aVh&,aft;kstfs ud dkjd % vHkh rd fuf'pr ifj.kke miyC/k ugha gSAa
5Vªkl
a &I;wiyjh FkeksZ mipkj % vis{kr;k de ÅtkZ okyk fMvksM ystj 810 ,u,e dk cM+k LikWV u;h okfgdkvksa ds {ks= esa iz;ksx fd;k tkrk gSA
bl mipkj ds dqN ekeyksa es]a [kkldj vdYV u;h okfgdkvksa es]a mRlkgtud ifj.kke ns[ks x;s gSAa
bl mipkj dks djokus ds fy, vki lgefr nsa ;g t:jh ugha vkSj vxj vki pkgsx
a s rks ge ml n'kk esa vkidh izxfr ij utj j[kuk tkjh j[ksx
a s tcfd
vki QksVksMk;ufed mipkj ¼ihMhVh½ ugha vktekus dk fodYi pqurs gSAa
mipkj&ckn dh O;oLFkk
mipkj ds ckn vkidks uhps ugha >qduk vkSj otu mBkuk ugha pkfg, vkSj vkidks nks rfd;ksa ds lkFk flj ds Åij djds lksuk pkfg,A tSlk fd igys
crk;k x;k gS vkidks /kwi vkSj cgqr rst jks'kuh ds laidZ esa ugha vkuk pkfg,A
mipkj ds ckn mipkj ds izfr izfrfØ;k vkSj jsfVuksFksjis h dh fLFkfr esa fdlh cnyko] [kkldj ,sls cnyko dk irk yxkus ds fy, le;&le; ij iqu%
ijh{k.k vko';d gksrk gS] ftlds fy, vfrfjDr mipkj dh t:jr gksxhA eSa le>rk gwa fd ;g jksxh dh ftEesnkjh gS fd og ystj mipkj ds ckn vko';d
QkWyksvi eqykdkrksa dks cuk;s j[ksA eSa Lohdkj djrk gwa fd bl dk;Zfof/k dh izÑfr vkSj mís';] blls tqMs+ tksf[keks]a fodYiksa vkSj laHkkfor tfVyrkvksa
ds ckjs esa esjs MkWDVj }kjk eq>s le>k fn;k x;k gS vkSj ;g fd esjs lHkh iz'uksa ds larks"ktud mÙkj ns fn;s x;s gSAa eSa bl ckr ls voxr gwa fd MkWDVjh
vkSj ltZjh lVhd foKku ugha gS vkSj eSa Lohdkj djrk gwa fd izkIr gksus okys ifj.kkeksa ds ckjs esa dksbZ Hkh xkjaVh ugha nh tk ldrhA bl lcdks eq>s ,slh
Hkk"kk esa crk fn;k x;k gS ftls fd eSa le>rk gwAa
( 51 )
mi;qZDr tkudkjh dks eSua s i<+ fy;k gS ;k eq>s i<+dj lquk fn;k x;k gS vkSj eSa mipkj ls tqMs+ laHkkO; tksf[keksa dks tkurs gq, blds fy, vuqefr iznku
djrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 52 )
Trans Pupillary Thermotherapy (TTT)
Courtesy: Shroff Eye Centre, New Delhi
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I hereby authorize Dr. ......................................................................................... to perform upon me Trans-Pupillary Thermotherapy in Right /
Left eye for neovascular changes in the Macula (which is the vital region of the retina for clear central vision) caused by Age Related
Macular Degeneration / Pathologic Mypia / other causes .......................................................................
Transpupillary thermotherapy (TTT) is a type of laser therapy designed for the treatment of sub retinal new-vessel formation especially
when these new vessels involve the subfoveal region. These new vessels most commonly develop in i) Aging Macular Degeneration ii)
Myopia, iii) Post inflammatory and iv) Idiopathic causes. TTT is also used in the treatment of certain tumours. When the fovea (the vital
region of the retina for fine central reading and colour vision) is not involved, these vessels can be destroyed by laser photocoagulation.
However there is also simultaneous destruction of the retinal cells overlying these abnormal new vessels. This loss of function of retinal
cells is usually acceptable in other areas but not at the fovea. Hence the search for alternative therapies which can destroy these abnormal
vessels without destroying the overlying foveal retinal cells. The various alternatives tried for this are:1) Surgery 2) Photodynamic therapy (PDT) 3) TTT 4) Radiation 5) Anti-angiogenic factors.
1.
Surgery : Results especially in Aging Macular Degeneration have been poor because in removing the membrane retinal pigment
epithelial cells are also lost and vision usually does not improve. There is also a risk of significant vision loss if complications occur.
2.
Photodynamic Therapy : This is applicable only to certain specific types of new-vessels. The cost of treatment is very high because
of high cost of dye. The treatment may need to be repeated depending on the progress seen on follow up examinations.
3.
Radiation - Results have not been encouraging.
4.
Anti-angiogenic factors :- Results have not been encouraging.
5.
Trans Pupillary Thermo Therapy :- Large spot of diode laser 810 nm with relatively low energy is applied to the area of new-vessels.
Treatment results have been encouraging. About two-thirds of patients have stabilization of vision. A very small number may have
actual improvement in vision. Some patients may experience reduction in central vision after the treatment. TTT treatment may
need to be repeated depending on the progress seen on follow up examinations and fluorescein/indocyanine green angiograms.
For the laser treatment, local anaesthetic drops are put into the eye and a contact lens is used. After treatment you should not bend down,
lift weight and you should sleep with head up with 2 pillows. For a few hours after the treatment, you will have some blurred vision because
of the drops used to prepare your eye for the treatment. You should also wear dark sunglasses to protect your eye from the light. During this
time, you must not drive any vehicles. You do not have to agree to have this therapy and, if you wish, we will continue to monitor your
progress even if you choose not to try Transpupillary Thermotherapy (TTT).
After treatment, periodic re-examination is necessary to monitor the response to treatment and detect any changes in the status of the
retinopathy, especially any change that would require additional treatment. I understand that it is the patient’s responsibility to maintain
follow up appointments necessary after laser treatment. I acknowledge that the nature and the purpose of this procedure, the risks
involved, alternatives and the possible complications have been explained to me and that all my questions, if any, have been answered to
my satisfaction. I am aware that the practice of medicine & surgery is not an exact science, and I acknowledge that no guarantee can be
made as to the results that may be obtained. All this has been explained to me in the language I understand.
I have read, or had read to me, the above information, and I consent to treatment, recognizing the potential risks that are involved.
( 53 )
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
( 54 )
Vªkal I;wfiyjh FkeksZFksjsih ¼VhVhVh½
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dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
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gsrq QksVksMk;ufed Fksjis h ¼ihMhVh½ dks lEiUu djus ds fy, vf/kÑr djrk gwAa
Vªkl
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ds mipkj ds fy, rS;kj fd;k x;k ystj mipkj dk ,d izdkj gSA
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gksrh gSAa VhVhVh dk mi;ksx dqN V~;ew jksa ds mipkj esa Hkh fd;k tkrk gSA tc Qkfovk ¼mRÑ"V e/;orhZ ikBu vkSj jaxksa dh n`f"V ds fy, jsfVuk dk
egRoiw.kZ Hkkx½ lEc) ugha gksrk gS rks bu okfgdkvksa dks ystj QksVksdksvkWxqy's ku ds }kjk u"V fd;k tk ldrk gSA fQj Hkh] bu vlkekU; u;h okfgdkvksa
dks <adus okyh jsfVuy dksf'kdkvksa dk Hkh lkFk gh esa fouk'k gks tkrk gSA jsfVuy dksf'kdkvksa ds izdk;Z dh ;g gkfu izk;% vU; {ks=ksa esa Lohdk;Z gksrh gS
ysfdu Qksfovk esa ughaA fygktk] oSdfYid mipkjksa dh [kkst dh x;h tks fd <adus okyh Qksfovy jsfVuy dksf'kdkvksa dks u"V fd;s fcuk bu vlkekU;
okfgdkvksa dks u"V dj ldsA blds fy, vktek;s x;s fofHkUu fodYi gSa %
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1½
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2½
QksVksMk;ukfed mipkj % ;g u;h okfgdkvksa ds dqN fof'k"V izdkjksa ij gh ykxw gksrk gSA mipkj dh ykxr Mkb dh Åath ykxr dh otg ls
cgqr vf/kd gksrh gSA QkWyks&vi ds ijh{k.kksa esa ns[kh x;h izxfr ds vk/kkj ij ihMhVh mipkj dks nksgjk;s tkus dh t:jr iM+ ldrh gSA
3fofdj.k & ifj.kke mRlkgtud ugha jgs gSAa
4,aVh&,aft;kstfs ud dkjd % ifj.kke mRlkgtud ugha jgs gSAa
5Vªkl
a &I;wiyjh FkeksZ mipkj % vis{kr;k de ÅtkZ okyk fMvksM ystj 810 ,u,e dk cM+k LikWV u;h okfgdkvksa ds {ks= esa iz;ksx fd;k tkrk gSA
bl mipkj ds mRlkgtud ifj.kke ns[ks x;s gSAa yxHkx nks&frgkbZ jksfx;ksa dh n`f"V fLFkj gqbZ gSA cgqr gh FkksMh+ la[;k esa n`f"V esa okLrfod
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xzhu ,aft;ksxzkEl esa ns[kh x;h izxfr ds vk/kkj ij VhVhVh mipkj dks nksgjk;s tkus dh vko';drk iM+ ldrh gSA
ystj mipkj ds fy, yksdy ,usLFksfVd MªkIl dks vka[k esa Mkyk tkrk gS vkSj dkaVSDV ysl
a dk bLrseky fd;k tkrk gSA mipkj ds ckn vkidks uhps
>qduk] otu mBkuk ugha pkfg, vkSj vkidks nks rfd;k j[kdj flj dks Åij dh vksj j[kdj lksuk pkfg,A mipkj ds ckn dqN ?kaVksa rd vkidh n`f"V
mipkj ds fy, vkidh vka[kksa dks rS;kj djus ds fy, mi;ksx esa yk;s x;s MªkIl dh otg ls /kq/a kyh jgsxhA blds vykok jks'kuh ls viuh vka[kksa dks cpkus
ds fy, vkidks dkys jax dk /kwi dk p'ek iguuk pkfg,A bl le; ds nkSjku vkidks dksbZ okgu ugha pykuk gSA t:jh ugha fd vki bl mipkj ds
fy, lgefr iznku djsa vkSj vxj vki pkgsx
a s rks ge ml n'kk esa Hkh vkidh izxfr dks ekWfuVj djuk tkjh j[ksx
a s tcfd vkius Vªkl
a &I;wiyjh FkeksZ mipkj
¼VhVhVh½ dk fodYi ugha pquk gSA
mipkj ds ckn mipkj ds izfr izfrfØ;k vkSj jsfVuksFksjis h dh fLFkfr esa fdlh cnyko] [kkldj ,sls cnyko dk irk yxkus ds fy, le;&le; ij iqu%
ijh{k.k vko';d gksrk gS] ftlds fy, vfrfjDr mipkj dh t:jr gksxhA eSa le>rk gwa fd ;g jksxh dh ftEesnkjh gS fd og ystj mipkj ds ckn vko';d
QkWyksvi eqykdkrksa dks cuk;s j[ksA eSa Lohdkj djrk gwa fd bl dk;Zfof/k dh izÑfr vkSj mís';] blls tqMs+ tksf[keks]a fodYiksa vkSj laHkkfor tfVyrkvksa
ds ckjs esa esjs MkWDVj }kjk eq>s le>k fn;k x;k gS vkSj ;g fd esjs lHkh iz'uksa ds larks"ktud mÙkj ns fn;s x;s gSAa eSa bl ckr ls voxr gwa fd MkWDVjh
vkSj ltZjh lVhd foKku ugha gS vkSj eSa Lohdkj djrk gwa fd izkIr gksus okys ifj.kkeksa ds ckjs esa dksbZ Hkh xkjaVh ugha nh tk ldrhA bl lcdks eq>s ,slh
Hkk"kk esa crk fn;k x;k gS ftls fd eSa le>rk gwAa
mi;qZDr tkudkjh dks eSua s i<+ fy;k gS ;k eq>s i<+dj lquk fn;k x;k gS vkSj eSa mipkj ls tqMs+ laHkkO; tksf[keksa dks tkurs gq, blds fy, vuqefr iznku
djrk gwAa
( 55 )
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 56 )
Intravitreal Injection for Endophthalmitis
Jatin Ashar, Subrata Mandal
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been explained in the language I best understand that drugs would be injected into the vitreous cavity of my eye after appropriate
anesthesia to treat and limit the infection in my eye. I have been explained I may or may not regain vision after the procedure and may need
a repeat injection or surgery in future. Possible complications of the procedure include retinal detachment, glaucoma, hypotony, cataract,
and bleeding. I may also experience side effects such as eye pain, subconjunctival hemorrhage, swelling of the cornea and inflammation
of the eye. As with any medication, there is a risk of causing allergic reactions in a small number of patients. Symptoms of allergic
reactions include rash, hives, itching and shortness of breath.
I also understand that my eye condition may not get better or may worsen. Any or all the complications explained to me may cause a
further deterioration in vision or have a possibility of blindness. Additional procedure may be required for management of the complications.
The nature of my eye condition has been explained to me and the proposed treatment has been described. The risks, benefits, alternatives,
and limitations of treatment have been discussed with me. All my questions have been answered.
I here by authorize the doctor to administer intravitreal antibiotics in my R/L eye.
This consent is valid until I revoke it or my condition changes to a point that the risks and benefits of the injection are significantly
different from this date.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 57 )
,aMksFkSyfefVl ds fy, baVªkfoVfj;y batsD'ku
tfru v'kkj] lqczr eaMy
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eq>s ml Hkk"kk es]a ftls fd eSa vPNh rjg le>rk gw]a HkyhHkkafr le>k fn;k x;k gS fd esjh vka[k dk mipkj djus vkSj laØe.k dks lhfer djus ds fy,
mi;qDr ,usLFksfl;k ds ckn esjh vka[k dh foVfjvl dsfoVh esa nokvksa dks batDs 'ku ds tfj;s Mkyk tk,xkA eq>s le>k fn;k x;k gS fd bl izfØ;k ds
ckn eSa n`f"V dks iqu% izkIr dj ldrk gwa vkSj ugha Hkh dj ldrk vkSj Hkfo"; esa fQj ls batDs 'ku ;k ltZjh dh t:jr iM+ ldrh gSA bl dk;Zfof/k dh
laHkkfor tfVyrkvksa esa jsfVuy vyxko] Xywdksek] gkbiksVks uh] eksfr;kfcan vkSj jDrlzko 'kkfey gSA blds vykok eSa vka[k esa nnZ] lc datfDVoy jDrlzko]
dkfuZ;k dh lwtu vkSj vka[kksa dh tyu dk vuqHko dj ldrk gwAa
tSlk fd fdlh Hkh nokbZ ds lkFk gksrk gS jksfx;ksa dh FkksMh+ la[;k esa ,yftZd izfrfØ;k,a mRiUu gks ldrh gSAa ,yftZd izfrfØ;kvksa ds y{k.kksa esa nnksj]s
gkbOt] [kqtyh vkSj lkalksa dk m[kM+uk 'kkfey gSA
eSa ;g Hkh le>rk gwa fd esjh vka[k dh voLFkk csgrj ugha Hkh gks ldrh ;k cnrj gks ldrh gSA eq>s le>k;h x;h dksbZ ;k lHkh tfVyrk,a n`f"V ds vkSj
Hkh [kjkc gksus dk dkj.k cu ldrh gSa ;k mudh otg ls eSa n`f"Vghu gks ldrk gwAa tfVyrkvksa ds izc/a ku ds fy, vfrfjDr dk;Zfof/k dh vko';drk
iM+ ldrh gSA esjh vka[k dh voLFkk dh izÑfr eq>s le>k nh x;h gS vkSj izLrkfor mipkj dks of.kZr dj fn;k x;k gSA mipkj ds tksf[keks]a ykHkks]a fodYiksa
vkSj lhekvksa dh esjs lkFk ppkZ dh x;h gSA esjs lHkh iz'uksa ds mÙkj fn;s x;s gSAa
blds }kjk eSa MkWDVj dks viuh nk;ha@ck;ha vk[ka esa baVªkfoVfj;y ,aVhckW;ksfVDl dks Mkyus ds fy, vf/kÑr djrk gwAa
;g vuqefr ml le; rd oS/k gS tc rd fd eSa bls jí ugha djrk ;k esjh vka[k dh voLFkk ml fcanq rd cny ugha tkrh gS tgka ij batDs 'ku ds
tksf[ke vkSj ykHk bl rkjh[k ls mYys[kuh; :i ls fHkUu gksAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 58 )
Electrophysiological Tests
Courtesy: Shroff Eye Centre, New Delhi
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
Electro-Retinogram (ERG)
This investigation procedure comprises of electrodes, which are put on the cornea and on the skin with which a signal is generated from
the retina in response to a flast of light. This tells us,the gross retinal function. The test takes about 45 minutes to 1 hour and includes 30
minutes of dark adaptation (sitting in a dark room) which can be a little tiring. Very rarely the contact lens electrodes can cause corneal
discomfort or abrasion which can be managed by proper medication. For this test, the pupils need to be dilated after which you may not
be able to drive or do near work for atleast 3-4 hours. Sometimes, in cases of very small children or uncooperative patients the test needs
to be carried out under anesthesia.
Visual Evoked Potential (VEP)
This investigation procedure comprises of electrodes, which are put on the skin with which a signal is generated from visual pathway in
response to a flash of light. This tells us the gross visual pathway function. The test takes about 30-45 minutes to perform. For this test, the
pupils need not be dilated. Sometimes, in cases of very small children or uncooperative patients, the test needs to be carried out under
anesthesia.
Electro - Oculogram (EOG)
This investigation procedure comprises of electrodes which are put on the skin, with which a signal is generated from the retina in
response to successive movements of the eye in opposite directions. This tells us the gross retinal function. The test takes about 30-45
minutes to perform. The pupils need not be dilated for this test.
Informed Consent
The information on ERG/EOG/VEP has been read by me / out to me and having understood the content, I give my consent to the
performance of this test on me.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
( 59 )
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
( 60 )
bysDVªksfQft;ksykWftdy ijh{k.k
JkWQ vkbZ lsaVj] u;h fnYyh ds lkStU; ls
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
bysDVªks&jsfVuksxzke ¼bZvkjth½
tkap&iM+rky dh bl dk;Zfof/k esa bysDVªkM
s ~l lekfgr gksrs gS]a ftUgsa fd dkfuZ;k ij vkSj Ropk ij j[kk tkrk gS ftlls izdk'k dh ped dh izfrfØ;k
esa jsfVuk ls flXuy mRiUu gksrk gSA ;g gesa lai.w kZ jsfVuy izdk;Z ds ckjs esa crkrk gSA ijh{k.k esa rdjhcu 45 feuV ls ysdj 1 ?kaVs rd dk le; yxrk
gS vkSj blesa va/ksjs esa vuqdy
w u ¼va/ksjs dejs esa cSBuk½ dk 30 feuV 'kkfey gksrk gS] tks fd FkksMk+ Fkdk nsus okyk gks ldrk gSA cgqr gh fojys rkSj ij
bysDVªkM
s ~l dkuhZy cspSuh ;k [kjksp
a dk dkj.k cu ldrs gS]a ftldk fd leqfpr nokbZ ls izc/a k fd;k tk ldrk gSA bl ijh{k.k ds fy, iqrfy;ksa dks
QSykus dh t:jr iM+rh gS] ftlds ckn de ls de 3&4 ?kaVksa ds fy, vki okgu ugha pyk ldrs ;k fudV dk dke ugha dj ldrs gSAa dbZ ckj] cgqr
gh NksVs cPpksa ;k lg;ksx ugha nsus okys jksfx;ksa ds ekeyksa esa csgks'kh dh n'kk esa bl ijh{k.k dks djus dh t:jr iM+ ldrh gSA
fotqvy ,oksDM iksVsa'ky ¼ohbZih½
tkap&iM+rky dh bl dk;Zfof/k esa bysDVªkM
s ~l lekfgr gksrs gS]a ftUgsa fd Ropk ij j[kk tkrk gS ftlls izdk'k dh ped dh izfrfØ;k esa pk{kq"k jkLrs ds
izdk;Z flXuy mRiUu gksrk gSA ;g gesa lai.w kZ pk{kq"k jkLrs ds izdk;Z ds ckjs esa crkrk gSA ijh{k.k esa rdjhcu 30 ls 45 feuV rd dk le; yxrk gSA
bl ijh{k.k ds fy, iqrfy;ksa dks QSykus dh t:jr iM+rh gSA dbZ ckj] cgqr gh NksVs cPpksa ;k lg;ksx ugha nsus okys jksfx;ksa ds ekeyksa esa csgks'kh dh
n'kk esa bl ijh{k.k dks djus dh t:jr iM+ ldrh gSA
bysDVªks&vksdqyksxzke ¼bZvksth½
tkap&iM+rky dh bl dk;Zfof/k esa bysDVªkM
s ~l lekfgr gksrs gS]a ftUgsa fd Ropk ij j[kk tkrk gS ftlls fd foijhr fn'kkvksa esa vka[kksa dh Øfed gypy
dh izfrfØ;k esa jsfVuk ls flXuy mRiUu gksrk gSA ;g gesa lai.w kZ jsfVuy izdk;Z ds ckjs esa crkrk gSA ijh{k.k esa rdjhcu 30&35 feuV rd dk le;
yxrk gSA bl ijh{k.k ds fy, iqrfy;ksa dks QSykus dh ugha t:jr iM+rh gSA
lwfpr lgefr
bZvkjth@bZvksth@ohbZih ij tkudkjh eSa i<+ yh gS@eq>s i<+dj lquk nh x;h gS vkSj varoZLrq dks le>dj eSa bl ijh{k.k dks vius Åij djus ds fy,
lgefr iznku djrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
( 61 )
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 62 )
OCULOPLASTY
&
ORBIT
Enucleation
Noornika Khuraijam
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been informed in my own language that my right/ left eye may be harboring a tumor/ disease which if not removed may result in
loss of vision in the same eye and may lead to spread of the disease to other parts of the body and cause risk to my life.
It has been explained to me that the exact confirmation of diagnosis can be obtained only after microscopic examination after removal of
the eye.
The option of removing a piece of tissue through surgery or with the help of a needle for the purpose of diagnosis and its risks involved have
been explained and given to me.
I understand that the entire eye along with its coverings and part of the nerve attached to it will be removed and replaced by an artificial
prosthesis. I also understand that I will have to wear prosthetic eye for cosmetic purpose after the surgery.
I understand that in spite of the best efforts by the operating surgeons, there may be incomplete removal which may require additional
surgery or treatment.
I hereby authorize …………………………..and those he/ the institute may designate as staff, associates or assistants to perform surgery
for removal of my right/left eye.
It has been explained to me that during the course of treatment, unforeseen conditions may be revealed or encountered which may
necessitate surgical and emergency procedures in addition to or different from those contemplated at the time of initial diagnosis. I,
therefore, further request and authorize the above designated staff to perform such additional surgical or other procedures as they deem
necessary or desirable.
I consent to the use of anesthesia and to use of anesthetics as may be deemed necessary or desirable.
I further consent to the administration of such drugs, infusions, plasma or blood transfusion or any other treatment or procedures deemed
necessary.
I consent to the observing, photographing or televising of the procedure to be performed for medical, scientific or educational purpose
provided my identity is not revealed by the pictures or by descriptive text accompanying them.
I have been given the opportunity to ask all/any questions and I have also been given the option to ask for any second opinion.
I am fully aware that the surgery is being performed in good faith and that no guarantee or assurance has been given as to the result that
may be obtained.
Any tissues or parts surgically removed may be disposed off by the institution in accordance with customary practice.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
( 63 )
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
( 64 )
,U;wfDy,'ku
uwjfudk [kqjStke
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eq>s esjh viuh Hkk"kk esa lwfpr dj fn;k x;k gS fd esjh nk;ha@ck;ha vka[k esa ,sls V~;ew j@chekjh iSnk gks jgh gks ldrh gS ftls ugha gVk;s tkus ds QyLo:i
ml vka[k dh jks'kuh tk ldrh gS vkSj 'kjhj ds nwljs fgLlksa esa chekjh QSy ldrh gS vkSj esjh tku tk ldrh gSA
eq>s ;g ckr le>k nh x;h gS fd funku dks lVhd iqf"V vka[kksa dks fudkyus ds ckn ekbØksLdksfid ijh{k.k ls gh izkIr fd;k tk ldrk gSA
funku ds mís'; ls ltZjh ds tfj;s ;k lqbZ dh enn ls Ård ds VqdM+s dk fudkyus dk fodYi vkSj blls tqMs+ tksf[keksa dks eq>s le>k fn;k x;k gSA
eSa le>rk gwa fd viuh dofjax ds lkFk&lkFk lewph vka[k vkSj mlls tqMh+ ul ds ,d fgLls dks gVk;k tk,xk vkSj mldh txg ij udyh vka[k yxk
nh tk,xhA eSa ;g Hkh le>rk gwa fd eq>s ltZjh ds ckn lqna j yxus ds fy, udyh vka[k iguuh iM+x
s hA
eSa le>rk gwa fd vkWijs'ku djus okys ltZuksa ds loZJ"s B iz;klksa ds ckotwn gks ldrk gS fd iwjh fudklh ugha gks ik;s ftlds fy, vfrfjDr ltZjh ;k
mipkj dh vko';drk iM+As
eSa blds }kjk ------------------------------------------------------------------------ vkSj mu yksxksa dks nk;ha@ck;ha vka[k dks fudkyus ds fy, ltZjh djus gsrq vf/kÑr djrk gw]a
ftUgsa fd mlus@laLFkku us LVkQ] ,lksfl,V ;k lgk;d dsd :i esa fu;qDr fd;k gksA
eq>s ;g ckr le>k nh x;h gS fd mipkj dh vof/k ds nkSjku vizR;kf'kr n'kk,a mRiUu gks ldrh gSa ;k mudk lkeuk djuk iM+ ldrk gS tks fd mlls
fHkUu lftZdy ;k vkikrdkyhu dk;Zfof/k;ksa dh vko';drk dks mRiUu djs]a ftudh fd 'kq#vkrh funku ds le; vis{kk dh x;h FkhA vr%] eSa mi;qZDr
fufnZ"V LVkQ ls vuqjks/k djrk gwa vkSj mls vf/kÑr djrk gwa fd og bl izdkj dh vfrfjDr lftZdy ;k vU; dk;Zfof/k;ksa dks lEiUu djs tSlk fd os
vko';d ;k okaNuh; le>rs gksAa
eSa ,usLFksfl;k vkSj ,usLFksfVDl dk mi;ksx djus ds fy, lgefr iznku djrk gwa tSlk fd vko';d ;k okaNuh; le>k x;k gSA
eSa bl izdkj dh nokvks]a batDs 'kuks]a IykTek ;k jDRk vk/kku ;k fdlh vU; mipkj ;k dk;Zfof/k dks fd;s tkus dh Hkh vuqefr iznku djrk gwa tSlk fd
vko';d le>k x;k gksA
eSa fpfdRldh;] oSKkfud ;k 'kS{kf.kd mís'; ls dk;Zfof/k ds voyksdu] QksVksxzkQh ;k Vsyhfotu ij izlkfjr djus dh vuqefr iznku djrk gwa c'krsZ fd
rLohjksa }kjk ;k muds lkFk okys fooj.kkRed ikB ds }kjk esjh igpku ugha tkfgj gksrh gksA
eq>s lHkh@dksbZ Hkh iz'u iwNus dk volj fn;k x;k gS vkSj eq>s dksbZ f}rh;d iz'u iwNus dk Hkh fodYi iznku fd;k x;k gSA
eSa bl ckr ls iwjh rjg ls voxr gwa fd ltZjh lfnPNk ds lkFk dh tk jgh gS vkSj ;g fd mu ifj.kkeksa dks ysdj dksbZ xkjaVh ;k oknk ugha fd;k x;k
gS tks fd izkIr gks ldrs gSAa
ltZjh ls vyx fd;s x;s fdUgha Årdksa ;k vaxksa dks pkyw ifjikVh ds vuqlkj laLFkku }kjk fuLrkfjr fd;k tk ldrk gSA
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
( 65 )
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 66 )
Evisceration
Noornika Khuraijam
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been informed in my mother tongue that my right/ left eye may be harboring a disease which if not removed may result in loss of
vision in the same eye and may lead to spread of the disease to other parts of the body and cause risk to my life and a painful blind eye.
