Consent Forms in Ophthalmic Practice - dosonline.orgdosonline.org/consent_form.pdf · Consent Forms in Ophthalmic Practice in Hindi ... I understand the procedure has the following

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 nf"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<+k gqvk ncko ¼Xywdksek½

6- eksfr;kfcan] tks fd ysalksa dh varr% ;k QkSju fudklh dks vko';d cuk ldrk gS

7- dkWuhZy dh [kjkfc;ksa dk cgqr gh /khes Bhd gksuk ;k ugha Bhd gksuk

8- dkWuhZy DykmfMax ;k LdSfjax

vka[kksa ds bnZfxnZ laosnukgkjh batsD'kuksa dh tfVyrk,a

1- us=xksyd dk [ksn

2- izdkf'kd ul dks lqbZ ls {kfr] tks fd n`f"V dks u"V dj nsrh gS

3- jsVªkscqyckj jDrlzko

4- iydksa dh laHko Mªwfiax

5- lokZaxh izHkko ftlesa fd thou dks [krjs esa Mkyus okyh tfVyrkvksa vkSj ekSr dh laHkkO;rk gksrh gS

jksxh dh lgefrÅij crk;s x;s tksf[keksa ds ckotwn] eSa le>rk gwa fd vxj eSa vkWijs'ku ugha djokrk gwa rks esjh n`f"V dks vkSj Hkh vf/kd [krjk gSA eSaus lgefr izi=dks i<+ vkSj le> fy;k gS] esjs iz'uksa ds mÙkj fn;s tk pqds gSa] vkSj eSa vius ltZu dks viuh ----------------------------¼^^nk;ha** ;k ^ck;ha** vka[k lq>k,a½ dk vkWijs'kudjus ds fy, vkxs c<+us gsrq vf/kÑr djrk gwaA

( 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 AvastinTM

treatment.

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`<+ oSKkfud rjhds vkSj Bksl fpfdRldh; lk{; ij vk/kkfjrdj ldrs gSa vkSj mlds mi;ksx vkSj izHkkoksa ds fjdkMksZa dks cuk;s j[k ldrs gSaA us= fo'ks"kK ,,eMh vkSj leku n'kkvksa ds mipkj ds fy, vokfLVuVh,e

^^vkQ yscy** dk mi;ksx dj jgs gSa D;ksafd vuqla/kku crkrs gSa fd ohbZth,Q vlkekU; ulksa ds fodkl ds dkj.kksa esa ls ,d gS tks fd bu n'kkvksa dksmRiUu djrs gSaA vokfLVuVh,e ls mipkj ikus okys jksfx;ksa esa de rjy inkFkZ vkSj T;knk lkekU; fn[kus okys eSdqys Fks vkSj mudh n`f"V lq/kjh gqbZ FkhAfygktk] vokfLVuVh,e dk mi;ksx eSdqyj ,fMek ;k eSdqyk dh lwtu dks Bhd djus ds fy, Hkh fd;k tkrk gSA gky gh esa] izdk;Z esa ,d leku vkSjbaVªkfoVfj;y izca/k ds fy, rS;kj dh x;h nok dks ,,eMh ds mipkj ds fy, ,QMh, }kjk eatwjh iznku dh x;hA

laHkkfor lhek,amipkj dk y{; n`f"V dh vkSj vf/kd gkfu dks jksduk gSA gkykafd dqN jksfx;ksa us n`f"V dks fQj ls izkIr fd;k gS ij gks ldrk gS fd nok ml n`f"Vdks cgky ugha dj ik;s tks fd igys gh tk pqdh gS vkSj chekjh ds dkj.k vkxs n`f"V ds tkus dks varr% 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 gSaAizFke nks folqMkbuVh,e uked nok ds lkFk QksVksMk;kufed mipkj vkSj eSdqtsuVh,e uked nok dk vka[k esa batsD'ku gSaA rhljh nok] yqlsafVlVh,e vokfLVuVh,e

ds leku gksrh gSA ,QMh, ls eatwjh izkIr nokvksa ds vfrfjDr dqN us=&fo'ks"kK vkidh rjg dh vka[kksa dh n'kkvksa ds mipkj ds fy, baVªkfoVfj;yfVª;kefluksyku & ^^vkQ&yscy** dks mi;ksx esa ykrs gSaA

dSalj ds jksfx;ksa dks vokfLVu Vh,e fn;s tkus ij mRiUu gksus okyh tfVyrk,atc esVkLVsfVd dksyksjsDVy dSalj okys jksfx;ksa dks vokfLVuVh,e nh x;h rks dqN jksfx;ksa us tBjkaf=; Nsnksa ;k ?kko Hkjus esa ijs'kkfu;ksa] /keuh; FkzksEcks,Ecksfyd?kVukvksa ¼tSls fd nkSjk ;k ân;k?kkr½] mPp jDrpki] izksVhuqfj;k vkSj dkatsfLVo gkVZ QsY;ksj dk lkeuk fd;kA bu ijs'kkfu;ksa dks eglwl djus okys jksfx;ksadks u dsoy esVkLVsfVd dksyksu dSalj Fkk cfYd mUgsa vkids eqdkcys 400 xquk [kqjkd T;knk fu;fer varjkyksa ij vkSj bl izdkj ls ¼var%f'kjk esa nzodks Mkyus ds tfj;s½ nh x;h Fkh ftlus fd muds iwjs 'kjhj esa nok dks QSyk fn;k FkkA

