Laser Peripheral Iridotomy (LPI) Consent Form

FOR REVIEW ONLY Please review this document for your information. Your signature will be required on the date of your procedure.

PROCEDURE

Laser Peripheral Iridotomy (LPI)

DESCRIPTION OF PROCEDURE

Laser Peripheral Iridotomy (LPI) is a laser procedure used to treat or prevent narrow-angle glaucoma and angle-closure glaucoma. It involves creating a small hole in the iris (the colored part of the eye) to improve the flow of fluid within the eye and reduce the risk of increased eye pressure.

BENEFITS

The goal of this procedure is to:

Reduce the risk of angle-closure glaucoma.
Lower intraocular pressure.
Prevent damage to the optic nerve.
Help to preserve vision.

ALTERNATIVES

Alternatives to LPI laser treatment may include:

Eye drop medications: Various eye drops can help manage glaucoma.
Other laser procedures: Other types of laser treatment for glaucoma exist.
Incisional glaucoma surgery: Surgical procedures may be necessary in some cases.
Observation: In some cases, close monitoring of the condition may be an option.

The risks and benefits of these alternatives have been explained to me.

RISKS AND COMPLICATIONS

I understand that, as with any medical procedure, there are risks and potential complications associated with LPI laser treatment. These include, but are not limited to:

Temporary discomfort: Some discomfort or a mild burning sensation may occur during or after the procedure.
Temporary blurred vision: Vision may be temporarily blurred following the procedure.
Eye pain: Pain in the eye is possible.
Increased intraocular pressure: Eye pressure may temporarily increase after the procedure.
Inflammation: Inflammation within the eye is possible and is usually treated with eye drops.
Bleeding: Bleeding within the eye is a potential risk, though rare.
Infection: Infection within the eye is rare but serious.
Cataract progression: There is a potential risk of cataract development or progression.
Corneal damage: Damage to the cornea is possible.
Glaucoma progression: In rare cases, the underlying glaucoma may progress despite the LPI.
Visual disturbances: This includes glare, halos, or double vision. These are sometimes temporary, but can be permanent.
Need for further treatment: Additional medications, laser treatment, or surgery may be needed in the future.
Rarely, loss of vision.

I have been informed about the material risks that are specific to my circumstances.

ACKNOWLEDGEMENT OF UNKNOWN RISKS

I understand that it is not possible or reasonable to predict every possible risk or complication that may occur.

POST-PROCEDURE CARE

I understand that I will need to follow my physician's instructions carefully after the procedure. This may include:

Using prescribed eye drops.
Avoiding rubbing the eye.
Attending follow-up appointments to monitor my eye pressure and response to treatment.
Reporting any changes in vision, pain, or redness immediately.

AUTHORIZATION OF ADDITIONAL PROCEDURES IN UNFORESEEN CIRCUMSTANCES

I understand that during the procedure, unforeseen or unknown conditions may be discovered that require additional or different procedures than those initially planned. I authorize the above-named healthcare provider, or their designate, to perform such additional procedures that, in their professional judgment, are immediately necessary and desirable to address these conditions, and where delaying such procedures would not be in my best interest.

CONSENT TO ANESTHESIA AND MEDICATIONS

I consent to the administration of appropriate anesthesia and all other medications deemed necessary to facilitate the treatment.

CONFIRMATION OF UNDERSTANDING

I have had the opportunity to ask questions about the procedure, its alternatives, risks, and benefits. I believe I have received enough information to make an informed decision. I voluntarily consent to the Laser Peripheral Iridotomy (LPI) procedure described above.

RIGHT TO WITHDRAW CONSENT

I understand that I have the right to withdraw my consent at any time before the procedure begins.

ACKNOWLEDGEMENT

I acknowledge that no guarantees have been made to me as to the result of the procedure(s).

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