Consent Forms in Ophthalmic Practice...Consent Forms in Ophthalmic Practice in Hindi & English...

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

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 )

Økvks ltZjhfciqy cS';] vrqy dqekj

jksxh dk uke %. .................................................................. mez@fyax %. .............. jksxh dh vkbZMh %. ....................... rkjh[k %. .................

dk iq=@iq=h . ........................................................................................................................................................................................irk % . ......................................................................................................................................VsyhQksu ua % . .....................................

izLrkfor mipkj

MkWDVj us Li"V fd;k gS fd esjh ----------------------------------------------------------------------------------------- ¼jksxh dk uke½ -------------------------------------------------------------------vka[k esa

jsfVuk ls tqM+k t[e gS tks fd --------------------------------------------------------- ds fodkl ds fy, tksf[ke dk dkjd gS vkSj Øk;ks ltZjh izLrkfor dh gSA

tksf[ke;s lk/kkj.k tksf[ke gSaA nwljs vlkekU; tksf[ke Hkh gks ldrs gSa ftUgsa fd ;gka lwphc) ugha fd;k x;k gSA

eSa le>rk gwa fd fdlh Hkh laosnukgkjh dkjd ds lkFk ¼cPpksa ds ekeys esa½ tksf[ke tqM+s gksrs gSaA

eq>s mi;ksx esa yk;h x;h nokvksa esa ls fdlh ds Hkh dkj.k ik'oZ&izHkko mRiUu gks ldrs gSaA vke ik'oZ&izHkkoksa esa pDdj vkuk] feryh] Ropk ij nnksjssvkSj dCt 'kkfey gSA

eSa le>rk gwa fd fpfdRldh; izfØ;k ds fuEufyf[kr [kkl tksf[ke vkSj lhek,a gSa %

1- gkykafd jsfVuk ds vf/kdrj t[eksa dk bykt gks ldrk gS ysfdu ;g 'kr&izfr'kr izHkkoh ugha gSA dqN ekeyksa esa nks ls T;knk cSBd dh t:jriM+ ldrh gSA

2- dkuhZy dk tyuk3- jsfVuk dk vyx gksuk ;k eSdqyj fldqM+u ftlds fy, vfrfjDr ltZjh dh t:jr iM+ ldrh gS4- tyu5- jax fn[kus esa ijs'kkuh6- vka[kksa esa jDrlzko

vk[kksa ds bnZfxnZ laosnukgkjh batsD'kuksa dh LFkkfud ijs'kkfu;ksa esa 'kkfey gSa %1- vka[k dh iqryh ds Nsn2- izdkf'kd ul dk fouk'k3- jsfVuk ds lapj.k ds lkFk O;o/kku4- iyd dh laHkkfor yVdu5- 'olu ls tqM+k ncko6- vlkekU; :i ls fuEu jDrpki

O;fDrxr tksf[keeSa 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 %. .........................................................................................................................................................................................................................................................................................................................................................................................................................

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 dh Vhe ds lkFk fdUgha egRoiw.kZ tksf[keksa vkSj viuh O;fDrxr ifjfLFkfr;ksaa ds fy, [kkltfVyrkvksa ij ppkZ dh gS] ftu ij fd eSaus bl vkWijs'ku dks djokrs le; fopkj fd;k gSA

eSa le>rk gwa fd fo'ks"kK ltZu ds vykok nwljk MkWDVj bl vkWijs'ku dks dj ldrk gSA

( 4 )

vkWijs'ku lQy gksxk eq>s bldh dksbZ xkjaVh ugha nh x;h gSA

eq>s vius lkFk ?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 %. ............................................................................................

( 5 )

Retinal DetachmentBipul Baishya, Y.R. Sharma


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:


I understand there are risks associated with any anesthetic agent.


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.


.......................................................................................................................................................................................................................................

.......................................................................................................................................................................................................................................

( 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 agree to any other additional procedures considered necessary in the judgment of my surgeon during this operation.



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.




Address: .............................................................................................................................................................................................................................

Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................




Doctor’s name

Date

Witness 1 Witness 2


Name: ................................................................................................... Name: ...................................................................................................

Address: .............................................................................................. Address: ..............................................................................................

Tel: ....................................................................................................... Tel: .......................................................................................................