I understand that the total contents of the eyeball will be removed and an artificial prosthesis may have to be implanted to maintain the
shape of the eye. I also understand that I will have to wear prosthetic eye for cosmetic purpose after surgery.
I understand that in spite of the best efforts by the operating surgeons, there may be incomplete removal which may require additional
surgery or treatment. I also understand that the other eye may be affected after surgery, which may require additional treatment.
I hereby authorize …………………………..and those he/ the institute may designate as staff, associates or assistants to perform surgery
for removal of my right/left eye.
It has been explained to me that during the course of treatment, unforeseen conditions may be revealed or encountered which may
necessitate surgical and emergency procedures in addition to or different from those contemplated at the time of initial diagnosis. I,
therefore, further request and authorize the above designated staff to perform such additional surgical or other procedures as they deem
necessary or desirable.
I consent to the use of anesthesia and to use of anesthetics as may be deemed necessary or desirable.
I further consent to the administration of such drugs, infusions, plasma or blood transfusion or any other treatment or procedures deemed
necessary.
I consent to the observing, photographing or televising of the procedure to be performed for medical, scientific or educational purpose
provided my identity is not revealed by the pictures or by descriptive text accompanying them.
I have been given the opportunity to ask all/any questions and I have also been given the option to ask for any second opinion.
I am fully aware that the surgery is being performed in good faith and that no guarantee or assurance has been given as to the result that
may be obtained.
Any tissues or parts surgically removed may be disposed off by the institution in accordance with customary practice.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
( 67 )
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
( 68 )
,folfljs'ku
uwjfudk [kqjStke
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eq>s esjh viuh Hkk"kk esa lwfpr dj fn;k x;k gS fd esjh nk;ha@ck;ha vka[k esa ,sls V~;ew j@chekjh iSnk gks jgh gks ldrh gS ftls ugha gVk;s tkus ds QyLo:i
ml vka[k dh jks'kuh tk ldrh gS vkSj 'kjhj ds nwljs fgLlksa esa chekjh QSy ldrh gS vkSj esjh tku tk ldrh gS vkSj va/kh vka[k esa nnZ jg ldrk gSA
eSa le>rk gwa fd us=xksyd dh lewph lkexzh dks fudkyk tk,xk vkSj vka[kksa dh vkÑfr dks cuk;s j[kus ds fy, udyh vka[k dks yxkuk iM+ ldrk gSA
eSa le>rk gwa fd vkWijs'ku djus okys ltZuksa ds loZJ"s B iz;klksa ds ckotwn gks ldrk gS fd iwjh fudklh ugha gks ik;s ftlds fy, vfrfjDr ltZjh ;k
mipkj dh vko';drk iM+As
eSa ;g Hkh le>rk gwa fd ltZjh ds ckn nwljh vka[k izHkkfor gks ldrh gS] ftlds fy, vfrfjDr mipkj dh vko';drk iM+ ldrh gSA
eSa blds }kjk ------------------------------------------------------------------------ vkSj mu yksxksa dks nk;ha@ck;ha vka[k dks fudkyus ds fy, ltZjh djus gsrq vf/kÑr djrk gw]a
ftUgsa fd mlus@laLFkku us LVkQ] ,lksfl,V ;k lgk;d ds :i esa fu;qDr fd;k gksA
eq>s ;g ckr le>k nh x;h gS fd mipkj dh vof/k ds nkSjku vizR;kf'kr n'kk,a mRiUu gks ldrh gSa ;k mudk lkeuk djuk iM+ ldrk gS tks fd mlls
fHkUu lftZdy ;k vkikrdkyhu dk;Zfof/k;ksa dh vko';drk dks mRiUu djs]a ftudh fd 'kq#vkrh funku ds le; vis{kk dh x;h FkhA vr%] eSa mi;qZDr
fufnZ"V LVkQ ls vuqjks/k djrk gwa vkSj mls vf/kÑr djrk gwa fd og bl izdkj dh vfrfjDr lftZdy ;k vU; dk;Zfof/k;ksa dks lEiUu djs tSlk fd os
vko';d ;k okaNuh; le>rs gksAa
eSa ,usLFksfl;k vkSj ,usLFksfVDl dk mi;ksx djus ds fy, lgefr iznku djrk gwa tSlk fd vko';d ;k okaNuh; le>k x;k gSA
eSa bl izdkj dh nokvks]a batDs 'kuks]a IykTek ;k jDRk vk/kku ;k fdlh vU; mipkj ;k dk;Zfof/k dks fd;s tkus dh Hkh vuqefr iznku djrk gwa tSlk fd
vko';d le>k x;k gksA
eSa fpfdRldh;] oSKkfud ;k 'kS{kf.kd mís'; ls dk;Zfof/k ds voyksdu] QksVksxzkQh ;k Vsyhfotu ij izlkfjr djus dh vuqefr iznku djrk gwa c'krsZ fd
rLohjksa }kjk ;k muds lkFk okys fooj.kkRed ikB ds }kjk esjh igpku ugha tkfgj gksrh gksA
eq>s lHkh@dksbZ Hkh iz'u iwNus dk volj fn;k x;k gS vkSj eq>s dksbZ f}rh;d iz'u iwNus dk Hkh fodYi iznku fd;k x;k gSA
eSa bl ckr ls iwjh rjg ls voxr gwa fd ltZjh lfnPNk ds lkFk dh tk jgh gS vkSj ;g fd mu ifj.kkeksa dks ysdj dksbZ xkjaVh ;k oknk ugha fd;k x;k
gS tks fd izkIr gks ldrs gSAa
ltZjh ls vyx fd;s x;s fdUgha Årdksa ;k vaxksa dks pkyw ifjikVh ds vuqlkj laLFkku }kjk fuLrkfjr fd;k tk ldrk gSA
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
( 69 )
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 70 )
Orbitotomy
Rachna Meel
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been explained in my mother tongue that a mass has grown adjacent to my left/ right eye. The growth is causing the following:
Displacement and/ protrusion of the eye ball
Yes/No
Decrease vision (Which is due to globe distortion
and/or compression of the optic nerve)
Yes/No
Restriction of the movements of the eyeball
Yes/No
Abnormal deviation of the eyeball
Yes/No
Drooping of the eyelid
Yes/No
Altered sensations in the area surrounding the eye (forehead/ nose/ cheek)
Yes/No
Incomplete closure of the eye
Yes/No
I understand that I need to undergo orbitotomy in order to remove this mass. It is a surgical procedure that involves entering and/or
opening up the orbit that is the bony compartment within which the eye is placed. The mass that is removed will then be examined by the
pathologist. The histopathological diagnosis will guide further treatment that may involve no further management/ local radiotherapy/
chemotherapy.
I fully understand that it may not be possible to remove the mass completely. The vision, eyeball and eyelid movements, deviation of the
eyeball and the sensations around the eye may not recover completely and may even deteriorate due to surgical manipulation.
The surgery has a risk of post operative bleeding and infection in the orbit that may need further treatment in the form of medication or
surgery. I also understand the risks of general anesthesia under which this surgery will be done.
Having clearly understood all that is stated above I hereby authorize the doctors to carry out orbitotomy on the right /left side.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
( 71 )
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
( 72 )
vksfcZVksVkseh
jpuk ehy
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eq>s esjh ekr`Hkk"kk esa ;g ckr le>k nh x;h gS fd esjh ck;ha@nk;ha vka[k ds fudV ekal c<+ x;k gSA
;g o`f) fuEufyf[kr dks tUe ns jgh gS %
us=xksyd dk foLFkkiu vkSj mHkkj
gka@ugha
?kVh gqbZ n`f"V ¼tks fd Xyksc fo:i.k vkSj@
gka@ugha
;k izdkf'kd ul ds laihM+u ds pyrs gS½
us=xksyd dh gypyksa dh lhek
gka@ugha
us=xksyd dk vlkekU; fopyu
gka@ugha
iydksa dh Mªfw iax
gka@ugha
vka[kksa ds bnZfxnZ ¼eLrd] ukd] xky½ esa cnyh gqbZ laons uk
gka@ugha
vka[kksa dk vk/kk&v/kwjk can gksuk
gka@ugha
eSa le>rk gwa fd eq>s bl ekal dks gVokus ds fy, vkWjfcVksVkseh djokus dh t:jr gSA ;g lftZdy dk;Zfof/k gS ftlls fd vksfcZV esa izo's k djuk vkSj@;k
[kksyuk tqMk+ gqvk gksrk gS] tks fd gfì;ksa dk [kkuk gksrk gS ftlds vanj vka[k fLFkr gksrh gSA gVk;s tkus okys ekal fiaM dk blds ckn iSFkksykWftLV }kjk
ijh{k.k fd;k tk,xkA fgLVksiFS kksykWftdy funku vkxs ds mipkj dks funsfZ 'kr djsxk ftlls fd vkxs dk dksbZ izc/a ku@yksdy jsfM;ksFksjis h@dheksFksjis h tqMh+
gqbZ ugha gks ldrhA
eSa iwjh rjg ls bl ckr dks le>rk gwa fd ekal ds fiaM dks iwjh rjg ls fudkyuk laHko ugha Hkh gks ldrk gSA n`f"V] us=xksyd vkSj iqryh dh gypyks]a
us=xksyd ds fopyu vkSj vka[kksa ds bnZfxnZ dh laons uk dh gks ldrk gS fd iwjh rjg ls Hkjik;h ugha gks vkSj gks ldrk gS fd og ltZfdy gLr{ksi ds
pyrs vkxs vkSj [kjkc gks tk;sA
ltZjh esa vkWijs'ku ds ckn ds jDrlzko vkSj vksfcZV esa laØe.k dk tksf[ke gksrk gS ftlds fy, nokbZ ;k ltZjh ds :i esa vkxs ds mipkj dh t:jr
iM+ ldrh gSA blds vykok eSa lkekU; csgks'kh ds tksf[keksa dks Hkh le>rk gwa ftlds rgr ;g ltZjh dh tk,xhA
ml lc dks Li"V :i ls le> ysus ds ckn ftls fd Åij crk;k x;k gS eSa blds }kjk MkWDVjksa dks nk;ha@ck;ha rjQ vksfcZVksVkseh dks lEiUu djus
ds fy, vf/kÑr djrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
( 73 )
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 74 )
Entropion
Prashant Yadav
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been explained in my own language the risks and complications of surgery. I have also been fully explained the surgery is being
done to correct my lid deformity and there will be no improvement in my vision.
The complications which may occur are enumerated below:
•
•
•
•
•
•
•
•
•
•
•
Infection and gape of the surgical wound
Suture erosion, infection and granuloma formation
Lid edema and scar of the incision
Risks of corneal irritation, injury and ulceration
Hemorrhage and haematoma formation
Excessive watering / dry eye,
Damage to the lid margin
Loss of eyelashes
Ptosis and lid retraction.
A skin graft may be required to correct the deformity. I have been explained that:
a.
The skin graft site maybe post auricular or the anterior forearm
b.
Graft rejection, infection, contracture or fibrosis may occur
c.
It has been explained to me that regular aseptic cleaning of the graft has to be done. It also has been explained to me that the
donor site in case of a skin graft may gape or get infected and regular aseptic cleaning of the donor site is required.
d.
A tarsorrhaphy may have to be in place for 3-6 months to prevent contracture of the graft.
Chances of under correction overcorrection and resurgery have been fully explained.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 75 )
,aVªksfiu
iz'kkar ;kno
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eq>s esjh viuh Hkk"kk esa ltZjh ds tksf[keksa vkSj tfVyrkvksa dks le>k fn;k x;k gSA eq>s ;g ckr Hkh iwjh rjg ls le>k nh x;h gS fd esjh iiksV dh
dq:irk dks Bhd djus ds fy, ltZjh dh tk jgh gS vkSj esjh n`f"V esa dksbZ lq/kkj ugha gksxkA mRiUu gks ldus okyh tfVyrkvksa dks uhps of.kZr fd;k
x;k gS %
Û
Vkads dk {kj.k] laØe.k vkSj xzus qyksek fuekZ.k
Û
iiksVs dk ,fMek vkSj phjs dk ?kko
Û
dkuhZy [kqtyh] pksV vkSj QksMs+ dk tksf[ke
Û
jDrlzko vkSj gSekVksek dk fuekZ.k
Û
vR;f/kd iuhyh@'kq"d vka[k
Û
iiksVk ekftZu dks {kfr
Û
cjkSfu;ksa dks uqdlku
Û
iksfll vkSj iiksVk izR;kgkjA
dq:irk dks Bhd djus ds fy, fLdu xzkV dh vko';drk iM+ ldrh gSA eq>s le>k fn;k x;k gS fd %
,- fLdu xzkV dh txg iksLV vkSfjdqyj ;k 'kjhj dk vxz Hkkx ;k vxzckgq gks ldrh gS
ch- xzkV dk udkjk tkuk] laØe.k] vodqp
a u ;k Qkbczkfs ll mRiUu gks ldrk gS
lh- eq>s ;g ckr le>k nh x;h gS fd xzkV dh fu;fer dhVk.kqghu lQkbZ djuh gksxhA eq>s ;g Hkh le>k fn;k x;k gS fd fLdu xzkV dh n'kk
esa nkrk LFky [kqy ;k laØfer gks ldrk gS vkSj nkrk LFky dh fu;fer dhVk.kqghu lQkbZ vko';d gSA
Mh- xzkV ds vodqp
a u dks jksdus ds fy, VklksZjgkQh dks 3&6 eghuksa ds fy, dke esa ykuk iM+ ldrk gSA
Û
vaMj djsD'ku] vksoj djsD'ku vkSj fQj ls ltZjh dh xqt
a kb'kksa dks iwjh rjg ls le>k fn;k x;k gSA
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 76 )
Ectropion
Prashant Yadav
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been explained in my own language the risks and complications of surgery. I have also been fully explained the surgery is being
done to correct my lid deformity and there will be no improvement in my vision.
The complications which may occur are enumerated below:
•
Infection and gape of the surgical wound
•
Suture erosion, infection and granuloma formation
•
Lid edema and scar of the incision
•
Risks of corneal irritation, injury and ulceration
•
Hemorrhage and haematoma formation
•
Excessive watering / dry eye
•
Damage to the lid margin
•
Loss of eyelashes
•
Ptosis and lid retraction
•
A mucous membrane graft/ nasal septal/ aural cartilage maybe required to correct the deformity. Graft rejection, infection,
contracture and/or fibrosis may occur. Regular aseptic cleaning of the graft site has to be done. It also has been explained to me that
the donor site (buccal mucosa) of the mucous membrane graft may get infected and I have been explained the importance of regular
oral hygiene
•
Chances of undercorrection, overcorrection and resurgery have been fully explained
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 77 )
,DVªksfivu
iz'kkar ;kno
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eq>s esjh viuh Hkk"kk esa ltZjh ds tksf[keksa vkSj tfVyrkvksa dks le>k fn;k x;k gSA eq>s ;g ckr Hkh iwjh rjg ls le>k nh x;h gS fd esjh iiksV dh
dq:irk dks Bhd djus ds fy, ltZjh dh tk jgh gS vkSj esjh n`f"V esa dksbZ lq/kkj ugha gksxkA mRiUu gks ldus okyh tfVyrkvksa dks uhps of.kZr fd;k
x;k gS %
Û
laØe.k vkSj lftZdy ?kko dk [kqyk gksuk
Û
Vkads dk {kj.k] laØe.k vkSj xzus qyksek fuekZ.k
Û
iiksVs dk ,fMek vkSj phjs dk ?kko
Û
dkuhZy [kqtyh] pksV vkSj QksMs+ dk tksf[ke
Û
jDrlzko vkSj gSekVksek dk fuekZ.k
Û
vR;f/kd iuhyh@'kq"d vka[k
Û
iiksVk ekftZu dks {kfr
Û
cjkSfu;ksa dks uqdlku
Û
iksfll vkSj iiksVk izR;kgkjA
Û
dq:irk dks Bhd djus ds fy, 'ys"ek dh f>Yyh xzkV@uty lsIVy@vkSjy dkfVZyt
s dh vko';drk iM+ ldrh gSA xzkV dk udkjk tkuk]
laØe.k] vodqp
a u vkSj@;k Qkbczkfs ll mRIkUu gks ldrk gSA xzkV okyh txg dh fu;fer dhVk.kqghu djuh gksxhA eq>s ;g Hkh le>k fn;k x;k
gS fd 'ys"ey f>Yyh xzkV dk nkrk LFky ¼cqDdy eqdkslk½ laØfer gks ldrk gS vkSj eq>s fu;fer ekSf[kd lkQ&lQkbZ ds egRo dks le>k fn;k
x;k gSA
Û
vaMj djsD'ku] vksoj djsD'ku vkSj fQj ls ltZjh dh xqt
a kb'kksa dks iwjh rjg ls le>k fn;k x;k gSA
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 78 )
Ptosis
Dinesh Shrey
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been explained in the language that I understand, that the surgery is being done for drooping of my Rt/ Lt/ Both eyelids under Local
Anaesthesia.
During the course of the surgery, there are chances of:
•
Undercorrection / Overcorrection after surgery that may require resurgery
•
Lid edema, lid swelling and infection
•
Inability to fully close the eye (lagophthalmos)
•
Lid lag during down gaze leading to scleral show
•
Corneal exposure and keratopathy
•
Injury to the surface of the eyeball/ globe
•
Misdirection of the eyelashes that may point towards the eyes instead of away from it
•
Blurred vision or double vision for one or two days postoperatively
•
Watering of the eyes for the first few days after surgery
•
Scarring at the incision site
Knowing the above mentioned facts, I give my consent for my Rt/ Lt/ Both eyelids ptosis surgery.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 79 )
iksfll
fnus'k Js;
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eq>s esjs le> esa vkus okyh Hkk"kk esa ;g crk fn;k x;k gS fd yksdy ,usLFkslhfl;k ds rgr esjh nk;ha@ck;ha@nksuksa iydksa dh Mªfw iax ds fy, ltZjh dh
tk jgh gSA
ltZjh dh vof/k ds nkSjku] bl ckr dh xqt
a kb'k gS fd %
Û
ltZjh ds ckn vaMjdjsD'ku@vksojdjsD'ku ftlds fy, fQj ls ltZjh dh vko';drk iM+ ldrh gS
Û
iiksV dh ,fMek] iiksV dh lwtu vkSj laØe.k
Û
vk[kksa dks iwjh rjg ls can djus esa v{ke gksuk ¼ySxvkFkSyeksl½
Û
uhps utj gksus ds nkSjku iiksV dk ihNs jg tkuk ftlls us=xksyd dh lQsn ckgjh iyd fn[krh gS
Û
dkWuhZy dk vjf{kr gksuk vkSj dsjSVksiSFkh
Û
us=xksyd@Xyksc dh lrg dks pksV
Û
cjkSfu;ksa dh xyr fn'kk tks fd vka[kksa ls nwj gksus dh ctk; mldh vksj tk ldrh gS
Û
vkWijs'ku ds ckn ,d ;k nks fnuksa ds fy, /kq/a kyh n`f"V ;k nksgjh n`f"V
Û
phjs okyh txg ij t[e
Åij crk;s x;s rF;ksa dks tkurs gq, eSa viuh nk;ha@ck;ha@nksuksa iiksVksa dh iksfll ltZjh ds fy, viuh vuqefr iznku djrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 80 )
Syringing and Probing
Dinesh Shrey
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been explained in the language that I understand that I / my son / daughter has a block in the passage which is responsible for
drainage of tears from eyes to nose. An attempt will be made to open the passage whereby a fine metal probe will be inserted so as to
overcome the blockage. The procedure will be done under General Anaesthesia.
•
Syringing and Probing is successful in 95% of cases of nasolacrimal duct blockage that are caused by a simple duct blockage.
•
The procedure needs to be repeated sometimes if the blockage is not relieved.
•
The tear duct may have a complicated type of obstruction or the tear duct might not have developed completely. These complications
may be noticed at the time of surgery during probing. Further surgery may be required consequently.
•
Bleeding from the nose can occur for upto three days after surgery.
•
Lid swelling can occur due to false passage and extravasation of saline.
Knowing the above mentioned facts, I give my consent for my/ my son/ daughter’s surgery.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 81 )
fipdkjh ls lQkbZ vkSj tkap&iM+rky
fnus'k Js;
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eq>s esjs }kjk le> esa vkus okyh Hkk"kk esa ;g crk fn;k x;k gS fd eS@
a esjk csVk@csVh ds vk[kksa ds fudklh ds ekxZ esa vojks/k gS ftldh otg ls vka[kksa
ls ukd vkalw cgrk gSA fudklh ds bl ekxZ dks [kksyus ds fy, iz;kl fd;k tk,xk] ftlds }kjk /kkrq dh fpduh NM+ Mkyh tk,xh rkfd fudklh ds ekxZ
ds vojks/k ls futkr ik;h tk ldsA ;g dk;Zfof/k lkekU; csgks'kh dh n'kk esa lEiUu dh tk,xhA
Û
fipdkjh ls lQkbZ vkSj tkap&iM+rky uSlksyfS Øey uyh vojks/k ds 95 izfr'kr ekeyksa esa lQy gS] tks fd ljy uyh vojks/k ls mRiUu gksrk gSA
Û
vojks/k ls vxj eqfDr ugha feyrh rks dbZ ckj bl dk;Zfof/k dks nksgjkus dh t:jr iM+rh gSA
Û
vkalw dh uyh esa tfVy fdLe dh ck/kk gks ldrh gS vFkok vkalw dh uyh gks ldrh gS fd iwjh rjg ls fodflr ugha gqbZ gksA fipdkjh ls lQkbZ
ds nkSjku ltZjh ds le; esa ;s tfVyrk,a utj vk ldrh gSAa blds QyLo:i vkxs vkSj ltZjh dh t:jr iM+ ldrh gSA
Û
ltZjh ds ckn rhu fnuksa rd ukd ls jDrlzko gks ldrk gSA
Û
fudklh ds xyr ekxZ vkSj lsykbu dh fudklh ds pyrs iiksVs esa lwtu vk ldrh gSA
Åij crk;s x;s rF;ksa dks tkurs gq, eSa viuh nk;ha@ck;ha@nksuksa iiksVksa dh iksfll ltZjh ds fy, viuh vuqefr iznku djrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 82 )
Punctal Plugs
Prakashchand Agarwal, Bhavna Chawla
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been informed in the language I best understand that I am/ my child is suffering from dry eye syndrome due to inadequate
production of tears. Blocking the tear drainage system with artificial punctal plugs may improve my symptoms by retaining more tears in
the eye. This is a temporary procedure and may be reversible. I have been explained that alternative treatment options include the frequent
use of artificial tears or ointment depending on severity of the condition, topical cyclosporine eyedrops or a permanent closure of the
punctum and canaliculus by thermal cautery or ligation.
Risks associated with this procedure include infection, excessive tearing, irritation and foreign body sensation, loss of the plug and rarely,
lodging of the plug in the tear drainage pathway (canaliculus) leading to scarring. In such cases, surgery may be necessary to re-establish
tear drainage. The plugs may require replacement or removal. I have been fully explained the permanent nature of the disease and that this
treatment might give symptomatic relief by retaining the tears to moisten the ocular surface. This procedure will not cure the primary
cause of dry eye syndrome. Regular follow up may be required to assess the ocular surface status and modify medications accordingly.
I certify that I have fully understood the implications of the above consent and authorise the doctors to insert punctal plugs in my/ my
child’s
RIGHT
lower
upper
LEFT
lower
upper
eyelid(s)
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 83 )
iadVy IyXl
izdk'kpan vxzoky] Hkkouk pkoyk
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eq>s ,slh Hkk"kk es]a ftls fd eSa le>rk gw]a lwfpr dj fn;k x;k gS fd eS@
a esjk cPpk vkalqvksa ds de cuus ds dkj.k 'kq"d vka[k flaMªkes ls =Lr gSA udyh
iaDVy IyXl ls vkalw fudlh ekxZ dks vo#) dj nsus ls vka[kksa esa T;knk vkalw jksdus ds }kjk esjs y{k.kksa esa lq/kkj gks ldrk gSA ;g vLFkk;h
dk;Zfof/k gS vkSj bls myVk tk ldrk gSA eq>s ;g ckr le>k nh x;h gS fd mipkj ds oSdfYid fodYiksa esa udyh vkalqvksa vFkok voLFkk dh xaHkhjrk
ds vk/kkj ij eyge] VkWfidy lkbDykstiksjkbu vkbZMªkIl dk vDlj iz;ksx ;k FkeZy dkSVjh ;k fyxs'ku ds }kjk iaDVe vkSj dSukfydqyl dks ges'kk
ds fy, can djuk 'kkfey gSA
bl dk;Zfof/k ls tqMs+ tksf[keksa esa laØe.k] vR;f/kd vkal]w [kqtyh vkSj ckgjh pht iM+s gksus dh vuqHkwfr] Iyx dh gkfu vkSj dHkh&dHkkj vkalw fudklh ds
ekxZ ¼dSukfydqyl½ esa Iyx dk vkuk ftlls fu'kkuk iM+ tkrs gSAa bl rjg ds ekeyksa esa vkalw ds cgko ds ekXkZ dks fQj ls dk;e djus ds fy, ltZjh
vko';d gks ldrh gSA eq>s chekjh dh LFkk;h izÑfr ds ckjs esa le>k fn;k x;k gS vkSj ;g fd ;g mipkj vksdqyj lrg dks ue j[kus ds fy, vkalqvksa
dks jksddj y{k.k ls jkgr iznku dj ldrk gSA ;g dk;Zfof/k 'kq"d vka[kksa ds flaMªkes ds izkFkfed dkj.k dks Bhd ugha djsxhA vksdqyj lrg dh fLFkfr
dk vkdyu djus vkSj mlds vuqlkj nokbZ dks ifjof)Zr djus ds fy, fu;fer QkWyks&vi dh vko';drk iM+ ldrh gSA
eSa izekf.kr djrk gwa fd eSua s mi;qZDRk lgefr ds fufgrk'k;ksa dks iwjh rjg ls le> fy;k gS vkSj MkWDVjksa dks esjh@esjh cPps dh nk;ha fupyh@Åijh]
ck;ha fupyh@Åijh iydksa esa iaDVy Iyx Mkyus ds fy, vf/kÑr djrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 84 )
Dacryocystorhinostomy (DCR)
Rachna Meel
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been informed in my mother tongue that the natural passage for tear drainage from my eye (right/ left) is blocked. I understand that
in order to overcome the problem of tearing in my eye because of the blockade I need to undergo dacryocystorhinostomy. This surgery
involves by-passing the normal drainage system by making a direct communication between this passage and the nose. This will be done
by making a bony opening in the adjacent wall of the nose, through a skin incision on the nose. A nasal pack would be kept in the nose
for 24 hours post-operatively. Syringing of the passage created by the surgery may be required post-operatively.
I have been explained the risks of this surgery involving: failure ( approx 10%), excessive bleeding during the surgery or postoperatively,
infection at the site of surgery and a potential risk of loss of vision due to any of the above reasons. I also understand the risks of local
anesthesia under which this surgery will be performed.
Having completely understood the implications of the consent I hereby authorize the doctors to perform dacryocystorhinostomy on my
left /right side.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: ...................................................................................................
Address: ..............................................................................................
Address: ..............................................................................................
Tel: .......................................................................................................
Tel: .......................................................................................................
