-
Consent Forms inOphthalmic Practice
inHindi & English
EDITORS
English EditionDr. Bhavna ChawlaDr. Namrata Sharma
Dr. Lalit Verma
Hindi EditionDr. P.S. Negi
Dr. Y.C. Gupta
Published By:
Dr. Amit KhoslaSecretary, DOS
Room No.2225, 2nd FloorNew Building
Sir Ganga Ram HospitalRajinder Nagar, New Delhi - 110060
Disclaimer
This manual is for educational purpose only and is not intended
to constitute legal
advice. Hence it should not be relied upon as a source for legal
advice.
-
Contents
RETINA
1.
Cryosurgery-------------------------------------------------------------------------------------------------------------------
1
2. Retinal Detachment
----------------------------------------------------------------------------------------------------------
5
3. Vitreo Retinal Surgery
-------------------------------------------------------------------------------------------------------
9
4. Macular Hole Surgery
-----------------------------------------------------------------------------------------------------
13
5. Avastintm Intravitreal Injection
-------------------------------------------------------------------------------------------
17
6. Macugentm Intravitreal Injection
-----------------------------------------------------------------------------------------
21
7. Lucentistm Intravitreal Injection
------------------------------------------------------------------------------------------
25
8. ROP Laser
-------------------------------------------------------------------------------------------------------------------
29
9. Laser Indirect Ophthalmoscopy
-----------------------------------------------------------------------------------------
31
10. Laser Photocoagulation for Diabetic Retinopathy
--------------------------------------------------------------------
35
11. Laser Photocoagulation for Proliferative Retinopathy
----------------------------------------------------------------
39
12. Laser Photocoagulation for Maculopathy
------------------------------------------------------------------------------
43
13. Fundus Fluorescein Angiography / Ophthalmoscopy/ Indocyanine
Green Angiography ----------------------- 47
14. Photodynamic Therapy (PDT)
------------------------------------------------------------------------------------------
49
15. Trans Pupillary Thermotherapy
(TTT)---------------------------------------------------------------------------------
53
17. Intravitreal Injection for Endophthalmitis
------------------------------------------------------------------------------
57
16. Electrophysiological Tests
------------------------------------------------------------------------------------------------
59
OCULOPLASTY & ORBIT
1. Enucleation
------------------------------------------------------------------------------------------------------------------
63
2. Evisceration
-----------------------------------------------------------------------------------------------------------------
67
3. Orbitotomy
------------------------------------------------------------------------------------------------------------------
71
4. Entropion
--------------------------------------------------------------------------------------------------------------------
75
5. Ectropion
--------------------------------------------------------------------------------------------------------------------
77
6. Ptosis
-------------------------------------------------------------------------------------------------------------------------
79
7. Syringing and
Probing-----------------------------------------------------------------------------------------------------
81
8. Punctal Plugs
---------------------------------------------------------------------------------------------------------------
83
9. Dacryocystorhinostomy (DCR)
-----------------------------------------------------------------------------------------
85
10. Contracted Socket
---------------------------------------------------------------------------------------------------------
87
OCULAR SURFACE, CORNEA & REFRACTIVE SURGERY
1. Optical Penetrating Keratoplasty
-----------------------------------------------------------------------------------------
89
2. Therapeutic Keratoplasty
-------------------------------------------------------------------------------------------------
91
3. Automated Lamellar Therapeutic Keratoplasty (ALTK)
-------------------------------------------------------------
95
4. Deep Anterior Lamellar Keratoplasty (DALK)
-------------------------------------------------------------------------
97
-
5. Descemet’s Stripping Endothelial Keratoplasty (DSEK/DSAEK)
-------------------------------------------------- 99
6. Phototherapeutic Keratectomy (PTK)
---------------------------------------------------------------------------------
103
7. Photorefractive Keratectomy (PRK)
-----------------------------------------------------------------------------------
107
8. LASIK
----------------------------------------------------------------------------------------------------------------------
111
9. Astigmatic Keratotomy (AK)
--------------------------------------------------------------------------------------------
115
10. Intacs
-----------------------------------------------------------------------------------------------------------------------
119
11. Phakic IOL
-----------------------------------------------------------------------------------------------------------------
123
12. Conductive Keratoplasty
-------------------------------------------------------------------------------------------------
129
13. Pterygium Surgery
--------------------------------------------------------------------------------------------------------
133
14. Corneal Scraping
----------------------------------------------------------------------------------------------------------
135
15. Fibrin Glue Adhesive for Corneal Perforation
------------------------------------------------------------------------
137
16. Symblepharon Release
---------------------------------------------------------------------------------------------------
139
17. Amniotic Membrane Transplantation (AMT)
-------------------------------------------------------------------------
141
18. Limbal Stem Cell Transplantation (LSCT)
----------------------------------------------------------------------------
143
19. Osteo-odonto Keratoprosthesis (OOKP)
------------------------------------------------------------------------------
145
SQUINT
1. Squint Surgery
------------------------------------------------------------------------------------------------------------
147
2. Botox (Botulinum Toxin) Injection
-------------------------------------------------------------------------------------
151
GLAUCOMA
1. Trabeculectomy With / Without Anti-Fibroblastic Agents
---------------------------------------------------------- 155
2. Diode Laser Cyclo-photocoagulation
(DLCP)------------------------------------------------------------------------
159
3. Argon Laser Trabeculoplasty (ALT)
-----------------------------------------------------------------------------------
163
4. Laser Iridotomy
-----------------------------------------------------------------------------------------------------------
167
CATARACT
1. Cataract Surgery With / Without Implantation of Intraocular
Lens ----------------------------------------------- 169
2. Pediatric Cataract
---------------------------------------------------------------------------------------------------------
175
3. YAG Capsulotomy
--------------------------------------------------------------------------------------------------------
179
MISCELLANEOUS
1. Examination Under Anesthesia (EUA)
---------------------------------------------------------------------------------
181
2. Optical Iridectomy
--------------------------------------------------------------------------------------------------------
183
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RETINA
-
( 1 )
CryosurgeryBipul Baishya, Atul Kumar
Name of Patient
.......................................................................
Age/Sex ......... Patient ID ............................... Date
.............................................
Son / Daughter of
............................................................................................................................................................................................................
Address
........................................................................................................................................
Tel
.............................................................................
Proposed TreatmentThe doctor has explained that I, (name of
patient …………….………), have a retinal lesion in my……..eye which is a
risk factor fordevelopment of ……………… and Cryosurgery is
proposed.
RisksThese are the commoner risks. There may be other unusual
risks that have not been listed here.
I understand there are risks associated with any anesthetic
agent (in case of children).
I may have side effects from any of the drugs used. The commoner
side effects include light-headedness, nausea, skin rash and
constipation.
I understand the procedure has the following specific risks and
limitations:
1. Although most retinal lesions can be treated, it is not 100%
effective. In some cases, more than two sittings may be required.2.
Corneal burns3. Retinal detachment or macular puckering that may
require additional surgery4. Inflammation5. Pigmentary
disturbances6. Bleeding in eye
Local complications of anesthesia injections around the eye
include:1. Perforation of eyeball2. Destruction of optic nerve3.
Interference with circulation of retina4. Possible drooping of
eyelid5. Respiratory depression6. Hypotension
Individual RisksI understand the following are possible
significant risks and complications specific to my individual
circumstances, that I have consideredin deciding to have this
operation:
.......................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................
Declaration by PatientI acknowledge doctors from the ophthalmic
team have informed me about the procedure, alternative treatments
and answered myspecific queries and concerns about this matter.