( 7 )

jsfVuk dk vyxkofciqy cS';] okbZ- vkj- 'kekZ



izLrkfor mipkjMkWDVj us Li"V fd;k gS fd esjh ---------------------------------------------------------------------------------------------------- ¼jksxh dk uke½ ------------------------------------------------- vka[k esajsfVuk dk vyxko gS vkSj ;g fd -----------------------------------------------------izLrkfor gS %

tksf[kedqN lkekU; tksf[ke gSaA nwljs vlkekU; tksf[ke Hkh gks ldrs gSa] ftUgsa fd ;gka ij lwphc) ugha fd;k x;k gSA

eSa le>rk gwa fd fdlh Hkh laosnukgkjh dkjd ds lkFk tksf[ke tqM+s gq, gksrs gSaA

eq>s mi;ksx esa yk;h x;h nokvksa esa ls fdlh ds Hkh dkj.k ik'oZ&izHkko mRiUu gks ldrs gSaA vke ik'oZ&izHkkoksa esa pDdj vkuk] feryh] Ropk ij nnksjsvkSj dCt 'kkfey gSA


1- gkykafd jsfVuk ds vf/kdrj vyxkoksa dk mipkj fd;k tk ldrk gS ij ,d NksVk vuqikr ¼5 izfr'kr½ gks ldrk gS fd vkWijs'ku ds yk;d ughagks vkSj va/ksiu dks jksdk ugha tk ldsA

2- ltZjh ds iz;kstu dks iwjk djus esa foQyrk3- ,d ls vf/kd ltZjh dh vko';drk iM+ ldrh gSA tSls fd vxj lsjy cdfyax ltZjh foQy gksrh gS rks flfydkWu vkW;y ;k xSl VSEiksusM ds

lkFk foVjsDVkWeh dh vko';drk iM+ ldrh gSA4- flfydkWu vkW;y ;k xSl batsD'ku dh n'kk esa ltZjh ds vk/kkj ij fLFkfr dks cuk;s j[kuk gSA5- vxj xSl dk batsD'ku fn;k tkrk gS rks eq>s ml le; rd gokbZ ;k=k ls cpuk gksxh tc rd fd xSl vo'kksf"kr ugha gks tkrh-6- vxj flfydkWu vkW;y dk batsD'ku fn;k tkrk gS rks rsy dks fudkyus ds fy, nksckjk ltZjh vko';d gksxhA7- ltjh ds vafre ifj.kke dk irk pyus esa 18 eghuksa rd dk le; yx ldrk gSA gkykafd cgqr ls ekeyksa esa vPNk ifj.kke vkrk gS ij ;g

blds lesr dbZ dkjdksa ij fuHkZj djrk gS fd vyxko fdrus le; ls ekStwn FkkA8- fdu ekeyksa esa vPNs ifj.kke vk,axs budk vkWijs'ku ls igys vuqeku yxkuk gks ldrk gS fd laHko ugha gksA9- bl ckr dk [krjk gksrk gS fd eq>s Hkfo"; esa mlh vka[k esa ;k nwljh okyh esa jsfVuk dk vkxs Hkh vyxko fodflr gks tk;sA10- dqN ekeyksa esa] ,d ls vf/kd vkWijs'ku dh t:jr iM+ ldrh gSA11- 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 gkykafd bldk mipkj fd;k tk ldrk gS ij dqN 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 %. .........................................................................................................................................................................................................................................................................................................................................................................................................................

( 8 )



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

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




uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................

irk %. .....................................................................................................................................................................................................





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


Son / Daughter of ............................................................................................................................................................................................................

Address ........................................................................................................................................ Tel .............................................................................

Proposed TreatmentThe doctor has explained that I, (name of patient …………….………), have …............................... in my ........................... Eye andthat………………………………is proposed.


I understand there are risks associated with any anesthetic agent.


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.


.......................................................................................................................................................................................................................................

.......................................................................................................................................................................................................................................

( 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 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.



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.




Address: .............................................................................................................................................................................................................................

Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................




Doctor’s name

Date

Witness 1 Witness 2


Name: ................................................................................................... Name: ...................................................................................................

Address: .............................................................................................. Address: ..............................................................................................

Tel: ....................................................................................................... Tel: .......................................................................................................

