Derby Eyes



IMPLANTABLE CONTACT LENS (ICL) SURGERY AGREEMENT AND CONSENT FORMName: ______________________________________Date of birth: ______________________________________Date: ______________________________________(Circle where appropriate)Left eye / Right eye First / Second eye Please take sufficient time to read and understand this form before signing it This form is a legal document that requires your signature before you can be accepted for surgery. It is signed by you and the surgeon and is witnessed at the clinic on the day of surgery. This form gives the surgeon the right to treat you and sets out the entire legal relationship between the patient and the surgeon. This form covers all subsequent treatments. This form lists the complications, the alternatives to surgery and the risks involved. This information is given so that you can make an informed decision about having surgery. If you have any questions regarding any of our literature please contact us before attending for surgery. We give you this information in advance so that you can consider all aspects of treatment in advance. You will not be presented with any new information on the day of surgery. Please note that this information is applicable to everyone and your final decision must be based on the specific advice of the surgeon given on consultation. Surgery may be aborted after it has started resulting in the complications of surgery but not the benefits. Alternative Methods of Correcting Eyesight Contact lenses and glasses provide correction for all levels of short sight, long sight and astigmatism. Laser treatment can correct levels of refraction up to –10d for short sight, +4d for long sight plus up to - 4d of astigmatism. Refractive Lens Exchange (also known as Clear Lens Extraction) can correct levels of eye sight like ICL and has the advantage over ICL of being able to correct both near and distance vision and avoids the future need of cataract removal. Monovision is where one eye is treated for good distance vision and the other left short sighted for good reading vision and can avoid the need for reading glasses, usually needed after the age of 45 (approximately). The Underlying Principle of ICL’s (medical term: Phakic lens implants)The lens is inserted through a small incision in the side of the eye and sits just behind the clear front surface of the eye (cornea) like a small contact lens. The incision is usually self-sealing although occasionally fine stiches may be required. During the procedure, a small hole may need to be created in the iris to reduce the risk of the internal eye pressure becoming raised. The hole can also be before the surgery using a YAG LASER. The iris hole created during surgery may be cosmetically unattractive to some patients.ICL Surgery Please initial each point below to confirm that you have understood the information given: 2....................ICL is a surgical procedure and as with any surgery it is not 100% safe or risk free. 3....................Treatment will not improve or prevent vision defects caused by glaucoma, retinal detachment, diabetes, age-related macular degeneration and other eye diseases. Your quality of vision may still be affected after successful ICL surgery if you suffer from a pre-existing eye disease. 4....................Surgery is carried out under a local anesthetic (either drops or an injection). You may also undergo light sedation or elect to have the surgery with only local anesthesia. The anesthetic injection can cause partial or complete visual loss; short term complications; induced squint; enlarged pupils, drooping of the eye lid and bruising of the eye. 5....................Complications associated with surgery, medications and local anesthesia injections around the eye include: perforation of the eye; destruction of the optic nerve; interference with the circulation of the retina; allergic reaction; respiratory depression; hypotension; cardiac problems; in rare situations blindness; brain damage or death; iritis (acute or chronic) if recurrent may be an indication for ICL removal. 6....................ICL cannot prevent progressive deteriorating eyesight. The manufacturers of the lenses do not recommend the use of this type of lens on the over 50’s. However, under certain circumstances the surgeon will discuss the reasons why he recommends this to you if you are over 50. 7....................The results of ICL unless they are removed are permanent but owing to the natural changes of eyesight due to age or illness the underlying need for glasses may change. 8....................If the first eye suffers complications the second eye surgery may be delayed indefinitely leading to imbalance of vision (anisometropia) which may cause disorientation, nausea, double vision and headaches. If there is a marked difference in the prescriptions of each eye which cannot be tolerated with glasses you will have to wear a contact lens in the non-operated eye or function with only one eye for clear distance vision. The binocular vision can be affected and this can lead to double vision and difficulty judging distances. 9..................You may already have (or will develop) the age-related need for reading glasses. At around 45 everybody (except short sighted patients who can take their glasses off to read) requires bifocal glasses or separate reading glasses to see clearly at close range. All ICL patients will need reading glasses after 45 (approximately) unless one eye is left a little short sighted for reading (monovision).Rules to follow after the surgery: Uncontrolled infection or high internal pressure can lead to very serious permanent damage to the eye, see 10.1 to 10.6 below: 10.1...............You must not rub or touch your eyes after surgery. For up to 1 week after the surgery you should sleep with an eye patch, in order to avoid rubbing your eye and to avoid contact with anything. Eye rubbing could cause the ICL to move from its natural position and threaten the cornea. 