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AGREEMENT TO TREATMENT The Lasik Surgery Clinic
AGREEMENT TO TREATMENT & CONSENT FORM
(Please take sufficient time to read 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 surgery. This form gives the doctor the right to treat you and sets out the legal relationship between us.
The purpose of this form is to list the alternatives available to you and the known complications. It is given to you so that you can make an informed decision about having Lasik treatment to correct or modify your shortsightedness, farsightedness, or astigmatism. When considered in conjunction with the information package presented (Video), it will give you a balanced view of Lasik and the risks involved. If you have any questions, please contact us before undergoing treatment.
We will give you as much information as we can before you come for surgery so that you can consider all aspects of treatment in advance. You should not be presented with any new information on the day of the surgery. Please note that this information is applicable to everyone and your final decision must be based upon the specific advice of the treating doctor who will have conducted a full eye examination, taking into consideration your medical history, personal circumstances and expectations.
The Lasik Surgery Clinic does not interfere with the doctor/patient relationship. It is solely the treating doctor’s decision that determines your suitability for treatment.
Several organizations (eg. Police, Armed Forces, Fire Bridage, Civil Aviation Authority, etc) have strict eyesight requirements and may not accept people who have had laser treatment. Should you be considering employment with such an organization, you need to confirm the requirements with that organization prior to undergoing treatment.
Treatment appointments are provisional and pre-payments do not constitute a contract to treat you. These are hence refundable. There is no entitlement to compensation should an appointment or treatment not take place. This is regardless of the reason, including sickness or vehicle breakdown. Treatment can be aborted even after the corneal flap is cut.
Alternative Methods of Correcting Vision
The use of spectacles is the safest and most popular method of vision correction for shortsightedness, farsightedness and astigmatism. This option should be considered first before making a decision to undergo Lasik surgery. However, the use of spectacles may be disadvantageous and pose a hindrance in sports and many outdoor activities. Glasses with high power lenses can often look unsightly and feel cumbersome.
Contact lens wear is the other popular non-surgical method of vision correction. Contact lens wear does not suffer from many of the disadvantages of spectacle wear. They are less cumbersome and do not fog up. They offer a larger and more natural field of view. However, much time and money is spent fitting, wearing and maintaining them. More significantly, contact lens wear can give rise to potentially serious medical eye disorders like corneal ulcers, scarring and what is commonly known as GPC. There is also concern about long-term effects like changes in the shape of the cornea after long hours of contact lens wear for many years, that have a deleterious effect on the eye’s health.
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CONSENT FORM FOR REFRACTIVE SURGERY - LASIK
The following points are understood:
1. The treating doctor must ensure that you are fully informed of the risks and have realistic expectations of the procedures. The treating doctor has sole medical responsibility towards you. He/she decides the treatment protocol, dosage of medication and all aspects of aftercare and emergency procedures. He/she supervises the assistants and is responsible for their work. The doctor will only undertake surgery upon satisfaction with laser settings and calibration, microkeratome condition and sterilization along with confidence that all the necessary equipment is in good working order.
2. The goal of Lasik is to reduce or eliminate the need to wear spectacles or contact lenses. It is an elective procedure with no pressing medical need to have it done in most cases, unlike other eye operations that are performed on damaged or diseased eyes. Lasik involves the surgical cutting of a thin flap of the eye’s surface by a special device (microkeratome). The laser then sculpts tissue in the deeper layers of the cornea after which the flap is repositioned and heals itself by natural adhesion without the need for sutures.
3. Lasik is a surgical procedure and like all surgery, it is dependent on doctor’s skill and is not risk free.
4. The results of Lasik appear to be permanent (as observed with patients treated since the early 1990’s). However, owing to natural changes of eyesight with age, illness or long-term effects, which have yet to be measured, the need for glasses may change. Lasik does not prevent the onset and development of other eye diseases.
5. People with good eyesight will require reading glasses after the age of about 40 years. There is an advantage of being mildly shortsighted later in life in that reading glasses may not be needed. If shortsightness is fully corrected by LASIK, reading glasses may be needed later on. Lasik may also unmask the need to wear reading glasses earlier in some patients.
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Possible Complications
1. There are complications that may affect some patients. These include a possible loss of cornea flap, folds of the cornea flap, shifting or wrinkling of the flap, corneal scarring, interface inflammation, infection, epithelial in-growth underneath the flap, and instability of the flap requiring corneal sutures (stitched); all of which can result in permanent loss of best corrected vision.
2. Some patients may also experience the following: under-correction, regression of refraction, difficulty relating to the fitting of contact lenses, droopy eyelids, double vision, haze or induced astigmatism. Patients with large pupils can experience glare or rings around bright lights when in dark conditions. This occurs when the pupil expands beyond the treated area. All of the above may result in night vision problems and may make night driving difficult.
3. Visual sharpness is measured by the smallest letters or the best line readable on the eye test chart; using lenses (glasses) as necessary. A risk of Lasik is the permanent loss of best-corrected vision. This means seeing worse after Lasik than before despite the best spectacles correction. Other attributes of vision may be affected such as a loss of contrast sensitivity. This is the reduced ability to distinguish between different shades of gray under conditions of diminished illumination.
4. As with all types of surgery, there is a possibility of infection. Infection, when severe and unresponsive to antibiotics, can cause blindness. Other adverse reactions like those due to antibiotic eye drops or drug reactions can occur among others.
5. Since it is impossible to state every complication that may occur as a result of any surgery, the complications listed on this form are not exhaustive.
6. Differences between the two eyes (imbalanced power) can interfere with binocular vision to the extent of causing headaches and dizziness and impairing the judgment of distance.
7. Some complications may require additional surgery eg further ‘enhancement’ laser application to compensate for under-correction or to reverse over-correction.
8. Should an adverse reaction occur eg pain, swelling, irritation, infection etc, it is the patient’s responsibility to contact us immediately. Patients should stop using suspected medication whether they be taken orally or used topically as with eye drops or ointment if an allergic reaction occurs. Patients must not rub or touch their eyes after surgery.
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Visual Results
1. Vision usually becomes stable after about one month. However, it may take much longer in some patients, especially if complications arise. Most patients have good vision within a few days. Most visual side effects improve with time.
2. After treatment, you may still need glasses or contact lenses. There is no guarantee of the result of good vision. The Laser is programmed for very precise degrees of correction, but due to individual variation in healing and tissue density, under, over-correction or induced astigmatism can occur despite the surgeon’s best effort. For a patient whose career or lifestyle depends on good and balanced sight in both eyes, it is advisable to consider very carefully the implications of treatment complications.
3. Second treatment to the same eye (i.e. enhancement treatment) may be possible and recommended in certain situations. Enhancement, however, is associated with additional risks.
4. Although overall results show a high degree of patient satisfaction, it is not possible to predict a result for any single individual. Some people will not be satisfied with the results or be able to cope with complications and may experience distress and anxiety. You should be aware that the outcome may be disappointing despite the best of intentions.
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