YAG Capsulotomy Consent Form

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

PROCEDURE

YAG Capsulotomy

DESCRIPTION OF PROCEDURE

YAG Capsulotomy is a laser procedure used to treat clouding of the posterior capsule that can occur after cataract surgery. The posterior capsule is the thin membrane that holds the artificial lens in place. During YAG Capsulotomy, a laser is used to create a small opening in this capsule to allow light to pass through and improve vision.

BENEFITS

The goal of this procedure is to:

Improve vision that has become cloudy after cataract surgery.
Reduce glare and halos.

ALTERNATIVES

The alternative to YAG Capsulotomy is typically:

Observation: If the clouding is mild, observation may be an option. However, vision may continue to worsen.

The risks and benefits of this alternative have been explained to me.

RISKS AND COMPLICATIONS

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

Pain or discomfort: Some discomfort is normal during and immediately after the procedure.
Temporary blurred vision: This is common and usually resolves within a few hours.
Increased intraocular pressure: This can usually be managed with medication.
Retinal detachment: This is a rare but serious complication.
Macular edema: Swelling in the central part of the retina.
Damage to the intraocular lens: This is rare.
Floaters: An increase in floaters may be noticed after the procedure.
Bleeding: Bleeding within the eye is rare.
Infection: Infection is rare but can occur.

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 or explain 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:

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.

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 YAG Capsulotomy 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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