( 85 )
MSfØvksflLVksjfuksLVkseh ¼Mhlhvkj½
jpuk ehy
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eq>s esjh ekr`Hkk"kk esa lwfpr dj fn;k x;k gS fd esjh vka[k ¼nk;ha@ck;ha½ ls vkalqvksa ds cgko ds fy, LokHkkfod ekxZ vo#) gSA eSa le>rk gwa fd
vojks/k dh otg ls esjh vka[k esa vkalw cgus dh leL;k ls futkr ikus ds Øe esa eq>s MSfØvksflLVksjfuksLVkseh djokus dh t:jr gSA bl ltZjh ls fudklh
dh lkekU; O;oLFkk vkSj ukd ds chp lh/kk laidZ cukdj mls ckgj&ckgj ls fudkyk tkrk gSA bl dke dks ukd ij Ropk ds phjs ds tfj;s ukd ls
yxh nhokj esa gfì;ksa esa lqjk[k djds fd;k tk,xkA vkWijs'ku ds ckn pkSchl ?kaVksa rd ukd esa uty iSd dks j[kk tk,xkA ltZjh ds }kjk rS;kj fd;s
x;s cgko ekxZ dh fipdkjh ls lQkbZ vkWijs'ku ds ckn t:jh gks ldrh gSA
eq>s bl ltZjh ls tqMs+ gq, tksf[keksa ds ckjs esa le>k fn;k x;k gS % foQyrk ¼rdjhcu 10 izfr'kr½] ltZjh ds nkSjku ;k vkWijs'ku ds ckn vR;f/kd jDrlzko]
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fy, vf/kÑr djrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
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fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 86 )
Contracted Socket
Prashant Yadav
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been explained in my own language the risks and complications of surgery which is being performed to relieve my orbital socket
contracture. These are enumerated below:
•
The surgery is being done to correct my contracted socket and there will be no gain in my vision.
•
Infection and hemorrhage and gape of the surgical wound may occur.
•
Suture erosion, infection and granuloma formation may occur.
•
I may require a mucous membrane graft/ amniotic membrane graft or dermis fat graft. I have been explained that:
a.
Graft rejection, infection, contracture or fibrosis may occur.
b.
It has been explained to me that regular aseptic cleaning of the graft has to be done and that the donor site in case of a mucous
membrane graft is buccal mucosa. I have also been explained the importance of regular oral hygiene.
c.
In case of dermis fat graft, the graft site will be my gluteal region and I been fully explained the importance of donor site
hygiene.
•
I will require fornix formation sutures which will be removed after 3 weeks
•
I will be required to wear a conformer for 2 months
•
I will be given an artificial eye after 2 months. There is a risk of inadequate fitting of the artificial eye. There will only be minimal
ocular movements.
•
There is a high risk of failure of the socket reconstruction and I may require multiple surgeries.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 87 )
vodqafpr lkWdsV
iz'kkar ;kno
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eq>s esjh viuh Hkk"kk esa ltZjh ds tksf[keksa vkSj tfVyrkvksa ds ckjs esa le>k fn;k x;k gS] ftls fd esjs vkfcZVu lkWdVs vodqp
a u ls futkr fnykus ds
fy, lEiUu fd;k tk jgk gSA bUgsa uhps fn;k x;k gS %
Û
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Û
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jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
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irk %......................................................................................................................................................................................................
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MkWDVj }kjk ?kks"k.kk
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fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
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xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 88 )
OCULAR SURFACE,
CORNEA & REFRACTIVE
SURGERY
Optical Penetrating Keratoplasty
Gaurav Prakash
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been informed in my mother tongue that I/ my child is suffering from whitening of the cornea (Corneal opacity) /other disease
involving the cornea and that a surgery to remove this along with some normal cornea will be done. A donor cadaveric cornea will be used
to replace this and will be placed with help of sutures.
I have been fully explained regarding the permanent nature of the opacity/ lesion and that it has to be removed to enhance vision. I have
been explained the risk of infection, graft rejection, suture loosening and replacement, no improvement or worsening of Best corrected
visual acuity, glaucoma secondary to surgery or to medications, cataract formation and high astigmatism after surgery. There may be a
need for repeat surgery which may or may not lead to improvement of vision. I have been explained the need for follow up as frequently
as advised by the doctors that may span upto years, with multiple investigations at each visit. I have been explained that using medications
properly is required for success of the graft. I have been explained that I will need to urgently come for follow-up to ophthalmic casualty
if there is a sudden onset of redness, photophobia, foreign body sensation, pain or detoriation of vision as these may be early signs of graft
infection or rejection. I understand that inspite of all efforts, there is a possibility that there may be worsening of the visual acuity or the
cosmetic appearance of the eye.
I certify that I have fully understood the implications of the above consent and authorise the doctors to perform Penetrating Keratoplasty
on my / my child’s right / left eye.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 89 )
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dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
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ldrh gS tks fd n`f"V dks lq/kkj dks tUe ns Hkh ldrk gS vkSj ugha HkhA eq>s le>k fn;k x;k gS fd MkWDVj ftruh ckj dgsxk mruh ckj QkWyks&vi foftV
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nnZ ;k n`f"V fcxM+us dh vdLekr 'kq#vkr gksrh gS rks vkikrdkyhu us= fpfdRlk ds fy, QkSju vkuk iM+x
s k D;ksfa d ;s xzkV laØe.k ;k udkj ds 'kq#vkrh
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jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
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irk %......................................................................................................................................................................................................
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MkWDVj dk gLrk{kj %
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( 90 )
Therapeutic Keratoplasty
Anand Agarwal, Shalini Mohan
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
Therapeutic keratoplasty is an ocular surgical procedure which is carried out in patients having infections involving the transparent outer
coat of the eye ie cornea. The procedure is usually undertaken in cases with impending corneal perforation or frank perforation or
sometimes in cases which are not responding to conventional medical therapy and cases with infection spreading onto deeper layers of
the cornea. The procedure is usually carried out under general anesthesia but can be performed under local anesthesia as well depending
upon the condition of the patient’s eye and systemic status of the patient.
Post operative care
The eye may be red, swollen and painful following the procedure for which pain relieving oral medications and some eyedrops are given
to bring about relief. Out patient visits are done on first day post operatively, day three, day seven and then after every two weeks. It is very
important for you to realize that the primary motive of the surgical procedure is salvaging of the eye, and prevention of spread of infection
into the eye which can be devastating. Attainment of useful vision is only a secondary objective of the procedure for which additional
procedures including a repeat corneal replacement may be required at a later date once the infection gets controlled.
Post operative course and complications
1.
Corneal wound healing problems including persistent epithelial defect
2.
Secondary glaucoma
3.
Graft rejection and opacification of the donor cornea
4.
Suture related problems including loose, broken sutures, suture abscess
5.
Recurrence of original infection in the graft
6.
Endophthalmitis and shrinkage of globe- these are rare
It is very important for the patient to realize that you have to be on certain topical medications in the form of antibiotics, local anti
inflammatory agents, lubricants etc. for a prolonged period of time to bring about an optimal graft and visual acuity outcome. Also, the
importance of regular follow up as decided by the treating physician cannot be over emphasized. Needless to say that you are actively
involved in the care of the graft to ensure success.
I have been made aware of the above mentioned facts and I have been counseled about the potential benefits and possible side effects of
the procedure and by thoroughly going through all of the above, I give my full informed consent for the above procedure.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
( 91 )
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 92 )
FksjSfIVd dsjSVksIykLVh
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ls tqMk+ laØe.k gksrk gSA bl dk;Zfof/k dks izk;% vklUu dkWuhZy Nsn ;k Li"V Nsn vFkok dbZ ckj ,sls ekeyks]a tks fd ikjaifjd fpfdRlk mipkj ls Bhd
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ckj laØe.k ds fu;af=r gks tkuss ij ckn esa pydj vko';drk iM+ ldrh gSA
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ls lfØ; :i ls tqM+s gq, gSaA
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tk pqdk gS vkSj bu lHkh ckrksa dks dk;ns ls le>&cw> dj eSua s mi;qZDr dk;Zfof/k ds fy, viuh iwjh lwfpr lgefr iznku dh gSA
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
( 93 )
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( 94 )
Automated Lamellar Therapeutic Keratoplasty (ALTK)
Gaurav Prakash
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been informed in my mother tongue that I/ my child is suffering from whitening of the cornea (Corneal opacity) / corneal ectasia
(keratoconus) / other disease involving anterior part of the cornea (specify ...................................................) and that a surgery to remove upto
anterior, middle and deep part of the cornea (epithelium, basement membrane & upto mid stroma) will be done. A part of a donor
cadaveric cornea will be used to replace this and will be placed with the help of sutures.
I have been fully explained regarding the permanent nature of the opacity/ lesion and that it has to be removed to enhance vision. I have
been explained the risk of perforation of the host eye, leading to the need for a full thickness corneal transplant. There is risk of infection,
graft rejection, suture loosening and replacement , increased blood vessels in interface possibly leading to haemorrhage, no improvement
or worsening of Best corrected visual acuity, glaucoma secondary to surgery or to medications, cataract formation and high astigmatism
after surgery. There may be a need for repeat surgery which may or may not lead to improvement of vision. I have been explained the need
for follow up as frequently as advised by the doctors that may span upto years, with multiple investigations at each visit. I have been
explained that using medications properly is required for success of the graft. I have been explained that I will need to urgently come for
follow-up to ophthalmic casualty if there is sudden onset of redness, photophobia, foreign body sensation, pain or detoriation of vision as
these may be early signs of graft infection or rejection. I understand that inspite of all efforts, there is a possibility that there may be
worsening of the visual acuity or the cosmetic appearance of the eye.
I certify that I have fully understood the implications of the above consent and authorise the doctors to perform Automated Lamellar
Therapeutic Keratoplasty on my/ my child’s right / left eye.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 95 )
vkV¨esVsM Y©esYkj F¨jkiqfVd dsjkV¨IYkkLVh ¼,,yVhds½
x©jo Ádk'k
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eq>s esjh ekr`Òk"kk esa crk;k x;k gS fd eS@
a esjk cPpk dkfuZ;k ds 'osru ¼dkfuZ;k dh vikjnf'kZrk@d‚fuZ;Yk bDVsfl;k ¼dsjkV¨d¨ul½@dkfuZ;k ds vxz
Òkx ¼Li"V djsa --------------------------------------------------------------------------------½ esa g¨us okY¨ fdlh vU; j¨x ls ihfM+r gS v©j ;g Òh fd d‚fuZ;k ds vxz] e/; ;k fupY¨
fgLls ¼bfifFkfYk;e] cslesVa esca jsu v©j e/; LV¨ek rd½ d¨ fudkYkus ds fYk, 'kY;fØ;k dh tk,xhA bls ÁfrLFkkfir djus ds fYk, nkrk ds dsMos fjd
dkfuZ;k ds fdlh fgLls dk mi;¨x fd;k tk,xk v©j bls Vkad¨a dh enn ls ÁfrLFkkfir fd;k tk,xkA
eq>s vikjnf'kZrk@{kfr dh LFkkbZ ÁÑfr ds ckjs esa iwjh rjg le>k;k x;k gS v©j ;g Òh crk;k x;k gS fd n`f"V ¼'kfä½ c<+kus ds fYk, bls fudkYkk tkuk
gSA eq>s gksLV dh vka[k esa fNæ g¨us ds t¨f[ke ds ckjs esa crk;k x;k gS ftlds dkj.k iwjh e¨VkbZ ds dkfuZ;k ds ÁR;kj¨i.k dh t:jr iM+ ldrh gSA
laØe.k] fuj¨i ds vLohdj.k] Vkad¨a ds <hYkk g¨us v©j ÁfrLFkkiu] varjkQYkd esa jäokfgfu;¨a ds c<+ tkus ls jälzko g¨us] n`f"V dh rh{.krk esa d¨bZ
lq/kkj u vkus ;k Bhd dh xbZ loZJ"s B n`f"V rh{.krk ds v©j Òh [kjkc g¨us tkus] 'kY;fØ;k ds x©.k ÁÒko ds :i esa XYkkd¨ek g¨us ds t¨f[ke d¨ Òh
Li"V fd;k x;k gSA nqckjk 'kY; fØ;k djus dh vko';drk iM+ ldrh ftlls n`f"V 'kfä c<+ Òh ldrh gS v©j ugÈ Òh c<+ ldrhA eq>s ;g Òh crk;k
x;k gS fd M‚DVj ftruh ckj cqYkk,xk eq>s mruh ckj Q‚Yk¨vi ds fYk, tkuk g¨xk v©j ÁR;sd eqYkkdkr ij cgqr&lh tkapas djkuh iM+ ldrh gSAa eq>s
;g Òh Li"V fd;k x;k gS fd ;fn vka[k vpkud YkkYk g¨ tkrh gS] Ádk'k Òhfr g¨rh gS vka[k esa dqN iM+s g¨us] nnZ ;k n`f"V 'kfä ds vogzkl dh vuqÒfw r
g¨rh gS r¨ esjk rqjra us"k fpfdRlk vkikr d{k esa Q‚Yk¨vku ds fYk, vkuk vko';d g¨xk D;¨afd ;g fuj¨i ds laØe.k ;k vLohdj.k dk 'kq#vkrh ladrs
g¨ ldrk gSA eSa le>rk gwa fd lkjh d¨f'k'k¨a ds ckotwn laÒo% gS fd vka[k dh n`f"V dh rhozrk ;k vka[k dh Álk/kd okákÑfr v©j Òh [kjkc g¨ tk,A
eSa Áekf.kr djrk gwa fd eSa mi;qZä lgefr ds fufgrkFk¨± d¨ iwjh rjg le>rk gw]a v©j fpfdRld¨a d¨ viuh@vius cPps dh nkb±@ckb± dh vkV¨esVM
s
Y©esYkj F¨jkiqfVd dsjkV¨IYkkLVh djus ds fYk, Ákf/kÑr djrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 96 )
Deep Anterior Lamellar Keratoplasty (DALK)
Gaurav Prakash
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been informed in my mother tongue that I/ my child is suffering from whitening of the cornea (Corneal opacity) / corneal ectasia
(keratoconus) / other disease involving anterior part of the cornea (specify ...................................................) and that a surgery to remove upto
anterior, middle and deep part of the cornea (epithelium, basement membrane & stroma upto or just before Descemets) will be done. A
part of a donor cadaveric cornea will be used to replace this and will be placed with the help of sutures.
I have been fully explained regarding the permanent nature of the opacity/ lesion and that it has to be removed to enhance vision. I have
been explained the risk of perforation of the host eye, leading to the need for a full thickness corneal transplant. There is risk of infection,
graft rejection , suture loosening and replacement , increased blood vessels in interface possibly leading to haemorrhage, no improvement
or worsening of Best corrected visual acuity, glaucoma secondary to surgery or to medications, cataract formation and high astigmatism
after surgery. There may be a need for repeat surgery which may or may not lead to improvement of vision. I have been explained the need
for follow up as frequently as advised by the doctors that may span upto years, with multiple investigations at each visit. I have been
explained that using medications properly is required for the success of the graft. I have been explained that I will need to urgently come
for follow-up to ophthalmic casualty if there is a sudden onset redness , photophobia, foreign body sensation , pain or detoriation of vision
as these may be early signs of graft infection or rejection. I understand that inspite of all efforts, there is a possibility that there may be
worsening of the visual acuity or the cosmetic appearance of the eye.
I certify that I have fully understood the implications of the above consent and authorise the doctors to perform Deep Anterior Lamellar
Keratoplasty on my / my child’s right / left eye.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 97 )
Mhi ,aVhfj;j Y©esYkj dsjkV¨IYkkLVh ¼Mh,,yds½
x©jo Ádk'k
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eq>s esjh ekr`Òk"kk esa crk;k x;k gS fd eS@
a esjk cPpk dkfuZ;k ds 'osru ¼dkfuZ;k dh vikjnf'kZrk @ d‚fuZ;Yk bDVsfl;k ¼dsjkV¨d¨ul½/dkfuZ;k ds vxz
Òkx ¼Li"V djsa ---------------------------------------------------------------------------------------------------½ esa g¨us okY¨ fdlh vU; j¨x ls ihfM+r gS v©j~ ;g Òh fd d‚fuZ;k ds vxz]
e/; ;k fupY¨ fgLls ¼bfifFkfYk;e] cslesVa esca jsu v©j e/; LVª¨ek rd½ d¨ fudkYkus ds fYk, 'kY;fØ;k dh tk,xhA bls ÁfrLFkkfir djus ds fYk, nkrk
ds dsMos fs jd dkfuZ;k ds fdlh fgLls dk mi;¨x fd;k tk,xk v©j bls Vkad¨a dh enn ls ÁfrLFkkfir fd;k tk,xkA
eq>s vikjnf'kZrk@{kfr dh LFkkbZ ÁÑfr ds ckjs esa iwjh rjg le>k;k x;k gS v©j ;g Òh crk;k x;k gS fd n`f"V ¼'kfä½ c<+kus ds fYk, bls fudkYkk tkuk
gSA eq>s gksLV dh vka[k esa fNæ g¨us ds t¨f[ke ds ckjs esa crk;k x;k gS ftlds dkj.k iwjh e¨VkbZ ds dkfuZ;k ds ÁR;kj¨i.k dh t:jr iM+ ldrh gSA
laØe.k] fuj¨i ds vLohdj.k] Vkad¨a ds <hYkk g¨us v©j ÁfrLFkkiu] varjkQYkd esa jäokfgfu;¨a ds c<+ tkus ls jälzko g¨us] n`f"V dh rh{.krk esa d¨bZ
lq/kkj u vkus ;k Bhd dh xbZ loZJ"s B n`f"V rh{.krk ds v©j Òh [kjkc g¨us tkus] 'kY;fØ;k ds x©.k ÁÒko ds :i esa XYkkd¨ek g¨us ds t¨f[ke d¨ Òh
Li"V fd;k x;k gSA nqckjk 'kY; fØ;k djus dh vko';drk iM+ ldrh ftlls n`f"V 'kfä c<+ Òh ldrh gS v©j ugÈ Òh c<+ ldrhA eq>s ;g Òh crk;k
x;k gS fd M‚DVj ftruh ckj cqYkk,xk eq>s mruh ckj Q‚Yk¨vi ds fYk, tkuk g¨xk v©j ÁR;sd eqYkkdkr ij cgqr&lh tkapas djkuh iM+ ldrh gSAa eq>s
;g Òh Li"V fd;k x;k gS fd ;fn vka[k vpkud YkkYk g¨ tkrh gS] Ádk'k Òhfr g¨rh gS vka[k esa dqN iM+s g¨us] nnZ ;k n`f"V 'kfä ds vogzkl dh vuqÒfw r
g¨rh gS r¨ esjk rqjra us"k fpfdRlk vkikr d{k esa Q‚Yk¨vku ds fYk, vkuk vko';d g¨xk D;¨afd ;g fuj¨i ds laØe.k ;k vLohdj.k dk 'kq#vkrh ladrs
g¨ ldrk gSA eSa le>rk gwa fd lkjh d¨f'k'k¨a ds ckotwn laÒo% gS fd vka[k dh n`f"V dh rhozrk ;k vka[k dh Álk/kd okákÑfr v©j Òh [kjkc g¨ tk,A
eSa Áekf.kr djrk gwa fd eSa mi;qZä lgefr ds fufgrkFk¨± d¨ iwjh rjg le>rk gw]a v©j fpfdRld¨a d¨ viuh@vius cPps dh nkb±@ckb± dh vkV¨esVM
s
Y©esYkj F¨jkiqfVd dsjkV¨IYkkLVh djus ds fYk, Ákf/kÑr djrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 98 )
Descemet’s Stripping Endothelial Keratoplasty
(DSEK/DSAEK)
Bhavna Chawla
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been informed in the language I best understand that I am suffering from an ocular condition (specify ________________ such as
Fuchs’ Corneal Dystrophy, trauma, previous intraocular surgery, failed graft) in which a critical number of endothelial cells (inner layer
of the cornea) have been lost because of which the cornea has become swollen and cloudy. The remainder of the corneal layers, the stroma
and the outer epithelium, are healthy.
An operation known as Descemet’s Stripping Endothelial Keratoplasty (DSEK/DSAEK) will be carried out in which a thin button of
donor tissue containing the endothelial cell layer will be inserted onto the back surface of my eye.
Advantages of DSEK over full thickness corneal transplantation are that it is faster to perform, the wound is smaller, more stable and less
likely to break open from inadvertent trauma. Because the technique requires very few sutures, there is negligible postoperative astigmatism
which can otherwise delay visual recovery. Since only the thin inner layer of the cornea is replaced, over 90% of the patient’s own cornea
remains behind contributing to greater structural integrity and a reduced incidence of rejection.
Risks and complications of DSEK/DSAEK
These include general risks similar to those of a full thickness corneal transplantation such as hemorrhage in the eye, infection, a retinal
detachment, rejection of the transplanted tissue, chronic inflammation, double vision, loss of corneal clarity, no improvement in vision
or worsening of BCVA, glaucoma secondary to surgery or to medications and cataract formation.
Risks specific to DSEK include displacement of the thin button of endothelium within the first few days or weeks after surgery requiring
a repeat surgery to reposition it. If the DSEK operation fails, the operation can be repeated with another button of donor endothelium.
Alternatively, a traditional corneal transplant operation can also be performed. Repeat surgery may or may not lead to improvement of
vision.
Other complications from the local anesthesia include perforation of the eyeball, damage to the optic nerve, a droopy eyelid, interference
with the circulation of the blood vessels in the retina, respiratory depression, and hypotension.
I have been explained the need for follow up as frequently as advised by the doctors that may span upto years, with multiple investigations
at each visit. I have been explained that using medications properly is essential for the success of the graft. I have been explained that I will
need to urgently come for follow-up to ophthalmic casualty if there is a sudden onset redness, photophobia, pain or deterioration of vision
as these may be early signs of graft infection or rejection.
I understand that there may be other unexpected risks or complications that can occur that are not listed here. I also understand that
during the course of the proposed operation, unforeseen conditions may be revealed that require the performance of additional procedures,
and I authorize such procedures to be performed. I further acknowledge that no guarantees or promises have been made to me concerning
the results of any procedure or treatment.
This consent form has also educated me about the various options available to me.
I certify that I have fully understood the implications of the above consent and authorize the doctors to perform endothelial keratoplasty
on my right / left eye.
( 99 )
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 100 )
MhLlhesV~l fLVªfiax baM¨F¨fYk;Yk dsjkV¨IYkkLVh
¼Mh,lbZds@Mh-,l-,-bZ-ds½
Òkouk pkoYkk
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eq>s ml Òk"kk esa ftls eSa lcls vPNh rjg le>rk gwa lwfpr fd;k x;k gS fd eSa vka[k dh fdlh voLFkk ¼Li"V djs-a -----------------------------------------------------------------------------------------------------------------------------------tSls QqDl dkfuZ;Yk fMLVª¨Qh] ?kko] iqjkuh var% us"kh; 'kY;fpfdRlk] vlQYk fuj¨i½ ls ihfM+r gwa ftlesa
egRoiw.kZ la[;k esa dkfuZ;k dh baM¨fFkfYk;eh d¨f'kdk,a u"V g¨ xbZ gSa ftlds dkj.k dkfuZ;k esa lwtu vk xbZ gS v©j og efYku g¨ xbZ gSA dkfuZ;k dh
'¨"k ijrs]a LVª¨ek v©j ckgjh bfifFkfYk;eh d¨f'kdk,a LoLFk gSAa
,d 'kY;fØ;k dh tk,xh ftls fMLlseVs l
~ fLVªfiax baM¨fFkfYk;Yk dsjVs ¨IYkkLVh dgk tkrk gS] ftlesa bfifFkfYk;eh d¨f'kdkv¨a dh ijr ;qä nkrk ds Ård¨a
dk ,d irYkk lk cVu esjh vka[k ds ihNs dh lrg ds Òhrj ?kqlk fn;k tk,xkA
iwjh e¨VkbZ ds dkfuZ;k ds ÁR;kj¨i.k dh rqYkuk esa Mh,lbZds dk YkkÒ ;g gS fd ?kko N¨Vk g¨rk gS] ;g vf/kd fVdkÅ v©j vlko/kkuh ls Ykxus okYkh p¨V
ls blds VwVus dk [krjk de jgrk gSA pwfa d bl rduhd esa Vkads cgqr de Ykxkus iM+rs gSa blfYk, 'kY;fØ;k ds ckn dk n`f"VoS"kE; u ds cjkcj g¨rk
gS t¨ vU;Fkk n`f"V ds iquYkkZÒ esa nsj dj ldrk gSA pwfa d dkfuZ;k dh dsoYk irYkh lh Òhrjh ijr dk ÁR;kj¨i.k fd;k tkrk gS] blfYk, 90% ls vf/kd
j¨fx;¨a dk dkfuZ;k ihNs cuk jgrk gS t¨ vf/kd lajpukRed v{krrk Ánku djrk gS v©j vLohdj.k dh ?kVukv¨a d¨ de dj nsrk gSA
Mh,lbZds@Mh,l,bZds ds t¨f[ke v©j tfVYkrk,a
buesa vka[k esa jälzko] laØe.k] jsfVuk dk foYkxko] ÁR;kj¨if.kr Ård¨a dk vLohdj.k] iqjkuk Ánkg] nqgjh n`f"V] d‚fuZ;k dh Li"rk dk vÒko] n`f"V 'kfä
esa d¨bZ lq/kkj u g¨uk ;k chlhoh, dk v©j Òh [kjkc g¨ tkuk] 'kY;fØ;k ;k mipkj ds x©.k ÁÒko ds :i esa e¨fr;kfcan ;k XYkkd¨ek ;k e¨fr;kfcan ds
cuus tSls iwjh e¨VkbZ ds dkfuZ;Yk ÁR;kj¨i.k tSls lkekU; t¨f[ke 'kkfeYk g¨srs gSAa
Mh,lbZds ds fof'k"V t¨f[ke¨a esa ÁkjaÒ ds dqN gh fnu¨a ;k gr¨a ds Òhrj baM¨fFk;e dh irYkh cVu dk viuh txg ls f[kld tkuk 'kkfeYk gS ftls mldh
txg ij j[kus ds fYk, nqckjk 'kY;fØ;k djuh iM+rh gSA ;fn Mh,lbZds ÁfØ;k vlQYk g¨ tkrh gS r¨ nkrk ds baM¨fFkfYk;e ds nwljs cVu ds lkFk nqckjk
'kY;fØ;k djuh iM+ ldrh gSA vU;Fkk] dkfuZ;k ds ÁR;kj¨i.k dh ijaijkxr 'kY;fØ;k Òh dh tk ldrh gSA nqckjk 'kY;fØ;k djus ls vka[k¨a dh n`f"V
esa lq/kkj g¨ Òh ldrk gS v©j ugÈ ÒhA
LFkkfud laons ukgj.k ls g¨us okYkh vU; tfVYkrkv¨a esa us"kx¨Ykd esa fNæ] n`d~ raf"kdkv¨a d¨ {kfr] >qdh iYkds]a jsfVuk dh jäokfgfu;¨a esa jä Áokg esa
O;o/kku] 'olu lac/a kh volkn] v©j fuEu jä pki 'kkfeYk gSAa
eq>s Li"V :i ls crk;k x;k gS fd eq>s fpfdRld¨a ds lq>k, vuqlkj ckj&ckj Q‚Yk¨vi ds fYk, vkuk g¨xk t¨ o"k¨± pYk ldrk gS v©j ÁR;sd eqYkkdkr
ij cgqr&lh tkapas djkuh g¨axhA eq>s crk;k x;k gS fd fuj¨i dh lQYkrk ds fYk, lgh <ax ls nokv¨a dk mi;¨x vfuok;Z gSA eq>s crk;k x;k gS fd
;fn vka[k vpkud YkkYk g¨ tkrh gS] Ádk'k Òhfr] vka[k esa dqN iM+s g¨us] nnZ ;k n`f"V 'kfä ds vogzkl dh vuqÒfw r g¨rh gS r¨ esjk rqjra us"k fpfdRlk
vkikr~ d{k esa Q‚Yk¨vi ds fYk, vkuk vko';d g¨xk D;¨afd ;g fuj¨i ds laØe ;k vLohdj.k dk ÁkjafÒd Yk{k.k g¨ ldrk gSA
eSa le>rk gwa fd vU; vuisf{kr t¨f[ke v©j tfVYkrk,a g¨ ldrh gSa ftudh lwph ;gka ugÈ nh xbZ gSA eSa ;g Òh le>rk gwa fd ÁLrkfor 'kY;fØ;k ds
n©jku vÁR;kf'kr voLFkkv¨a dk irk pYk ldrk gS ftuds fYk, vfrfjä ÁfØ;k,a djus dh vko';drk iM+ ldrh gS v©j bl rjg dh ÁfØ;k,a djus
dk vf/kdkj Ánku djrk gwAa eSa ;g Òh Lohdkj djrk gwa fd eq>ls fdlh Òh ÁfØ;k ;k mipkj ds ifj.kke ds ckjs esa fdlh rjg dh xkjaVh ;k okns ugÈ
fd, x, gSAa
bl lgefr Ái= us eq>s nwljs miYkC/k fodYi¨a ds fYk, eq>s f'kf{kr fd;k gSA
eSa Áekf.kr djrk gwa fd eSua s mi;qZä lgefr fufgrkFk¨± d¨ vPNh rjg le> fYk;k gS v©j viuh nkb±@ckb± vka[k esa baM¨fFkfYk;eh dsjkV¨IYkkLVh djus dk
Ákf/kdkj nsrk gwAa
( 101 )
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
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gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
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( 102 )
Phototherapeutic Keratectomy (PTK)
Chandrashekhar
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
Patient Consent
In giving my permission for excimer laser surgery, I understand the following:
1.