10.2...............You should put drops in your eyes on the other side to the incision to avoid opening the wound, to avoid infection and inflammatory reaction. 10.3...............For the first month after the surgery you should avoid strenuous work and heavy exercise and contact sports which can increase the pressure on your eye. Increased pressure may open the wound. 10.4...............After the surgery you may be given tablets to avoid internal increased eye pressure. 10.5...............You must not wear any eye make up for the first 14 days; you must keep water out of the eye for the first 7 days when showering, bathing and washing hair/ face and you must not go swimming for 5 weeks after surgery to avoid infection.10.6...............Certain symptoms indicate that you are in need of immediate care. Please contact the surgeon (mobile number will be provided) without delay if you have any of the following: ? Excessive pain; indicating infection or open wound. ? Loss of vision; indicating infection or retinal detachment. ? Increasing redness of the eye; indicating infection. ? Headaches and nausea; indicating raised internal eye pressure. 10.7...............Surgery is usually pain free with only mild discomfort for the first 48 hours. It is normal to feel itchy, have sticky eyelids and experience occasional discomfort for a while after the surgery and a little fluid discharge is common. You can take a pain reliever such as Paracetamol every 4-6 hours but not Aspirin as this can cause bleeding. 10.8...............The final result can take 6 weeks or longer if there are no complications, after this time new glasses for reading or the remaining error can be prescribed by your optician if required. Possible Complications 11...................If the ICL is found to have moved from its intended position and is causing visual symptoms, then the surgeon may need to reposition the ICL and a further surgical procedure will need to be performed. This may be required if a Toric ICL is found to be in the wrong position for treating the astigmatism. 12..................Complications include the possibility of damage to the structure of the eye which could lead to problems such as: bleeding; infection (endophthalmitis-painful infection in the eye); bruising; cataracts (patients who have an ICL may develop cataract at an earlier stage compared to the population who have not had ICL surgery); raised internal eye pressure (glaucoma); blurring of vision; inflammatory fluid in the retina (cystoid macular oedema requiring prolonged treatment); damage to the back of the eye (detached retina); corneal decompensation (clouding of the normally clear front window of the eye); allergy to the medication used; refractive surprise/unexpectedly large (or different from that expected) leading to a need for glasses and total loss of vision and even loss of the eye can arise from a complication and/or uncontrolled infection or failure to successfully repair a detached retina. 13..................The lens may detach itself which could result in its movement or dislocation. Dislocation of the lens can be caused by a blow or trauma to the eye/head as a result of contact sports or accidents requiring removal or repositioning of the lens. This will require immediate corrective surgery. 14..................You are advised that your eyes should be examined by an ophthalmologist every 1 to 2 years to ensure that the lens has not moved and is not touching the inside surface of the cornea. Contact with the inner surface of the cornea can damage endothelial cells which can lead to permanent damage of sight. This may be caused by eye rubbing which should be avoided if you have ICL surgery. 15..................An endothelial cell count examination must be done at 1,3, 6, 12, 18 and 24 months after surgery and annually thereafter. If the corneal endothelial cell count is found to be rapidly diminishing this may necessitate the removal of the ICL. No charge will be made for endothelial cell count examinations carried out in the first 12 after surgery. Thereafter you will be charged a fee of ?50 for subsequent endothelial cell count examinations.16..................The eye pressure will need to be monitored after the ICL surgery every 6 months for one year after surgery and once a year thereafter and if it is found to be high, it may need to be treated with eye pressure lowering drops or tablets. If the eye pressure does not settle after the appropriate treatment, the ICL may need to be removed. 17..................Side effects associated with surgery may include: increased night glare and halos; posterior vitreal detachment (PVD) causing black blobs in eyesight (floaters); droopy eyelid; induced astigmatism and double vision. 19...................A possible side effect of lens surgery can sometimes be dry eye. This can be mild to severe and normally clears within a few months after surgery with the help of artificial tears. 20..................Should an adverse reaction occur e.g. pain (except minor discomfort); swelling; irritation; infection or clouding of vision, it is your responsibility to contact us immediately as delay could lead to blindness. You should stop taking medication or ointment if an allergic reaction occurs and seek immediate medical attention. 21 .................Damage to the natural lens of the eye during the surgery may require the surgeon to change the procedure from putting the intended ICL to an Intraocular Lens Implant (IOL). The latter may be a monofocal or multifocal IOL. 22..................The lens may be visible by others on close examination and can cause reflection from lights and camera flashes in photographs. In addition, you may be troubled by glare or halos from lights when it is dark outside. These symptoms may affect your ability to drive at night and occasionally prevent someone from being able to drive at night. Predictability 23..................Approximately 10 in 100 patients will require further surgery, laser or otherwise. 