I acknowledge that I have discussed with the surgical team any
significant risks and complications specific to my individual
circumstancesthat I have considered in deciding to have this
operation.
I understand that a doctor other than the specialist surgeon may
perform the procedure.
-
( 2 )
I have received no guarantee the operation will be
successful.
I have received a copy of this form to take home with me.
If a needle stick/sharps injury occurs to staff during any
operation I give my permission for blood to be taken and tested for
HIV and otherblood borne disorders.
I understand I will be advised and counselled as soon as
practicable after the operation if this has been necessary.
Signature / Thumb Impression of Patient/ Parent / Guardian:
...............................................................................................................................
Name:
................................................................................................
Relationship .......................................... Date
.............................................
Address:
.............................................................................................................................................................................................................................
Phone (Off)
..............................................................
(Res)
..............................................................
(Mob)
............................................................
Declaration by DoctorI declare that I have explained the nature
and consequences of the procedure to be performed, and discussed
the risks that particularlyconcern the patient.
I have given the patient an opportunity to ask questions and I
have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1 Witness 2
Signature:
.............................................................................................
Signature:
.............................................................................................
Name:
...................................................................................................
Name:
...................................................................................................
Address:
..............................................................................................
Address:
..............................................................................................
Tel:
.......................................................................................................
Tel:
.......................................................................................................
-
( 3 )
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.........................................................................................................................................................................................................................................................................................................................................................................................................................
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-
( 4 )
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jksxh@vfHkHkkod dk gLrk{kj@vaxwBs dk fu'kku %.
.........................................................................................................................................
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......................................................................................
fj'rk %. ..........................................................
rkjh[k %. ..........................
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.....................................................................................................................................................................................................
Qksu % ¼vkfQl½.
........................................................... ¼/kj½.
................................................. eksckby%.
...................................................
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.................................................................................
gLrk{kj %.
........................................................................................
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......................................................................................
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.............................................................................................
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.......................................................................................
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.............................................................................................
Qksu %.
......................................................................................
Qksu %.
............................................................................................
-
( 5 )
Retinal DetachmentBipul Baishya, Y.R. Sharma
Name of Patient
.......................................................................
Age/Sex ......... Patient ID ............................... Date
.............................................
Son / Daughter of
............................................................................................................................................................................................................
Address
........................................................................................................................................
Tel
.............................................................................
Proposed TreatmentThe doctor has explained that I, (name of
patient …………….…......................……),have a retinal detachment
in my…...........…..eye andthat………………………………is proposed:
RisksThese are the commoner risks. There may be other unusual
risks that have not been listed here.
I understand there are risks associated with any anesthetic
agent.
I may have side effects from any of the drugs used. The commoner
side effects include light-headedness, nausea, skin rash and
constipation.
I understand the procedure has the following specific risks and
limitations:1. Although most retina detachments can be treated, a
small proportion (5%) may be inoperable and blindness cannot be
prevented.2. Failure to accomplish intent of surgery3. More than
one surgery may be required. Like if Scleral buckling surgery
fails, Vitrectomy may be required with Silicone Oil or Gas
tamponade.4. In case of Silicone Oil or Gas injection, I have to
maintain position depending upon the surgery.5. If Gas is injected,
I have to restrict air travel until gas is absorbed.6. If Silicone
oil is injected, then resurgery will be required to remove the
oil.7. It may take up to 18 months before the final outcome of the
surgery is known. Although many cases achieve a good result,
this
depends on several factors including how long the detachment had
been present.8. It may not be possible to predict before the
operation which cases will do well.9. There is a chance I may
develop further retina detachments in future in the same eye or in
the opposite eye.10. In some cases, more than one operation may be
required11. Though rare, I may develop complications like vitreous
hemorrhage, infection, elevated eye pressure (glaucoma), poorly
healing
or non-healing corneal defects, corneal clouding and scarring,
cataract, which might require eventual or immediate removal oflens,
double vision, eyelid droop, and loss of circulation to vital
tissues in the eye, resulting in decrease or loss of vision
There is an extremely small risk (1:17000 cases) that the
opposite eye to the one having surgery may become inflamed,
especially ifcomplications occur after the operation. This is
called sympathetic ophthalmia .Although this can be treated, in
some cases, eyesightmay be lost.
I understand some of the above risks are more likely if I smoke,
am overweight, diabetic, have high blood pressure or have had
previousheart disease.
Individual RisksI understand the following are possible
significant risks and complications specific to my individual
circumstances, that I have consideredin deciding to have this
operation:
.......................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................
-
( 6 )
Declaration By PatientI acknowledge doctors from the ophthalmic
team have informed me about the procedure, alternative treatments
and answered myspecific queries and concerns about this matter.
I acknowledge that I have discussed with the surgical team any
significant risks and complications specific to my individual
circumstancesthat I have considered in deciding to have this
operation.
I agree to any other additional procedures considered necessary
in the judgment of my surgeon during this operation.
I have received no guarantee the operation will be
successful.
I have received a copy of this form to take home with me.
If a needle stick/sharps injury occurs to staff during any
operation I give my permission for blood to be taken and tested for
HIV andother blood borne disorders.
I understand I will be advised and counselled as soon as
practicable after the operation if this has been necessary.
Signature / Thumb Impression of Patient/ Parent / Guardian:
...............................................................................................................................
Name:
................................................................................................
Relationship .......................................... Date
.............................................
Address:
.............................................................................................................................................................................................................................
Phone (Off)
..............................................................
(Res)
..............................................................
(Mob)
............................................................
Declaration by DoctorI declare that I have explained the nature
and consequences of the procedure to be performed, and discussed
the risks that particularlyconcern the patient.
I have given the patient an opportunity to ask questions and I
have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1 Witness 2
Signature:
.............................................................................................
Signature:
.............................................................................................
Name:
...................................................................................................
Name:
...................................................................................................
Address:
..............................................................................................
Address:
..............................................................................................
Tel:
.......................................................................................................
Tel:
.......................................................................................................
-
( 7 )
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..................................................................
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.........................................................................................................................................................................................................................................................................................................................................................................................................................
-
( 8 )
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.........................................................................................................................................
uke %.
......................................................................................
fj'rk %. ..........................................................
rkjh[k %. ..........................
irk %.
.....................................................................................................................................................................................................
Qksu % ¼vkfQl½.
........................................................... ¼/kj½.
................................................. eksckby%.
...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSaus laiUu dh tkus okyh dk;Zfof/k dh
izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa
dh ppkZ dh gS tks fdfo'ks"k :i ls jksxh ls lacaf/kr gSA
eSaus jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj
fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1 xokg 2
gLrk{kj %.
.................................................................................
gLrk{kj %.
........................................................................................
uke %.
......................................................................................
uke %.
.............................................................................................
irk %.
.......................................................................................
irk %.
.............................................................................................
Qksu %.
......................................................................................
Qksu %.
............................................................................................
-
( 9 )
Vitreo Retinal SurgeryBipul Baishya, R.V. Azad
Name of Patient
.......................................................................
Age/Sex ......... Patient ID ............................... Date
.............................................
Son / Daughter of
............................................................................................................................................................................................................
Address
........................................................................................................................................
Tel
.............................................................................
Proposed TreatmentThe doctor has explained that I, (name of
patient …………….………), have …............................... in my
........................... Eye andthat………………………………is proposed.
RisksThese are the commoner risks. There may be other unusual
risks that have not been listed here.
I understand there are risks associated with any anesthetic
agent.
I may have side effects from any of the drugs used. The commoner
side effects include light-headedness, nausea, skin rash and
constipation.