The surgical removal of the superficial layers of my cornea using the excimer laser has been elected by me as an alternative to other
forms of corneal surgery.
2.
As with all surgery, I understand the results cannot by guaranteed.
3.
I understand that my vision may be made worse by this procedure. Complications could include: Loss of sharp vision, increased
corneal scarring, increased night glare or corneal infection. Any pre-existing viral infections may reappear with the use of postoperative drops. If the cornea has extensive scars, it is possible that a corneal perforation may occur that could produce other
changes such as infections, cataracts or the need for additional surgery. I understand that I must be examined closely to ensure
proper healing of the treated eye.
4.
I understand Phototherapeutic Keratectomy (PTK) with the excimer laser may increase my need for glasses and may require the use
of corrective lenses to achieve my best vision.
5.
I understand that although sharper vision and less glare are anticipated, it is possible that glare and clarity may be made worse
following this procedure.
6.
I understand that for those severe corneal problems, where the surgical option for me is a corneal transplant, excimer laser PTK
may not eliminate the need for a corneal transplant.
7.
I understand it is impossible to state every possible complication that may occur as a result of this surgical procedure.
8.
I understand that not all the beneficial effects of PTK are currently known.
9.
I also understand that all the risks and complications are not known.
10.
I acknowledge this disclosure of information has been made to me and that all my questions have been answered to my satisfaction.
I have read this form (or it has been read to me) and I fully understand the complications, risks and benefits that can result from PTK
Surgery. I realize there are no guarantees with PTK Surgery.
I still however elect to have PTK laser treatment in my R/L / both eye(s).
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
( 103 )
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 104 )
Q¨V¨F¨jkI;qfVd dsjkVsDV¨eh ¼ihVhds½
paæ'¨[kj
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dk iq=@iq=h .........................................................................................................................................................................................
irk % . ..................................................................................................................................... VsyhQksu ua %. ........................................
j¨xh dh lgefr
,Dllkbej Y¨tj 'kY;fØ;k djus dh vuqefr%
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fodYi ds :i esa pquk gSA
2eSa le>rk gwa fd nwljh lÒh 'kY;fØ;kv¨a dh rjg ifj.kke¨a dh xkajVh ugÈ nh tk ldrhA
3-
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ldrk gS v©j vfrfjä 'kY;fØz;k dh vko';drk iM+ ldrh gSA eSa le>rk gwa fd ;g lqfuf'pr djus ds fYk, mipkfjr vka[k dk ?kko ,d lgh
<ax ls Òjs] ckjhdh ls esjh tkap dh tkuh pkfg,A
eSa le>rk gwa fd ,Dlkbe Y¨tj ls Q¨V¨F¨jkI;qfVd dsjkVsDV¨eh ¼ihVsd½s p'es] dh esjh vko';drk c<+k ldrh gS v©j esjh vf/kdre n`f"V ds
fYk, lq/kkjd Y¨al¨a dh vko';drk iM+ ldrh gSA
eSa le>rk gwa fd gkYkkafd vis{kkÑr rh{.k n`f"V v©j de p©a/k visf{kr gS Y¨fdu ;g Òh laÒo gS fd bl ÁfØ;k ds ckn p©a/k v©j n`f"V n¨u¨a v©j
Òh [kjkc g¨ tk,aA
eSa le>rk gwa fd dkfuZ;k dh mu xaÒhj leL;kv¨a ds fYk,] ftuds fYk, esjs fYk, dkfuZ;k ds ÁR;kj¨i.k dk fodYi miYkC/k gS] ,Dllkbej Y¨tj
ihdsVh dkfuZ;k ds ÁR;kj¨i.k dh vko';drk [kRe u dj ldsA
eSa le>rk gwa fd bl 'kY;fØ;kRed ÁfØ;k ds QYkLo:i g¨us okYkh ÁR;sd tfVYkrk dk o.kZu dj ikuk vlaÒo gSA
eSa le>rk gwa fd ihdsVh ds lÒh ykÒnk;d ÁÒko vÒh Kkr ugÈ gSaA
eSa ;g Òh le>rk gwa fd lÒh t¨f[ke v©j tfVYkrk,a Kkr ugÈ gSaA
eSua s ;g QkseZ i<+ fYk;k gS ¼;k bls i<+ dj eq>s lquk;k x;k gS½ v©j eSa ihdsVh 'kY;fØ;k dh lÒh tfVYkrkv¨a] t¨f[ke¨a v©j YkkÒ¨a d¨ iwjh rjg
le>rk gwAa eSa le>rk gwa fd ihdsVh 'kY;fØ;k dh d¨bZ xkjaVh ugÈ gSA
eSa fQj Òh viuh nkb±@ckb± vka[k@n¨u¨a vka[k¨a dh ihdsVh Y¨tj fpfdRlk djkus dk pquko djrk gwaA
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
( 105 )
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
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( 106 )
Photorefractive Keratectomy (PRK)
Chandrashekhar
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
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 as with all forms of treatment, the results in my case cannot be
guaranteed. For example:
1.
I understand that an overcorrection or undercorrection could occur, causing me to become farsighted or nearsighted or increase
my astigmatism and that this could be either permanent or treatable. I understand an overcorrection or undercorrection is more
likely in people over the age of 40 years and may require the use of glasses for reading or for distance vision some or all of the time.
2.
If I currently need reading glasses, I will likely still need reading glasses after this treatment. It is possible that dependence on
reading glasses may increase or that reading glasses may be required at an earlier age if I have PRK surgery.
3.
Further treatment may be necessary, including a variety of eye drops, the wearing of eyeglasses or contact lenses (hard or soft), or
additional PRK or other refractive surgery.
4.
My best vision, even with glasses or contacts, may become worse.
5.
There may be a difference in spectacle correction between eyes, making the wearing of glasses difficult or impossible. Fitting and
wearing contact lenses may be more difficult.
6.
I have been informed, and I understand, that certain complications and side effects have been reported in the post-treatment period
by patients who have had PRK, including the following:
A.
Possible short-term effects of PRK surgery: The following have been reported in the short- term post treatment period and
are associated with the normal post-treatment healing process: mild discomfort or pain (first 72 to 96 hours), corneal
swelling, double vision, feeling something is in the eye, ghost images, light sensitivity, and tearing.
B.
Possible long-term complications of PRK surgery:
Haze: Loss of perfect clarity of the cornea, usually not affecting vision, which usually resolves over time.
Starbursting
: After refractive surgery, a certain number of patients experience glare, a “starbursting” or halo effect around
lights, or other low-light vision problems that may interfere with the ability to drive at night or see well in dim light.
Although there are several possible causes for these difficulties, the risk may be increased in patients with large pupils or high
degrees of correction. For most patients, this is a temporary condition that diminishes with time or is correctable by wearing
glasses at night or taking eye drops. For some patients, however, these visual problems are 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 or take eye drops. I
understand that it is not possible to predict whether I will experience these night vision or low light problems, and that I may
permanently lose the ability to drive at night or function in dim light because of them. I understand that I should not drive
unless my vision is adequate. These risks in relation to my particular pupil size and amount of correction have been
discussed with me.
LossofBestVision: A decrease in my best vision even with glasses or contacts.
IOP Elevation: An increase in the inner eye pressure due to post-treatment medications, which is usually resolved by drug
therapy or discontinuation of post-treatment medications.
Mild or severe infection: 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.
Keratoconus: Some patients develop keratoconus, a degenerative corneal disease affecting vision that occurs in approximately
1/2000 in the general population. While there are several tests that suggest which patients might be at risk, this condition can
( 107 )
develop in patients who have normal preoperative topography (a map of the cornea obtained before surgery) and pachymetry
(corneal thickness measurement) . Since keratoconus may occur on its own, there is no absolute test that will ensure a
patient will not develop keratoconus following laser vision correction. Severe keratoconus may need to be treated with a
corneal transplant while mild keratoconus can be corrected by glasses or contact lenses.
C.
Infrequent complications. The following complications have been reported infrequently by those who have had PRK
surgery: itching, dryness of the eye, or foreign body feeling in the eye; double or ghost images; patient discomfort; inflammation
of the cornea or iris; persistent corneal surface defect; persistent corneal scarring severe enough to affect vision; ulceration/
infection; irregular astigmatism (warped corneal surface which causes distorted images); cataract; drooping of the eyelid;
loss of bandage contact lens with increased pain (usually corrected by replacing with another contact lens); and a slight
increase of possible infection due to use of a bandage contact lens in the immediate post-operative period.
I understand there is a remote chance of partial or complete loss of vision in the eye that has had PRK surgery.
I understand that it is not possible to state every complication that may occur as a result of PRK surgery. I also understand that complications
or a poor outcome may manifest weeks, months, or even years after PRK surgery.
I understand this is an elective procedure and that PRK surgery is not reversible.
For women only: I am not pregnant or nursing. I understand that pregnancy could adversely affect my treatment result.
I have spoken with my physician, who has explained PRK, its risks and alternatives, and answered my questions about PRK surgery. I
therefore consent to having PRK surgery on:
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 108 )
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dh fji¨Vs± vkbZ gS%a
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i;kZIr u g¨ r¨ eq>s okgu ugÈ pYkkuk pkfg,A esjh vka[k dh iqrYkh dh fo'¨"k eki v©j lq/kkj dh ek"kk lac/a kh bu t¨f[ke¨a ds ckjs esa esjs
lkFk ppkZ dh xbZ gSA
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vkbZv¨ih dk cguk% mipkj¨Ùkj nh tkus okYkh nokv¨a ds dkj.k vka[k ds vkarfjd ncko esa o`f) g¨ ldrh gS] t¨ lkekU;r;k v©"kf/k mipkj
;k mipkj¨Ùkj nokv¨a ds can djus ls Bhd g¨ tkrk gSA
gYdk ;k xaÒhj laØe.k% gYds laØe.k dk lkekU;r;k ,aVh c‚;¨fVDl ls bYkkt fd;k tk ldrk gS v©j lkekU;r;k muls n`f"V dh dkLFkk;h
gzkl ugÈ g¨rkA xaÒhj laØe.k] pkgs ,sVa hc‚;¨fVDl ls lQYkrkiwoZd mudk mipkj g¨ Òh tk, rc Òh LFkk;h oz.kfpUg N¨M+ ldrs gSa v©j
n`f"V gzkl iSnk dj ldrs gSa ftlds fYk, lqjk/kkRed Y¨tj 'kY;fØ;k dh vko';drk g¨rh gS] ;k cgqr xaÒhj g¨us ij dkfuZ;k ds ÁR;kj¨i.k
dh t:jr iM+ ldrh gSA
dsjkV¨d¨ul% dqN j¨fx;¨a esa n`f"V d¨ ÁÒkfor djus okYkk dkfuZ;k dk ,d {k;dkjh j¨x dsjkVsd¨ul fodflr g¨ tkrk gSA ;g j¨x vke
( 109 )
vkcknh esa 2000 esa ls fdlh ,d O;fä d¨ g¨rk gSA gkYkkafd dbZ tkapas gSa t¨ crk ldrh gSa fd d©u&ls j¨xh d¨ bldk t¨f[ke g¨ ldrk
gS] Y¨fdu ;g voLFkk mu j¨fx;¨a esa Òh fodflr g¨ ldrh gS] 'kY;fØ;k ls igY¨ ftudh V¨i¨xzkQh ¼'kY;fØ;k ds igY¨ rS;kj fd;k tkus
okYkk d‚fuZ;k dk uD'kk½ v©j iSfdesVªh ¼d‚fuZ;k dh e¨VkbZ dh eki½ lkekU; g¨rh gSA pwfa d dsjkV¨d¨ul vius vki g¨ ldrk gS] blfYk,
;g lqfuf'pr djkus okYkh d¨bZ iq[rk tkap ugÈ gS fd j¨xh esa Y¨tj n`f"V la'k¨/ku ds ckn dsjkV¨d¨ul fodflr ugÈ g¨xkA xaÒhj
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( 110 )
LASIK
Prakashchand Agarwal, Reena Sharma
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
LASIK reshapes the cornea, it involves raising a thin flap of corneal tissue using a blade/ femtosecond laser and remodelling of corneal
shape using excimer laser.
During the procedure the patient is required to fix his / her gaze at the blinking light, to ensure proper centration. Clicking sound is heard
and a smell similar to that of charring of hair is perceived.
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 that I presently have without spectacles or/ and contact lenses. However I understand that an excellent unaided vision may
not be guaranteed
Alternative Treatments
I understand that continuous use of spectacles and / or contact lenses can provide excellent vision and LASIK is an alternative to decrease
the dependence on spectacles and / or contact lenses.
Possible Side Effects, Risks and Complications
Undercorrection or Over Correction
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 undercorrection or over correction.
As a result, I may require some spectacles to achieve best possible vision for distance and /or near. If treatment may be required, a period
of 6 months must elapse between it and the original surgery.
Presbyopia
I understand that as I get older (45 yrs 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.
Decrease of Best Corrected Vision
I understand that post-LASIK, best spectacle correction may not be as good as before the procedure.
Glare, Starbursts and Double Vision
These may occur, more so in the first 24 hours. In most cases, they disappear in 1-4 weeks.
Rare Complications
Infection, inflammation, corneal oedema, loss or damage to the corneal flap.
Long Term Changes
There may be alteration in power requiring spectacles or contact lenses.
( 111 )
Technical Failure
It may lead to abandoning the procedure and performing a repeat procedure at a later date.
I certify that I have fully understood the implications of the above consent and authorize the doctors to perform the procedure on my R/
L Eye. I have had all the questions answered to my satisfaction.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 112 )
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( 113 )
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( 114 )
Astigmatic Keratotomy (AK)
Asim K. Kandar
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
Introduction
Astigmatic keratotomy (AK) is a surgical procedure which consists of making fine microscopic arcuate (curved) incisions, either singly
or as a pair, at optical zones of either 6 or 7 mm, or relaxing incisions at the limbus, which is the junction of the clear part of the eye (cornea)
with the white (sclera) of the eye. These cuts are made for the purpose of flattening the steepest part of the cornea in an attempt to obtain
a more spherical cornea. AK permanently changes the shape of the cornea. Although the goal of AK is to improve vision to the point of
not wearing glasses, this result is not guaranteed.
AK 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 that 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 AK
If you decide not to have AK, there are other methods of correcting your astigmatism. These alternatives include, among others,
eyeglasses, contact lenses, and other refractive surgical procedures such as PRK or LASIK.
Patient Consent
I give my consent to my ophthalmologist to perform AK, and I declare that I have received no guarantee as to the success of my particular
case. I understand that the following risks are associated with the procedure:
Potential Risks and Complications
1.
I understand that there is a possibility that my vision may not improve with this surgery or that the desired results of surgery may not
be obtained. It is possible that I may require additional surgery at a later date or that I could still need glasses after surgery. It is
possible that I may not be able to wear contact lenses after having this surgery.
2.
As a result of the surgery, it is possible that I could lose vision or best-corrected vision. This could happen as a result of infection that
could not be controlled with antibiotics or other means, which could even cause loss of my eye.
3.
Irregular healing of incisions may cause the corneal surface to be distorted. In that case, it may be necessary for me to wear a contact
lens to affect useful vision, and there is a possibility that this may not restore useful vision.
4.
I understand that I may experience incapacitating light sensitivity from sunlight or other bright light sources for a varying length
of time, or possibly permanently.
5.
I understand that I may experience incapacitating glare or halos from oncoming headlights or other bright light sources, particularly
in the evening or at nighttime, for a varying length of time or possibly permanently. I am aware that this may interfere with driving
for an indefinite period both during day and night, and I understand that I am not to drive until I am certain that my vision is
adequate both during day and night.
6.
I understand that fluctuations or variation in vision may occur during the day during the initial stabilization period (up to three
months or longer).
7.
As occurs in all surgical procedures, scarring is the result of making incisions in living tissue. This particular surgery is no
exception.
8.
My eye will be more susceptible to a blow to the eye during the healing phase and possibly somewhat after healing as the microscopic
scar tissue may not be as strong as the normal tissue. Protective eyewear is recommended for all contact and racquet sports where
a direct blow to the eye could cause permanent injury to the eye.
( 115 )
9.
Additional reported complications include corneal perforation, which could possibly require sutures; incisional inclusions, corneal
vascularization, corneal ulcer formation, endothelial cell loss, epithelial healing defects, and very rarely, endophthalmitis (internal
infection of the eye, which could lead to permanent loss of vision).
10.
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.
Patient’s Statement of Acceptance and Understanding
The details of the procedure known as AK 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 have read this informed consent form (or it has been read to me),
and I fully understand it and the possible risks, complications, and benefits that can result from surgery. I therefore consent to AK surgery.
I wish to have AK performed on my R/L/Both eye(s).
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 116 )
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8-
esjh vka[k ?kko Òjus dh voLFkk ;k laÒor% ?kko Òjus ds ckn Òh vk?kkr ds Áfr vf/kd lqxzká g¨xh D;¨afd lw{en'kÊ oz.k Ård lkekU; Ård¨a
ftrus n`<+ ugÈ g¨axs lÒh laidZ v©j jSdVs ls [¨Y¨ tkus okY¨ [¨Yk¨a ds n©jku lqj{kkRed us= igukos dh lYkkg nh tkrh gSA D;¨afd vka[k d¨ Ykxus
okYkk lh/kk vk?kkr vka[k d¨ {kfr igqp
a k ldrk gSA
( 117 )
9-
vfrfjä Áfrosfnr tfVYkrkv¨a esa dkfuZ;k ds fNæ 'kkfeYk gSa ftuds fYk, laÒor% Vkads Ykxkus dh vko';drk iM+ ldrh gS( phjs ls lacfa /kr varos'Z ku]
dkfuZ;k dk okfgdko/kZu] dkfuZ;k esa oz.k cuus] bihfFkfYk;eh d¨f'kdkv¨a dk {k;] bihfFkfYk;eh ?kko ds Òjus esa foÑfr] v©j cgqr gh fojY¨ ekeYk¨a
esa ,aM¨IF©YkekbfVl ¼vka[k dk van:uh laØe.k ftlds dkj.k LFkk;h :i ls n`f"V tk ldrh gS½ 'kkfeYk gSAa
10-
lÒh 'kY;fØ;kv¨a dh rjg blesa Òh laKkgj.k] nokv¨a ds ÁfrdwYk ÁÒko¨a ;k nwljs dkjd¨a ls ftlesa esjs 'kjhj ds nwljs fgLls 'kkfeYk g¨ ldrs gS]a
tfVYkrk,a g¨a ldrh gSAa eSa le>rk gwa fd pwfa d fdlh Òh 'kY;fØ;k ds ifj.kke Lo:i g¨us okYkh ÁR;sd tfVYkrk d¨ Lo"V djuk vlaÒo gS blfYk,
g¨ ldrk gS fd bl Ái"k dh tfVYkrkv¨a dh lwph iwjh u g¨A
j¨xh dh LohÑfr v©j le>nkjh dk c;ku
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fpfdRld us esjs Á'u¨a ds lar¨"ktud mÙkj fn, gSAa eSua s ;g lwfpr lgefr Ái"k i<+ fYk;k gS ¼;k eq>s i<+ dj lquk;k x;k gS½ v©j eSa bls v©j laÒkfor
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eSa nkb±@ckb± vka[k@n¨u¨a vka[k¨a ij ,ds djkuk pkgrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
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irk %......................................................................................................................................................................................................
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fo'ks"k :i ls jksxh ls lacfa /kr gSA
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MkWDVj dk gLrk{kj %
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rkjh[k %
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( 118 )
Intacs
Rashim Mannan, J. S. Titiyal
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
Nature of the Intacs Procedure
Intacs® is a non-laser procedure with FDA approval for use in patients with myopia and astigmatism. Intacs are intrastromal corneal ring
segments in the shape of a semi-circle which an ophthalmologist inserts into the non-seeing periphery of the cornea through a tiny
incision. These segments flatten the central cornea without removing tissue to better focus light. The segments are made of the same
material that’s been implanted in human eyes after cataract surgery, called PMMA (polymethylmethacrylate). The procedure is performed
under local anesthesia, peri-bulbar block or topical (eye drops) anesthesia. During the procedure, if performed under topical anesthesia,
patient has to fix his or her gaze on the bright light of the operating microscope or as instructed by the operating ophthalmologist.
Expected benefits: Intacs® have the advantage of removability or exchangeability for different sized segments, and maintaining a more
natural corneal shape. Intacs cannot be felt by the patient, require no maintenance, and are probably less visible than a contact lens to the
naked eye. Patients who elect to have Intacs® are not “locked in” to the procedure forever, as are patients who undergo other refractive
procedures such as LASIK or PRK.
Alternative treatments: I understand that continuous use of spectacles and / or contact lenses can provide good vision and Intacs® is an
alternative to decrease the dependence on glasses and / or contact lenses.
Possible Side Effects, Risks and Complications
1.
OVER/UNDER-CORRECTION: I understand that calculations used in this surgery are based on previous experience on large
number of patients and these use average values. I understand that Intacs® do not provide a full correction or a full reversal back to
eye’s normal refractive state. Rather, the goal is to reduce myopia and astigmatism and /or to alter the shape of the cornea so that
contact lenses can have a better fit. Thus depending on individual variations in response to the procedure, there may be some
under-correction or over-correction.
2.
VISUAL ACUITY FLUCTUATION: I may have blurred vision or fluctuating vision following the procedure, this is due to
modulation in the corneal tissue in response to Intacs® in the corneal stroma.
3.
LIGHT SENSTIVITY: I may experience glare or halos form light sources, more so during night time. These tend to disappear with
time but glare may persist for a long time particularly at night.
4.
INDUCED ASTIGMATISM: I understand that I may experience a temporary blurring or distortion of vision for several days after
the procedure. This type of visual distortion is normal during the healing process and, in most cases, it decreases over time.
However, in rare instances, it may be permanent.
5.
PRESBYOPIA AND OTHER OCULAR CONDITIONS: I understand that Intacs® will NOT prevent the development of naturally
occurring eye problems such as glaucoma, cataracts, retinal degeneration, or detachment. Further Intacs® do not correct the
condition known as presbyopia (or aging of the eye), which may require reading glasses for close work at about age 40.
6.
OTHER COMPLICATIONS: Like any other surgical procedure of the eye, insertion of Intacs® can lead to trauma to corneal tissue
leading to corneal edema, perforation, infection, which if severe could result in the loss of the eye or, rarely, a cataract. I understand
that stromal thinning may occur due to shallow placement, which would require removal of the Intacs®. Further I have been made
fully aware that if there are complications or problems during the surgery, the surgeon may not be able to insert Intacs®, and the
surgery may have to be cancelled.
There are other risks associated with any surgery. Since it is impossible to state every risk or complication that may occur as a result of any
surgery, the possible risks and complications listed in this informed consent may be incomplete. There may be risks or complications
associated with this surgery that are unknown because this is a relatively new procedure.
( 119 )
I hereby give permission to release/publish medical data and/or video/audio record/photograph the current procedure and the procedures
performed in subsequent/ follow up visits for the advancement of medical knowledge.
In signing this consent form for insertion of Intacs® I am stating that I have read this consent form (or it has been read to me) and I fully
understand the nature and the purpose of and the possible side effects, risks and complications of this procedure. Although it is impossible
for the doctor to inform me of every possible complication that may occur, the doctor has answered all my questions to my satisfaction.
I give permission to perform Intacs® insertion on my R/L/Both eye(s).
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 120 )
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( 121 )
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( 122 )
Phakic IOL
Rashim Mannan, J. S. Titiyal
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
Nature Of The Phakic Iol Procedure
Surgical implantation of a phakic intraocular lens is one of a number of alternatives for correcting nearsightedness. In phakic implant
surgery, an artificial lens (such as the ICL or Verisyse phakic intraocular lens) is surgically placed inside your eye. The lens is made from
material similar to the type used for intraocular lenses currently being implanted in the eye to correct vision after cataract surgery. The
difference between phakic implant surgery and other intraocular lens implants is that your natural lens is not removed during phakic
implant surgery. The phakic lens is inserted in addition to your natural lens. The procedure is performed under local anesthesia, peribulbar block.
The surgeon will make two small holes in the colored portion of your eye (the iris) to help ensure that intraocular fluid does not build up
behind the phakic lens; this procedure is called an iridotomy. It will take place either at the time of surgery by using an instrument (a
surgical iridotomy) or within two weeks before the placement of the phakic implant by using a laser (YAG-laser iridotomy).
Indications & Expected Benefits
If you have myopia, hyperopia or astigmatism, phakic implant surgery may improve your natural vision without the use of glasses or
contacts. Further they have the advantage of removability and maintaining a more natural corneal shape. Phakic IOL cannot be felt by the
patient, require no maintenance, and are less visible than a contact lens to the naked eye. Patients who elect to have Phakic IOL implants
are not “locked in” to the procedure forever, as are patients who undergo other refractive procedures such as LASIK or PRK.
Alternative Treatment
I understand that continuous use of spectacles and / or contact lenses can provide good vision and Phakic IOL is an alternative to decrease
the dependence on glasses and / or contact lenses.
Possible Side Effects, Risks And Complications
Vision Threatening Complications:
ANAESTHETIC COMPLICATIONS: In most cases, the surgery will be accomplished with use of an injection around the eye for
anesthesia. Very rare complications from injections include damage to the eye muscles, perforation of the eye, and damage to the retina
or optic nerve leading to loss of vision.
INFECTION: 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 treated with antibiotics, could lead to permanent scarring and loss of vision.
IRIS ATROPHY: I understand that I could experience damage to the iris (the colored portion of the eye) leading to iris atrophy or develop
a rise in the pressure in my eye (secondary glaucoma). I may require another iridotomy if this occurs or eye drops to control the pressure.
RETINAL DETATCHMENT: I understand that I could develop a retinal detachment, a separation of the retina from its adhesion at the
back of the eye, which usually results from a tear in the retina and could lead to vision loss. Patients with moderate to high levels of
nearsightedness have a higher risk of retinal detachment when compared to the general population. This risk level may be increased with
implantation of the phakic IOL.
CATARACT: I understand that I may develop a cataract, or a clouding of the eye’s natural lens, which impairs normal vision, and may
require removal of the lens, the phakic implant, and insertion of an artificial lens.
( 123 )
CORNEAL INVOLVEMENT: I understand that I may develop corneal swelling (edema) and/or ongoing loss of cells lining the inner
surface of my cornea (endothelial cells). These cells play a role in keeping the cornea healthy and clear. Corneal edema and loss of
endothelial cells may result in a hazy and opaque appearance of the cornea, which could reduce vision and may require a corneal
transplant.
GLAUCOMA: I understand that I may develop glaucoma, which is an increase in the pressure of the eye caused by slowed fluid drainage.
Glaucoma can lead to vision loss, and may require treatment with long-term medications or surgery.
I understand that other complications could threaten my vision, including, but not limited to, iritis or inflammation of the iris (immediate
and persistent), uveitis, bleeding, swelling in the retina (macular edema), and other visual complications. Though rare, certain complications
may result in total loss of vision or even loss of the eye. Complications may develop days, weeks, months, or even years later.