vka[k dh chekfj;ksa okys jksfx;ksa ds mipkj ds fy, vokfLVu Vh,e dks fn;s tkus ds le; ds tksf[kevka[k dh chekjh okys jksfx;ksa ds fy, bu ijs'kkfu;ksa ds tksf[ke de gSaA vka[kksa dh chekfj;ksa ds fy, vokfLVuVh,e izkIr djus okys jksxh dSalj jksfx;ksa dseqdkcys T;knk LoLFk gksrs gSa vkSj dsoy mudh vka[kksa dh dsfoVh esa Mkyh tkus okyh mYys[kuh; :i ls de ek=k izkIr djrs gSaA tgka vka[kksa esa vokfLVuVh,e

ds mi;ksx ds ckjs esa ,QMh, ls eatwjh izkIr ,sls dksbZ v/;;u ugha gSa tks fd ;g lkfcr djrs gksa fd ;g lqjf{kr vkSj izHkkoh gS] ogha blh izdkj dh nokyqlsafVlVh,e dks gky gh esa ,,eMh ds fy, eatwjh iznku dh x;hA ul ds vanj nzo Mkydj vokfLVuVh,e izkIr djus okys jksfx;ksa ds ,d v/;;u esa dsoyjDrpki esa gYdh o`f) ns[kh x;hA vkidh rjg baVªkfoVfj;y vokfLVuVh,e ls mipkj ikus okys jksfx;ksa ds ,d nwljs v/;;u esa bu o`f);ksa ;k vU; xaHkhjleL;kvksa dks ugha ns[kk x;k gS ftUgsa fd dSalj ds jksfx;ksa esa ns[kk x;k FkkA fQj Hkh] vka[k dh chekfj;ksa ds fy, baVªkfoVfj;y vokfLVuVh,e ds ykHkksa vkSjtksf[keksa dk vHkh iwjh rjg ls irk ugha pyk gSA blds vfrfjDr] tc jksfx;ksa dh cM+h la[;k esa nok dk mi;ksx fd;k tkrk gS rks ,d NksVh la[;k esatkuysok leL;kvksa dk la;ksx iSnk gks ldrk gS ftldk fd mipkj ds lkFk dksbZ fj'rk ugha gksrk gSA mnkgj.k ds fy, e/kqesg dks jksfx;ksa dks fny dsnkSjs ;k vk?kkr dk tksf[ke igys ls gh c<+k gqvk gksrk gSA vxj vokfLVuVh,e ls mipkj ik jgs jksfx;ksa esa ls dksbZ fny ds nkSjs ;k vk?kkr ls =Lr gksrkgS rks gks ldrk gS fd mldk dkj.k e/kqesg gks u fd vokfLVuVh,e ds lkFk mipkjA

vka[kksa ds baVªkfoVfj;y batsD'kuksa ds Kkr tksf[kevkidh chekjh esa gks ldrk gS fd lq/kkj ugha vk;s ;k og cnrj gks ldrh gSA bu ijs'kkfu;ksa esa ls dksbZ ;k lHkh ?kVh gqbZ n`f"V vkSj@;k va/kRo iSnk djus

( 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 i<+ fy;k x;k gSA esjh vka[k dh voLFkk dh izÑfr eq>s 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


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


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


I understand that LucentisTM 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 LucentisTM, 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 LucentisTM 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: .......................................................................................................

( 27 )

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



lq>koeSdqtsu yqlsafVlVh,e 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 dsfy, fd;k tkrk gSA 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 gSaAigyk folqMkbuVh,e uked nok ds lkFk QksVksMk;kufed mipkj gSA vU; nks yqlsafVlVh,e vkSj eSdqtsuVh,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&izHkkoyqlsafVl ds lkFk lokZf/kd vke ik'oZ izHkkoksa esa 'kkfey gSa %

1- vka[kksa dh tyu

2- /kqa/kyh n`f"V ;k n`f"V esa ifjorZu

3- eksfr;kfcan

4- vka[kksa esa jDrlzko

5- vka[kksa esa lwtu

6- vka[k ls ikuh cguk

7- vka[k esa tyu ;k ihM+k

8- vka[kksa dk nnZ

9- vkidh n`f"V esa ^^/kCcksa** dk fn[kuk

10- ,sls ik'oZ&izHkkoksa esa tks fd vka[kksa ls tqM+s gq, ugha gS lokZf/kd vke ik'oZ&izHkko gSa mPp jDrpki] ukd vkSj xys esa laØe.k vkSj fljnnZA

11- gkykafd vke ugha gSa ij vka[kksa ls tqM+h gqbZ n'kk,a vkSj muls vlEc) jDr ds FkDds ¼/keuh; FkzksEcks,Ecksfyd ?kVuk,a½ iSnk gks ldrh gSaA

jksxh dh ftEesnkfj;kavxj eSa xHkZorh gwa] xHkZ /kkj.k djus dh ;kstuk cuk jgwa ;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:axh % 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 jgwaxh 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

( 28 )

,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 djrhgwa rks QkSju vius MkWDVj ls laidZ d:axhA ftruh tYnh laHko gks ldsxk eSa viuk mipkj dj jgs us= fo'ks"kK dks bu leL;kvksa ds ckjs esa crkÅaxhA

eSa fdlh nwljs ltZu dks lwfpr d:axh fd esjh nokbZ py jgh gS ftls fd jksdus dh t:jr gS rkfd esjh ltZjh gks ldsA


eSa le>rk gwa fd yqlsafVlVh,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 yqlsafVlVh,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;yyqlsafVlVh,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 %. ............................................................................................