I understand the procedure has the following specific risks and
limitations:
1. Failure to accomplish intent of surgery2. Retinal detachments
that may require additional surgery or may be inoperable3.
Depending upon the surgery, Silicone Oil or Gas may be required for
tamponade.4. In case of Silicone Oil or Gas injection, I have to
maintain position depending upon the surgery.5. If Gas is injected,
I have to restrict air travel until gas is absorbed.6. If Silicone
oil is injected then resurgery will be required to remove the
oil.7. It may take up to 18 months before the final outcome of the
surgery is known.8. In a few cases, the underlying condition cannot
be treated and blindness cannot be prevented.9. It may not be
possible to predict before the operation which cases will do
well.10. There is a chance I may develop further retina detachments
in future in the same eye or in the opposite eye.11. In some cases,
more than one operation may be required12. Though rare I may
develop complications like vitreous hemorrhage, infection, elevated
eye pressure (glaucoma), poorly healing or
non-healing corneal defects, corneal clouding and scarring,
cataract, which might require eventual or immediate removal of
lens,double vision, eyelid droop, and loss of circulation to vital
tissues in the eye, resulting in decrease or loss of vision
There is an extremely small risk (1:17000 cases) that the
opposite eye to the one having surgery may become inflamed,
especially ifcomplications occur after the operation. This is
called sympathetic ophthalmia .Although this can be treated, in
some cases, eyesight maybe lost.
I understand some of the above risks are more likely if I smoke,
am overweight, diabetic, have high blood pressure or have had
previousheart disease.
Individual RisksI understand the following are possible
significant risks and complications specific to my individual
circumstances, that I have consideredin deciding to have this
operation:
.......................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................
-
( 10 )
Declaration by PatientI acknowledge doctors from the ophthalmic
team have informed me about the procedure, alternative treatments
and answered my specificqueries and concerns about this matter.
I acknowledge that I have discussed with the surgical team any
significant risks and complications specific to my individual
circumstancesthat I have considered in deciding to have this
operation.
I agree to any other additional procedures considered necessary
in the judgment of my surgeon during this operation.
I agree to the disposal by the hospital authorities of any
tissues that may be removed during the procedure. I understand that
some tissuesor samples may be kept as part of my hospital
records.
I have received no guarantee the operation will be
successful.
I have received a copy of this form to take home with me.
If a needle stick/sharps injury occurs to staff during any
operation I give my permission for blood to be taken and tested for
HIV and otherblood borne disorders.
I understand I will be advised and counselled as soon as
practicable after the operation if this has been necessary.
Signature / Thumb Impression of Patient/ Parent / Guardian:
...............................................................................................................................
Name:
................................................................................................
Relationship .......................................... Date
.............................................
Address:
.............................................................................................................................................................................................................................
Phone (Off)
..............................................................
(Res)
..............................................................
(Mob)
............................................................
Declaration by DoctorI declare that I have explained the nature
and consequences of the procedure to be performed, and discussed
the risks that particularlyconcern the patient.
I have given the patient an opportunity to ask questions and I
have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1 Witness 2
Signature:
.............................................................................................
Signature:
.............................................................................................
Name:
...................................................................................................
Name:
...................................................................................................
Address:
..............................................................................................
Address:
..............................................................................................
Tel:
.......................................................................................................
Tel:
.......................................................................................................
-
( 11 )
foVsfjvks jsfVuy ltZjhfciqy cS';] vkj- oh- vktkn
jksxh dk uke %.
..................................................................
mez@fyax %. .............. jksxh dh vkbZMh %.
....................... rkjh[k %. .................
dk iq=@iq=h .
........................................................................................................................................................................................irk
% .
......................................................................................................................................VsyhQksu
ua % . .....................................
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------------------------------------------------------------------------------------------------------------
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-----------------------------------------------------izLrkfor gS
%
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eSa le>rk gwa fd fdlh Hkh laosnukgkjh dkjd ds lkFk tksf[ke
tqM+s gq, gksrs gSaA
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vkSj lhek,a gSa %
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dk irk pyus esa 18 eghuksa rd dk le; yx ldrk gSA8- dqN ekeyksa esa
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esa jsfVuk dk vkxs Hkh vyxko fodflr gks tk;sA11- dqN ekeyksa esa]
,d ls vf/kd vkWijs'ku dh t:jr iM+ ldrh gSA12- gkykafd eqf'dy ls gh
,slk gksrk gS ysfdu esjs Hkhrj okbVfjvl jDrlzko] laØe.k] vka[k dk
aÅapk ncko ¼Xywdksek½] dkWuhZy dh [kjkfc;ksa ds ?kko
ds eqf'dy ls Hkjus ;k ugha Hkjus] dkWuhZy DykmfMax vkSj LdSfjax]
eksfr;kfcan] ftlds fy, ysalksa dks varr% ;k QkSju fudkyus dh t:jr
iM+ldrh gS] Mcy fotu] iydksa ds yVduk vkSj vka[kksa ds egRoiw.kZ
Årdksa esa ifjlapj.k ds ugha gksus tSlh tfVyrk,a fodflr gks ldrh
gSa] ftldsQyLo:i utj esa deh ;k mldk [kkRek gks ldrk gSA
bl ckr dk cgqr gh de tksf[ke ¼1%17000 ekeys½ gksrk gS fd ftl
vka[k dh ltZjh dh x;h gS mlds cxy okyh vka[k yky gks ldrh gS]
fo'ks"kdjml le; tcfd tfVyrk,a vkWijs'ku ds ckn iSnk gksrh gSaA bls
flEiSFksfVd vkFkSyfe;k dgk tkrk gSA gkykafd bldk mipkj fd;k tk ldrk
gS ijdqN ekeyksa esa vka[kksa dh n`f"V tk ldrh gSA
eSa le>rk gwa fd Åij crk;s x;s tksf[keksa esa ls dqN ds vklkj
ml le; T;knk gksrs gSa tcfd eSa /kweziku djrk gwa] esjk otu T;knk
gS] e/kqesg ls ihfM+rgwa] mPp jDrpki gS ;k igys fny dh chekjh gks
pqdh gSA
O;fDrxr tksf[ke
eSa le>rk gwa fd fo'ks"k :i ls esjh ifjfLFkfr;ksa ls tqM+s
laHkkfor egRiw.kZ tksf[ke vkSj tfVyrk,a fuEufyf[kr gSa] ftu ij fd
eSaus bl vkWijs'ku dks djokusdk fu.kZ; djrs le; fopkj fd;k gS %.
.......................................................................................................................................................................................................................................................................................................................................................................................................................
