Laser Retinopexy (LRP)
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 Retinopexy (LRP)​

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DESCRIPTION OF PROCEDURE

Laser Retinopexy (LRP) is a procedure used to treat retinal tears or holes. A laser is used to create seal around the retinal tear or hole and prevent retinal detachment.​

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BENEFITS

The goal of this procedure is to:

• Treat, prevent or reduce the risk of retinal detachment.

• Preserve vision.

ALTERNATIVES

Alternatives to Laser Retinopexy may include:

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• Observation: In some cases, small, asymptomatic tears may be monitored. However, this may carry the risk of progression to retinal detachment.

• Cryopexy: This involves freezing the tissue around the tear. It is an alternative, but laser is often preferred due to less inflammation and greater patient comfort.

• Vitrectomy Surgery: This is a more invasive surgical procedure, usually reserved for retinal detachments or more complex cases.

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

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RISKS AND COMPLICATIONS

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

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• Pain or discomfort: Some discomfort is normal during and immediately after the procedure.

• Temporary blurred vision: Usually resolves within a few hours.

• Increased intraocular pressure: This can usually be managed with medication.

• Failure of the procedure: In some cases, the laser treatment may not adequately seal the tear, and further treatment, including surgery, may be necessary.

• Damage to the retina: Rare.

• Bleeding: Rare.

• Infection: Rare.

• Macular Edema: Rare.

• Visual field defects: Rare.

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.​

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POST-PROCEDURE CARE

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

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• Avoiding strenuous activity.

• Attending follow-up appointments.

• Reporting any changes in vision or pain.

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.​

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CONSENT TO ANESTHESIA AND MEDICATIONS

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

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REGULATORY CONSIDERATIONS

I understand that Laser Retinopexy may be considered off label in certain circumstances by regulatory agencies, such as Health Canada.

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CONFIRMATION OF UNDERSTANDING

I acknowledge that I have read and understood the above information presented to me and I have been offered a copy of this consent form.  I have had the opportunity to ask questions about the procedure, its alternatives, risks, and benefits. I agree I have received all of the information to make an informed decision. I voluntarily consent to the Laser Retinopexy procedure described above.​

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RIGHT TO WITHDRAW CONSENT

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

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ACKNOWLEDGEMENT

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