Non-vision-threatening Side Effects
GLARE OR HALOS: I understand that there may be increased sensitivity to light or night glare. I also understand that at night there may
be a “starbursting” or halo effect around lights. The risk of this side effect may be related to the size of my pupil, and larger pupils may put
me at increased risk.
UNDER/OVER CORRECTION: I understand that an over-correction or under-correction could occur, causing me to become farsighted,
remain nearsighted, or increase my astigmatism and that this could be either permanent or treatable with either glasses, contact lenses, or
additional surgery.
REPEAT SURGERY: I understand that the phakic lens may need to be repositioned, removed surgically, or exchanged for another lens
implant. The lens may change position (de-centration), or I may require a different size or power of lens than that of the implanted lens.
Potential complications of additional surgery include all of the complications possible from the original surgery.
PROTECTIVE GLASSES: I understand that, after phakic implant surgery, the eye may be more fragile to trauma from impact. I
understand that the treated eye, therefore, is somewhat more vulnerable to all varieties of injuries. 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.
PRESYOPIA: 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 at an earlier age if I have this surgery.
I understand that the correction that I can expect to gain from phakic implant surgery 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.
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.
I understand that because I have a phakic lens, it is important for me to be seen at all follow-up visits as felt necessary by my surgeon.
I hereby give permission to release/publish medical data and/or video/audio record/photograph the current procedure and the procedures
performed in subsequent/ follow up visits for the advancement if medical knowledge.
In signing this consent form for insertion of Phakic IOL I am stating that I have read this consent form (or it has been read to me) and I
fully understand the nature and the purpose of and the possible side effects, risks and complications of this procedure. Although it is
impossible for the doctor to inform me of every possible complication that may occur, the doctor has answered all my questions to my
satisfaction.
I give permission to perform phakic IOL insertion on my R/L/Both eye(s).
( 124 )
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 125 )
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dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
Q‚fdd vkbZv¨,Yk dh ÁÑfr%
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vka[k esa 'kY;fØ;k }kjk ,d Ñf"ke Y¨al ¼tSl]s vkbZlh,Yk ;k osfjlkbls Q‚fdd baVªkv‚D;qYkj Y¨al½ Ykxk;k tkrk gSA ;g Y¨al mlh inkFkZ ls cuk g¨rk gS
ftl inkFkZ ls cus Y¨al bu fnu¨sa e¨sfr;kfcan ds v‚ijs'ku ds ckn n`f"V lgh djus ds fYk, vka[k esa ÁR;kj¨fir fd, tkrs gSAa Q‚fdd ÁR;kj¨i.k v©j nwljs
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gSAa ;g ÁfØ;k Yk¨dYk ,suLs Fkhfl;k] isjh cYcj CYk‚d ds varxZr dh tkrh gSA
fpfdRld ;g lqfuf'pr djus ds fYk, fd Qk¡fdd Y¨al ds ihNs var%us"kh; rjYk tek u g¨a] vkidh vka[k ds jaxhu Òkx ¼vkbfjl½ esa n¨ N¨Vs fNæ djsxkA
bl ÁfØ;k d¨ vkbfjM¨Veh dgk tkrk gSA ,d midj.k ¼,d 'kY;fØ;kRed vkbfjV¨Veh½ dk mi;¨x djds 'kY;fØ;k ds n©jku fd;k tk,xk ;k ,d
Y¨tj ¼okbZ,th & Y¨tj vkbfjM¨Veh½ dk mi;¨x djds Qk¡fdd ySl ds LFkkiu ds n¨ g¶ras igY¨ fd;k tk,xkA
fpfdRlk lq>ko v©j visf{kr YkkÒ
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oSdfYid mipkj
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fojYk tfVYkrkv¨a esa vka[k dh isf'k;¨a d¨ {kfr] vka[k esa fNæ g¨ tkuk] v©j jsfVuk ;k n`d~ raf"kdkv¨a d¨ {kfr 'kkfeYk gSa ftlls n`f"V dk gzkl g¨ ldrk gSA
laØe.k% eSa le>rk gwa fd gYds ;k xaÒhj laØe.k laÒo gSA gYds laØe.k¨a dk lkekU;r;k ,sVa hc‚;¨fVDl ls bYkkt fd;k tk ldrk gS v©j lekU;r;k
muls vLFkkbZ n`f"V gzkl ugÈ g¨rkA ,sVa hc‚;¨fVDl ls mipkj ds ckotwn xaÒhj laØe.k¨a ls LFkk;h oz.kfpUg cu ldrs gSa v©j n`f"V dk {k; g¨ ldrk gSA
vkbfjl ,VªkQ
s h eSa le>rk gwa fd eSa vkbfjl ¼vk[ka ds jaxhu Òkx½ dk {kfr vuqÒo dj ldrk gwa ftlls vkbfjl ,VªkQ
s h g¨ ldrk gS ;k esjh vka[k esa
ncko c<+ ldrk gS ¼f}rh;d XYkkd¨ek½ g¨ ldrk gSA ;fn ,slk g¨rk gS r¨ eq>s nqckjk bfjM¨V¨eh djkuh iM+ ldrh gS ;k ncko fu;af"kr djus ds fYk,
vka[k esa VidkbZ tkus okYkh nok dk mi;¨x djuk iM+ ldrk gSA
jsfVuk dk foYkxko% eSa le>rk gwa fd eSa jsfVuk ds fcYkxko] ;kuh vka[k ds ihNs vius çkd`frd LFkku ls jsfVuk ds vYkxko dk f'kdkj g¨ ldrk gw]a t¨
lkekU;r;k jsfVuk ds QVus ls g¨rk gS v©j ftldh otg ls n`f"V dk {k; g¨ ldrk gSA lkekU; vkcknh dh rqYkuk esa gYds] fu;af=r fudV n`f"Vrk ls
ihfM+r j¨fx;¨a esa jsfVuk ds fcYkxko dk t¨f[ke vf/kd jgrk gSA Qkfdd vkbZv¨,Yk ds ÁR;kj¨i.k ls t¨f[ke dk ;g Lrj c<+ ldrk gSA
e¨fr;kfcan% eSa le>rk gwa fd eq>s e¨fr;kfcan g¨ ldrk gS ;k vka[k ds lkekU; Y¨al /kq/a kY¨ g¨ ldrs gSa ftlls lkekU; n`f"V det¨j g¨ tkrh gS] v©j Y¨al
fudkY¨ tkus] Qkfdd ÁR;kj¨i.k v©j d`f"ke Y¨al Ykxkus dh vko';drk iM+ ldrh gSA
( 126 )
dkfuZ;k dk buoksyesUV eSa le>rk gwa fd esjh dkfuZ;k esa lwtu ¼'k¨Fk½ vk ldrk gS v©j@;k esjh dkfuZ;k dh fupYkh lrg ds vLrj dh d¨f'kdkv¨a
¼baM¨fFkfYk;eh d¨f'kdkv¨a½ dk {k; g¨ ldrk gSA ;s d¨f'kdk,a dkfuZ;k d¨ LoLFk v©j LoPN j[kus esa Òwfedk fuÒkrh gSAa d¨fuZ;k esa lwtu vkus v©j
baM¨fFkfYk;eh d¨f'kdkv¨a ds {k; ls dkfuZ;k /kq/a kYkh v©j vikjn'kÊ g¨ ldrh gS ftlls n`f"V det¨j iM+ ldrh gS v©j dkfuZ;k ds ÁR;kj¨i.k dh vko';drk
iM+ ldrh gSA
XYkkd¨ek% eSa le>rk gwa fd eq>s XYkkd¨ek g¨ ldrk gS t¨ rjYk ds /khes cgko ds dkj.k vka[k esa ncko c<+us ls g¨rk gSA XYkkd¨ek ls n`f"V det¨j iM+
ldrh gS v©j dkfuZ;k ds ÁR;kj¨i.k dh vko';drk iM+ ldrh gSA
eSa le>rk gwa fd vU; tfVYkrk,a esjh n`f"V ds fYk, [krjk cu ldrh gS]a buesa vkbfjfVl ;k vkbfjl dk Ánkg ¼rkRdkfYkd v©j iqjkuk½] ;wfw o;k'k¨Fk] jälzko]
jsfVuk esa lwtu v©j n`f"V lac/a kh vU; tfVYkrk,a 'kkfeYk gS]a Y¨fdu bUgÈ rd lhfer ugÈ gaSA gkYkkafd fojY¨ ekeYk¨a esa gh g¨rk gS Y¨fdu dqN tfVYkrkv¨a
ds QYkLo:i vka[k¨a dh j¨'kuh iwjh rjg tk ldrh gS ;k vka[k gh [kjkc g¨ ldrh gSA tfVYkrk,a fnu¨a( g¶r¨a] eghu¨a ;k ;gka rd fd o"k¨± ckn Òh g¨
ldrÈ gSAa
n`f"V ds fYk, [krjk u cuus okYkh tfVYkrk,a
p©a/k ;k ÁÒkeaMYk% eSsa le>rk gwa fd Ádk'k ds Áfr laons u'khYkrk ;k jkf"k p©a/k c<+ ldrh gSA eSa ;g Òh le>rk gwa fd jkr esa **rkjkfoLQ¨V** ;k Ádk'klz¨r
ds vkl&ikl vkÒkeaMYk fn[k ldrk gSA bl nq"ifj.kke dk t¨f[ke esjh vka[k dh iqrfYk;¨a dh eki ls lacfa /kr g¨ ldrh gS v©j vis{kkÑr cM+h iqrYkh
eq>s vf/kd t¨f[ke esa MkYk ldrh gSA
vYi@vfr la'k¨/ku% eSa le>rk gwa fd vfr la'k¨/ku ;k vYi la'k¨/ku g¨ ldrk gS ftlls eSa fudV n`f"Vn¨"k ;k nwj n`f"Vn¨"k dk f'kdkj g¨ ldrk gwa
;k esjk n`f"VoS"kE; c<+ ldrk gS v©j ;g Òh fd ;g ;k r¨ LFkk;h g¨ ldrk gS ;k p'es] dkaVSDV Y¨al¨a ;k vfrfjä 'kY;fpfdRlk ls mipkj ;¨X; g¨
ldrk gSA
nqckjk 'kY;fpfdRlk% eSa le>rk gwa fd Qsfdd Y¨l¨a d¨ iquLFkkZfir djuk iM+ ldrk gSA 'kY;fØ;k }kjk fudkYkuk ;k nwljs Y¨al ls iqujizR;kj¨i.k djuk
iM+ ldrk gSA Y¨al¨a dh fLFkfr cnYk ldrh gS ¼MhlsVa ª's ku½] ;k ÁR;kj¨fir Y¨al ds ikoj ls vYkx eki v©j ikoj okY¨ Y¨al dh vko';drk iM+ ldrh gSA
vfrfjä 'kY;fpfdRlk dh laÒkfor leL;kv¨a esa ewYk 'kY;fpfdRlk dh lÒh laÒkfor leL;k,a 'kkfeYk g¨rh gSAa
lqj{kkRed p'ek% eSa le>rk gwa fd Qsfdd ÁR;kj¨i.k 'kY;fpfdRlk ds ckn esjh vka[k Vôj ls Ykxus okYks vk?kkr ds Áfr vf/kd uktqd g¨ ldrh gSA
eSa le>rk gwa fd mipkfjr vka[k gj rjg dh p¨V¨a ds fYk, dqN vf/kd vk?kkr ;¨X; g¨rh gSA eSa el>rk gwa fd eq>s ,sls [¨Yk¨a ;k nwljh xfrfof/k;¨a esa
Òkx Y¨rs le; lqj{kkRed p'es Ykxkus dh lYkkg nh tk,xh ftlesa vka[k ls xsna ] x¨Ykh] dqguh] ?kwl
a k ;k vk?kkrdkjh nwljh oLrqv¨a ds Vdjkus dh vk'kadk
vf/kd g¨ ldrh gSA
tjk nwjn`f"V% eSa le>rk gwa fd ;fn bl le; eq>s i<+us ds p'es dh vko';drk gS r¨ g¨ ldrk gS fd bl mipkj ds ckn Òh i<+us ds p'es dh vko';drk
iM+As ;g Òh g¨ ldrk gS fd ;fn eSa ;g 'kY;fpfdRlk djkrk gwa r¨ i<+us ds p'es ij esjh fuÒZjrk v©j c<+ tk, ;k de mez esa gh i<+us ds p'es dh
t:jr iM+ tk,A
eSa le>rk gwa fd eSa Qsfdd vkbZvks,y ÁR;kj¨i.k ls ftl la'k¨/ku dh vis{kk djrk gwa 'kY;fpfdRlk ls og la'k¨/ku ÁkIr u g¨A eSa le>rk gwa fd ;g
vis{kk djuk ;FkkZFkokn ugÈ gS fd bl ÁfØ;k ds QYkLo:i gj le;] v©j gj ifjfLFkr esa '¨"k thou Òj ds fYk, esjh n`f"V fcYkdqYk lgh g¨ tk,xhA
lw{e foLr`r n`f"V dh ekax djus okY¨ Á;¨tu¨a ds fYk, viuh n`f"V ds ifjektZu ds fYk, p'es dh t:jr iM+ ldrh gS v©j ;g Òh fd 'kY;fpfdRlk
ds rqjra ckn ;k cjl¨a ckn bldh t:jr iM+ ldrh gSA
eSa le>rk gwa fd pwfa d fdlh Òh 'kY;fpfdRlk dh lÒh leL;kv¨a d¨ O;ä djuk laÒo ugÈ g¨rk blfYk, g¨ ldrk gS fd bl Ái"k esa of.kZr leL;kv¨a
dh lwph iwjh u g¨A
eSa le>rk gwa fd pwfa d eSua s Qsfdd Y©al Ykxok;k gS blfYk, esjk mu lÒh QkYk¨vi eqYkkdkr¨a ij tkap djkuk egRoiw.kZ gS ftUgsa esjk 'kY;fpfdRld vko';d
le>rk gSA
,rn}kjk eSa fpfdRlh; Kku dh Áxfr ds fYk, orZeku ÁfØ;k v©j vkxs pYkdj@Q‚Yk¨vi ds n©jku dh tkus okYkh ÁfØ;kv¨a ds vkadM+s v©j@;k
ohfM;¨@v‚fM;¨ tkjh@Ádkf'kr djus dh vuqefr nsrk gwAa
Qsfdd vkbZv¨,Yk ds lféos'k ds fYk, bl lgefr Ái= ij gLrk{kj djds eSa ?k¨"k.kk djrk gwa fd eSua s ;g lgefr Ái= i<uk fYk;k gS ¼;k eq>s bls i<+
dj lquk;k x;k gS½ v©j eSua s bl ÁfØ;k dh ÁÑfr v©j mÌs'; v©j blds laÒkfor nq"ÁÒko¨a] t¨f[ke¨a v©j leL;kv¨a d¨ le> fYk;k gSA gkYkkafd fpfdRld
ds fYk, ÁR;sd ÁÒkfor leL;k ds ckjs esa lwpuk ns ikuk laÒo ugÈ gS Y¨fdu fpfdRld us esj lÒh Á'u¨a ds lar¨"ktud mÙkj fn, gSAa
eSa viuh nkb±@ckb± vka[k@n¨u¨a vka[k¨a esa Qsfdd vkbZv¨,Yk bulVZ djus dh vuqefr nsrk gwAa
( 127 )
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
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Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 128 )
Conductive Keratoplasty
Chandrashekhar
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
In giving my permission for Conductive Keratoplasty (CK) I understand the following:
The long-term risks and effects of CK 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:
1.
I understand that the visual acuity I initially gain from CK could regress, and that my vision may go partially or completely back to
the level it was immediately prior to having the procedure
2.
I understand that it is possible that damage to my cornea could also be caused by scarring, ulceration, or an eye infection that could
not be controlled with antibiotics or other means
3.
I understand that I may not get a full correction from my CK procedure and this may require future enhancement procedures or the
use of glasses or contact lenses. This procedure may also cause an increase in my astigmatism, which may cause blurred vision
4.
I understand that an over-correction could occur, causing me to become nearsighted, and that this nearsightedness could be either
permanent or treatable
5.
I understand that the correction that I can expect to gain from CK may not be perfect and 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
6.
I understand that there may be pain, scratchiness, a foreign body sensation, or slight dryness in my eye, particularly during the first
48 hours after surgery
7.
I understand that there may be increased sensitivity to light. I understand this condition usually resolves within the first few weeks
following treatment, but it may also be permanent
8.
I understand that there may be a “balance” problem between my two eyes after CK has been performed on one eye, but not the other.
This phenomenon is called anisometropia. I understand this 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
9.
I understand I may temporarily experience corneal haze, small round hazy areas where the cornea was heated during the CK
treatment. This haze will usually fade over time and may only be visible with a microscope within 3 months following surgery
10.
I understand that if I currently need reading glasses, I will still likely need reading glasses after this treatment
11.
Even 90% clarity of vision is still slightly blurry. Enhancement surgeries can be performed when vision is stable UNLESS it is
unwise or unsafe. An assessment and consultation will be held with the surgeon at which time the benefits and risks of an
enhancement surgery will be discussed
12.
I understand that there is a natural tendency of the eyelids to droop with age and that eye surgery may hasten this process.
13.
I understand that the follow-up effects of CK are unknown and that CK has not been in use long enough to measure long-term
effects (those occurring after 10 years or more) following the procedures, and that unforeseen complications or side effects could
occur
14.
I understand that I may be given medication in conjunction with the procedure. I understand that I must not drive for at least one
day following the procedure and not until I am certain that my vision is adequate for driving
15.
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
( 129 )
The details of the procedure known as CK have been presented to me in detail and explained to me by my ophthalmologist. My
ophthalmologist has answered all my questions to my satisfaction. I therefore consent to CK surgery my R/L eye.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 130 )
daMfDVo dsjkV¨IYkkLVh
paæ'¨[kj
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
daMfDVo dsjkV¨IYkkLVh ¼lhds½ ds fYk, vuqefr nsrs gq, eSa fuEufYkf[kr d¨ le>rk gw%a
lhds ds nh?kZdkfYkd t¨f[ke v©j ÁÒko vKkr gSAa eq>s vius fo'¨"k ekeY¨ dh lQYkrk dh d¨bZ xkjaVh ugÈ feYkh gSA eSa le>rk gwa fd ÁfØ;k ds lkFk
fuEufYkf[kr t¨f[ke tqMs+ gS%a
1eSa le>rk gwa fd lhds ls ÁkjaÒ esa eq>s t¨ n`f"V lac/a kh xfrfof/k ÁkIr g¨xh og i'pxeu dj ldrh gS v©j vkaf'kd :i ls ;k iwjh rjg ls ÁfØ;k
djkus ls Bhd igY¨ ds Lrj ij okil tk ldrh gS
2eSa le>rk gwa fd laÒo gS fd oz.k fpUg] oz.k] ;k vka[k ds fdlh laØe.k ds dkj.k esjs dkfuZ;k d¨ {kfr igqp
a ldrh gS] ftls ,sVa hck;¨fVDl ;k
nwljs lk/ku¨a ls dUVªky
s ugÈ fd;k tk ldrk
3eSa le>rk gwa fd g¨ ldrk gS fd viuh lhds ÁfØ;k ls eq>s iwjk la'k¨/ku u ÁkIr g¨ v©j g¨ ldrk gS fd Òfo"; esa lao`f) ÁfØ;k dh vko';drk
iM+As ;g ÁfØ;k esjs n`f"V oS"kE; d¨ c<+k ldrh gS] t¨ /kq/a kYkh n`f"V dk dkj.k cu ldrk gS
4eSa le>rk gwa fd vfrla'k¨/ku g¨ ldrk gS t¨ eq>s fudV n`f"Voku cuk ldrk gS v©j ;g fudVn`f"VoÙkk ;k r¨ LFkk;h ;k mipkj ;¨X; g¨ ldrh
gSA
5eSa le>rk gwa fd eSa lhds ls t¨ la'k¨s/ku ÁkIr djus dh vis{kk djrk gwa og iwjh rjg lgh ugÈ g¨ ldrk v©j ;g vis{kk djuk ;FkkFkZokn ugÈ
g¨xk fd bl ÁfØ;k ds QYkLo:i esjh n`f"V '¨"kthou Òj ds fYk, gj le;] gj ifjfLFkfr esa iwjh rjg lgh g¨ tk,xhA eSa le>rk gwa fd vius
thou ds fdlh eqdke ij dqN Á;¨tu¨a ds fYk, t¨ lw{e foLr`r n`f"V dh ekax djrs gS]a eq>s viuh n`f"V ds ifjektZu ds fYk, p'es dh vko';drk
iM+ ldrh gS] v©j 'kY;fpfdRlk ds rqjra ckn ;k o"k¨± ckn ,slk g¨ ldrk gS
6eSa le>rk gwa fd esjh vka[k¨a esa nnZ] fdjfdjkgV] dqN iM+s g¨us ;k gYds ls lw[¨iu dh vuqÒfw r g¨ ldrh gS] fo'¨"kr;k 'kY;fpfdRlk ds igY¨
48 ?kaVs ds n©jku
7eSa le>rk gwa fd Ádk'k ds Áfr laons u'khYkrk esa o`f) g¨ ldrh gSA eSa el>rk gwa fd mipkj ds 'kq#vkrh dqN g¶r¨a ds n©jku ;g j¨x Bhd g¨
tkrk gS Y¨fdu ;g LFkk;h Òh g¨ ldrk gSA
8eSa le>rk gwa fd esjh n¨u¨a vka[k¨a esa ugÈ] cfYd ,d vka[k esa lhds g¨us ds ckn esjh n¨u¨a vka[k¨a ds chp larqYku dh leL;k iSnk g¨ ldrh gSA
bl x¨pj rF; d¨ n`f"V fo"kerk dgk tkrk gSA eSa le>rk gwa fd blls vka[k ij ruko iM+x
s k v©j nwjh dk vuqeku Ykxkus v©j xgjkbZ d¨ le>us
esa dfBukbZ g¨ ldrh gSA eSa le>rk gwa fd esjh igYkh vka[k dk ?kko Òjus esa lkekU; ls vf/kd le; Ykx ldrk gSA bl le; ds Ykack f[kapus
ls eSa n`f"V fo"kerk vuqÒo dj ldrk gwa
9eSa le>rk gwa fd eSa vLFkk;h :i ls dkfuZ;k dk /kq/a kYkkiu vuqÒo dj ldrk gw]a N¨Vs&N¨Vs /kq/a kY¨ fgLls tgka ij lhds mipkj ds n©Sjku dkfuZ;k
xeZ dh xbZ FkhA ;g /kq/a kYkkiu le; ds chrus ij lkekU;r;k [kRe g¨ tk,xk v©j 'kY;fpfdRlk ds rhu eghus ds Òhrj dsoYk lw{en'kÊ ls ns[kk
tk ldsxkA
10- eSa le>rk gwa fd ;fn eq>s bl le; i<+us dk p'ek Ykxrk gS r¨ bl mipkj ds ckn Òh eq>s p'es dh t:jr iM+ ldrh gSA
11- oLrqr% n`f"V dh 90% Li"Vrk vÒh rd dqN /kq/a kYkh gSA n`f"V ds fLFkj g¨ tkus ds ckn laof` ) 'kY;fpfdRlk dh tk ldrh gS] c'krsZ fd ;g vfoosdiw.kZ
v©j vlqjf{kr u g¨A 'kY;fpfdRld ds lkFk ewY;kadu v©j ijke'kZ fd;k tk,xk v©j mlh le; lao`f) 'kY;fpfdRlk ds YkkÒ¨a v©j t¨f[ke¨a ij
ppkZ dh tk,xh
12eSa le>rk gwa fd iYkd¨a dh LokÒkfod Áo`fÙk g¨rh gS fd mez c<+us ds lkFk os >qdrh tkrh gSa v©j ;g Òh fd vka[k dh 'kY;fpfdRlk bl ÁfØ;k
d¨ rst dj ldrh gS
13- eSa le>rk gwa fd lhds ds QkYk¨vi ÁÒko vKkr gSa v©j lhds brus Ykacs le; ls pYku esa ugÈ gS fd ÁfØ;kv¨sa ds ckn ds nh?kZdkfYkd ÁÒko ekis
tk ldsa ¼,sls ÁÒko t¨ 10 o"kZ ;k blls Òh vf/kd le; ckhn fn[krs gS½a v©j ml rjg dh vuisf{kr leL;k,a ;k nq"ÁÒko g¨ ldrs gSa
14- eSa le>rk gwa fd eq>s ÁfØ;k ds lkFk&lkFk nok,a Òh nh tk ldrh gSAa eSa le>rk gwa fd eq>s ÁfØ;k ds de ls de ,d fnu ckn rd okgu ugÈ
pYkkuk pkfg, v©j rc rd ugÈ pYkkuk pkfg, tc rd fd eSa vk'oLr u g¨ tkÅa fd esjh n`f"V okgu pYkkus ds fYk, i;kZIr gS
15- eSa le>rk gwa fd tSlk fd lÒh rjg dh 'kY;fpfdRlkv¨a ds lkFk g¨rk gS] laons ukgj.k] nokv¨a ds ÁfrdwYk ÁÒko¨a] ;k esjs 'kjhj ds nwljs fgLl¨a
ls tqMs+ vU; dkjd¨a ds dkj.k leL;k,a iSnk g¨ ldrh gSAa eSa le>rk gwa fd fpfdRld ds fYk, fdlh Òh 'kY;fpfdRlk dh lÒh laÒkfor leL;kv¨a
dk O;¨jk ns ikuk vlaÒo g¨rk gS blfYk, g¨ ldrk gS fd bl Ái= esa nh xbZ leL;kv¨a dh lwph iwjh u g¨A
( 131 )
eq>s esjs us"k fo'¨"kK }kjk lhds ds uke ls tkuh tkus okYkh ÁfØ;k dk foLr`r O;¨jk fn;k x;k gSA esjs us"kfpfdRld us esjs lÒh Á'u¨a ds lar¨"ktud
mÙkj fn, gSAa blfYk, eSa viuh nkb±@ckb± vka[k esa lhds 'kY;fpfdRlk djus dh vuqefr nsrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 132 )
Pterygium Surgery
Saurbhi Khurana
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been explained in the language that I understand that I have a fold of conjunctiva enroaching upon the cornea in my R/L eye, which
is to be surgically removed. The following has been explained to me:
•
Corneal opacity would persist after surgery
•
Risk of recurrence of fold and need for repeat surgery
•
Visual prognosis remains guarded in view of persisting astigmatism, hence vision may / may not improve after removal of the
lesion
•
A piece of conjunctiva from the same / other eye may be required to prevent recurrence of the fold if an autoconjunctival graft is
planned after excision
•
If Mitomycin C is applied after excision to decrease the incidence of recurrence, risk of scleral thinning has been explained
•
Redness, irritation, watering may persist for a few days after surgery
•
In case of autograft, sutures will be applied and may lead to irritation. Risk of infection of the graft has been explained
•
Additional laser procedure may be required for removal of corneal opacity after surgery
•
Surgery would be done under local infiltration/ anesthetic drops
After knowing all this, I give my free and voluntary consent to undergo pterygium excision i.e. removal of conjunctival fold from my eye.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 133 )
Vsfjft;e 'kY;fpfdRlk
l©jfÒ [kqjkuk
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eSa t¨ Òk"kk le>rk gwa ml Òk"kk esa eq>s le>k x;k gS fd esjh dUtaDVªkbZok dh ,d ijr esjh dkfuZ;k ij vfrØe.k dj jgh gS ftls 'kY;fpfdRld
}kjk gVk;k tkuk gS- eq>s fuEufYkf[kr ckrsa le>kbZ xbZ gS%a
Û
'kY;fpfdRlk ds ckn Òh dkfuZ;k dh vikjnf'kZrk cuh jg ldrh gS
Û
ijr ds nqckjk cu tkus dk t¨f[ke jgsxk v©j nqckjk mldh 'kY;fpfdRlk dh vko';drk iM+ ldrh gS
Û
oZreku n`f"VoS"kE; ds eÌsutj n`"; iwZokuqeku lqjf{kr jgrk gS blfYk, ?kko d¨ fudkYk fn, tkus ds ckn n`f"V esa lq/kkj g¨ Òh ldrk gS v©j
ugÈ Òh
Û
ijr ds nqckjk vkus ls j¨dus ds fYk, mlh vka[k@nwljh vka[k ls dUtaDVªkbZok ds ,d VqdM+s dh t:jr g¨xh] ;fn ?kko fudkYkus ds ckn viuh
gh dUtaDVªkbZok ds mij¨i.k dh ;¨tuk ckukbZ tkrh gS r¨
Û
;fn nqckjk ijr d¨ vkus ls j¨dus ds fYk, ?kko fudkY¨ tkus ds ckn ekbV¨flu&lh Ykxk;k tkrk gS r¨ LDY¨jk ds irY¨ g¨us ds t¨f[ke dk Li"Vhdj.k
fd;k tk pqdk gS
Û
YkYkkbZ] Ánkg] v©j ikuh dk vkuk 'kY;fpfälk ds dqN fnu ckn rd cuk jg ldrk gS
Û
viuh gh vka[k ds 'Y¨"ek ds mij¨i.k ds ekeY¨ esa Vkads Ykxk, tka,xs v©j mudh otg ls {k¨Ò g¨ ldrk gSA mij¨i.k esa laØe ds t¨f[ke d¨
Li"V fd;k tk pqdk gS
Û
'kY;fpfdRlk ds ckn dkfuZ;k dh vikjnf'kZrk d¨ fudkYkus ds fYk, vfrfjä Y¨tj ÁfØ;k dh vko';drk g¨xh
Û
'kY;fpfdRlk LFkkuh; var%lj.k@laons uk gj.k Mª‚Il MkYk dj dh tk,xh
;g lc tkuus ds ckn esSa Vsfjft;e ,Dlfltu] ;kuh viuh vka[k ls 'Y¨"ek dh ijr d¨ fudkYkus dh Lora"k v©j LosZfPNd vuqefr nsrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 134 )
Corneal Scraping
Saurbhi Khurana
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been explained in my own language thah I am suffering from an ocular infection i.e. a corneal ulcer in my R/L eye. I am to undergo
a diagnostic procedure in the form of a corneal scraping for the same. The following has been explained to me:
•
After topical anaesthesia, material would be taken from the ulcerated area with the help of a needle and sent for investigations.