( 29 )

ROP LaserParijat Chandra


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

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

I have been informed in my mother tongue that my child’s eye(s) are affected with the disease Retinopathy of Prematurity (ROP) whichurgently requires retinal laser photocoagulation treatment.

I have been fully explained regarding Retinopathy of Prematurity, its vision blinding complications, and the urgent necessity for retinallaser treatment. I have been clearly explained about the laser procedure, its side effects and risks involved. I understand that depending ondisease severity and treatment response, additional laser treatments may be required later. I understand that despite the best of lasertreatment, sometimes the disease may progress leading to visually disabling sequelae and blindness, and later may require surgicalintervention which may or may not be beneficial.

I allow the attending neonatologist to administer drugs, infusions or any other treatment/ procedures as deemed necessary or desirableduring the laser procedure (and in any unforeseen or emergency conditions they encounter).

I certify that I have fully understood the implications of the above consent and authorise the doctors to perform retinal laser photocoagulationon my child’s right / left eye.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 30 )

vkjvksih ystjikfjtkr panzk



eq>s esjh ekr`Hkk"kk esa lwfpr dj fn;k x;k gS fd esjs cPps dh vka[k¼[ksa½ jsfVuksiSFkh vkQ izheSP;ksfjVh ¼vkjvksih½ chekjh ls izHkkfor gSa ftlds fy, QkSjujsfVuy ystj QksVksdksvkWxqys'ku mipkj dh t:jr gSA

eq>s jsfVuksiSFkh vkQ izheSP;ksfjVh] mldh va/kk dj nsus okyh tfVyrkvksa vkSj jsfVuy ystj mipkj dh rqjar vko';drk ds ckjs esa iwjh rjg ls le>kfn;k x;k gSA eq>s ystj dh dk;Zfof/k] mlds ik'oZ&izHkkoksa vkSj mlls tqM+s tksf[keksa ds ckjs esa Li"V :i ls le>k fn;k x;k gSA eSa le>rk gwa fd chekjhdh xaHkhjrk vkSj mipkj ds izfrlkn ds vk/kkj ij ckn esa pydj vfrfjDr ystj mipkjksa dh vko';drk iM+ ldrh gSA eSa le>rk gwa fd loksZÙke ystjmipkj ds ckotwn dbZ ckj chekjh c<+ ldrh gS ftlls fd va/kRo iSnk gksxk vkSj ckn esa vkWijs'ku dh t:jr iM+ ldrh gS tks fd ykHknk;d gks Hkhldrk gS vkSj ugha HkhA

eSa mipkj dj jgs cPpksa ds MkWDVj dks ystj dk;Zfof/k ds nkSjku nok,a nsus] batsD'ku yxkus ;k fdlh vU; mipkj@izfØ;k dh vuqefr iznku djrkgwa ftls fd ystj dk;Zfof/k ¼vkSj muds lkeus is'k vkus okyh fdlh vizR;kf'kr ;k vkikrdkyhu n'kkvksa esa½ ds nkSjku vko';d ;k okafNr le>k tk;sA

eSa izekf.kr djrk gwa fd eSaus mi;qZDr lgefr ds fufgrk'k;ksa dks iwjh rjg ls le> fy;k gS vkSj MkWDVjksa dks vius cPps dh nk;ha@ck;ha vka[k ij jsfVuyystj QksVksdksvkxqys'ku dks lEiUu djus ds fy, vf/kÑr djrk gwaA


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

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MkWDVj dk gLrk{kj %

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

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

( 31 )

Laser Indirect OphthalmoscopyBhuvan Chanana


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

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

This document is intended to provide you with information so that you can decide whether you should have a type of laser surgery calledlaser indirect ophthalmoscopy or LIO. You have the right to ask any questions you might have about the procedure before agreeing to havethe ophthalmologist, or eye surgeon, perform it on your eye.

Indications for Laser Indirect OphthalmoscopyThe eye functions much like a camera. The front of the eye contains the structures which focus the image and regulate the amount of lightthat enters the eye, similar to the lens and shutter of a camera. In the back of the eye is the retina, which functions like the film in thecamera. Without film, a camera cannot take a picture, and without a functioning retina, the eye cannot see.

LIO is done to laser the peripheral retina. It is used to treat peripheral retinal lesions like lattice degeneration or a retinal break, which maypredispose your eyes to retinal detachment. LIO is also done to delimit peripheral detached retina to prevent its further progression. LIOcan also be used for augmentation of pan-retinal photocoagulation where the peripheral retina cannot be lasered by using a slit lampmachine.

Possible Benefits of Laser Indirect OphthalmoscopyLaser indirect ophthalmoscopy or LIO uses a laser to treat the peripheral retina so that it will form a strong adhesion of the retina withunderlying layers, preventing the retina to detach, and avoiding a potentially blinding condition.

To perform the procedure, the pupil of the eye is made bigger (dilated) with eye drops. The laser is aimed at the peripheral retina throughthe pupil with the help of an indirect ophthalmoscope. Since the laser treats the peripheral retina, some peripheral or side vision may belost, and this may cause reduced night vision. This usually does not present a problem for most of the cases.

Alternatives to Laser Indirect OphthalmoscopyCryotherapy has also been used to treat peripheral retinal lesions. Cryotherapy uses a probe placed against the outside of the eye to treatthe peripheral retina by freezing it. Most ophthalmologists now treat the peripheral retina with a laser instead of cryotherapy.

