Laser Procedure Note

Patient Name ______________________________ Date______________________

1. Pre procedure diagnosis

_______________________________________________________________________________

2. Procedure and Eye

________________________________________________Eye:____________________________

3. Pre procedure topical medications administered (and time)

________________________________________________________________________________

4. Vital signs
BP _____/______ HR________ Acuity – OD:________ OS:_________

5. IOP: OD__________ OS___________ Method:____________ @_________AM/PM

6. Patient dilated
Yes / No ( Tropicamide / Phenylephrine )

7. Miotic used
Yes / No (____% Pilocarpine)

8. Summary of laser procedure

YAG ARGON / GREEN SLT
Energy (mJ): Duration (sec): Duration: 3nsec
Pulse Setting: Spot Size (µm): Spot Size: 400 µm
Applications (#): Power (mW): Energy (mJ):
Lens Used: Applications (#): Applications (#):
Lens Used: Lens Used:

9. Complications
______________________________________________________________________________

10. Post-op medications instilled in office

______________________________________________________________________________

11. Post-op IOP: OD__________ OS___________ Method:____________ @_________AM/PM

12. Post-op medications prescribed and follow up

__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________________________

________________________________________
REMOVE NOTE AND PUT ON LETTERHEAD
CHANGE FONT SIZE FOR LARGE PRINT
Please review the form, modify it to fit your actual practice and type of injection, and place on your letterhead.
Please offer the patient a copy of the form. The last page serves to verify that the surgeon has obtained informed
consent from the patient; it can be copied and sent to the ambulatory surgery center if needed as verification of
consent. This consent form is intended as a sample only and is provided as a risk management service. It is not
intended to constitute a standard of care and should not be relied upon as a source for legal advice. If legal
advice is desired or needed, an attorney should be consulted.
Version 4/6/2007
From [Link]

ARGON LASER TRABECULOPLASTY

SELECTIVE LASER TRABECULOPLASTY

Indications. The argon laser trabeculoplasty and selective laser trabeculoplasty surgeries are used
for patients with open angle glaucoma. The laser is utilized to treat the drainage system of the eye
known as the trabecular meshwork. Treating this area of the natural internal draining system is
designed to improve the outflow of fluid from the eye. This type of laser surgery will be effective in
some patients but not others. Your response is determined by the type of glaucoma you have and
the specific structures found in your drainage system. Your doctor cannot predict how well the laser
will work before the laser surgery.

Procedure. The procedure may be performed in one or two trips to the laser center. The laser
machine is similar to the examination microscope that your doctor uses at each visit to look into your
eyes. The laser itself makes little noise and flashes a light about as bright as the flash on a camera.
Nearly all patients find the procedure comfortable and pain free. The procedure generally takes from
10 to 20 minutes.

Medications. You may need to use drops both before and after the laser treatment. As the pressure
in the eye may temporarily go up after the laser treatment, you will likely need to have your pressure
measured after one half to one hour following the laser surgery. If the pressure does elevate, you
may need additional medicines to lower the pressure, which will be administered in the office. Rarely,
the pressure in the eye could elevate to a level that might require surgery in the operating room to
relieve the glaucoma. You will need to use drops after the laser to help the eye heal correctly. You
will probably use the new drops for approximately one week. In most cases you will be asked to
continue your other glaucoma medications after the laser surgery. The doctor will notify you if there
are exceptions to continuing your medications.

Risks and complications. Glaucoma laser surgery may be followed by complications. Most patients
notice some blurring of their vision after laser surgery. This generally clears within a few hours. The
chance of your vision being permanently affected by this laser is very, very small. Although rare and
unusual, there may be bleeding within the eye, inflammation, cataract and increase in the pressure in
the eye requiring different and more extensive treatment. It will take several weeks to determine how
much of your eye pressure will be lowered with this treatment. You may require additional laser
surgery to lower the pressure if you have a response but one that is insufficient to control the
pressure.

Patient consent. Not every conceivable complication could be covered in this form and I understand
that no warranty or guarantee has been made to me regarding the result of the proposed laser
surgery. I have read and understand the consent form, my questions have been answered and I
authorize my surgeon to proceed with the operation on my ______________ (state “right” or “left”)
eye.