•
The procedure is being done to isolate the organisms responsible for the infection in order to start appropriate treatment for the
same.
•
This is not a therapeutic procedure and will not lead to improvement in symptoms/ healing of the lesion or in visual recovery.
•
There is a risk of corneal perforation during the procedure for which surgical intervention may be required.
•
This procedure may/ may not isolate the organism responsible for the infection and accordingly may have to be repeated.
After knowing all this, I give my free and voluntary consent to undergo corneal scraping from my R/L eye.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 135 )
dkfuZ;y LØsfix
lqjfÒ [kqjkuk
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ..................................................................................................................................... VsyhQksu ua %. ........................................
eq>s esjh Òk"kk esa le>k;k x;k gS fd eSa us"k ds ,d laØe.k] ;kuh viuh nkb±@ckb± vka[k dh dkfuZ;y vylj ls ihfM+r gwAa eq>s blds funku ds fYk,
dkfuZ;y LØsfix ds :i esa ,d uSnkfud ÁfØ;k djkuh gSA eq>s fuEufYkf[kr ds ckjs esa crk;k x;k gS%
Û
LFkkfud laons ukgj.k ds oz.k Q¨M+s okYkh txg ls ,d lwbZ dh lgk;rk ds dqN æO; fudkYkk tk,xk v©j mls tkap ds fYk, Òstk tk,xkA
Û
;g ÁfØ;k ml laØe.k ds fYk, ftEesnkj tho dk irk Ykxkus ds fYk, dh tk jgh gS rkfd mlds fYk, mi;qä mipkj 'kq: fd;k tk ldsA
Û
;g mipkjkRed ÁfØ;k ugÈ gS v©j blls Yk{k.k¨a esa lq/kkj ugÈ g¨xk@?kko ugÈ Òjsxk ;k n`f"V dh fjdojh ugÈ g¨xhA
Û
ÁfØ;k ds n©jku dkfuZ;k esa fNæ g¨us dk t¨f[ke gS ftlds fYk, gLr{¨i dh vko';drk iM+ ldrh gSA
Û
g¨ ldrk gS fd ÁfØ;k ls laØe.k ds fYk, ftEesnkj tho u feY¨ v©j bls fQj ls djuk iM+As
;g lc tkuus ds ckn eSa viuh nkb±@ckb± vka[k ds dkfuZ;k ls [kqjpu fudkYkus dh Lora"k v©j LosZfPNd lgefr nsrk gwa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 136 )
Fibrin Glue Adhesive for Corneal Perforation
Kiran G.
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been clearly explained in the language I best understand that in view of my (diagnosis-corneal perforation), application of fibrin
glue will be attempted to seal the defect.
I have also been informed of the fact that this procedure is being attempted because the tissue defect in my cornea is less than 2 mm in
diameter.
I am fully aware of the risk of failure of the procedure which may necessitate reapplication of the glue or alternate treatment modalities like
corneal patch grafting.
I am also aware of the fact that glue may produce inflammation of varying intensities in the eye and that the risk of endophthalmitis is
greater with this procedure than a patch graft.
Nevertheless, I wish to have the procedure performed in my R/L eye and I am willing to accept the potential risks that my doctor has
discussed with me.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 137 )
Qk;fczu XYkw v<sflo Q‚j dkfuZ;Yk iQ¨Zjs'ku
fdju thjksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eq>s ml Òk"kk esa ftls eSa lcls vPNh rjg le>rk gw]a Li"V :i ls le>k;k x;k gS fd esjs ¼funku&dkfuZ;k ds fNæ½ d¨ ns[krs gq, bl [kkeh d¨ can
djus ds fYk, Qk;fczu XYkw Ykxkus Ykxkus dk Á;kl fd;k tk,xkA
eq>s bl rF; ls Òh voxr djk;k x;k gS fd bl ÁfØ;k dk Á;kl blfYk, fd;k tk jgk gS fd esjh dkfuZ;k dh Ård foÑfr dk O;kl 2 feeh ls de gSA
eSa ÁfØ;k dh ukdkeh ds t¨f[ke ls Òh iwjh rjg voxr gwa ftlds fYk, XYkw ;k dkfuZ;k ds VqdM+s ds j¨i.k tSlh oSdfYid mipkj dh vko';drk g¨xhA
eSa bl rF; ls Òh voxr gwa fd XYkw vka[k esa vYkx&vYkx rhczrkv¨a ds Ánkg iSnk dj ldrk gS v©j ;g Òh fd bl ÁfØ;k ds lkFk baM¨IF©YekbfVl dk
t¨f[ke VqdM+s ds j¨i.k ls vf/kd g¨rk gSA
fQj Òh eSa viuh nkb±@ckb± vka[k esa ;g ÁfØ;k djkus dk bPNqd gwa v©j eSa mu laÒkfor t¨f[ke¨a d¨ Lohdkj djus d¨ rS;kj gwa ftuds ckjs esa fpfdRld
us esjs lkFk ppkZ dh gSA
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 138 )
Symblepharon Release
Reena Sharma
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been informed in my mother tongue that I/ my child is suffering from adhesion of ocular surface and lids (Symblepharon) due to
disease involving the conjunctiva and cornea and that a surgery to remove this will be done. An amniotic membrane graft (human
placental tissue) or mucous membrane graft may be applied to the ocular surface with the help of sutures. Bandage contact lens will be
applied after the surgery.
I have been fully explained regarding the permanent nature of the lesion and that it has to be released to improve the ocular surface. This
procedure primarily will not improve vision. I have been explained the risk of inadvertent perforation of the eye during the surgery,
infection, inadequate release or reformation of adhesions. There may be a need for repeat surgery which may or may not lead to
improvement of vision. I have been explained the need for follow up as frequently as advised by the doctors that may span upto years, with
multiple investigations at each visit. I have been explained that proper use of medications is required for success of the treatment. I
understand that inspite of all efforts, there is a possibility that there may be no improvement or worsening of the visual acuity or the
cosmetic appearance of the eye.
I certify that I have fully understood the implications of the above consent and authorise the doctors to perform symblepharon release
with/ without AMT on my/ my child’s right / left eye.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 139 )
flaCY¨Qsj‚u fjYkht
jhuk 'kekZ
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eq>s esjh ekr`Òk"kk esa crk;k x;k gS eS@
a esjk cPpk datfa DVok v©j dkfuZ;k ls lac) j¨x ds dkj.k vkdqyj ljQsl v©j iYkd ds fpidkYk ¼flaCY¨Qsj‚u½
ls ihfM+r gS v©j ;g Òh fd bls Bhd djus ds fYk, 'kY;fpfdRlk dh tk,xhA Vkad¨a dh enn ls vkdqyj ljQsl ij ,fEuv‚fVd esca jsu ¼ekuo IY¨lsVa ds
Ård½ ;k 'Y¨"ek dYkk dk j¨i.k Ykxk;k tk,xkA 'kY;fpfdRlk ds ckn cSM
a t
s dkaVSDV Y¨al Ykxk;k tk,xkA
eq>s ?kko dh LFkkbZ ÁÑfr ds ckjs esa iwjh rjg le>k;k x;k gS v©j ;g Òh fd vkdqyj ljQsl d¨ lq/kkjus ds fYk, bls [k¨Ykuk gSA ;g ÁfØ;k ewYkr%
n`f"V ugÈ lq/kkjsxhA eq>s 'kY;fpfdRlk ds n©jku vlko/kkuh o'k vka[k esa fNæ] laØe.k] vi;kZIr eqfä] ;k vklatu¨a ds iqufuZeku dh vk'kadk ds ckjs esa
crk;k x;k gSA nqckjk fpfdRlk dh vko';drk iM+ ldrh gS ftlls n`f"V esa lq/kkj g¨ ldrk gS ;k ugÈ Òh g¨ ldrkA eq>s le>k;k x;k gS fd fpfdRld
ds lq>k, vuqlkj eq>s ckj&ckj Q‚Yk¨vi ds fYk, vkuk g¨xk t¨ cjl¨a pYk ldrk gS v©j ÁR;sd eqYkkdkr ij vusd tkapas dh tk ldrh gSAa eq>s le>k
x;k gS fd bYkkt dh lQYkrk ds fYk, nokv¨a dk Á;¨x vko';d gSA eSa le>rk gwa fd lÒh Á;kl¨a ds ckotwn laÒkouk gS fd n`f"V dh rh{.krk ;k vka[k
dh Álk/kd cká vkÑfr esa d¨bZ lq/kkj u g¨ ;k v©j Òh [kjkc g¨ tk,A
eSa Áekf.kr djrk gwa fd eSua s mi;qZä lgefr ds fufgrkFk¨± d¨ iwjh rjg le> fYk;k gS v©j fpfdRld d¨ ,,eVh ds lkFk@mlds fcuk viuh@vius cPps
dh nkb±@ckb± vka[k dh flaCY¨Qsj‚u fjYkht djus ds fYk, vf/kÑr djrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 140 )
Amniotic Membrane Transplantation (AMT)
Asim K. Kaudar
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been informed in my mother tongue that I/ my child is suffering from a disease involving the ocular surface
(specify ....................................) and that a surgery will be performed in which an amniotic membrane (covering of the foetal sac) will be
used to cover the ocular surface. The amniotic membrane will be sutured into place with circumferential interrupted sutures with 10-0
monofilament nylon sutures and the peripheral edge of the membrane will be sutured to the conjunctiva with 8-0 polyglactin interrupted
sutures. The excess membrane will be trimmed and a bandage contact lens will be put after surgery.
I have been fully explained regarding the permanent nature of the opacity/ lesion. I have been explained the risk of perforation of the host
eye, leading to the need for a full thickness corneal transplant. There is risk of infection, suture loosening and replacement , increased
blood vessels in interface possibly leading to haemorrhage, no improvement or worsening of best corrected visual acuity and pain,
glaucoma secondary to surgery or to medications after surgery. The membrane may shed off prematurely leading to repeat surgery which
may or may not lead to improvement of vision. I have been explained the need for follow up as frequently as advised by the doctors that may
span upto years, with multiple investigations at each visit. I have been explained that use of medications properly is required for success
of the surgery. There is chance of falling of the bandage contact lens and it may require replacement. I have been explained that I will need
to urgently come for follow-up to ophthalmic casualty if there is sudden onset redness, photophobia, pain or detoriation of vision as these
may be early signs of amniotic membrane infection. I understand that inspite of all efforts, there is a possibility that there may be
worsening of the visual acuity or the cosmetic appearance of the eye.
I certify that I have fully understood the implications of the above consent and authorise the doctors to perform Amniotic Membrane
Transplantation on my right / left eye.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 141 )
,fEuv‚fVd esaczsu VªkalIYkkaVs'ku ¼,,eVh½
vklhe ds- danj
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eq>s esjh ekr`Òk"kk esa lwfpr fd;k xk;k gS fd eS@
a esjk CkPpk vkdqyj ljQsl ls lac) j¨x ¼Li"V djs-a ---------------------------------------------------------------½ ls ihfM+r
gS v©j ;g Òh ,d 'kY;fpfdRlk dh tk,xh ftlesa vkdqyj ljQsl d¨ <adus ds fYk, ,d ,fEuv‚fVd esca jsu ¼Òz.w kh; F©Ykh ds vkoj.k½ dk mi;¨x fd;k
tk,xkA ,fEuv‚fVd esca jsu d¨ 10&0 e¨u¨fQYkkesVa uk;Yk‚u Vkad¨a dh enn ls ÒXuØe ifj/kh; Vkad¨a ls flYkk tk,xk v©j esca uzs ds ifj/kh; fdukjs d¨
ÒXuØe 8&0 i‚fYkXY©fDVu Vkad¨a dh enn ls datfa DVuk ds lkFk flYkk tk,xkA vfrfjä esca uzs d¨ rjk'k fn;k tk,xk v©j 'kY;fpfdRlk ds ckn cSM
a t
s
dkaVSDV Y¨al Ykxk;k tk,xkA
eq>s vikjnf'kZrk@?kko dh LFkkbZ ÁÑfr ds ckjs esa iwjh rjg le>k;k x;k gSA eq>s nkrk dh vka[k esa fNæ g¨us ds t¨f[k.k ds ckjs esa crk;k x;k gSA ftldh
otgls iwjh e¨VkbZ dh dkfuZ;k ds ÁR;kj¨i.k dh vko';drk iM+ ldrh gSA laØe.k] Vkads ds <hYkk iM+ tkus v©j ÁfrLFkkiu] varjkQYkd esa jäokfgfu;¨a
ds c<+ tkus v©j laÒor% mldh otg ls jälzko g¨us] loZJ"s V la'k¨f/kr n`'; xfrfof/k;¨a esa d¨bZ lq/kkj u g¨us ;k v©j Òh [kjkc g¨ tkus] v©j nZn] ltZjh
;k nokv¨a ds x©.k ÁÒko ds :i esa XYkkd¨eke g¨ tkus dk t¨f[ke gSA esca uzs le; ls igY¨ fxj ldrh gS ftlds dkj.k nqckjk ltZjh djuh iM+ ldrh
gS ftlls n`f"V esa lq/kkj g¨ Òh ldrk gS v©j ugÈ ÒhA eq>s crk;k x;k gS fd fpfdRld ds lq>k, vuqlkj esjk ckj&ckj QkYk¨vi ds fYk, vkuk vko';d
g¨xk t¨ cjl¨a pYk ldrk gS v©j ÁR;sd QkYk¨vi ds le; dbZ tkapas dh tk ldrh gSAa eq>s crk;k x;k gS fd ltZjh dh lQYkrk ds fYk, mfpr
vkS’kf/k ds Á;¨x vko';d gSA cSM
a t
s dkaVSDV Y¨al ds fxjus dh Òh laÒkouk gS v©j mlds ÁfrLFkkiu dh vko';drk iM+ ldrh gSA eq>s crk;k x;k gS
fd ;fn esjh vka[k esa vpkud YkYkkbZ vk tkrh gS] Ádk'k Òhfr] nnZ g¨us Ykxrh gS ;k n`f"V v©j Òh [kjkc g¨us Ykxrh gS r¨ eq>s rqjra us=fpfdRld vkikr
d{k esa Q‚Yk¨vi ds fYk, vkuk g¨xk D;¨afd ;g ,fEuv¨fVd esca jsu esa laØe.k dk ÁkjafÒd ladrs g¨ ldrk gSA eSa le>rk gwa fd lÒh Á;kl¨a ds ckotwn
laÒo gS fd n`'; xfrfof/k ;k vka[k dh Álk/kd oká vkÑfr v©j Òh [kjkc g¨ tk,A
eSa Áekf.kr djrk gwa fd eSua s mi;qZä vuqÁ;¨x¨a ds fufgRkkFk¨± d¨ iwjh rjg le> fYk;k gS v©j fpfdRldd¨a d¨ viuh nkb±@ckb± vka[k esa ,fEuv‚fVd esca uzs
ÁR;kj¨i.k dk vf/kdkj Ánku djrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 142 )
Limbal Stem Cell Transplantation (LSCT)
Asim K. Kaudar, Bhavna Chawla
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been informed in the language I best understand that I/ my child is suffering from an ocular surface disease with conjunctivalization
of the cornea (specify .........................................) and that a surgery to improve the ocular surface will be done along with removal of the
superficial part of the cornea depending upon depth of involvement. A part (limbal tissue) of a donor cadaveric cornea / from opposite
normal eye / from live related donor will be used either directly or after expansion in tissue culture media to replace the diseased tissue
with the help of sutures.
I have been fully explained regarding the permanent nature of the disease and that this treatment is intended to improve the ocular surface.
I have been explained the risk of perforation of the host eye, leading to full thickness corneal transplant. There is a risk of infection, graft
rejection, suture loosening and replacement, increased blood vessels possibly leading to haemorrhage, no improvement or worsening of
best corrected visual acuity. The opacity may increase after the surgery. There may be a need for repeat surgery which may or may not lead
to improvement of vision. I have been explained the need for follow up as frequently as advised by the doctors that may span upto years,
with multiple investigations at each visit. I have been explained that using medications properly is required for success of the graft. I have
been explained that I will need to urgently come for follow-up to ophthalmic casualty if there is a sudden onset of redness, photophobia,
foreign body sensation, pain or detoriation of vision as these may be early signs of infection or rejection. I understand that inspite of all
efforts, there is a possibility that there may be worsening of the visual acuity or the cosmetic appearance of the eye.
I certify that I have fully understood the implications of the above consent and authorise the doctors to perform Limbal Stem Cell
Transplantation on my right / left eye.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 143 )
fYkacYk LVse lsYk VªkalIYkkaVs'ku ¼,y,llhVh½
vlhe ds- danj] Òkouk pkoYkk
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eq>s ml Òk"kk esa ftls eSa lcls vPNh rjg le>rk gwa le>k;k x;k gS fd eS@
a esjk cPpk dkfuZ;k esa datfa DVoYkkbts'ku ¼Li"V :i ls O;¨jk nsa
----------------------------------------------------------½ ds lkFk vkD;wYkj lQsZl fMtht ls ihfM+r gS v©j ;g Òh fd tfVYkrk dh xgjkbZ ds vk/kkj ij dkfuZ;k ds Åijh
fgLls d¨ fudkYkus ds lkFk&lkFk us= dh lrg d¨ lq/kkjus ds fYk, ,d 'kY;fpfdRlk dh tk,xhA nkrk ds dsMkosfjd dkfuZ;k nwljh lkekU; vka[k@fj'rs
ds thfor nkrk ds dkfuZ;k ds ,d Òkx ¼fYkacYk Ård½ dk lh/¨ ;k Ård lao/kZu ek/;e esa foLrkj ds ckn Vkad¨a dh lgk;rk ls j¨xh Ård¨a d¨ ÁfrLFkkfir
djus ds fYk, mi;¨x fd;k tk,xkA
eq>s j¨x dh LFkk;h ÁÑfr ds ckjs esa iwjh rjg crk;k x;k gS v©j ;g Òh fd bYkkt dk mns'; us= dh lrg d¨ lq/kkjuk gSA eq>s nkrk dh vka[k esa fNæ
g¨ tkus ds t¨f[ke ds ckjs esa Òh crk;k x;k gS ftldh otg ls iwjh e¨VkbZ ds dkfuZ;k dk ÁR;kj¨i.k djuk iM+ ldrk gSA laØe.k] fuj¨i dh vLohÑfr]
Vkads ds <hYkk g¨us v©j ÁfrLFkkiuk] jä okfgfu;¨a dh la[;k ds c<+ tkus v©j QYkLo:i jälzko] loZJ"s B n`f"V rh{.krk esa d¨bZ lq/kkj u g¨us ;k mlds
v©j Òh [kjkc g¨ tkus dk t¨f[ke gSA nqckjk 'kY;fpfdRlk djus dh vko';drk iM+ ldrh gS ftlls esa lq/kkj g¨ ldrk gS ;k ugÈ Òh g¨ ldrkA eq>s
fpfdRld dh lYkkg ds vuqlkj ckj&ckj Q‚Yk¨vi ds fYk, vkus dh vko';drk ds ckjs esa crk;k x;k gS t¨ cjl¨a pYk ldrk gS v©j ÁR;sd eqYkkdkr
ij dbZ tkapas dh tk ldrh gSAa vpkud YkYkkbZ vk tkus] Ádk'k Òhfr g¨us d¨bZ pht iM+s g¨us dh vuqÒfw r g¨us] nnZ gS ;k n`f"V v©j [kjkc g¨ tkus ij
eq>s rqjra us"kfpfälk vkikr d{k esa Q‚Yk¨vi ds fYk, vkus dh t:jr ds ckjs esa crk;k x;k gS D;¨afd ;s laØe.k ;k vLohÑfr ds ÁkjafÒd Yk{k.k g¨
ldrs gSAa eSa le>rk gwa fd lÒh Á;kl¨a ds ckotwn laÒkouk gS fd vka[k dh n`'; rh{k.rk ;k Álk/kd okáÑfr v©j Òh [kjkc g¨ ldrh gSA
eSa Áekf.kr djrk gwa fd eSua s mi;qZä lgefr ds fufgrkFk¨± d¨ iwjh rjg le> fYk;k gS v©j fpfdRld¨a d¨ viuh nkb±@ckb± vka[k esa fYkacYk LVse lsYk
Vªkl
a IYkkaV's ku dsjus dk vf/kdkj Ánku djrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 144 )
Osteo-odonto Keratoprosthesis (OOKP)
Noopur Gupta, Radhika Tandon
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been informed in my mother tongue that I will need a specially designed keratoprosthesis where the artificial cornea is embedded
in a biological frame made of the canine tooth to enhance support and long-term stability of the visual aid to treat my blind eye/eyes as this
is the last option of restoring vision in my present condition and no other surgical procedure e.g. keratoplasty will be successful as I have
severe dry eyes also.
I understand that Keratoprosthesis will replace my opaque, white cornea and act like a telescope, so that the light rays can go in the eye and
reach the retina (back of the eye which is the seeing machinery of the eye) and I will be able to see.
I have been fully explained that for osteo-odonto-keratoprosthesis (OOKP), one of my healthy canine tooth/teeth will be harvested for
the surgery and a layer of the inner lining of the cheek will also be taken to cover the surface of the eye. The surgery will be done in two
stages which will be two months apart, so it may take a long time to gain vision after the first stage of the surgery.
I have been explained the potential benefits and risks of the procedure and that there is a possibility of no visual gain after surgery. There
may be potential complications like extrusion or necrosis of the OOKP lamina, infection in the eye and increased pressure in the eye.
There may be need of further surgeries if tissue grows over the OOKP cylinder or a membrane forms behind the cylinder, both of which
will need to be removed.
I certify that I have fully understood the implications of the above consent and authorize the doctors to perform OOKP surgery in my right/
left eye.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 145 )
vk¡fLVvks&v¨M¨aV¨ dsjkV¨Á¨LF¨fll ¼vksvksdsih½
uwiqj xqIrk] jkf/kdk VaMu
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
eq>s esjh ekr`Òk"kk esa crk;k x;k gS fd eq>s fo'¨"k :i ls fMtkbu fd, x, ,d dsjkV¨Á¨LF¨fll dh vko';drk g¨xh] ftlesa esjh va/kh vka[k@vka[k¨a dk
bYkkt djus ds fYk, n`'; lgkjs ds leFkZu v©j nh?kZ dkfYkd LFkkf;Ro d¨ c<+kus ds fYk, jnu ds nar ds tho oSKkfud <kaps esa Ñf"ke dkfuZ;k tM+h tkrh
gS] D;¨afd esjh orZeku voLFkk esa esjh n`f"V cpkus dk vafre fodYi ;gh gS v©j dsjkV¨IYkkLVh lQYk ugÈ g¨axh D;¨afd esjh vka[¨a xaÒhj :i ls lw[kh Òh gSAa
eSa le>rk gwa fd dsjkV¨Á¨LF¨fll esjs vikjn'kÊ lQsn dkfuZ;k d¨ ÁfrLFkkfir dj nsxk v©j fdlh nwjn'kÊ dh rjg dke djsxk rkfd Ádk'k dh fdj.¨a
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( 146 )
SQUINT
Squint Surgery
Shailesh G.M, Rohit Saxena
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
Information about Squint
Adults & children of any age with eye deviation may benefit from eye muscle surgery to make both eyes look straight. This will help
maximizing the chance of binocular fusion (3-D vision/depth perception) and normalizing the field of vision. Apart from making them
look cosmetically better, squint surgery may also allow patients to see more comfortably with a relaxed head position.
Events during surgery
•
General anesthesia is given in children & some special squint cases.
•
Local anesthesia in the form of injections around the eye is given in adults.
•
During surgery, one eye or both eye muscles are either tightened or loosened & the positions of the eye muscles are changed to
make eyes look straight.
Risks associated with Squint surgery
While we are unable to list every possible complication, the following are some potential risks.
Major risks
1)
Due to anesthesia (both general & local) – includes breathing difficulties, vomiting, sore throat, or even risk of heart attack or
death. Local complications of anesthesia injections around the eye can be in the form of perforation of eyeball, destruction of optic
nerve, interference with circulation of retina, drooping of eyelid, hypotension & respiratory depression.
2)
Need for reoperation – Over- and under-correction after surgery is common. A reoperation may be necessary because a totally
predictable response is not possible in every case. Need for reoperation may be high in cases where prior surgery has been
performed, when the squint is complicated, in cases of a slipped or lost muscle, excessive hemorrhage, or fat exposure. Reoperation
in some cases may be needed in the other (normal) eye also later to fine tune the surgical results.
3)
Loss of vision – is quite rare but can be associated with anesthesia or other causes like hemorrhage, retinal detachment (after needle
perforation), infection, or change in blood supply to the eye.
Minor risks: include inflammation of the eye (conjunctivitis), reaction to the sutures, pain, temporary double vision, temporary blurry
vision, alteration of the eyelid position and scar tissue formation including implantation cysts.
General information
•
Discomfort of eyes, redness & swollen eyelids for the first few days after surgery is common.
•
If child wears glasses, they will likely continue to wear glasses after the surgery.
•
Eyes are not patched after surgery & usually there is no permanent scar.
•
Eye drops are given 3 to 6 times a day for up to 1 month after surgery.
•
Temporary double vision after surgery is common.
•
Absorbable sutures are used & need not be removed after surgery.
Additional comments: ....................................................................................................................................................................................................
............................................................................................................................................................................................................................................
I have read & understand the consent form including potential risks & benefits of the squint surgery. I have discussed with my treating eye
( 147 )
surgeons & am satisfied with the explanation provided & I authorize them to proceed with my/child’s surgery. Occasionally a different,
unsuspected condition may arise at the time of surgery requiring immediate attention, and I authorize my surgeon to do what he/she
deems necessary.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 148 )
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( 149 )
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( 150 )
Botox (Botulinum Toxin) Injection
Shailesh G.M, Rohit Saxena
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I .............................................................................. have discussed my illness with my treating eye surgeon and I consent to having Botox
treatment carried out upon myself for the improvement of .......................................................................................