Risks and Complications of Laser Indirect OphthalmoscopyWhen deciding whether or not to have surgery, the patient must weigh the possible risks of the surgery against the benefits the surgery isexpected to produce. Laser surgery for peripheral retina has limited risks. While performing the surgery, structures of the eye can bedamaged and cause complications, which may lead to loss of vision. Surgery or medications may be needed to treat these complications.

In the majority of patients whose eyes were treated with LIO, the retina remained attached. While the goal of the surgery is prevent a retinaldetachment and blindness, even with proper treatment, not all eyes respond to the treatment. New lesions of the retina may develop andregular retinal screening is required. For some the laser surgery may have to be repeated in order to completely treat the retinal lesion.

Risks for LIO include, but are not limited to:

1. Failure to achieve the goal of surgery: even with treatment, retinal detachment may develop in few cases.2. Bleeding in the eye (vitreous hemorrhage)3. Elevated eye pressure (glaucoma)4. Decreased eye pressure (hypotony)

( 32 )

5. Corneal burns (clear covering of the front of the eye)6. Damage to the iris (colored portion of the eye)7. Damage to the lens (cataract)8. Loss of vision or loss of the eye9. Loss of peripheral (side) vision10. Corneal clouding or scarring11. Decrease or loss of vision caused by loss of circulation to the vital tissues in the eye

Consent for Laser Surgery for ROPThe ophthalmologist has explained to me the problem with my eyes, and the risks, benefits, and alternatives to LIO surgery. Although itis impossible for the doctor to inform me of every possible complication that may occur, the doctor has answered all my questions to mysatisfaction. I understand that there is no guarantee that the surgery will prevent blindness in my eye, and that the surgery may need to berepeated to effectively treat my condition.

In signing this informed consent for LIO, I am stating that I have been offered a copy and I fully understand the possible risks, benefits,and complications of the laser surgery.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 33 )

ystj buMkW;jsDV vkWFkSyeksLdksihHkqou pUuk



bl nLrkost dk y{; vkidks og tkudkjh iznku djuk gS ftlls fd vki bl ckr dk fu.kZ; dj ldsa fd vki ystj buMkW;jsDV vkWFkSyeksLdksih ;k,yvkbZvks uked ystj ltZjh dks djok,axs ;k ughaA us= fo'ks"kK ;k us= ltZu dks bls vkidh vka[k ij laiUu djus nsus ij lger gksus ls igys bldhdk;Zfof/k ds ckjs esa dksbZ Hkh iz'u iwNuk vkidk vf/kdkj gSA

ystj buMkW;jsDV vkWFkSyeksLdksih ds fy, lq>kovka[k dkQh dqN dSejs dh rjg ls dke djrh gSA vka[kksa ds lkeus ds fgLls esa og <kapk gksrk gS tks fd Nfo ij Qksdl djrk gS vkSj vka[kksa esa izos'kdjus okyh izdk'k dh ek=k dks fu;fer djrk gS] tks fd dSejs dh fQYe dh Hkkafr dke djrk gSA fQYe ds fcuk dSejk rLohj ugha mrkj ldrk vkSjdke djus okyh jsfVuk ds fcuk vka[ksa ns[k ugha ldrhaA

ifj/kh; jsfVuk dks ystj djus ds fy, ,yvkbZvks dh tkrh gSA bldk mi;ksx f>yfeyh ds fodkj ;k jsfVuy VwVu tSls ifj/kh; jsfVuy ?kkoksa dk mipkjdjus ds fy, fd;k tkrk gS] tks fd jsfVuy vyxko ds fy, vkidh vka[kksa dks igys ls gh izo`Ùk dj ldrk gSAvyx gqbZ ifj/kh; jsfVuk dks lhfer djus ds fy, Hkh ,yvkbZvks fd;k tkrk gS rkfd mls vkxs vkSj c<+us ls jksdk tk ldsA blds vykok ,yvkbZvks dkmi;ksx vf[ky&jsfVuy QksVksdksvkxqys'ku dh o`f) ds fy, fd;k tk ldrk gS] tgka ij ifj/kh; jsfVuk dks fLyV ySEi e'khu dk mi;ksx djds ystjls mipkfjr ugha fd;k tk ldrkA

ystj buMkW;jsDV vkWFkSyeksLdksih ds laHkkfor ykHkystj buMkW;jsDV vkWFkSyeksLdksih ;k vkbZ,yvks ifj/kh; jsfVuk dk mipkj djus ds fy, ystj dk mi;ksx djrh gS rkfd og varfuZfgr ijrksa ds lkFkjsfVuk ds etcwr tqM+ko dks fufeZr djs] jsfVuk dks vyx gksus ls jksds vkSj laHkkO; :i ls va/kRo dh n'kk ls cpk;sAbl dk;Zfof/k dks laiUu djus ds fy, vka[kksa dh iqryh dks vkbZ MªkIl ls cM+k cuk;k tkrk gS ¼QSyk;k tkrk gS½A ystj buMkW;jsDV vkFkSyeksLdksi dhenn ls iqryh ds tfj;s ifj/kh; jsfVuk ij yf{kr gksrh gSA pwafd ystj ifj/kh; jsfVuk dk mipkj djrh gS blfy, dqN ifj/kh; ;k ik'oZ dh utj tkldrh gS vkSj bldh otg ls jkr esa de fn[kk;h iM+ ldrk gSA ;g izk;% vf/kdrj ekeyksa esa leL;k ugha mRiUu djrkA