( 11 )

foVsfjvks jsfVuy ltZjhfciqy cS';] vkj- oh- vktkn



izLrkfor mipkjMkWDVj us Li"V fd;k gS fd esjh ------------------------------------------------------------------------------------------------------------ ¼jksxh dk uke½ ------------------------------------------- vka[k esa------------------------------------------ gS vkSj ;g fd -----------------------------------------------------izLrkfor gS %

tksf[kedqN lkekU; tksf[ke gSaA nwljs vlkekU; tksf[ke Hkh gks ldrs gSa] ftUgsa fd ;gka ij lwphc) ugha fd;k x;k gSA

eSa le>rk gwa fd fdlh Hkh laosnukgkjh dkjd ds lkFk tksf[ke tqM+s gq, gksrs gSaA

eq>s mi;ksx esa yk;h x;h nokvksa esa ls fdlh ds Hkh dkj.k ik'oZ&izHkko mRiUu gks ldrs gSaA vke ik'oZ&izHkkoksa esa pDdj vkuk] feryh] Ropk ij nnksjsvkSj dCt 'kkfey gSA


1- ltZjh ds iz;kstu dks iwjk djus esa foQyrk2- jsfVuk dk vyxko ftlds fy, vfrfjDr ltZjh dh vko';drk iM+ ldrh gS ;k gks ldrk gS fd mldk vkWijs'ku gh u fd;k tk ldsA3- ltZjh ds vk/kkj ij VSEiksusM ds fy, flfydkWu vkW;y ;k xSl dh vko';drk iM+ ldrh gSA4- flfydkWu vkW;y ;k xSl batsD'ku dh n'kk esa eq>s ltZjh ds vk/kkj ij fLFkfr dks cuk;s j[kuk gSA5- vxj xSl dk batsD'ku fn;k tkrk gS rks eq>s ml le; rd gokbZ ;k=k ls cpuk gksxh tc rd fd xSl vo'kksf"kr ugha gks tkrh-6- vxj flfydkWu vkW;y dk batsD'ku fn;k tkrk gS rks rsy dks fudkyus ds fy, nksckjk ltZjh vko';d gksxhA7- ltjh ds vafre ifj.kke dk irk pyus esa 18 eghuksa rd dk le; yx ldrk gSA8- dqN ekeyksa esa varjfufgr n'kk dk mipkj ugha gks ldrk vkSj n`f"Vghurk dks jksdk ugha tk ldrkA9- fdu ekeyksa esa vPNs ifj.kke vk,axs budk vkWijs'ku ls igys vuqeku yxkuk gks ldrk gS fd laHko ugha gksA10- bl ckr dk [krjk gksrk gS fd eq>s Hkfo"; esa mlh vka[k esa ;k nwljh okyh 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 )



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




uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................

irk %. .....................................................................................................................................................................................................





MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

gLrk{kj %. ................................................................................. gLrk{kj %. ........................................................................................

uke %. ...................................................................................... uke %. .............................................................................................

irk %. ....................................................................................... irk %. .............................................................................................

Qksu %. ...................................................................................... Qksu %. ............................................................................................

( 13 )

Macular Hole SurgeryRitesh Gupta


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 )



Address: .............................................................................................................................................................................................................................

Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................




Doctor’s name

Date

Witness 1 Witness 2


Name: ................................................................................................... Name: ...................................................................................................

Address: .............................................................................................. Address: ..............................................................................................

Tel: ....................................................................................................... Tel: .......................................................................................................

( 15 )

eSdqyj gksy ltZjhfjrs'k xqIrk



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 )


uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................

irk %. .....................................................................................................................................................................................................





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


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.



Address: .............................................................................................................................................................................................................................

Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................




Doctor’s name

Date

Witness 1 Witness 2


Name: ................................................................................................... Name: ...................................................................................................

Address: .............................................................................................. Address: ..............................................................................................

Tel: ....................................................................................................... Tel: .......................................................................................................

( 19 )

vokfLVuVh,e baVªsofVª;y btsD'kutghj vCckl] xqatu izdk'k



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


uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................

irk %. .....................................................................................................................................................................................................





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


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


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.



Address: .............................................................................................................................................................................................................................

Phone (Off) .............................................................. (Res) .............................................................. (Mob) ............................................................




Doctor’s name

Date

Witness 1 Witness 2


Name: ................................................................................................... Name: ...................................................................................................

Address: .............................................................................................. Address: ..............................................................................................

Tel: ....................................................................................................... Tel: .......................................................................................................

( 23 )

eSdqtsuVh,e baVªkfoVfj;y batsD'kuvi.kkZ xqIrk



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


uke %. ...................................................................................... fj'rk %. .......................................................... rkjh[k %. ..........................

irk %. .....................................................................................................................................................................................................





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


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


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

Consent Forms in Ophthalmic Practice...Consent Forms in Ophthalmic Practice in Hindi & English...

Documents

Transcript of Consent Forms in Ophthalmic Practice...Consent Forms in Ophthalmic Practice in Hindi & English...