-
( 12 )
jksxh }kjk ?kks"k.kkeSa bl ckr dh iqf"V djrk gwa fd us=
fo'ks"kKksa dh Vhe ds MkWDVjksa us fpfdRldh; izfØ;k] oSdfYid
mipkjksa ds ckjs esa eq>s tkudkjh iznku dh gS vkSjbl ekeys esa
esjs fof'k"V iz'uksa vkSj fparkvksa dk tokc fn;k gSA
eSa bl ckr dh iqf"V djrk gwa fd eSaus ltZjh djus okys MkWDVjksa
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ifjfLFkfr;ksaa ds fy, [kkltfVyrkvksa ij ppkZ dh gS] ftu ij fd eSaus
bl vkWijs'ku dks djokrs le; fopkj fd;k gSA
eSa ,slh vU; dk;Zfof/k;ksa dks viuk, tkus ij lger gwa tks fd bl
vkWijs'ku ds nkSjku esjs ltZu dh jk; esa vko';d gksaxhA
eSa vLirky ds vf/kdkfj;ksa }kjk ,slh fdUgha Hkh Årdksa ds fuiVku
ds fy, lger gwa ftUgsa fd dk;Zfof/k ds nkSjku fudkyk tk ldrk gSA
eSa le>rk gwafd dqN Årdksa vkSj uewuksa dks vLirky ds esjs
fjdkMksZa ds fgLls ds :i esa j[kk tk ldrk gSA
vkWijs'ku lQy gh gksxk bldh eq>s dksbZ xkjaVh ugha nh x;h
gSA
eq>s ?kj ys tkus ds fy, bl izi= dh ,d izfr izkIr gqbZ gSA
vxj fdlh phM+&QkM+ ds nkSjku LVkQ dks lqbZ ;k /kkjnkj vkStkj
ls pksV vkrh gS rks eSa ,pvkbZoh vkSj jDr ls gksus okys nwljs
fodkjksa ds fy, jDr ysusvkSj mldk ijh{k.k djus dh vuqefr iznku djrk
gwaA
eSa le>rk gwa fd vkWijs'ku ds ckn vko';drk iM+us ij tSls gh
eqefdu gksxk eq>s lykg vkSj ijke'kZ iznku fd;k tk,xkA
jksxh@vfHkHkkod dk gLrk{kj@vaxwBs dk fu'kku %.
.........................................................................................................................................
uke %.
......................................................................................
fj'rk %. ..........................................................
rkjh[k %. ..........................
irk %.
.....................................................................................................................................................................................................
Qksu % ¼vkfQl½.
........................................................... ¼/kj½.
................................................. eksckby%.
...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSaus laiUu dh tkus okyh dk;Zfof/k dh
izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa
dh ppkZ dh gS tks fdfo'ks"k :i ls jksxh ls lacaf/kr gSA
eSaus jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj
fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1 xokg 2
gLrk{kj %.
.................................................................................
gLrk{kj %.
........................................................................................
uke %.
......................................................................................
uke %.
.............................................................................................
irk %.
.......................................................................................
irk %.
.............................................................................................
Qksu %.
......................................................................................
Qksu %.
............................................................................................
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( 13 )
Macular Hole SurgeryRitesh Gupta
Name of Patient
.......................................................................
Age/Sex ......... Patient ID ............................... Date
.............................................
Son / Daughter of
............................................................................................................................................................................................................
Address
........................................................................................................................................
Tel
.............................................................................
Indications and BenefitsYour doctor has diagnosed you with
macular hole and informed you that if it is left untreated, it is
likely that you will have gradual centralvision deterioration but
you will not lose all of the vision in your eye.
Your doctor has informed you that a procedure involving pars
plana vitrectomy with/without internal limiting membrane removal
andgas injection will be performed in your eye under local/general
anesthesia. The important factors in predicting whether the hole
closesas a result of surgery is the duration for which the hole has
been present and the size of the hole. The success rate for holes
that have beenpresent for less than six months is about 90%.
However, this reduces to around 60% for a hole which has been
present for a year or more.Your doctor has told you that a
successful macular hole closure does not guarantee complete visual
recovery and that a 2-line improvementis usually the measure of
success of the surgery. You have been told that postoperative
positioning also has an important role to play forclosure of
macular hole and that a good majority of the failures stem from
incomplete and inconsistent postoperative positioning.
ComplicationsAs with any surgical procedure, there are risks
associated with macular hole surgery. Not every conceivable
complication can be coveredin this form but the following are
examples of risk encountered with macular hole surgery. These
complications can occur days, weeks,months, or years later. They
can result in loss of vision or blindness. Careful follow-up is
required after surgery.
Complications of the surgery1. Failure to accomplish closure of
the hole(10-40% depending primarily on the duration and size)2.
Retinal detachments that may require additional surgery or may be
inoperable (1-2%)3. Vitreous hemorrhage4. Infection (0.02%-0.1%)5.
Elevated eye pressure (glaucoma)6. Cataract, which might require
eventual or immediate removal of lens7. Poorly healing or
non-healing corneal defects8 Corneal clouding and scarring
Complications of anesthesia injections around the eye
1. Perforation of eyeball2. Needle damage to the optic nerve,
which could destroy vision3. Retrobulbar hemorrhage4. Possible
drooping of eyelid5. Systemic effects that have the potential for
life-threatening complications and death
Patient ConsentIn spite of the risks noted above, I understand
that there is more risk to my vision if I do not have the operation
than if I do. I have read andunderstand the consent form, I have
had my questions answered, and I authorize my surgeon to proceed
with the operation on my..................................
(indicate “right” or “left” eye).
-
( 14 )
Signature / Thumb Impression of Patient/ Parent / Guardian:
...............................................................................................................................
Name:
................................................................................................
Relationship .......................................... Date
.............................................
Address:
.............................................................................................................................................................................................................................
Phone (Off)
..............................................................
(Res)
..............................................................
(Mob)
............................................................
Declaration by DoctorI declare that I have explained the nature
and consequences of the procedure to be performed, and discussed
the risks that particularlyconcern the patient.
I have given the patient an opportunity to ask questions and I
have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1 Witness 2
Signature:
.............................................................................................
Signature:
.............................................................................................
Name:
...................................................................................................
Name:
...................................................................................................
Address:
..............................................................................................
Address:
..............................................................................................
Tel:
.......................................................................................................
Tel:
.......................................................................................................
-
( 15 )
eSdqyj gksy ltZjhfjrs'k xqIrk
jksxh dk uke %.
..................................................................
mez@fyax %. .............. jksxh dh vkbZMh %.
....................... rkjh[k %. .................
dk iq=@iq=h .
........................................................................................................................................................................................irk
% .
......................................................................................................................................VsyhQksu
ua % . .....................................
lq>ko vkSj ykHkvkids MkWDVj dh tkap ds vuqlkj vkidh vka[k esa
eSdqyj Nsn gS vkSj vkidks crk;k gS fd vxj bldk bykt ugha fd;k x;k
rks bl ckr ds vklkjgSa fd vkidh e/;orhZ utj /khjs&/khjs [kjkc
gksrh tk,xh ysfdu vkidh vka[k dh iwjh jks'kuh ugha tk,xhA vkids
MkWDVj us vkidks crk;k gS fdLFkkfud@iwjh csgks'kh dh fLFkfr esa
vkidh vka[k esa vkarfjd :i ls lhfer djus okyh f>Yyh fudklh vkSj
xSl batsD'ku ds lkFk@ds fcuk iklZ IykukfoVjsDVkseh ls tqM+h
fØ;kfof/k viuk;h tk,xhA D;k ltZjh ds QyLo:i Nsn can gks tk,xk bldk
iwokZuqeku yxkus esa egRoiw.kZ dkjd Nsn ds ekStwnjgus dh vof/k vkSj
Nsn dk vkdkj gSA Ng eghuksa ls de le; le; ls ekStwn jgus okys
Nsnksa ds fy, lQyrk dh nj yxHkx 90 izfr'kr gSA fQjHkh] ,d lky ;k
vf/kd ls ekStwn jgus okys Nsn ds fy, ;g ?kVdj yxHkx 60 izfr'kr gks
tkrh gSA vkids MkWDVj us vkidks crk;k gS fd eSdqyj Nsndk lQyrkiwoZd
can gksuk ǹf"V dh iw.kZ:is.k HkjikbZ dh xkjaVh ugha djrk vkSj ;g
fd 2&ykbu lq/kkj izk;% ltZjh dh lQyrk dk iSekuk gksrk gSA
vkidkscrk;k x;k gS fd vkWijs'ku ds ckn dk LFkkiu Hkh eSdqyj ds Nsn
dks can djus esa egRoiw.kZ Hkfedk vnk djrk gS vkSj foQyrkvksa ds
dkQh cMs+ fgLlsdk dkj.k vkWijs'ku ds ckn dk v/kwjk vkSj vlaxr
LFkkiu gksrk gSA
tfVyrk,a'kY;fØ;k ls tqM+h fdlh Hkh dk;Zfof/k dh Hkkafr gh eSdqyj
Nsn dh ltZjh ls Hkh tksf[ke tqM+s gq, gksrs gSaA bl :i esa gjsd
dYiuh; tfVyrk dks 'kkfeyugha fd;k tk ldrk ysfdu eSdqyj Nsn ltZjh ls
tqM+s tksf[keksa ds mnkgj.k fuEufyf[kr gSaA ;s tfVyrk,a fnuksa]
grksa] eghuksa ;k lkyksa ckn iSnk gks ldrhgSaA budh otg ls n`f"V dk
pys tkuk ;k va/kkiu iSnk gks ldrk gSA ltZjh ds ckn lko/kkuh Hkjs
QkWyks&vi dh t:jr gksrh gSA
ltZjh dh tfVyrk,a1- Nsn dh canh dks iwjk djus esa foQyrk
¼10&40 izfr'kr eq[;r;k vof/k vkSj vkdkj ij fuHkjZ½
2- jsfVuk dk vyxko ftlds fy, vfrfjDr ltZjh dh t:jr iM+ ldrh gS
;k gks ldrk gS fd mldk vkWijs'ku gh u gks ik;s ¼1&2
izfr'kr½
3- foVfjvl jDrlzko
4- laØe.k ¼0-02 izfr'kr&0-1 izfr'kr½
5- vka[k dk c
-
( 16 )
jksxh@vfHkHkkod dk gLrk{kj@vaxwBs dk fu'kku %.