______________________________________ _________________________

Patient (or person authorized to sign for patient) Date

From the AAO

PLACE LETTERHEAD HERE AND REMOVE NOTE

ARGON LASER TRABECULOPLASTY
Note: This form is intended as a sample form of the information that you as the surgeon should personally
discuss with the patient. Please review and modify to fit your actual practice. Give the patient a copy and
send this form to the hospital or surgery center as verification that you have obtained informed consent.

Glaucoma can sometimes be treated successfully with medications to lower the pressure in the eye. If
medications are not effective, laser and other surgical procedures may be of value in controlling the pressure
and preventing further vision loss. Both medications and surgery are designed to do one of two things: 1)
decrease the amount of fluid production in the eye from the cells that make the fluid, or 2) help the fluid flow
out of the eye.

This is a laser surgery used for people with open-angle glaucoma. The laser is used to make a small burn on
the drainage tissue of the eye. Hopefully, the laser burn will cause the drain to open and let more fluid leak out.

There are some individuals who respond well to this and others who do not respond at all to the therapy. Your
response is determined by the type of glaucoma you have and the basic makeup of your eye. We usually
cannot predict how well the laser will work.

The procedure can be done in one or two trips to the laser area. The laser machine looks similar to the
examination microscope that the doctor uses at each visit to look at your eyes. The laser itself makes little
noise and flashes a light about as bright as a flash on a camera. Almost everybody find the procedure
comfortable and without pain. The procedure takes about ten to twenty minutes.

You may need drops before and after the laser. Most people need to have their pressure checked one hour
after the laser. This is because the pressure in the eye can go up after the laser treatment. This is the greatest
risk from this procedure. If the pressure does go up, you may require medications to lower the pressure, which
will be administered in the office. Rarely, the pressure in the eye elevates to a very high pressure and does not
come down. If this happens, you may require surgery in the operating room to lower the pressure. This is a
most unusual event.

Most people notice some blurring in their vision after the laser. This clears within a few hours in most
individuals. The chance of your vision being permanently affected from this laser is very, very small.

You will need to use drops after the laser to help the eye heal correctly. You will probably use the new drops
for about one week. In most cases, you are asked to continue your other glaucoma medications after the laser
procedure. The doctors will notify you if there is any exception to continuing your medications. How much your
pressure drops requires several weeks to determine. You may require additional laser surgery to lower the
pressure if it is not sufficiently lower after the first laser treatment.

________________________________________________________________________________________
Patient Signature (or Person Authorized to Sign for Patient) Date
PLACE LETTERHEAD HERE AND REMOVE NOTE.

CHANGE FONT SIZE FOR LARGE PRINT

NOTE: THIS FORM IS INTENDED AS A SAMPLE FORM. IT CONTAINS THE INFORMATION OMIC
RECOMMENDS YOU AS THE SURGEON PERSONALLY DISCUSS WITH THE PATIENT. PLEASE
REVIEW IT AND MODIFY TO FIT YOUR ACTUAL PRACTICE. GIVE THE PATIENT A COPY AND SEND
THIS FORM TO THE HOSPITAL OR SURGERY CENTER AS VERIFICATION THAT YOU HAVE OBTAINED
INFORMED CONSENT.

Version 12/1/2002

FROM [Link]

[ADDENDUM TO GENERAL CONSENT FORM FOR GLAUCOMA SURGERY]

LASER IRIDOTOMY

This is a laser surgery used for people with narrow-angle glaucoma. The laser is used to make a small hole in
the iris (colored part of the eye). The laser burn should let more fluid leak out through the drain in the eye.
Furthermore, it will hopefully prevent scar formation between the iris and cornea which can lead to progression
of the glaucoma.

There are some individuals who respond well to this and others who do not respond at all to the surgery. Your
response is determined by the type of narrow-angle glaucoma you have and the basic make-up of your eye.

The procedure can be done in one or two trips to the laser area. The laser machine looks similar to the
examination microscope that the doctor uses to look at your eyes at each visit. The laser itself makes little
noise and flashes a light about as bright as a flash on a camera. Almost everybody finds the procedure
comfortable and without pain. Some individuals feel a little pressure during the laser. The procedure usually
takes about ten to twenty minutes.