24..................Patients should gain good vision within a few days but the final result will not be achieved until after about six weeks. However, it could take much longer. 25..................After treatment you may still need glasses or contact lenses for sharpest vision. We cannot guarantee a good result. Patients whose career or lifestyle depends on good and balanced sight in both eyes are advised to consider very carefully the implications of surgery complications (especially if night-time vision is important). Removal of the lens normally reverses the effects of the surgery but the residual effects on the eyesight cannot be predicted. It is possible that the eyesight can be made worse than it was prior to surgery. 26..................If you have a high degree of short sight or the internal length of your eye is very long the risk of a complication called a retinal detachment is increased. Retinal detachments can usually be repaired but could lead to vision loss or blindness. 27..................Although overall results show a high degree of patient satisfaction it is not possible to predict a result for any single individual. Some people will not be satisfied with the results or be able to cope with complications and experience distress and anxiety. You could be bitterly disappointed. 28..................Laser treatment may be required to fine tune the final result. There is no extra cost for this procedure.PATIENT DECLARATION/CONSENT I have been advised that I should take as long as I wish before consenting to the surgery. I am not under any pressure by the surgeon to have surgery. The choice to go ahead is mine based on the benefits and drawbacks, as explained to me. On signing this form I am not under the influence of any drugs/medication and have not yet had any eye drops administered.Although it is impossible for the surgeon to inform me of every possible complication that may occur the surgeon has answered all my questions to my satisfaction. I am satisfied that all of the above has been fully explained and is understood. The surgeon will keep me fully informed and discuss the matter before proceeding.Signature ___________________________________________Print Name (block caps) ___________________________________________D.O.B. _______/_______/_______The witness confirms that the patient has read, initialed and completed this form in his/her own good time, is under no pressure or duress to sign the form.Witnessed by ___________________________________________________Print Name ___________________________________________________Home Postcode __________________________________________________SURGEON’S DECLARATION I have discussed the contents of this form with the patient and I am satisfied that they understand the meaning of the technical terms which it contains, the nature and purpose of both surgical procedures, the side effects and possible complications that are described. I agree to accept this patient on the above terms and provide surgery as set out in paragraph 4 on page one of this form.Signature of Surgeon ______________________________________Date _____/_______/_______ Confirmation Of ConsentSignature of Patient: Date:Signature of Surgeon: Date:IMPORTANT INFORMATION REGARDING ATTENDANCE FOR SURGERYContact Lens Removal If you wear contact lenses, it is essential that you adhere to our guide for contact lens removal. Contact lenses affect the surface of the eye, so your consultation or surgery could be postponed if the surface has not fully recovered. Prior to surgery please remove: - ? soft contact lenses (non toric) one day prior to your consultation or surgery ? toric soft lenses 3 days prior to your consultation or surgery ? hard or gas permeable lenses 3 days prior to your consultation or surgery If you wear contact lenses bring them with you for use in case you are not treated. Before You Come In Do not eat or drink within two hours of attending for surgery (unless diabetic in which case please seek specific advice from the surgeon). Eye make-up, perfume, aftershave, strong deodorant or hairspray must not be worn on the day of the surgery. Arrangements for the Surgery Day and Afterwards Please expect to spend at least half a day in the clinic and make no other plans for that day. Please bring a friend with you. You will need assistance in ascending or descending stairs or generally moving around, if help is required whilst at the clinic please ask a member of staff for assistance. You should be accompanied on your journey home. If you have small children, it would be advisable to have a friend or relative to look after them for the first 36 hours after surgery. You will not be able to drive on the day of consultation or for up to two weeks following surgery. You should expect to have one to two weeks off work or away from your normal routine so please do not make any important plans. We would advise patients to rest as much as possible during these days while the eye heals. Please ask the surgeon to advise when sports you play may be resumed. Cancellation of Surgery The surgery appointment is provisional. The most common causes of cancellation are: you have not removed your contact lenses for long enough; delay in the manufacture of your lenses; you suffer from other medical conditions or mechanical breakdown. Surgery may be postponed at short notice or on the day of scheduled treatment. There is a chance that the surgeon may choose not to proceed if he becomes aware of any new factor in your vision or medical condition that would exclude surgery Aftercare Appointments You will require antibiotic eye drops after the surgery and will need to be closely monitored to detect any possible side effects of these drugs. It is important to attend the clinic for regular aftercare and it is your responsibility to make appointments with us. Non-attendance could have an adverse effect on the final result. ................
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