.........................................................................................................................................
uke %.
......................................................................................
fj'rk %. ..........................................................
rkjh[k %. ..........................
irk %.
.....................................................................................................................................................................................................
Qksu % ¼vkfQl½.
........................................................... ¼/kj½.
................................................. eksckby%.
...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSaus laiUu dh tkus okyh dk;Zfof/k dh
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dh ppkZ dh gS tks fdfo'ks"k :i ls jksxh ls lacaf/kr gSA
eSaus jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj
fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1 xokg 2
gLrk{kj %.
.................................................................................
gLrk{kj %.
........................................................................................
uke %.
......................................................................................
uke %.
.............................................................................................
irk %.
.......................................................................................
irk %.
.............................................................................................
Qksu %.
......................................................................................
Qksu %.
-
( 17 )
AvastinTM Intraivtreal InjectionZahir Abbas, Gunjan Prakash
Name of Patient
.......................................................................
Age/Sex ......... Patient ID ............................... Date
.............................................
Son / Daughter of
............................................................................................................................................................................................................
Address
........................................................................................................................................
Tel
.............................................................................
Possible Benefits and “Off-Label” StatusAvastinTM was not
initially developed to treat your eye condition. Based upon the
results of clinical trials that demonstrated its safety
andeffectiveness, AvastinTM was approved by the Food and Drug
Administration (FDA) for the treatment of metastatic colorectal
cancer.Once a device or medication is approved by the FDA,
physicians may use it “off-label” for other purposes if they are
well-informed aboutthe product, base its use on firm scientific
method and sound medical evidence, and maintain records of its use
and effects. Ophthalmologistsare using AvastinTM “off-label” to
treat AMD and similar conditions since research indicates that VEGF
is one of the causes for the growthof the abnormal vessels that
cause these conditions. Some patients treated with AvastinTM had
less fluid and more normal-appearingmaculas, and their vision
improved. AvastinTM is also used, therefore, to treat macular
edema, or swelling of the macula. Recently, amedication similar in
function and designed for intravitreal administration was approved
by the FDA for the treatment of AMD.
Possible LimitationsThe goal of treatment is to prevent further
loss of vision. Although some patients have regained vision, the
medication may not restorevision that has already been lost, and
may not ultimately prevent further loss of vision caused by the
disease.
AlternativesYou do not have to receive treatment for your
condition, although without treatment, these diseases can lead to
further vision loss andblindness, sometimes very quickly. Other
forms of treatment are available. At present, there are three
FDA-approved treatments for neovascularage-related macular
degeneration. The first two are photodynamic therapy with a drug
called VisudyneTM and injection into the eye of a drugcalled
MacugenTM. The third medication, LucentisTM is similar to
AvastinTM. In addition to the FDA-approved medications,
someophthalmologists use intravitreal triamcinolone —”off-label” to
treat eye conditions like yours.
Complications when AvastinTM is given to patients with
cancerWhen AvastinTM is given to patients with metastatic
colorectal cancer, some patients experienced gastrointestinal
perforations or woundhealing complications, hemorrhage, arterial
thromboembolic events (such as stroke or heart attack),
hypertension, proteinuria, andcongestive heart failure. Patients
who experienced these complications not only had metastatic colon
cancer, but were also given 400times the dose you will be given, at
more frequent intervals, and in a way (through an intravenous
infusion) that spread the drugthroughout their bodies.
Risk when AvastinTM is given to treat patients with eye
conditionsThe risk of these complications for patients with eye
conditions is low. Patients receiving AvastinTM for eye conditions
are healthier thanthe cancer patients, and receive a significantly
small dose, delivered only to the cavity of their eye. While there
are no FDA-approvedstudies about the use of AvastinTM in the eye
that prove it is safe and effective, LucentisTM, a similar drug,
was recently approved for AMD.One study of patients who received
AvastinTM through an intravenous infusion reported only a mild
elevation in blood pressure. Anotherstudy of patients treated like
you will be with intravitreal AvastinTM did not have these
elevations or the other serious problems seen in thepatients with
cancer. However, the benefits and risks of intravitreal AvastinTM
for eye conditions are not yet fully known. In addition,whenever a
medication is used in a large number of patients, a small number of
coincidental life-threatening problems may occur thathave no
relationship to the treatment. For example, patients with diabetes
are already at increased risk for heart attacks and strokes. If
oneof these patients being treated with AvastinTM suffers a heart
attack or stroke, it may be caused by the diabetes and not the
AvastinTMtreatment.
Known risks of intravitreal eye injectionsYour condition may not
get better or may become worse. Any or all of these complications
may cause decreased vision and/or have a
-
( 18 )
possibility of causing blindness. Additional procedures may be
needed to treat these complications. Possible complications and
sideeffects of the procedure and administration of AvastinTM
include but are not limited to retinal detachment, cataract
formation, glaucoma,hypotony (reduced pressure in the eye), damage
to the retina or cornea, and bleeding. There is also the
possibility of an eye infection(endophthalmitis). Any of these rare
complications may lead to severe, permanent loss of vision.
Patient ResponsibilitiesI will immediately contact my doctor if
any of the following signs of infection or other complications
develop : pain, blurry or decreasedvision, sensitivity to light,
redness of the eye, or discharge from the eye. I will keep all
post-injection appointments so my doctor can checkfor
complications.
Although the likelihood of serious complications affecting other
organs of my body is low, I will immediately contact my physician
if Iexperience abdominal pain associated with constipation &
vomiting, abnormal bleeding, chest pain, severe headache, slurred
speech, orweakness on one side of the body. As soon as possible, I
will also notify the treating ophthalmologist of these
problems.
I will inform any other surgeon that I am on a medication that
needs to be stopped before I can have surgery.