ystj buMkW;jsDV vkWFkSyeksLdksih ds fodYifØ;ksFksjsih dk mi;ksx ifj/kh; jsfVuy ?kkoksa ds mipkj ds fy, Hkh fd;k tkrk gSA fØ;ksFksjsih ifj/kh; jsfVuk dk mipkj djus ds fy, mls cgqr gh Ba<kdjds vka[k ds ckgjh fgLls ds lkeus j[kh x;h lykbZ dk mi;ksx djrh gSA vf/kdrj us= fo'ks"kK vc fØ;ksFksjsih dh ctk; ifj/kh; jsfVuk dk mipkjystj ls djrs gSaA

ystj buMkW;jsDV vkWFkSyeksLdksih ds tksf[ke vkSj tfVyrk,altZjh djokbZ tk;s ;k ugha bldk fu.kZ; djrs le; jksxh dks ltZjh ds ykHkksa ds cjvDl mlds laHkkfor tksf[keksa dk vkdyu vo'; djuk pkfg,Aifj/kh; jsfVuk ds fy, ystj ltZjh ds lhfer tksf[ke gSaA ltZjh djrs le; vka[k ds <kaps dks uqdlku igqap ldrk gS vkSj ijs'kkfu;ka mRiUu gks ldrhgSa tks fd n`f"Vghurk dks tUe ns ldrh gSaA bu tfVyrkvksa ds mipkj ds fy, ltZjh ;k nokb;ksa dh vko';drk iM+ ldrh gSA

,yvkbZvks ls mipkj ik;s vf/kdka'k jksfx;ksa esa jsfVuk layXu cuh jghA tgka ltZjh dk mís'; jsfVuk ds vyxko vkSj va/ksiu dks jksduk gS ogha leqfprmipkj ds ckn Hkh mipkj ls lHkh vka[ksa Bhd ugha gksrh gSaA jsfVuk ds u;s ?kko fodflr gks ldrs gSa vkSj jsfVuk dk fu;fer ijh{k.k vko';d cu tkrkgSA dqN ds fy, ystj ltZjh dks nksgjkuk iM+ ldrk gS rkfd jsfVuk ls tqM+s ?kko dk iwjh rjg ls mipkj fd;k tk ldsA

,yvkbZvks ds fy, tksf[keksa esa 'kkfey gSa ij os bUgha rd lhfer ugha gSa %

1- ltZjh ds y{; dks ikus esa foQyrk % mipkj ds ckn Hkh dqN ekeyksa esa jsfVuy vyxko fodflr gks ldrk gSA2- vka[kksa esa jDrlzko ¼foVfjvl jDrlzko½3- vka[k dk c<+k gqvk ncko ¼Xywdksek½4- vka[k dk ?kVk gqvk ncko ¼gkbiksVksuh½

( 34 )

5- dkWuhZy cUlZ ¼vka[k ds lkeus dh fDy;j dofjax½6- vkbfjl ¼vka[k dk jaxhu fgLlk½ dks uqdlku7- ysal dks uqdlku ¼eksfr;kfcan½8- n`f"V dk pys tkuk ;k vka[k dh gkfu9- ifj/kh; ¼fdukjs dh½ n`f"V dh gkfu10- dkWuhZy DykmfMax ;k LdSfjax11- vka[kksa ds egRoiw.kZ Årdksa esa ifjlapj.k dh deh ls mRiUu n`f"V esa deh ;k mldh gkfu

vkjvksih gsrq ystj ltZjh ds fy, vuqefrus= fo'ks"kKksa us esjh vka[k dh leL;k vkSj vkbZ,yvks ltZjh ds tksf[keksa] ykHkksa vkSj fodYiksa ds ckjs esa eq>s le>k fn;k gSA gkykafd MkWDVj ds fy, mifLFkrgks ldus okyh gjsd laHko tfVyrk ds ckjs esa crkuk vlaHko gS ij MkWDVj esjs lHkh iz'uksa dk mÙkj nsdj eq>s larq"V dj fn;kA eSa le>rk gwa fd blckr dh dksbZ xkjaVh ugha gS fd ltZjh esjs vka[kksa ds va/ksiu dks jksd nsxh vkSj ;g fd esjh voLFkk ds izHkkoh mipkj ds fy, ltZjh dks nksgjkus dh vko';drkiM+ ldrh gSA

,yvkbZvks ds fy, bl lwfpr lgefr ij gLrk{kj djds eSa dg jgk gwa fd eq>s bldh ,d izfr iznku dh x;h gS vkSj eSa ystj ltZjh ds laHkkfor tksf[keksa]ykHkksa vkSj tfVyrkvksa dks le>rk gwaA


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

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MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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

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

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

( 35 )

Laser Photocoagulation for Diabetic RetinopathyAparna Gupta


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

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

This document is intended to provide you with information so that you can decide whether you should have Laser photocoagulation fordiabetic retinopathy

You have the right to ask any questions you might have about the procedure before agreeing to have the ophthalmologist, or eye surgeon,perform it on your eye.

Indications for Laser Photocoagulation for Diabetic RetinopathyThe eye functions much like a camera. The front of the eye contains the structures which focus the image and regulate the amount of lightthat enters the eye, similar to the lens and shutter of a camera. In the back of the eye is the retina, which functions like the film in thecamera. Without film, a camera cannot take a picture, and without a functioning retina, the eye cannot see.

Laser photocoagulation uses the heat from a laser to seal or destroy abnormal, leaking blood vessels in the retina. One of two approachesmay be used when treating diabetic retinopathy:

• Focal photocoagulation. Focal treatment is used to seal specific leaking blood vessels in a small area of the retina, usually near themacula. The ophthalmologist identifies individual blood vessels for treatment and makes a limited number of laser burns to sealthem off.