Botox is injected with a small needle into the skin/muscle, with the aim of inhibiting the underlying muscle contraction, therefore
improving my underlying muscle spasms/illness. In squint cases, the injection will weaken the overacting muscle & help in making the
eye look straight. Botox injection also gives additional information about squint and can be used instead of performing surgery.
I have been informed about the indications, treatment procedure, expected results & possible side effects. I understand that I may
experience swelling, redness, tenderness, flu-like syndrome, temporary muscle aching, as well as paralysis of a nearby muscle (which can
cause droopy eyelids, double vision, droopy mouth, or neck weakness), slight headache, pain and/or bruising that may occur for several
days after my treatment, however these symptoms will resolve.
Although the results are usually dramatic, I have been informed that the practice of medicine is not an exact science and that no guarantees
can be made concerning the expected results in my case. The injection will take 3-4 days to start acting & will usually last for up to 3
months. Repeated injections may be required as the effect starts decreasing from 3-months onwards.
I understand that I am required to have a follow-up consultation at 2 weeks, and that I am required to have photographs taken before,
during and after treatment for my medical records.
Contraindications
You should not have Botox if you are pregnant; nursing; allergic to albumin; have an infection, skin condition, or muscle weakness at the
site of the injection; or have Eaton-Lambert syndrome, Lou Gehrig’s disease, or myasthenia gravis. Botox contains human-derived
albumin and carries a theoretical risk of virus transmission.
I understand that whilst every precaution will be taken to prevent complications and that whilst complications from this procedure are
rare, they can and sometimes do occur. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient
opportunity for discussion to have any questions answered.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
( 151 )
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 152 )
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( 153 )
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( 154 )
GLAUCOMA
Trabeculectomy With / Without Anti-Fibroblastic Agents
Munish Dhawan, Ramanjit Sihota
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
Indications, Benefits, and Alternatives
I have been informed by my treating doctor that I have been diagnosed with glaucoma and if it is left untreated, it is very likely that I will
experience loss of vision which could end up in blindness. Glaucoma means rise in pressure of the eye which can sometimes be treated
successfully with medications, or if medications are not effective, laser and other surgical procedures may be of value in controlling the
pressure and preventing further vision loss.
My doctor has informed me that an operation called trabeculectomy is necessary to help control the pressure in my eye(s) because
prolonged rise of this pressure can damage my optic nerve leading to loss of vision and eventual blindness. When successful, this
procedure will lower the pressure in my eye, minimizing the risk of further vision loss from glaucoma. The purpose of the operation is to
control the pressure and preserve my vision; any vision lost to glaucoma cannot be restored.
Complications
As with any surgical procedure, there are risks associated with glaucoma drainage surgery. For example, there is always the possibility that
the surgery cannot control my eye pressure, for which medications or more procedures may be needed after surgery. Not every possible
complication can be covered in this form but the following are examples of risk encountered with glaucoma drainage surgery. These
complications can occur days, weeks, months, or years later. They can result in loss of vision or blindness. So frequent follow-up is
mandatory after surgery.
After complete healing also, regular eye examination is necessary to monitor eye pressure and to look for other problems.
Complications of the surgery
1.
Failure to control eye pressure, with the need for another operation (early or late)
2.
Generally vision might decrease for 2 months or so. There may be development of cataract which can reduce vision but it can be
treated with cataract surgery
3.
There might be too high or too low pressure after glaucoma surgery for which other necessary treatment or operation might be
needed.
4.
Bleeding in the eye
5.
Pronged redness and mild pain resulting in chronic inflammation
6.
Irritation or discomfort in the eye that may persist
7.
In spite of surgery, vision could become worse from continuing degenerative changes in the eye
8.
Infection resulting in pain, redness and decrease in vision which can occur early or much later
9.
In rare cases, there could be total loss of vision
Operation will be done under local or general anesthesia which also includes complications of anesthesia.
Complications of anesthesia injections around the eye
10.
Perforation of eyeball
11.
Needle damage to the optic nerve, which could destroy vision
12.
Interference with circulation of the retina
13.
Possible drooping of eyelid
14.
Systemic effects that have the potential for life-threatening complications and death
( 155 )
Patient Consent
There may arise unwanted situation during surgery. In that situation I give my full authority to my treating doctor to take any necessary
decision. In spite of the risks noted above, I understand that there is more risk to my vision if I do not have the operation than if I do. 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” or “left” eye).
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 156 )
,saVh&Qkbcz¨ CYkkfLVd ,tsaV¨a ds lkFk@muds fcuk VªscsdqY¨DV¨eh
equh'k /kou je.kthr flg¨Vk
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
fpfdRlk lq>ko] YkkÒ] v©j fodYi
esjk bYkkt dj jgs fpfdRld us eq>s crk;k gS fd funku gqvk gS fd eq>s XYkkd¨ek gSA cgqr laÒo gS fd eSa n`f"V gzkl dk vuqÒo d:a] g¨ ldrk gS bldk
lekiu va/¨iu esa g¨A XYkkd¨ek dk vFkZ gS vka[k ds ncko esa o`f)A dÒh&dÒh nokv¨as ls lQYkrkiwoZd bldk bYkkt fd;k tk ldrk gS] ;fn nok,a ÁÒkoh
u g¨a r¨ ncko fu;af=r djus v©j vf/kd n`f"V gzkl d¨ j¨dus ds fYk, Y¨tj ;k vU; 'kY;fpfdRlk ÁfØ;k,a mi;¨xh g¨ ldrh gSAa
esjs fpfdRld us eq>s crk;k gS fd esjh vka[k ¼vka[k¨a½ dk ncko fu;af=r djus ds fYk, Vªcs s dqY¨DV¨eh uke dk ,d v‚ijs'ku vko';d gS D;¨afd bl ncko
ds Ykacs le; rd c<+rs tkus ls n`f"V gzkl g¨rk gS v©j varr% va/kkiu vk tkrk gSA lQYk g¨us ij ;g v‚ijs'ku esjh vka[k dk ncko de dj nsxk v©j
XYkkd¨ek ds dkj.k v©j n`f"V gzkl d¨ de djsxkA bl v‚ijs'ku dk mÌs'; ncko fu;af"kr djuk] v©j esjh n`f"V d¨ v{kq..k j[kuk gS]
XYkkd¨ek dh otg ls [k¨bZ n`f"V Yk©VkbZ ugÈ tk ldrhA
leL;k,a
tSlk fd fdlh Òh 'kY;fpfälh; ÁfØ;k ds lkFk g¨rk gS] XYkkd¨ek Mªus t
s ltZjh ds lkFk Òh t¨f[ke tqMs+ gSAa mnkgj.k ds fYk, bldh laÒkouk ges'kk jgrh
gS fd 'kY;fpfdRlk esjh vka[k ds ncko d¨ fu;af=r u dj lds] ftlds fYk, 'kY;fpfdRlk ds ckn nokv¨a ;k v©j ÁfØ;kv¨a dh vko';drk iM+ ldrh
gSA bl Ái= esa laÒkfor lÒh leL;kv¨a d¨ 'kkfeYk djuk laÒo ugÈ gS Y¨fdu XYkkd¨ek Mªus t
s ltZjh djus ij lkeus vkus okYkh leL;kv¨a ds mnkgj.k
fuEufYkf[kr gS-a ;s leL;k,a fnu¨a] g¶r¨a] eghu¨a v©j o"k¨± ckn g¨ ldrh gSAa os n`f"V dk gzkl ;k va/kkiu iSnk dj ldrh gSAa blfYk, 'kY;fpfdRlk
ds ckn Ák;% Q‚Yk¨vi ds fYk, tkuk vfuok;Z g¨rk gSA
?kko ds iwjh rjg Òj tkus ds ckn Òh vka[k¨a ds ncko dh fuxjkuh djus v©j nwljh leL;kv¨a dk irk Ykxkus ds fYk, vka[k¨a dh fu;fer tkap vko';d
gSA
'kY;fpfdRlk dh leL;k,a
123456789-
¼tYnh ;k nsj ls½ nwljs v‚ijs'ku dh vko';drk ds lkFk vka[k dk ncko fu;af=r djus esa vlQYkrk]
lkekU;r;k n¨ eghus ds fYk, n`f"V de g¨ ldrh gS] e¨fr;kfcan g¨ ldrk gS t¨ n`f"V de dj ldrk gS Y¨fdu dVSjSDV ltZjh ls mldk bYkkt
fd;k tk ldrk gS
XYkkd¨ek ltZjh ds ckn ncko cgqr de ;k cgqr vf/kd g¨ ldrk gS ftlds fYk, nwljs vko';d bYkkt¨a ;k v‚ijs'ku¨a dh t:jr iM+ ldrh gS
vka[k esa jälzko
Ykacs le; rd YkYkkbZ v©j gYdk nnZ ftlds QYkLo:i nh?kZdkfYkd Ánkg g¨ ldrk gS
vka[k esa bfjVs”ku ;k fMldEQZV t¨ cuk jg ldrk gS
'kY;fpfdRlk ds ckotwn vka[k esa tkjh vigzklh ifjorZu¨a ds dkj.k n`f"V v©j [kjkc g¨ ldrh gS
laØe.k] ftuds dkj.k YkYkkbZ vk ldrh gS] n`f"V de g¨ ldrh gS t¨ tYnh ;k dkQh nsj ls Òh g¨ ldrk gS
fojY¨ ekeYk¨a esa iwjh rjg ls n`f"V dk gzkl g¨ ldrk gS
v‚ijs'ku Yk¨dYk ;k tujYk&,suLs Fkhfl;k nsdj fd;k tk,xk] ftlesa ,suLs Fkhfl;k dh leL;k,a Òh 'kkfeYk g¨ ldrh gSAa
vka[k ds vkl&ikl ,susLFkhfl;k dh lwbZ Ykxkus dh leL;k,a
1011121314-
us=x¨Ykd esa fNæ g¨ tkuk
lwbZ ls n`'; raf=dk d¨ {kfr igqp
a uk t¨ n`f"V d¨ u"V dj ldrk gS
jsfVuk esa jä lapkj esa ck/kk
laÒkfor iYkd Mwfiax
flLVesfVd ÁÒko t¨ tkuY¨ok leL;k,a iSnk dj ldrs gSa ;k e`R;q dk dkj.k cu ldrs gSa
( 157 )
j¨xh dh lgefr
'kY;fpfdRlk ds n©jku vokafNr fLFkfr;ka iSnk g¨ ldrh gSAa ml fLFkfr esa viuk bYkkt dj jgs fpfdRld d¨ d¨bZ Òh vko';d fu.kZ; Y¨us dk iwjk
vf/kdkj nsrk gwAa mi;qZä t¨f[ke¨a ds ckotwn eSa le>rk gwa fd ;fn eSa vkijs'ku ugÈ djkrk r¨ esjh n`f"V d¨ v‚ijs'ku djkus ls dgÈ vf/kd [krjk jgsxkA
eSua s lgefr Ái= d¨ i<+ v©j le> fYk;k gS v©j esjs lÒh Á'u¨a ds mÙkj fn, x, gSa v©j eSa vius 'kY;fpfdRld d¨ viuh --------------------------------------¼**nkb±** ;k **ckb±** vka[k dk fufnZ"V djs½a v‚ijs'ku djus dk vf/kdkj nsrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 158 )
Diode Laser Cyclo-photocoagulation (DLCP)
Anand Agarwal, Shalini Mohan
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
DLCP is an ocular surgical procedure which is usually carried out in people with advanced, recalcitrant glaucoma who have uncontrolled
high intra ocular pressures (IOPs) inspite of use of medications and repeated glaucoma filtration surgeries and used of glaucoma drainage
devices (GDDs). This procedure is effective in bringing down IOPs and relieving ocular pain if the cause of pain is high IOP. The
procedure is usually carried out under local peribulbar anesthesia and sometimes more than one sitting needs to be given ie the procedure
may have to be repeated to bring about clinical success.
Post operative care
The eye may be red, swollen and painful following the procedure for which pain relieving oral medications and some drops are given to
bring about relief. Out patient visits are done on first day post operatively, day seven and then after every two weeks.
The need for repeat procedure is decided by the treating physician after evaluating patient’s symptoms and IOP.
The usual side effects encountered are:
1.
Ocular pain
2.
Redness
3.
Peri ocular swelling
4.
Need for repeat treatments
5.
The procedure may be able to bring down the need for IOP lowering medications although some of them may be required to
maintain optimal IOP
5.
Rarely the eye may become smaller i.e. progress to atrophic bulbi
IT IS VERY IMPORTANT FOR THE PATIENT TO UNDERSTAND THAT THE PROCEDURE IS NOT MEANT TO IMPROVE THE
VISION OVER & ABOVE WHAT HE/SHE HAS ALREADY GOT.
I have been made aware of the above mentioned facts and I have been counseled about the potential benefits and possible side effects of
the procedure and by thoroughly going through all of the above, I give my full informed consent for the above procedure.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
( 159 )
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 160 )
Mk;¨M Y¨tj lkbDYk¨&Q¨V¨d‚xqY¨'ku ¼Mh ,y lh ih½
vkuan vxzokYk] 'kkfYkuh e¨gu
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
Mh,Yklhih ,d us= 'kY;fpfdRlk ÁfØ;k gS t¨ mér] nqnZE; XYkkd¨ek ls ihfM+r mu Yk¨x¨a ij dh tkrh gS ftuds mPp var% usf=; nkc ¼vkbZv¨ih½ nokv¨a
v©j ckj&ckj XYkkd¨ek fQYVjs'ku ltZjh djus v©j XYkkd¨ek Mªus t
s Msokbl¨a ¼thMhMh½ ds mi;¨x ds ckn Òh fu;af=r ugÈ g¨rsA ;g ÁfØ;k var% usf=;
nkc ¼vkbZv¨ih½ de djus v©j vka[k ds nnZ ls jkgr fnYkkus esa ÁÒkoh g¨rh gS] c'krsZ fd nnZ mPp vkbZv¨ih ds dkj.k g¨ jgk g¨A lkekU;r;k ;g ÁfØ;k
isjhcYcj ,suLs Fkhfl;k nsdj dh tkrh gS v©j dÒh&dÒh ,d ls vf/kd ckj djuh iM+rh gS] ;kuh fpfdRlh; lQYkrk ds fYk, ÁfØ;k nqgjkuh iM+ ldrh
gSA
'kY;fpfdRl¨Ùkj ifjp;kZ
ÁfØ;k ds ckn vka[k YkkYk g¨ ldrh gS] lwtu ;k ldrh gS ;k nnZ g¨ ldrk gS] ftlls jkgr fnYkkus ds fYk, [kkus v©j vka[k esa Vidkus dh nok,a nh
tk ldrh gSAa cfgjax j¨xh foÒkx esa v‚ijs'ku ds ckn igY¨ v©j~ lkrosa fnu v©j mlds ckn gj n¨ g¶rksa ij eqYkkdkrsa dh tkrh gSAa
nqckjk ÁfØ;k djus dh vko';drk j¨xh ds Yk{k.k¨a v©j vkbZv¨ih tkapus ds ckn bYkkt djus okYkk fpfdRld r; djrk gSA
lkekU;r% lkeus vkus okY¨ nq"ÁÒko gS%a
123455-
vka[k esa nnZ
YkYkkbZ
isfjvk¡dy
w j lwtu
iqu% fpfdRlk dh vko';drk
ÁfØ;k vkbZv¨ih de djus okYkh nokv¨a dh vko';drk de dj ldrh gS gkYkkafd ;F¨"V vkbZv¨ih cuk, j[kus ds fYk, dqN nokv¨a dh t:jr
iM+ ldrh gSA
fojY¨ ekeYk¨a esa vka[k N¨Vh g¨ ldrh gS] ;kuh ,Vªkfs Qd oYokbZ
j¨xh ds fYk, ;g le>uk cgqr egRoiw.kZ gS fd ÁfØ;k dk mÌs'; mldh orZeku n`f"V esa lq/kkj Ykkdj mlls vf/kd ;k mlls Åij dh n`f"V Ánku djuk
ugÈ gS
eq>s mi;qZä rF;¨a ls voxr djk;k x;k gS v©j eq>s ÁfØ;k ls j¨xh d¨ g¨us okY¨ YkkÒ¨a v©j laÒkfor nq"ÁÒko¨a ds ckjs esa lYkkg nh xbZ gS v©j mi;qZä
lkjh ckr¨a d¨ xaÒhjrk ls i<+us ds ckn eSa miq;Zä ÁfØ;k ds fYk, viuh iwjh lwfpr lgefr nsrk gwAa
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
( 161 )
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
xokg 2
gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
uke %. ......................................................................................
uke %. .............................................................................................
irk %........................................................................................
irk %. .............................................................................................
Qksu %. ......................................................................................
Qksu %. ............................................................................................
( 162 )
Argon Laser Trabeculoplasty (ALT)
Manoj Gupta
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
The argon laser causes photocoagulation of tissue. Thermal disruption of structural molecules, especially protein denaturation, results in
tissue changes that are observed such as contraction, condensation, and separation. Formation of amorphous gels as well as clot formation
can also occur. Higher temperatures result in non-selective coagulation necrosis of the target tissue and will lead to the burning of tissue.
Argon Laser Trabeculoplasty
Laser trabeculoplasy (LTP) is indicated for the treatment of open-angle glaucomas and is particularly effective in the treatment of
pigmentary and pseudoexfoliation glaucomas. LTP causes alteration of the TM by photocoagulation and a greater effect is seen with more
heavily pigmented TM. The precise mechanism of action is unknown but it relates to the change in conformation of the TM by collagen
shrinkage leading to the opening of meshwork in adjacent, nontreated regions.
Procedure
A slit lamp-mounted argon laser is usually used with the laser beam focused at the outflow angle with a contact lens such as a Goldmann
three-mirror lens. The laser settings are typically 800 mW to 1200 mW for 0.1 second and a 50-µm spot size. The laser is focused on the
TM and the power adjusted to cause a slight focal bubble or blanching of the TM. The TM is treated for 180º to 360º with a total of 50 to
100 spots. Treatment complications include elevation of IOP, inflammation, inadvertent treatment of the cornea or ciliary body, hemorrhage,
and pain.
Antiglaucoma Medication History
I have been explained about the procedure and the risk involved in the procedure in my own language. I have been explained that there
might be decrease in vision, corneal burn, raised IOP, and IOP may not decrease to desired level. Knowing all these inadvertent
complications, I am willing to undergo the above procedure and I give my consent for the procedure .
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
( 163 )
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 164 )
vkxZu Y¨tj VªscsdqYk¨IYkkLVh ¼,,yVh½
eu¨t xqIrk
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
vkxZu Y¨tj Ård¨a ds Q¨V¨dkxqY¨'ku dk dkj.k curk gSA lajpukRed v.kqv¨a dk rkih; fo?kVu] [kkl dj Á¨Vhu foÑfrdj.k ds dkj.k Ård ifjorZu
g¨rs gSa t¨ ladqpu] la?kuu] v©j vYkxko ds :i esa lkeus vkrs gSAa vfØLVYkh; tSYk ;k Fkôk Òh cu ldrk gSA Åaps rkieku ds dkj.k vfÒYkf{kr Ård¨a
dk vp;fur Ldanu foxYku g¨rk gS v©j Ård tYk tkrs gSAa
vkxZu Y¨tj VªscsdqYk¨IYkkLVh
Y¨tj Vªcs d
s qYk¨IYkkLVh dk lq>ko vksiu ,sx
a y ds XYkkd¨ek ds bYkkt ds fYk, fn;k tkrk gS v©j fiXesVa jh v©j L;wM¨,DlQ¨fYk,'ku XYkkd¨ek ds bYkkt esa
ÁÒkoh gSA ,YkVhih Q¨V¨dkxqY¨'ku }kjk Vh,e dk ,dkarj.k djrh gSA bl fØ;k dh lVhd ;kaf=dh vKkr gS Y¨fdu ;g dkY©tu ds ladqpu ls Vh,e
dh jpuk esa cnYkko ls lacfa /kr gS ftlls ikl ds vuqipkfjr es”kodZ dh tkYkh [kqYk tkrh gSA
ÁfØ;k
lkekU; :i ls Y¨tj fdj.k ds lkFk fLyV Y©ai ij LFkkfir vkxZu Y¨tj d¨ x¨YMeSu Fkzh fejWj Y¨al tSls dkaVSDVY¨al ds lkFk oká Áokg d¨.k ij dsfa ær
fd;k tkrk gSA Y¨tj dh Áokg fn'kk Á:ih r©j ij 0-1 lsdM
a ds fYk, 800 ,eMCY;w ls 1200 ,eMCY;w v©j 50 E;w,l ds fcanqeki ij g¨rh gSA Y¨tj
d¨ Vh,e ij dsfa ær fd;k tkrk gS v©j gYdk&lk ukÒh; cqYkcqYkk mRié djus ds fYk, ikoj leaftr fd;k tkrk gSA 180 ls 360 rd dqYk 50 ls 100
fcanqv¨a ij Vh,e dk mipkj fd;k tkrk gSA bYkkt dh leL;kv¨sa esa vkbZv¨ih dk c<+uk] Ánkg] dkfuZ;k ;k flfYk;jh c‚Mh dk vufÒÁsr mipkj] jälzko
v©j nnZ 'kkfeYk g¨ ldrs gSAa
,saVhXYkkd¨ek ds v©"kf/kÁ;¨x dk bfrgkl
eq>s esjh viuh Òk"kk esa ÁfØ;k v©j ÁfØ;k ds lkFk tqMs+ t¨f[ke¨a ds ckjs esa le>k;k x;k gSA eq>s crk;k x;k gS fd g¨ ldrk gS fd n`f"V de g¨ tk,]
dfuZ;k tYk tk,] vkbZv¨ih c<+ tk, v©j vkbZv¨ih okafNr Lrj rd de u g¨A bu lÒh vufÒÁsr leL;kv¨a ds ckotwn eSa mi;qZä ÁfØ;k djkuk pkgrk
gwa v©j ÁfØ;k ds fYk, viuh lgefr nsrk gw-a
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
( 165 )
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
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( 166 )
Laser Iridotomy
Deepankur Mahajan
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
Laser iridotomy is a procedure used for patients with narrow angle glaucoma in which a laser is used to make a small hole in the iris
(colored part of the eye) to allow free movement of fluid from posterior to anterior chamber of the eye which might help to control the
intraocular pressure and hopefully prevent scar formation between the iris and cornea which can check progression of the glaucoma.
Risks associated with this procedure include transient blurring of vision, post laser IOP spike, anterior uveitis, pupillary distortion,
corneal epithelial defects and corneal burns, bleeding/hyphema, cataract, diplopia, late iridotomy closure, retinal/macular burns, malignant
glaucoma, sterile hypopyon, cystoid macular edema and pupillary pseudomembrane. Additional medical or surgical intervention might
be required for these complications.
The procedure may require more than on sitting for completion in some cases. Some individuals respond only partially or not at all to the
procedure and may require additional medication/surgical intervention to check progression of glaucoma.
Post procedure topical medication including glaucoma medication might have to be continued/ changed.
I, ................................................................... have been fully explained in the best understood language (.............................................) that I have
RE/LE ........................................................ and have to undergo right/left eye laser iridotomy for the same.
The details of the procedure, alternatives and their risks and benefits have been explained to my satisfaction. I hereby give my full, free and
voluntary informed consent for right/left eye laser iridotomy.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 167 )
Y¨tj vkbfjM¨V¨eh
nhiadj egktu
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
Y¨tj vkbfjM¨V¨eh ,d ÁfØ;k gS t¨ ladh.kZ d¨.k XYkkd¨ek ds j¨fx;¨a esa Á;qä g¨rh gS] ftlesa vka[k ds fiNY¨ Ád¨"B ls vxY¨ Ád¨"B esa eqä :i ls
rjYk ds Áokg dh lqfo/kk nsus ds fYk, vkbfjl ¼vka[k ds jaxhu Òkx½ esa ,d N¨Vk&lk fNæ djus ds fYk, Y¨tj dk Á;¨x fd;k tkrk gS] t¨ var%usf=;
ncko fu;af=r djus esa enn dj ldrk gS v©j mEehn dh tkrh gS fd vkbfjl v©j dkfuZ;k ds chp LdkWj cuus ls j¨d ldrh gS t¨ XYkkd¨ek ds fodkl
d¨ j¨d ldrk gSA
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ds bfifFk;e dh foÑfr] dkfuZ;k dk tYk tkuk] jälzko@gkbQsek] e¨fr;kÇcan] fMIYk¨fi;k] vkbfjM¨V¨eh dk nsj ls can g¨uk] jsfVuYk@esdy
q j cuZ] dSl
a jh
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dh t:jr iM+ ldrh gSA
dqN ekeYk¨a esa g¨ ldrk gS fd ÁfØ;k ,d ls vf/kd ckj esa iwjh g¨A dqN O;fä ÁfØ;k ds Áfr vkaf'kd vuqfØ;k nsrs gSa ;k fljs ls vuqfØ;k ugÈ nsrs
v©j muds fYk, XYkkd¨ek d¨ c<+us ls j¨dus ds fYk, vfrfjä v©"kf/k Á;¨x@'kY;fpfdRlh; gLr{¨i dh vko';drk iM+ ldrh gSA
v‚ijs'ku ds ckn dh LFkkfud nok,a] XYkkd¨ek dh nokv¨a lfgr] tkjh j[kuh@cnYkuh iM+ ldrh gSAa
eq>s]----------------------------------------------------------------------------------------------------------------------------------------------------------- t¨ Òk"kk lcls vPNh rjg le> esa vkrh gS ml Òk"kk
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mlds fYk, nkb±@ckb± vk[k dk Y¨tj vkbfjM¨V¨eh djkuk gSA
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
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fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
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( 168 )
CATARACT
Cataract Surgery With / Without Implantation of
Intraocular Lens
Courtesy: Shroff Eye Centre, New Delhi
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
Introduction :
A cataract is opacity of the lens. Cataract operation is indicated only when you cannot function adequately due to poor sight produced by
the cataract. Maturity of cataract is no longer a criterion for surgery. The natural lens within your eye with a slight cataract, although not
perfect, has distinct advantages over an artificial lens.
In giving permission for cataract extraction with / without implantation of an intraocular lens in my eye, I declare that I understand the
following information
1.
Alternative Treatments :
There are three methods of restoring vision after cataract surgery
a) Cataract Spectacles b) Contact Lens c) Intraocular Lens
Cataract spectacles increase image size by 30%. They cannot be used if there is cataract in only one eye (the other is normal) because
they may cause double vision. A contact lens increases image size by 8%. However, it is difficult to handle and may not be tolerated
by everyone. Intraocular lens does not increase image size. It is surgically placed inside the eye permanently
2.
An intraocular lens is implanted by surgery (not by laser). The implanted lens will be left in the eye permanently. At the time of
surgery the doctor may decide not to implant an intraocular lens in the eye, if for any reason he feels that the lens implantation is
not indicated or may prove deleterious to the well being of the eye, even though permission may have been given to do so
3.
Though the intraocular implant power is calculated by utilizing a computerised Biometer (A-scan), a small correction in the
spectacles is to be considered inevitable postoperatively and this may be more in specific cases. An astigmatism (number with axis)
which may reduce with time, is to be taken as inevitable and normal. Therefore, a small power is to be expected in the spectacles for
distance and near for clear vision after the operation. In any case, the aim of cataract surgery is to remove the cloudy lens from the
eye and replace it with a plastic lens and not to rid the patient of his spectacles
4.
The calibre of vision obtained after a successful cataract surgery/lens implantation depends upon the retina behind. In an advanced
cataract even with the most sophisticated instruments (Ultrasound Scan etc.), it is not possible to be certain that the retina inside is
normal. Removal of cataract is like opening a door to a room. If the retina is normal, you will see well, but it is not possible in a
majority of advanced cataract cases to ascertain the visual status of the retina before operation
5.