You may need drops before and after the laser. Most people will need to have their pressure checked one hour
after the laser. This is because the pressure in the eye can go up after the laser treatment. This is the greatest
risk for this procedure. If it does occur, you may require medications to lower the pressure, which will be
administered in the office. Rarely, the pressure in the eye elevates to a very high pressure and does not come
down. If this happens, you may require surgery in the operating room to lower the pressure. This is a most
unusual event.
Most people notice some blurring in their vision after the laser. This clears within a few hours in most
individuals. The chance of your vision being permanently affected from this laser procedure is very, very small.

You will need to use drops after the laser to help the eye heal correctly. You will probably use the new drops
for about one week. In most cases, you are asked to continue your other glaucoma medications after the laser
procedure. The doctors will notify you if there is any exception to continuing your medications.

Other risks from this procedure include inflammation in the eye, cataract formation, bleeding (usually a small
amount but can be a large amount), double vision, scar formation between the iris and lens of the eye
(synechia) that prevents the pupil from moving correctly, late closure of the iridotomy that requires repeat laser
surgery to open the hole again, and (rarely) damage to the cornea or retina from the laser light. Most of these
risks are somewhat decreased by having a skilled surgeon, but cannot always be prevented.

Patient (or person authorized to sign for patient) Date

Witness Date
PLACE LETTERHEAD HERE AND REMOVE NOTE. Version 5/6/06

CHANGE FONT SIZE FOR LARGE PRINT

NOTE: THIS FORM IS INTENDED AS A SAMPLE ONLY OF THE INFORMATION YOU AS THE SURGEON
SHOULD PERSONALLY DISCUSS WITH THE PATIENT. PLEASE REVIEW IT AND MODIFY TO FIT YOUR
ACTUAL PRACTICE. GIVE THE PATIENT A COPY AND SEND THIS FORM TO THE HOSPITAL OR
SURGERY CENTER AS VERIFICATION THAT YOU HAVE OBTAINED INFORMED CONSENT.

From [Link]

Consent Form for Incision and Drainage of Chalazion

Condition and Proposed Treatment

Your eye care provider has evaluated you and diagnosed you with a chalazion, which is a localized
inflammatory response involving sebaceous glands of the eyelid that occurs when the gland duct is obstructed.
A chalazion may resolve spontaneously or with warm compresses, lid scrubs, and lid massage. When there is
no improvement, the chalazion may be incised and drained. After local anesthesia, a chalazion instrument is
put in place and an incision is made in the inner aspect of the eyelid. The contents of the chalazion are then
carefully drained with a curette followed by gentle pressure or heat to control any bleeding.

Alternatives to Surgery
1. Lid Hygiene – Warm compresses, lid massage and scrubs; may not improve
chalazion if deep.

2. Steroid Injection – May require more than one injection. Can result in depigmentation of the eyelid, steroid
deposits at the injection site, or in rare instances occlusion of retinal and choroidal blood vessels with
possible loss of vision
3. No Treatment – I may choose no treatment and tolerate the chalazion.

Risks and Complications

No procedure is entirely risk free. Adverse effects from incision and drainage of chalazion may include:

1. Infection – Infections can be treated with topical or oral antibiotics

2. Bleeding – Normally controlled with gentle pressure or heat cautery at the incision site.
3. Pain – Minimal and resolves with healing of incision.
4. Recurrence – Chalazion may recur if incomplete excision.
5. Loss of lashes in the involved area
6. Eyelid notching in the area of the inflammation
7. Damage to the globe from the scalpel, needle used to inject the anesthetic, or cautery instrument.
8. Vision loss, including blindness.

Consent for Treatment

By signing below I acknowledge that I have read and understand the above, and have had my questions
answered by the surgeon to my satisfaction. I consent to the incision and drainage of the chalazion on the
_______________(state “upper” or “lower”) lid of my _________ (state “right” or “left”) eye.
________________________ _________________________ ________

Patient Name Patient Signature Date