• Scatter (pan-retinal) photocoagulation. Scatter treatment is used to slow the growth of new abnormal blood vessels that havedeveloped over a wide area of the retina. The ophthalmologist may make hundreds of laser burns on the retina to stop the bloodvessels from growing. The person may need two or more treatment sessions.

Laser photocoagulation is not painful. The injection of anesthetic may be uncomfortable, and you may feel a slight stinging sensation orsee brief flashes of light when the laser is applied to your eye.

Possible Benefits of Laser Photocoagulation for Diabetic RetinopathyLaser treatment may not restore vision that has already been lost. But when performed in a timely manner,

• Focal photocoagulation, which targets specific blood vessels, is effective in reducing the risk of vision loss in people with macularedema. It lowers the risk of moderate vision loss by 20% in people who have mild to moderate non-proliferative retinopathy. It mayalso help prevent progression to more severe retinopathy.

• Scatter (pan-retinal) photocoagulation, which treats a wide area of the retina, reduces the risk for severe vision loss by 50% to 60%over 6 years in people with a high risk of vision loss. It reduces the risk of serious bleeding and progression of severe proliferativeretinopathy and the need for surgery (vitrectomy) by 50% in people with type 2 diabetes and people age 40 and older with type 1diabetes who already have severe non-proliferative or mild proliferative retinopathy. Studies suggest that up to 90% of cases of legalblindness caused by proliferative retinopathy could be prevented by prompt scatter photocoagulation.

Risks and Complications of Laser Photocoagulation for Diabetic RetinopathyLaser photocoagulation burns and destroys part of the retina and often results in some permanent vision loss. This is usually unavoidable.Treatment may cause mild loss of central vision, reduced night vision, and decreased ability to focus. Some people may lose some of theirside (peripheral) vision. However, the vision loss caused by laser treatment is mild compared with the vision loss that may be caused byuntreated retinopathy.

Rare complications of laser photocoagulation may cause severe vision loss. These include:

• Bleeding in the eye (vitreous hemorrhage).• Traction retinal detachment.

( 36 )

• Accidental laser burn of the fovea (a depression in the central macula that contains no blood vessels), resulting in severe centralvision loss.

Consent for Laser Photocoagulation for Diabetic RetinopathyThe ophthalmologist has explained to me the problem with my eyes, and the risks, benefits, and alternatives to laser photocoagulation.Although it is impossible for the doctor to inform me of every possible complication that may occur, the doctor has answered all myquestions to my satisfaction. I understand that there is no guarantee that the laser will prevent blindness in my eye, and that the laser mayneed to be repeated to effectively treat my condition.

In signing this informed consent for laser photocoagulation, I am stating that I have been offered a copy and I fully understand thepossible risks, benefits, and complications of the laser surgery.


Name: .................................................................................................. Relationship ........................................... Date .............................................

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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 37 )

Mk;fcfVd jsfVuksFksjsih ds fy, ystj QksVksdksvkxqys'kuvi.kkZ xqIrk



bl nLrkost dk y{; vkidks og tkudkjh iznku djuk gS ftlls fd vki bl ckr dk fu.kZ; dj ldsa fd vki Mk;fcfVd jsfVuksFksjsih ds fy, ystjQksVksdksvkxqys'ku djok,axs ;k ughaA us= fo'ks"kK ;k us= ltZu dks bls vkidh vka[k ij laiUu djus nsus ij lger gksus ls igys bldh dk;Zfof/k dsckjs esa dksbZ Hkh iz'u iwNuk vkidk vf/kdkj gSA

Mk;fcfVd jsfVuksFksjsih ds fy, ystj QksVksdksvkxqys'ku dk lq>kovka[k dkQh dqN dSejs dh rjg ls dke djrh gSA vka[kksa ds lkeus ds fgLls esa og <kapk gksrk gS tks fd Nfo ij Qksdl djrk gS vkSj vka[kksa esa izos'kdjus okyh izdk'k dh ek=k dks fu;fer djrk gS] tks fd dSejs dh fQYe dh Hkkafr dke djrk gSA fQYe ds fcuk dSejk rLohj ugha mrkj ldrk vkSjdke djus okyh jsfVuk ds fcuk vka[ksa ns[k ugha ldrhaA

ystj QksVksdksvkxqys'ku jsfVuk dh vlkekU;] fjlko okyh jDr okfgdkvksa dks lhy ;k u"V djus ds fy, ystj dh xjeh dk mi;ksx djrk gSA Mk;fcfVdjsfVuksFksjsih dk mipkj djrs le; nks igqapksa esa ls ,d dk mi;ksx fd;k tk ldrk gS %Û Qksdy QksVksdksvkxqys'kuA Qksdy mipkj dk mi;ksx jsfVuk ds NksVs ls Hkkx izk;% eSdqyk ds djhc esa fjlko djus okyh fof'k"V jDr okfgdkvksa

dks can djus ds fy, fd;k tkrk gSA us=&fo'ks"kK mipkj ds fy, ,d&,d jDRk okfgdkvksa dh igpku djrk gS vkSj mUgsa can djus ds fy, lhferla[;k ystj cUlZ djrk gSA