With modern instrumentation and micro surgical techniques, the rate of complications in cataract surgery with/without intraocular
lens implantation is very low. Complications can usually be managed by medical and/or surgical treatment. The chances of total
loss of vision are less than 0.5%. However, the following complications can occur and are mentioned in standard text books of
cataract and lens implantation surgery
a)
It is possible that vision may drop after surgery due to thickening/opacification of the posterior capsule. This is not a
complication but a sequelae to Extra Capsular Cataract Extraction. The condition is treated with the “Yag Laser”
b)
Complications may include haemorrhage (bleeding), posterior capsule rupture, nucleus drop, vitreous loss, wound leakage,
uveitis, cornea! decompensation, glaucoma, cystoid macular oedema or retinal detachment. In addition lens implantation
may be complicated by severe reaction to the lens (Toxic Lens Syndrome) or dislocation of the lens. The implanted lens may
have to be repositioned or removed surgically if it is likely to damage the eye. Though every effort is made to minimize the
chances of infection, it cannot be eliminated altogether. Loss of vision is a risk common to any intraocular surgery
c)
Although you may have opted for phacoemulsification surgery and the same may have been planned by your surgeon after
( 169 )
pre operative examination, if during surgery phacoemulsification is found to be unsafe or not feasible. your surgeon will
have the liberty to perform surgery by the conventional technique in the interest of patient safety
d)
Complications of surgery in general:- As the procedure is generally done under local anaesthesia the risk to life is less than
0.5%. Risk is greater in patients with Diabetes, Hypertension, Cardiac ailments and other systemic disorders & when surgery
is performed under general anaesthesia. There is a possibility of drug reaction, brain damage or risk to life
Since it is impossible to state every complication that may occur as a result of surgery, the list of complications in this form is not
exhaustive.
Consent for Operation
1.
I hereby authorize Dr. .................................................................................... and those whom he may designate as associates or assistants to
perform cataract operation with an intraocular lens / without an intraocular lens / as a secondary procedure on my left / right eye
It has been explained to me that during the course of operation/ procedure, unforeseen conditions may be revealed or encountered
which necessitate surgical or other procedures in addition to or different from those contemplated. I, therefore, further request and
authorize the above named Physician/Surgeon or his designates to perform such additional surgical or other procedures as he or
they deem necessary or desirable
2.
The nature and purpose of the operation, the necessity thereof, the possible alternative methods of treatment of my condition have
been fully explained to me and I understand the same
3.
I am fully aware that the surgery is being performed in good faith and that no guarantee or assurance has been given as to the result
that may be obtained
4.
I consent to the administration of anesthesia and to the use of such anesthetics as may be deemed necessary or desirable
5.
I further consent to the administration of such drugs or infusions deemed necessary in the judgement of the medical staff
6.
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
7.
Any tissues or parts surgically removed may be disposed off by the institution in accordance with customary practice
Informed Consent for Operation on Patients With Guarded / Poor Visual Prognosis
I have been explained by the attending surgeon/Designated Assistant prior to the operation that visual prognosis after surgery is
guarded/uncertain/poor/very poor. The reasons for this have been explained to me. The reasons are: (to be signed by the patient /
person authorised to consent for the patient.)
Trauma / Diabetic Retinopathy / Myopia / Glaucoma / Uveitis /Age Related Macular Degeneration / PVR / Complex Traction
Retinal Detachment/Combined tractional rhegmatogenous retinal detachment /Dislocated lens or IOL / Endophthalmitis (Severe
eye infection)
............................................................................................................................................................................................................................
............................................................................................................................................................................................................................
Signature of patient / person authorised to
consent for patient: ........................................................
I THE UNDERSIGNED (THE PATIENT OR NEAREST RELATIVE) HEREBY GIVE MY CONSENT FOR THE OPERATION OF
LEFT EYE / RIGHT EYE WITH THE FULL KNOWLEDGE OF POSSIBLE COMPLICATIONS AND GUARDED / POOR VISUAL
PROGNOSIS. I CERTIFY THAT I HAVE READ THIS INFORMED CONSENT / IT HAS BEEN READ OVER TO ME AND EXPLAINED
TO ME IN MY MOTHER TONGUE AND ALL BLANKS OR STATEMENTS REQUIRING INSERTION OR COMPLETION WERE
FILLED IN AND ANY INAPPLICABLE PARAGRAPHS STRICKEN OFF BEFORE I SIGNED. THE DOCTOR HAS ANSWERED
ALL MY QUESTIONS TO MY SATISFACTION.
( 170 )
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 171 )
baVªkvkD;wYkj Y¨al¨a ds lkFk@muds fcuk
dSVjSDV ltZjh
lkÒkj%: J‚Q vkbZ lsaVj] u;h fnYYkh
jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %..................
dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
ifjp;%
dSVjSDV Y¨al dh vikjnf'kZrk gSA dSVjSDV ds v‚ijs'ku dk lq>ko rÒh fn;k tkrk gS tc vki e¨fr;kfcan tU; [kjkc n`f"V ds dkj.k ;F¨"kzV :i ls dke
ugÈ dj ikrsA e¨fr;kfcan dk id tkuk vc 'kY;fpfdRlk dh dl©Vh ugÈ gSA gYds e¨fr;kfcan ds lkFk vka[k esa vka[k ds ÁkÑfrd Y¨al ds Ñf"ke Y¨al
ds jgus ds eqdkcY¨ vusd YkkÒ gSAa
viuh vka[k esa baVkª v‚D;wYkj Y¨al ds lkFk@;k mlds fcuk e¨fr;kfcan ds fu"d"kZ.k dh vuqefr nsrs gq, eSa ?k¨"k.kk djrk gwa fd eSa fuEu lwpukv¨a d¨ le>k gwa
1-
2-
3-
4-
5-
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dSVjSDV ltZjh ds ckn n`f"V dh okilh d¨ rhu fof/k;ka gSa
v½ dSVjSDV p'ek c½ dkaVSDVY¨al l½ baVªkvkD;wYkj Y¨al
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dj ldrk gSA dkaVDS V Y¨al fp= dk vkdkj 8% c<+krk gSA Y¨fdu mldk j[k&j[kko dfBu g¨rk gS v©j gj fdlh ls lgu ugÈ g¨rkA baVªkvkD;wYkj
Y¨al fp"k dk vkdkj ugÈ c<+krkA 'kY;fpfdRlk ls bls LFkkbZ :i ls vka[k ds Òhrj Ykxk;k tkrk gSA
d¨bZ var% us=h; Y¨al 'kY;fpfdRlk }kjk ¼Y¨tj }kjk ugȽ vka[k esa Ykxk;k tkrk gSA ÁR;kj¨fir Y¨al d¨ LFkkbZ :i ls vka[k esa N¨M+ fn;k tkrk
gSA 'kY;fpfdRlk ds le; fpfdRld var% us=h; Y¨al u Ykxkus dk QSlYkk dj ldrs gS]A c'krsZ fd fdlh dkj.ko'k mls Ykxrk gS fd ÁR;kj¨i.k
ugÈ fd;k tk ldrk ;k vka[k ds LokLF; ds fYk, gkfudkjd lkfcr g¨ ldrk gS] pkgs mls ,slk djus dh vuqefr feYkh g¨ rc ÒhA
gkYkkafd var% us=h; ÁR;kj¨i.k ds ikoj dk vkdYku daI;wVjhÑr ck;¨ehVj ¼,&LdSu½ dk mi;¨x djds fd;k tkrk gS] Y¨fdu v‚ijs'ku ds ckn
p'es esa ekewYkh la'k¨/ku d¨ vifjgk;Z le>k tkrk gS v©j fo'¨"k ekeYk¨a esa ;g vf/kd Òh g¨ ldrk gSA n`f"VoS"kE; ¼,fDll ds lkFk uacj½ d¨
vo';aÒkoh v©j lkekU; ekuk tk ldrk gSA blfYk, v‚ijs'ku ds ckn nwj v©j utnhd ds fYk, p'es esa Fk¨M+k lk ikoj g¨us dh vis{kk dh tk
ldrh gSA t¨ Òh g¨ dSVjsDV ltZjh dk mÌs'; vka[k ls /kq/a kYkk Y¨al fudkYk dj mldh txg IYkkfLVd dk Y¨al Ykxkuk g¨rk gS] j¨xh d¨ p'es
ls futkr fnYkkuk ugÈA
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midj.k¨a ¼vYVªklkmaM LdSu bR;kfn½ ds lkFk Òh fuf'pr :i ls dguk laÒo ugÈ gS g¨rk fd Òhrj jsfVuk lkekU; gSA e¨fr;kfcan dk fudkYkuk
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jsfVuk dh n`'; fLFkfr dk r; g¨ ikuk laÒo ugÈ g¨rkA
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esa tfVYkrkv¨a dh nj cgqr de g¨rh gSA tfVYkrkv¨a d¨ fpfdRlh; v©j@;k 'kY;fpfdRlh; bYkkt ls fu;af=r fd;k tk ldrk gSA iwjh rjg
n`f"V gzkl dh laÒkouk,a 0-5% ls Hkh de jgrh gSAa Y¨fdu fuEufYkf[kr tfVYkrk,a iSnk g¨ ldrh gSa v©j e¨fr;kfcan v©j Y¨al ÁR;kj¨i.k lac/a kh
ekud iqLrd¨a esa mudk mYY¨[k fd;k x;k gSA
,½
laÒo gS fd 'kY;fpfdRlk ds ckn i'p dSilwYk ds e¨Vk g¨us@vikjn'kÊ g¨us ds dkj.k n`f"V det¨j iM+ tk,A ;g tfVYkrk ugÈ] cfYd
,DLVªk dSIlqYkj dSVjSDV ,DlVªSD'ku dk ifj.kke gSA bl voLFkk dk bYkkt **okbZ,th Y¨tj** ls fd;k tkrk gS
ch½ tfVYkrkv¨a esa 'kkfeYk gS] gSejst ¼jälzko½] i¨LVsfj;j dSIlwYk dk QV tkuk] U;wfDYk;l Mª‚i] iksLVhfj;j dsiLyw dk VwVuk] ?kko dk fjluk]
;wfo;k'k¨Fk dkfuZ;k! dk fMdWEisl
a 's ku] XYkkd¨ek] flLV‚;M ekD;wYkj ,fMek ;k jsfVuk dk foYkxkoA blds vfrfjä Y¨al ds Áfr xaÒhj ÁfrfØ;k
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d¨ {kfr igqp
a kus dh vk'kadk g¨ r¨ mls 'kY;fpfdRlk ls fudkYkuk iM+ ldrk gSA gkYkkafd laØe.k de djus ds lÒh Á;kl fd, tkrs gSa
Y¨fdu mldh laÒkouk d¨ iwjh rjg [kRe ugÈ fd;k tk ldrkA
lh½ gkYkkafd g¨ ldrk gS fd vkius Qkd¨beY'ku ltZjh ilan dh g¨ v©j 'kY;fpfdRlk ls igsYk dh xbZ tkap ds ckn vkids 'kY;fpfdRld
( 172 )
us ogh djus dh ;¨tuk cukbZ g¨xh Y¨fdu ;fn Qkd¨beY'ku ltZjh vlqjf{kr ;k vO;kogkfjd ikbZ tkbZ gS r¨ vkidk 'kY;fpfdRld j¨xh
ds fgr esa ijaijkxr rduhd ls 'kY;fpfdRlk djus ds fYk, Lora= g¨xk
Mh½ 'kY;fpfdRlk dh lkekU; tfVYkrk,a] pwfa d ÁfØ;k lkekU;r;k Yk¨dYk ,suLs Fkhfl;k nsdj dh tkrh gS blfYk, tku dk t¨f[ke 0-5% ls de
jgrk gSA tc 'kY;fpfdRlk tujYk ,suLs Fkhfl;k nsdj dh tkrh gS r¨ Mk;kfcVht] mPpjäpki] fnYk ds j¨x¨a] v©j nwljs nSfgd fodkj¨a ds
j¨fx;¨a d¨ t¨f[ke vf/kd jgrk gSA nok dh ÁfrfØ;k] efLr"d {kfr ;k tku t¨f[ke dh Òh laÒkouk jgrh gSA
pwfa d 'kY;fpfdRlk ds QYkLo:i g¨us okYkh ÁR;sd tfVYkrk ds ckjs esa crkuk vlaÒo gS blfYk, bl Ái= esa nh xbZ tfVYkrkv¨a dh lwph lai.w kZ ugÈ g¨
ldrhA
v‚ijs'ku ds fYk, lgefr
1-
eSa ,rn~ }kjk M‚------------------------------------------------------------------------------------------------------------------------------------------------- v©j mUgsa ftud¨ og vius lg;¨fx;¨a
;k lgk;d¨a ds :i esa fu;qä djrs gS]a viuh ckb±@nkb± vka[k esa baVªkv‚D;wYkj Y¨al ds lkFk@baVªkv‚D;wYkj Y¨al ds fcuk dSVjsDV v‚ijs'ku djus
dk vf/kdkj nsrk gwa
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vfrfjä ;k vYkx nwljh 'kY;fpfdRlh; ;k vU; ÁfØ;kv¨a d¨ vko';d cuk ldrh gSAa blfYk, eSa mi;qZä uke ds vfrfjä 'kY;fpfdRlk ;k
nwljh ÁfØ;k,a djus dk vuqj¨/k djrk v©j vf/kdkj Ánku djrk gwa ftUgsa og ;k os vko';d ;k okafNr le>rs g¨a
2-
v‚ijs'ku dh ÁÑfr v©j mÌs';] mldh vko';drk] esjh voLFkk ds bYkkt ds vU; laÒkfor rjhd¨a ds ckjs esa eq>s iwjh rjg crk;k xk;k gS v©j
eSa mUgsa le>rk ga
3-
eSa iwjh rjg voxr gwa fd 'kY;fØ;k usduh;rh ls dh tk jgh gS v©j ÁkIr g¨ ldus okY¨ ifj.kke¨a ds ckjs esa d¨bZ xkjaVh ;k vk'oklu ugÈ fn;k
xk; gS
4-
eSa ,suLs F¨fl;k v©j ,sls ,usLF¨fVDl ds mi;¨x ls lger gwa ftls vko';d okafNr le>k tk,
5-
eSa fpfdRlh; dfeZ;¨a dh utj esa vko';d v©j okafNr nokv¨as v©j bu¶;wtu fn, tkus ls lger gwa
6-
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fp= ;k muds lkFk fn, tkus okY¨ o.kZukRed ikB ls esjk ifjp; ÁdV u g¨A
7-
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nsrk gwa c'krsZ fd
jf{kr@[kjkc n`'; iwokZuqeku okY¨ j¨fx;¨a ds v‚ijs'ku ds fYk, lwfpr lgefr
eq>s ifjp;kZ djus okY¨ ltZu@ukfer lgk;d }kjk v‚ijs'ku ls igY¨ crk;k x;k gS fd 'kY;fpfdRlk ds ckn n`'; iwokZuqeku jf{kr@vfuf'pr@cgqr
[kjkc gSA eq>s blds dkj.k crk, x, gSAa dkj.k gS%a ¼j¨xh@j¨xh ds fYk, lgefr nsus ds fYk, Ákf/kÑr O;fä }kjk gLrk{kj djus ds fYk,A½
vk?kkr] Mk;kcsfVd jsfVu¨iSFkh] ek;¨fi;k@XYkkd¨ek@;wfo;k'k¨Fk@mez lac/a kh us"kh; {k;@ihohvkj@daIY¨Dl VªSD'ku jsfVuYk fMVSpesVa @dackbaM VªSD'kuYk
jsXesV¨tsul jsfVuYk fMVSpesVa A LFkkarfjr Y¨al ;k vkbZv¨,Yk@,aM¨IF©YkekbfVl ¼vka[k dk xaÒhj laØe.k½
. ............................................................................................................................................................................................................
. ............................................................................................................................................................................................................
j¨xh@j¨xh ds fYk, lgefr ds fYk,
Ákf/kÑr O;fä ds gLrk{kj --------------------------------------------eSa v/k¨gLrk{kj drkZ ¼j¨xh ;k fudVre lac/a kh½ ,rn~}kjk laÒkfor tfVYkrkv¨a v©j lajf{kr@[kjkc n`f"V ds iwokZuqeku ds ckjs esa iwjh tkudkjh ds lkFk
viuh ckb±@nkb± vka[ka ds v‚ijs'ku dh lgefr nsrk gwAaw eSa Áekf.kr djrk gwa fd eSua s ;g lwfpr lgefr i<+ Ykh gS ;g eq>s i<+ dj lqukbZ xbZ gS v©j
esjh ekr`Òk"kk esa eq>s le>kbZ xbZ gSA v©j lkjh [kkYkh txgsa ;k fuos'ku ;k iwfrZ dh ekax djus okYks lÒh dFku esjs gLrk{kj djus ls igY¨ Òjs x, F¨
v©j Ykkxw u g¨us okY¨ iSjs dkV fn, x, F¨A fpfdRld us esjs lÒh Á'u¨a ds lar¨"ktud mÙkj fn, gSAa
( 173 )
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................
irk %......................................................................................................................................................................................................
Qksu % ¼vkfQl½. ........................................................... ¼/kj½. ................................................. eksckby%. ...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSua s laiUu dh tkus okyh dk;Zfof/k dh izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa dh ppkZ dh gS tks fd
fo'ks"k :i ls jksxh ls lacfa /kr gSA
eSua s jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1
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gLrk{kj %. .................................................................................
gLrk{kj %. ........................................................................................
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uke %. .............................................................................................
irk %........................................................................................
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( 174 )
Pediatric Cataract
Shalini Mohan, Anand Aggarwal
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
Pediatric cataract may affect one or both eyes of children in any age group. Some children have cataract at birth where as some can get it
during their developing years. The need for surgery is undertaken on the discretion of the ophthalmologist after a thorough assessment of
child’s visual behaviour. If the cataract is visually significant, then early surgery is the best option for improving visual outcome and giving
the child binocular vision. The surgery is performed under general anesthesia and whether or not the intra ocular lens is placed at the time
of primary surgery, depends on the age of the child and the laterality of cataract whether unilateral or bilateral. If both the eyes need to be
operated, then two separate requirements for anesthesia are needed and the time for second eye is decided by the ophthalmologist after
seeing the response of the first eye. It is very critical that clear ocular media is ensured so that the child can develop full visual potential.
Post operative care
The eye may be red, swollen and painful following the procedure for which pain relieving oral medications and some eyedrops are given
to bring about relief. The medications may need to be used for a prolonged period after the procedure to ensure maximal efficacy of the
procedure. Itisveryim portantforthechild’sparents/legalguardianstounderstandthattheirroleintheoptim alvisualoutcom eisas
param ountastheophthalm icphysician. Theyneedtoensureregularfollow upofthechild,to makenoteofabnorm alvisualbehaviour,
the need for regular examinations under anesthesia due to the changing refractive errors as the pediatric eye grows over time. Sometimes
children may have other associated ocular and systemic abnormalities accompanying their cataract which might need additional surgical
interventions/ systemic pediatric evaluation.
Post operative course & complications
1.
After cataract and membrane formation: The incidence has decreased in recent years with the availability of modern techniques of
surgery but can still occur especially in small children under the age of one year.
2.
Changing refractive errors and the frequent need of glasses: Periodic assessment of child’s refractive status is a must for which
repeated examinations under anesthesia are needed to ensure proper refraction. It is also important for the parents/ legal guardians
to realize that they ensure that the proper refractive correction in the form of glasses/ contact lenses is worn by the child during
waking hours.
3.
Amblyopia (lazy eye) treatment: This is the single most important factor in the success of unilateral cataract cases. The parents/
legal guardians need to ensure that the child is on proper occlusion therapy, the frequency of which is decided by the treating
ophthalmologist.
4.
Glaucoma: This is the single most important cause of late onset visual loss after successful pediatric cataract surgery. The rate of this
complication varies widely. To ensure safety, it is very important for the parents’/ legal guardians to ensure that periodic Intra ocular
pressure of the child’s eye is monitored so that early detection is possible and remedial measures can be undertaken.
5.
Retinal detachment/ endophthalmitis: These are rare complications.
6.
Strabismus (squint) and nystagmus: These may sometimes be present at the time of presentation. Both of these require separate
surgical intervention usually at a later date.
It is very important for you to realize that meticulous regular life long follow up is very important on your part so that the treating
physician is able to assess your child’s visual function and early detection of any complication as listed above is possible.
I have been made aware of the above mentioned facts and I have been counseled about the potential benefits and possible side effects of
the procedure and by thoroughly going through all of the above, I give my full informed consent for the above procedure on my child.
( 175 )
Signature / Thumb Impression of Patient/ Parent / Guardian: ............................................................................................................................
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 176 )
ihfM,sfVªd dSVjSDV
'kkfYkuh e¨gu] vkuan vxzokYk
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dk iq=@iq=h .........................................................................................................................................................................................
irk % . ...................................................................................................................................... VsyhQksu ua % . .....................................
ihfM,sfVªd dSVjSDV lÒh vk;qox¨± ds cPp¨a dh ,d ;k n¨u¨a vka[k¨a d¨ ÁÒkfor dj ldrk gSA dqN cPp¨a d¨ tUe ls gh e¨fr;kfcan jgrk gS v©j dqN
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dh vuqfØ;k ns[kus ds ckn r; djrk gSA ;g cgqr egRoiw.kZ gS fd Li"V us=h; ehfM;k lqfuf'pr fd;k tk, rkfd cPpk iw.kZ n`f"V {kerk fodflr dj
ldsA
'kY;fpfdRl¨Ùkj ifjp;kZ
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esa VidkbZ tkus okYkh nok,a nh tkrh gSAa ÁfØ;k dh vf/kdre ÁÒkodkfjrk lqfuf'pr djus ds fYk, ÁfØ;k ds ckn Ykach vof/k rd nokv¨a dk Á;¨x fd;k
tkrk gSA cPps ds ekrk&firk@dkuwuh vfÒÒkod¨a dk ;g le>uk cgqr egRoiw.kZ gS fd n`f"V laca/kh ;F¨"Vre ifj.kke esa mudh Òwfedk
us"kfo'¨"kKA fpfdRld ftruh gh vge g¨rh gSA muds fu;fer :i ls cPps dk Q‚Yk¨vi lqfuf'pr djus] vlkekU; n`'; crkZo ij
/;ku nsus dh t:jr g¨rh gS] ,susLFkhfl;k nsdj cnYkrh viorZukRed [kkfe;¨a ds fYk, fu;fer :i ls tkap dh vko';drk g¨rh
gS D;¨afd cPp¨a dh vka[ksa le; ds lkFk c<+rh jgrh gSaA dÒh&dÒh cPp¨a d¨ muds e¨fr;kfcan ds lkFk vka[k dh nwljh ;k nSfgd foÑfr;ka g¨
ldrh gSa t¨ vfrfjä 'kY;fpfdRlh; gL{¨i@nSfgd fcekfj;ksa ds boSY;w”ku dh t:jr iM+ ldrh gSA
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12-
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56-
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vc Òh g¨ ldrh gS]a fo'¨"kdj ,d lkYk ls de mez ds cPp¨a esAa
cnYkrh viorZukRed [kkfe;ka v©j p'esa dh Ákf;d vko';drk% cPps dh viorZukRed fLFkfr dk fu;rdkfYkd ewY;kadu vfuok;Z g¨rk gS] ftlds
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r; djrk gSA
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rjg i<+ Y¨us ds ckn eSa vius cPps ij mi;qZä ÁfØ;k djus dh iw.kZ lwfpr lgefr nsrk gwAa
( 177 )
jksxh@vfHkHkkod dk gLrk{kj@vaxBw s dk fu'kku %..........................................................................................................................................
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irk %......................................................................................................................................................................................................
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MkWDVj }kjk ?kks"k.kk
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fo'ks"k :i ls jksxh ls lacfa /kr gSA
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( 178 )
YAG Capsulotomy
Deepankur Mahajan
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
Posterior capsular opacification (PCO) is a condition which develops due to clouding of back membrane of the lens left behind following
modern cataract surgery to support the intraocular lens. Such a membrane causes blurring and dimunition of vision and occasionally
streaks or haloes around light.
Laser capsulotomy involves using Nd-Yag laser to make a central hole within the PCO when it is causing significant complaints to the
patient thereby providing a clear central visual axis to the patient.
Complications of the procedure include: Damage to IOL optic, IOL pitting, IOL subluxation, IOL dislocation, postoperative intraocular
pressure elevation, new floaters/ spots, cystoid macular edema, retinal swelling, retinal detachment and exacerbation of localized
endophthalmitis. Additional medical/surgical intervention may be required for these
Alternative treatment options include surgical posterior capsulotomy whereby eye has to be opened to remove opacified posterior capsule.
I, ................................................................... have been fully explained in the best understood language (.............................................) that I have
RE/LE posterior capsular opacification and have to undergo right/left eye Yag laser posterior capsulotomy for the same.
The details of the procedure and alternate treatments and their risks and benefits have been explained to my satisfaction. I hereby give my
full, free and voluntary informed consent for a posterior capsulotomy in my right/left eye with the YAG laser.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 179 )
okbZ,th dSIlwYk¨V¨eh
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nokbZ ls mipkj@'kY;fpfdRlh; gLr{¨i dh vko';drk iM+ ldrh gSA
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[k¨Ykuh iM+rh gSA
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( 180 )
MISCELLANEOUS
Examination Under Anesthesia (EUA)
Chaitali Basu
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been informed in the language I understand best, that my daughter/son/…….. is to undergo Examination Under Anaesthesia (
EUA) , and that :
•
The procedure is being done to thoroughly examine the patient who is not otherwise co-operative for normal examination.
•
During examination, if any need for an intervention is felt by my doctor, I give my consent for performing any procedure as may
be deemed advisable. I hereby certify that I have fully understood the reasons why the above procedure is considered necessary, its
advantages and possible alternative modes of treatment. I also hereby certify that no guarantee or assurance has been made as to the
result that may be obtained.
•
The procedure carries all the inherent risks of General Anaesthesia. The risk of complication with serious after effects and/or death,
though small is always present.
Knowing this I give my full, free and voluntary consent.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 181 )
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( 182 )
Optical Iridectomy
Asim K. Kandar
Name of Patient ....................................................................... Age/Sex ......... Patient ID ............................... Date .............................................
Son / Daughter of ............................................................................................................................................................................................................
Address ........................................................................................................................................ Tel .............................................................................
I have been informed in my mother tongue that I/ my child is suffering from whitening of the cornea (Corneal opacity) with some clear
area remaining (specify .........................................) and that a surgery will be performed to enhance the passage of light through the clear area.
A part of the iris (diaphragm of the eye) will be excised during the surgical procedure.
I have been fully explained regarding the permanent nature of the opacity/ lesion and that it may increase after the surgery and corneal
transplant may be required. I have been explained the risk of development of cataract, leading to cataract surgery and lens implantation.
There is risk of infection, hyphema due to haemorrhage from iris vessels leading to secondary rise of intraocular pressure. There is chance
of no improvement or worsening of best corrected visual acuity, glaucoma secondary to surgery or to medications, and high astigmatism
after surgery. There may be a need for repeat surgery which may or may not lead to improvement of vision. I have been explained the need
for follow up as frequently as advised by the doctors that may span upto years, with multiple investigations at each visit. I have been
explained that using medications properly is required for success of the procedure. I have been explained that I will need to urgently come
for follow-up to ophthalmic casualty if there is sudden onset of redness, photophobia, pain or detoriation of vision as these may be signs
of endophthalmitis. I understand that inspite of all efforts, there is a possibility that there may be worsening of the visual acuity or the
cosmetic appearance of the eye.
I certify that I have fully understood the implications of the above consent and authorise the doctors to perform Optical Iridectomy on my/
my child’s right / left eye.
Signature / Thumb Impression of Patient/ Parent / Guardian: ...............................................................................................................................
Name: .................................................................................................. Relationship ........................................... Date .............................................
Address: .............................................................................................................................................................................................................................
Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................
Declaration by Doctor
I declare that I have explained the nature and consequences of the procedure to be performed, and discussed the risks that particularly
concern the patient.
I have given the patient an opportunity to ask questions and I have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1
Witness 2
Signature: ............................................................................................. Signature: .............................................................................................
Name: ...................................................................................................
Name: .....................................................................................................
Address: ..............................................................................................
Address: ................................................................................................
Tel: .......................................................................................................
Tel: .........................................................................................................
( 183 )
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( 184 )