Patient ConsentThe above explanation has been read by/to me. The
nature of my eye condition has been explained to me and the
proposed treatment hasbeen described. The risks, benefits,
alternatives, and limitations of the treatment have been discussed
with me. All my questions have beenanswered.
I understand that AvastinTM was approved by the FDA for the
treatment of metastatic colorectal cancer, and has not been
approved for thetreatment of eye conditions. Nevertheless, I wish
to be treated with AvastinTM, and I am willing to accept the
potential risks that myphysician has discussed with me. I hereby
authorize the treating eye-surgeon to administer the intravitreal
AvastinTM in my affected eye asneeded. This consent will be valid
until I revoke it or my condition changes to the point that the
risks and benefits of this medication forme are significantly
different.
Signature / Thumb Impression of Patient/ Parent / Guardian:
...............................................................................................................................
Name:
................................................................................................
Relationship .......................................... Date
.............................................
Address:
.............................................................................................................................................................................................................................
Phone (Off)
..............................................................
(Res)
..............................................................
(Mob)
............................................................
Declaration by DoctorI declare that I have explained the nature
and consequences of the procedure to be performed, and discussed
the risks that particularlyconcern the patient.
I have given the patient an opportunity to ask questions and I
have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1 Witness 2
Signature:
.............................................................................................
Signature:
.............................................................................................
Name:
...................................................................................................
Name:
...................................................................................................
Address:
..............................................................................................
Address:
..............................................................................................
Tel:
.......................................................................................................
Tel:
.......................................................................................................
-
( 19 )
vokfLVuVh,e baVªsofVª;y btsD'kutghj vCckl] xqatu izdk'k
jksxh dk uke %.
..................................................................
mez@fyax %. .............. jksxh dh vkbZMh %.
....................... rkjh[k %. .................
dk iq=@iq=h .
........................................................................................................................................................................................irk
% .
......................................................................................................................................VsyhQksu
ua % . .....................................
laHkkfor ykHk vkSj ̂ ^vkQ&yscy** fLFkfrvokfLVuVh,e dks
'kq:&'kq: esa vkidh vka[k dh n'kk dks Bhd djus ds fy, ugha
fodflr fd;k x;k FkkA bldh lqj{kk vkSj izHkkfork dks iznf'kZr
djusokys fpfdRldh; ijh{k.kksa ds ifj.kkeksa ds vk/kkj ij
vokfLVuVh,e dks esVkLVsfVd dksyksjsDVy dSalj ds mipkj ds fy, [kk|
,oa vkS"kf/k iz'kklu ¼,QMh,½dh eatwjh izkIr gqbZA ,d ckj tc fdlh
fMokbl ;k nok dks ,QMh, dh eatwjh fey tkrh gS rks MkWDVj vxj mRikn
ds ckjs esa iwjh tkudkjh j[krs gSarks os vU; mís';ksa ds fy, mldk ̂
^vkQ&yscy** mi;ksx dj ldrs gSa] mlds mi;ksx dks n`
-
( 20 )
dh laHkkouk dk dkj.k cu ldrh gSaA bu ijs'kkfu;ksa dk mipkj djus
ds fy, vfrfjDr dk;Zfof/k;ksa dh t:jr iM+ ldrh gSA dk;Zfof/k vkSj
vokfLVuVh,e
ds lsou dh laHko ijs'kkfu;ksa vkSj ik'oZ&izHkkoksas esa
jsfVuk dk vyx gksuk] eksfr;kfcan dk fodkl] Xywdksek] gkbiksVksuh
¼vka[kksa esa ?kVk gqvk ncko½] jsfVuk;k dkfuZ;k dks {kfr vkSj
jDrlzko 'kkfey gSa ysfdu os bUgha rd lhfer ugha gaSA blds vykok
vka[kksa esa laØe.k ¼,aMvkFkSyfefVl½ dh Hkh laHkkouk gksrhgSA bu
fojy ijs'kkfu;ksa esa ls dksbZ Hkh n`f"V dh Hkkjh] LFkk;h gkfu dks
tUe ns ldrh gSA
jksxh dh ftEesnkfj;kavxj laØe.k ds fuEufyf[kr esa ls dksbZ Hkh
y{k.k ;k vU; ijs'kkfu;ka fodflr gksrh gSa rks eSa QkSju vius MkWDVj
ls laidZ d:axk % nnZ] /kqa/kyh ;k ?kVhgqbZ n`f"V] izdk'k ds izfr
laosnu'khyrk] vka[kksa dh ykyh ;k vka[kksa ls ikuh cgukA eSa
batsD'ku ds ckn ds eqykdkr ds lHkh le; ij gkftj jgwaxk rkfdesjk
MkWDVj ijs'kkfu;ksa dh tkap dj ldsA gkykafd esjs 'kjhj ds nwljs
vaxksa dks izHkkfor djus okyh xaHkhj ijs'kkfu;ksa dh laHkkouk de
gS] ij vxj eSa dCt,oa mYVh ls tqM+s isV nnZ] vlkekU; jDrlzko] Nkrh
esa nnZ] cgqr vf/kd fljnnZ] vkokt dk yM+[kM+kuk ;k 'kjhj dh ,d rjQ
detksjh dks eglwl djrkgwa rks QkSju vius MkWDVj ls laidZ d:axkA
ftruh tYnh laHko gks ldsxk eSa viuk mipkj dj jgs us= fo'ks"kK dks
bu leL;kvksa ds ckjs esa crkÅaxkAeSa fdlh nwljs ltZu dks lwfpr
d:axk fd esjh nokbZ py jgh gS ftls fd jksdus dh t:jr gS rkfd esjh
ltZjh gks ldsA
jksxh dh lgefrmi;qZDr Li"Vhdj.k dks esjs }kjk is crk nh x;h gS
vkSj izLrkfor mipkj dk of.kZr dj fn;k x;kgSA esjs lkFk mipkj ds
tksf[keksa] ykHkksa] fodYiksa vkSj lhekvksa dh ppkZ dh x;h gSA esjs
lHkh iz'uksa dk mÙkj ns fn;k x;k gSA
eSa le>rk gwa fd vokfLVuVh,e dks esVkLVsfVd dksyksjsDVy dSalj
ds mipkj ds fy, ,QMh, }kjk eatwjh iznku dh x;h gS vkSj vka[k dh
chekfj;ksa ds mipkjds fy, bls eatwj ugha fd;k x;k gSA fQj Hkh] eSa
vokfLVuVh,e ls mipkj ikuk pkgrk gwa vkSj eSa mu laHkkO; tksf[keksa
dks Lohdkj djus ds fy, bPNqdgwa ftudh fd esjs MkWDVj us esjs lkFk
ppkZ dh gSA blds }kjk eSa mipkj dj jgs us= ltZu dks viuh izHkkfor
vka[k esa t:jr ds vuqlkj baVªkfoVfj;yvokfLVuVh,e dks mi;ksx esa
ykus ds fy, vf/kÑr djrk gwaA ;g vuqefr esjs }kjk bls jí fd;s tkus
;k esjh voLFkkvksa ds ml gn rd ifjofrZr gksusrd oS/k jgsxh tcfd
esjs fy, vkS"kf/k ds tksf[ke vkSj ykHk mYys[kuh; :i ls fHkUu u gks
tk;saA
jksxh@vfHkHkkod dk gLrk{kj@vaxwBs dk fu'kku %.
.........................................................................................................................................
uke %.
......................................................................................
fj'rk %. ..........................................................
rkjh[k %. ..........................
irk %.
.....................................................................................................................................................................................................
Qksu % ¼vkfQl½.