Û LdSVj ¼vf[ky&jsfVuy½ QksVksdksvkxqys'kuA LdSVj mipkj dk mi;ksx u;h vlkekU; jDr okfgdkvksa dh o`f) dks /khek djus ds fy, fd;ktkrk gS tks fd jsfVuk ds cM+s fgLls ds Åij fodflr gks x;h gksrh gSaA us= fo'ks"kK jDr okfgdkvksa dks c<+us ls jksdus ds fy, jsfVuk ds Åijgtkjksa ystj cUlZ dj ldrk gSA O;fDRk dks nks ;k vf/kd mipkj l=ksa dh vko';drk iM+ ldrh gSA ?

ystj QksVkdksvkxqys'ku nnZukd ugha gksrk gSA csgks'kh dk batsD'ku cspSu djus okyk gks ldrk gS vkSj vki gYdh pqHku dh lulukgV eglwl dj ldrsgSa ;k vkidh vka[kksa ij ystj ds iz;ksx ds le; izdk'k dh laf{kIr ped dks ns[k ldrs gSaA

Mk;fcfVd jsfVuksFksjsih ds fy, ystj QksVksdksvkxqys'ku ds laHkkfor ykHkystj mipkj gks ldrk gS fd igys ls gh tk pqdh n`f"V dks cgky ugha dj ik;s ysfdu le;c) rjhds ls bls laiUu djus ij]Û QksVksdksvkxqys'ku] tks fd fof'k"V jDr okfgdkvksa dks yf{kr djrk gS] eSdqyj ,fMek okys yksxksa esa n`f"V dh gkfu ds tksf[ke dks de djus esa

izHkkoh gSA ;g gYdh ls ysdj e/;e rd dh xSj&izlkjh jsfVuksiSFkh okys yksxksa esa n`f"V dh e/;e gkfu dks 20 izfr'kr rd de djrk gSA bldsvykok ;g T;knk xaHkhj jsfVuksFksjsih esa c<+r dks jksdus esa Hkh enn dj ldrk gSA

Û LdSVj ¼vf[ky&jsfVuy½ QksVksdksvkxqys'ku] tks fd jsfVuk ds foLr`r {ks= dk mipkj djrk gS] n`f"V dh gkfu ds mPp tksf[ke okys yksxksa esa 6o"kksZa ds nkSjku n`f"V dh xaHkhj gkfu dks 50 ls 60 izfr'kr rd ds tksf[ke de djrk gSA ;g Vkbi 2 Mk;fcVht okys yksxksa vkSj 40 lky vkSjvf/kd mez ds Vkbi 1 Mk;fcVht okys yksxksa esa] ftUgsa fd igys ls gh xaHkhj xSj&izlkjh ;k e/;e izlkjh jsfVuksFksjih gS] xaHkhj jDrlzko ds tksf[kevkSj rhoz izlkjh jsfVuksFksjhih dh c<+r vkSj ltZjh ¼foVjsDVkseh½ dh t:jr dks 50 izfr'kr rd de djrk gSA v/;;uksa ls irk pyrk gS fd izlkjhjsfVuksFksjsih ds }kjk mRiUu fu;e ds vuqdwy va/ksiu ds 90 izfr'kr rd ds ekeyksa dks Rofjr LdSVj QksVkdksvkxqys'ku ds }kjk jksdk tk ldrkgSA

Mk;fcfVd jsfVuksFksjsih ds fy, ystj QksVksdksvkxqys'ku ds tksf[ke vkSj tfVyrk,aystj QksVksdksvkxqys'ku jsfVuk ds fgLls dks tykrk vkSj u"V djrk gS vkSj vDlj blds QyLo:i n`f"V dks dqN LFkk;h gksuh gks tkrh gSA ;g izk;%nqfuZokj gksrk gSA mipkj ds dkj.k e/;orhZ n`f"V dks gYdk uqdlku] jkr esa de fn[kk;h iM+uk vkSj /;ku dsafnzr djus dh {kerk esa deh vk ldrh gSAdqN yksx viuh ik'oZ ¼ifj/kh;½ n`f"V dks dqN [kks ldrs gSaA fQj Hkh] fcuk mipkj okyh jsfVuksiSFkh ds dkj.k mRiUu gksus okyh n`f"V dh gkfu dh rqyukesa ystj mipkj ds dkj.k gksus okyh n`f"V dh gkfu gYdh gksrh gSAystj QksVksdksvkxqys'ku dh fojy tfVyrk,a n`f"V dh xaHkhj gkfu dk dkj.k cu ldrh gSaA buesa 'kkfey gSa %Û vka[kksa esa jDrlzko ¼foVfjvl jDrlzko½AÛ f[kapko jsfVuy vyxkoA

( 38 )

Û Qksfov dk la;ksxo'k ystj cuZ ¼e/;orhZ eSdqyk esa ncko ftlesa esa dksbZ jDr okfgdk,a ugha gksrh gSa½] blds dkj.k e/;orhZ n`f"V dks xaHkhj gkfuigqaprh gSA

Mk;fcfVd jsfVuksFksjsih gsrq ystj QksVksdksvkxqys'ku ds fy, vuqefrus= fo'ks"kK us esjh vka[kksa dh leL;kvksa vkSj ystj QksVksdksvkxqys'ku ds tksf[keksa] ykHkksa vkSj fodYiksa ds ckjs esa eq>s le>k fn;k gSA gkykafd mifLFkrgks ldus okyh gjsd laHko tfVyrk ds ckjs esa MkWDVj ds fy, crk ikuk vlaHko gS ysfdu MkWDVj us esjs lHkh iz'uksa dk mÙkj nsdj eq>s larq"V dj fn;kAeSa le>rk gwa fd bl ckr dh dksbZ xkjaVh ugha fd ystj esjh vka[k esa va/ksiu dks jksd nsxh vkSj ;g fd esjh vka[k dh voLFkk ds izHkkoh mipkj ds fy,ystj dks nksgjkus dh t:jr iM+ ldrh gSA

ystj QksVksdksvkWxqys'ku ds fy, bl lwfpr lgefr ij gLrk{kj djrs gq, eSa crk jgk gwa fd eq>s bldh ,d izfr izkIr gqbZ gS vkSj eSa ystj ltZjh dslaHkkfor tksf[keksa] ykHkksa vkSj tfVyrkvksa dks le>rk gwaA


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 %. ............................................................................................

