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