........................................................... ¼/kj½.
................................................. eksckby%.
...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSaus laiUu dh tkus okyh dk;Zfof/k dh
izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa
dh ppkZ dh gS tks fdfo'ks"k :i ls jksxh ls lacaf/kr gSA
eSaus jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj
fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1 xokg 2
gLrk{kj %.
.................................................................................
gLrk{kj %.
........................................................................................
uke %.
......................................................................................
uke %.
.............................................................................................
irk %.
.......................................................................................
irk %.
.............................................................................................
Qksu %.
......................................................................................
Qksu %.
............................................................................................
-
( 21 )
MacugenTM Intravitreal InjectionAparna Gupta
Name of Patient
.......................................................................
Age/Sex ......... Patient ID ............................... Date
.............................................
Son / Daughter of
............................................................................................................................................................................................................
Address
........................................................................................................................................
Tel
.............................................................................
IndicationsMacugen is used to treat adults with an eye problem
called the wet form (neovascular) of age-related macular
degeneration. Maculardegeneration causes vision loss leading to
blindness.
ContraindicationsDo not use Macugen if you have an infection in
or around your eye
Possible LimitationsThe goal of treatment is to prevent further
loss of vision. Although some patients have regained vision, the
medication may not restorevision that has already been lost, and
may not ultimately prevent further loss of vision caused by the
disease.
AlternativesYou do not have to receive treatment for your
condition, although without treatment, these diseases can lead to
further vision loss andblindness, sometimes very quickly. Other
forms of treatment are available. At present, there are three
FDA-approved treatments forneovascular age-related macular
degeneration. The first is photodynamic therapy with a drug called
VisudyneTM. The other two areinjection into the eye of MacugenTM.
and LucentisTM . In addition to the FDA-approved medications, some
ophthalmologists use intravitrealAvastinTM and triamcinolone
—”off-label” to treat eye conditions like yours.
Side EffectsThe most common side effects with Macugen
include:
1. inflammation of the eye2. blurred vision or changes in
vision3. cataracts4. bleeding in the eye5. swelling of the eye6.
eye discharge7. irritation or discomfort of the eye8. eye pain9.
seeing “spots” in your vision
Patient ResponsibilitiesI will inform my doctor if I’m pregnant,
planning to conceive or breast feeding.
I will immediately contact my doctor if any of the following
signs of infection or other complications develop:pain, blurry or
decreasedvision, sensitivity to light, redness of the eye, or
discharge from the eye. I will keep all my post-injection
appointments so that my doctorcan check for complications.
Although the likelihood of serious complications affecting other
organs of my body is low, I will immediately contact my physician
if Iexperience abdominal pain associated with constipation &
vomiting, abnormal bleeding, chest pain, severe headache, slurred
speech, orweakness on one side of the body. As soon as possible, I
will also notify the treating ophthalmologist of these
problems.
-
( 22 )
I will inform any other surgeon that I am on a medication that
needs to be stopped before I can have surgery
Patient ConsentThe above explanation has been read by/to me. The
nature of my eye condition has been explained to me and the
proposed treatment hasbeen described. The risks, benefits,
alternatives, and limitations of the treatment have been discussed
with me. All my questions have beenanswered.
I understand that Macugen TM was approved by the FDA for the
treatment of metastatic colorectal cancer, and has not been
approved forthe treatment of eye conditions. Nevertheless, I wish
to be treated with Macugen TM, and I am willing to accept the
potential risks that myphysician has discussed with me. I hereby
authorize the treating eye-surgeon to administer the intravitreal
Macugen TM in my affected eyeas needed. This consent will be valid
until I revoke it or my condition changes to the point that the
risks and benefits of this medicationfor me are significantly
different.
Signature / Thumb Impression of Patient/ Parent / Guardian:
...............................................................................................................................
Name:
................................................................................................
Relationship .......................................... Date
.............................................
Address:
.............................................................................................................................................................................................................................
Phone (Off)
..............................................................
(Res)
..............................................................
(Mob)
............................................................
Declaration by DoctorI declare that I have explained the nature
and consequences of the procedure to be performed, and discussed
the risks that particularlyconcern the patient.
I have given the patient an opportunity to ask questions and I
have answered these.
Doctor’s signature
Doctor’s name
Date
Witness 1 Witness 2
Signature:
.............................................................................................
Signature:
.............................................................................................
Name:
...................................................................................................
Name:
...................................................................................................
Address:
..............................................................................................
Address:
..............................................................................................
Tel:
.......................................................................................................
Tel:
.......................................................................................................
-
( 23 )
eSdqtsuVh,e baVªkfoVfj;y batsD'kuvi.kkZ xqIrk
jksxh dk uke %.
..................................................................
mez@fyax %. .............. jksxh dh vkbZMh %.
....................... rkjh[k %. .................
dk iq=@iq=h .
........................................................................................................................................................................................irk
% .
......................................................................................................................................VsyhQksu
ua % . .....................................
lq>koeSdqtsu dk mi;ksx mez ls tqM+s eSdqyj fodkj ds xhys :i
¼fu;ksoSLdqyj½ dgh tkus okyh vka[k dh leL;k okys o;Ldksa ds mipkj
ds fy, fd;k tkrkgSA eSdqyj fodkj va/ksiu dh vksj ys tkus okyh n`f"V
dh gkfu dks mRiUu djrk gSA
uqdlkunsg vljvxj vkidh vka[k ;k mlds vklikl laØe.k gS rks
eSdqtsu dk mi;ksx ugha djsaA
laHkkfor lhek,amipkj dk y{; n`f"V dks vkxs vkSj gkfu gksus ls
jksduk gSA gkykafd dqN yksxksa us n`f"V iqu% izkIr dh gS ij gks
ldrk gS fd nokbZ igys gh tk pqdhn`f"V dks fQj ls cgky ugha djs vkSj
;g Hkh laHko gS fd chekjh ds dkj.k n`f"V dh vkxs dh gkfu dks Hkh
vaarr% ugha jksd ik;sA
fodYivki viuh n'kk dk mipkj ugha Hkh djok ldrs gSa] gkykafd
mipkj ds fcuk ;s chekfj;ka n`f"V dh vkSj Hkh gkfu vkSj va/ksiu dh
vksj ys tk,axh] dbZ ckjcgqr gh tYnhA mipkj ds nwljs :i miyC/k gSaA
orZeku esa] fu;ksoSLdwyj mez ls tqM+s eSdqyj fodkj ds fy, ,QMh, ls
eatwjh izkIr rhu mipkj gSaAigyks folqMkbuVh,e uked nok ds lkFk
QksVksMk;kufed mipkj gSA vU; nks eSdqtsuVh,e vkSj yqlsafVlVh,e ds
vka[k ds batsD'ku gSaA ,QMh, ls eatwjh izkIrnokvksa ds vfrfjDr dqN
us=&fo'ks"kK vkidh rjg dh vka[kksa dh n'kkvksa ds mipkj ds fy,
baVªkfoVfj;y vokfLVuVh,e vkSj fVª;kefluksyksu &^^vkQ&yscy**
dks mi;ksx esa ykrs gSaA
ikk'oZ&izHkkoeSdqtsu ds lkFk lokZf/kd vke ik'oZ izHkkoksa
esa 'kkfey gSa %1- vka[kksa dh tyu2- /kqa/kyh n`f"V ;k n`f"V esa
ifjorZu3- eksfr;kfcan4- vka[kksa esa jDrlzko5- vka[kksa esa lwtu6-
vka[k ls ikuh cguk7- vka[k esa tyu ;k ihM+k8- vka[kksa dk nnZ9-
vkidh n`f"V esa ^^/kCcksa** dk fn[kuk
jksxh dh ftEesnkfj;kavxj eSa xHkZorh gwa] xHkZ /kkj.k djus dh
;kstuk cuk jgh gwa ;k Lruiku djk jgh gwa rks vius MkWDVj dks lwfpr
d:axhA
vxj laØe.k ds fuEufyf[kr esa ls dksbZ Hkh y{k.k ;k vU;
ijs'kkfu;ka fodflr gksrh gSa rks eSa QkSju vius MkWDVj ls laidZ
d:axk % nnZ] /kqa/kyh ;k ?kVhgqbZ n`f"V] izdk'k ds izfr
laosnu'khyrk] vka[kksa dh ykyh ;k vka[kksa ls ikuh cgukA eSa
batsD'ku ds ckn ds eqykdkr ds lHkh le; ij gkftj jgwaxk rkfdesjk
MkWDVj ijs'kkfu;ksa dh tkap dj ldsA gkykafd esjs 'kjhj ds nwljs
vaxksa dks izHkkfor djus okyh xaHkhj ijs'kkfu;ksa dh laHkkouk de
gS] ij vxj eSa dCt,oa mYVh ls tqM+s isV nnZ] vlkekU; jDrlzko] Nkrh
esa nnZ] cgqr vf/kd fljnnZ] vkokt dk yM+[kM+kuk ;k 'kjhj dh ,d rjQ
detksjh dks eglwl djrkgwa rks QkSju vius MkWDVj ls laidZ d:axkA
ftruh tYnh laHko gks ldsxk eSa viuk mipkj dj jgs us= fo'ks"kK dks
bu leL;kvksa ds ckjs esa crkÅaxkA
-
( 24 )
eSa fdlh nwljs ltZu dks lwfpr d:axk fd esjh nokbZ py jgh gS ftls
fd jksdus dh t:jr gS rkfd esjh ltZjh gks ldsA
jksxh dh lgefrmi;qZDr Li"Vhdj.k dks esjs }kjk is crk nh x;h gS
vkSj izLrkfor mipkj dk of.kZr dj fn;k x;kgSA esjs lkFk mipkj ds
tksf[keksa] ykHkksa] fodYiksa vkSj lhekvksa dh ppkZ dh x;h gSA esjs
lHkh iz'uksa dk mÙkj ns fn;k x;k gSA
eSa le>rk gwa fd eSdqtsuVh,e dks esVkLVsfVd dksyksjsDVy dSalj
ds mipkj ds fy, ,QMh, }kjk eatwjh iznku dh x;h gS vkSj vka[k dh
chekfj;ksa ds mipkjds fy, bls eatwj ugha fd;k x;k gSA fQj Hkh] eSa
eSdqtsuVh,e ls mipkj ikuk pkgrk gwa vkSj eSa mu laHkkO; tksf[keksa
dks Lohdkj djus ds fy, bPNqd gwaftudh fd esjs MkWDVj us esjs lkFk
ppkZ dh gSA blds }kjk eSa mipkj dj jgs us= ltZu dks viuh izHkkfor
vka[k esa t:jr ds vuqlkj baVªkfoVfj;yeSdqtsuVh,e dks mi;ksx esa
ykus ds fy, vf/kÑr djrk gwaA ;g vuqefr esjs }kjk bls jí fd;s tkus
;k esjh voLFkkvksa ds ml gn rd ifjofrZr gksus rdoS/k jgsxh tcfd
esjs fy, vkS"kf/k ds tksf[ke vkSj ykHk mYys[kuh; :i ls fHkUu u gks
tk;saA
jksxh@vfHkHkkod dk gLrk{kj@vaxwBs dk fu'kku %.
.........................................................................................................................................
uke %.
......................................................................................
fj'rk %. ..........................................................
rkjh[k %. ..........................
irk %.
.....................................................................................................................................................................................................
Qksu % ¼vkfQl½.
........................................................... ¼/kj½.
................................................. eksckby%.
...................................................
MkWDVj }kjk ?kks"k.kk
eSa ?kks"k.kk djrk gwa fd eSaus laiUu dh tkus okyh dk;Zfof/k dh
izÑfr vkSj mlds ifj.kkeksa dks le>k fn;k gS vkSj mu tksf[keksa
dh ppkZ dh gS tks fdfo'ks"k :i ls jksxh ls lacaf/kr gSA
eSaus jksxh dks iz'u iwNus dk volj iznku fd;k gS vkSj mudk mÙkj
fn;k gSA
MkWDVj dk gLrk{kj %
MkWDVj dk uke %
rkjh[k %
xokg 1 xokg 2
gLrk{kj %.
.................................................................................
gLrk{kj %.
........................................................................................
uke %.
......................................................................................
uke %.
.............................................................................................
irk %.
.......................................................................................
irk %.
.............................................................................................
Qksu %.
......................................................................................
Qksu %.
............................................................................................
-
( 25 )
LucentisTM Intravitreal InjectionAparna Gupta
Name of Patient
.......................................................................
Age/Sex ......... Patient ID ............................... Date
.............................................
Son / Daughter of
............................................................................................................................................................................................................
Address
........................................................................................................................................
Tel
.............................................................................
IndicationsLucentis is used to treat adults with an eye problem
called the wet form (neovascular) of age-related macular
degeneration. Maculardegeneration causes vision loss leading to
blindness.
ContraindicationsDo not use Lucentis if you have an infection in
or around your eye
Possible LimitationsThe goal of treatment is to prevent further
loss of vision. Although some patients have regained vision, the
medication may not restorevision that has already been lost, and
may not ultimately prevent further loss of vision caused by the
disease.
AlternativesYou do not have to receive treatment for your
condition, although without treatment, these diseases can lead to
further vision loss andblindness, sometimes very quickly. Other
forms of treatment are available. At present, there are three
FDA-approved treatments forneovascular age-related macular
degeneration. The first is photodynamic therapy with a drug called
VisudyneTM. The other two areinjection into the eye of LucentisTM.
and MacugenTM. In addition to the FDA-approved medications, some
ophthalmologists use intravitrealAvastinTM and triamcinolone
—”off-label” to treat eye conditions like yours.
Side EffectsThe most common side effects with Lucentis
include:1. Inflammation of the eye2. Blurred vision or changes in
vision3. Cataracts4. Bleeding in the eye5. Swelling of the eye6.
Eye discharge7. Irritation or discomfort of the eye8. Eye pain9.
Seeing “spots” in your vision10. The most common non–eye-related
side effects were high blood pressure, nose and throat infection,
and headache.11. Although uncommon, conditions associated with eye-
and non–eye-related blood clots (arterial thromboembolic events)
may
occur.
Patient ResponsibilitiesI will inform my doctor if I’m pregnant,
planning to conceive or breast feeding.
I will immediately contact my doctor if any of the following
signs of infection or other complications develops: pain, blurry or
decreasedvision, sensitivity to light, redness of the eye, or
discharge from the eye. I will keep all my post-injection
appointments so that my doctorcan check for complications.
Although the likelihood of serious complications affecting other
organs of my body is low, I will immediately contact my
-
( 26 )
physician if I experience abdominal pain associated with
constipation & vomiting, abnormal bleeding, chest pain, severe
headache,slurred speech, or weakness on one side of the body. As
soon as possible, I will also notify the treating ophthalmologist
of these problems.
I will inform any other surgeon that I am on a medication that
needs to be stopped before I can have surgery
Patient ConsentThe above explanation has been read by/to me. The
nature of my eye condition has been explained to me and the
propo