( 39 )

Laser Photocoagulation for Proliferative RetinopathyCourtesy: Shroff Eye Centre, New Delhi


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

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

I hereby authorize Dr. ......................................................... to perform upon me Laser Photocoagulation in the Right / Left eye. The aim of thistreatment is to decrease the risk of severe visual loss by preventing development of or promoting regression or shrinkage of abnormalretinal blood vessels.

I acknowledge that I understand that:

1. I have been diagnosed to have ............................................................2. This treatment is usually indicated when it is likely that bleeding inside the eye from new abnormal blood vessels can occur.

Sometimes laser photocoagulation may be indicated to prevent the development of new blood vessels. The intent of treatment is toreduce likelihood of hemorrhage and/or retinal detachment that could cause severe and possible permanent loss of vision. Howeverhemorrhage and/or retinal detachment can occur despite laser treatment.

3. This treatment is not designed to improve my vision, only to stabilize it. In fact, it may make the vision somewhat worse. Forexample, the treatment may diminish my night vision and side vision to some extent. There is a 5% to 10% chance that it willdiminish my reading vision as well.

4. No safer alternative exists to reduce the likelihood of losing vision. If treatment is not carried out. I understand that there is anincreased risk of permanent vision loss from bleeding and scar tissue formation inside the eye.

5. Application of Cryo in Proliferative Vascular Retinopathy. In some cases of Diabetic Retinopathy or Eales Disease inspite of goodphotocoagulation, there can be neovascularization or recurrent Vitreous Hemorrhage. Hence, to ablate peripheral retina, Cryotherapyis used to avoid further problems.

6. Laser treatment may be carried out in one or several treatment sessions depending on the severity and extent of the new vessels andmy tolerance for the treatment. When a peribulbar or retrobulbar Injection is given for local anesthesia, there is an extremelysmall chance of ocular penetration.

7. After treatment, periodic re-examination is necessary to monitor the response to treatment and detect any changes in the status ofthe retinopathy, especially any change that would require additional treatment. I understand that it is the patient’s responsibility tomaintain follow up appointments necessary after laser treatment.

I acknowledge that the nature and the purpose of this procedure, the risks involved, alternatives and possible complications have beenexplained to me by my doctor and that all my questions have been answered to my satisfaction. I am aware that the practice of medicineand surgery is not an exact science, and I acknowledge that no guarantee can be made as to the results that may be obtained. All this hasbeen explained to me in the language I understand.

I have read, or had read to me, the above information and I consent to treatment, recognizing the potential risks that are involved.



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

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

( 40 )




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 41 )

izksfyQjsfVo jsfVuksFksjsih ds fy, ystj QksVksdksvkxqys'ku

JkWQ vkbZ lsaVj] u;h fnYyh ds lkStU; ls



eSa blds }kjk MkW- ----------------------------------------------------dks vius Åij nk;h@ck;ha vka[k esa ystj QksVksdksvkxqys'ku dks lEiUu djus ds fy, vf/kÑr djrkgwaA bl mipkj dk mís'; vlkekU; jsfVuy jDr okfgdkvksa ds fodkl dks jksd dj ;k mlds ykSVko ;k fldqM+u dks c<+kok nsdj n`f"V dh xaHkhj gkfudks de djuk gSA

eSa Lohdkj djrk gwa fd eSa le>rk gwa fd %

1- funku djds irk yxk;k x;k gS fd eq>s -----------------------------------------------2- bl mipkj dk lq>ko izk;% ml le; fn;k tkrk gS tc bl ckr ds vklkj gksrs gSa fd u;h vlkekU; jDr okfgdkvksa ls vka[k ds vanj jDrlzko

gks ldrk gSA dbZ ckj ystj QksVksdksvkxqys'ku dk lq>ko u;h jDr okfgdkvksa ds fodkl dks jksdus ds fy, fn;k tk ldrk gSA mipkj dk iz;kstujDrlzko vkSj@;k jsfVuy vyxko dh laHkkouk dks de djuk gS tks fd nf"V dks xaHkhj vkSj laHko gkfu igqapk ldrk gSA cgjgky] jDrlzko vkSj@;kjsfVuy vyxko ystj mipkj ds ckotwn Hkh mifLFkr gks ldrk gSA

3- bl mipkj dks esjh n`f"V dks lq/kkjus ds fy, ugha] flQZ mls fLFkj djus ds fy, rS;kj fd;k x;k gSA njvly] ;g n`f"V dks fdafpr cnrj cukldrk gSA mnkgj.k ds fy,] mipkj jkr esa esjh utj vkSj ik'oZ utj dks dqN gn rd de dj ldrk gSA bl ckr ds 5 ls 10 izfr'kr rdds vklkj gksrs gSa fd ;g esjh i<+us dh utj esa Hkh deh yk;sA

4- n`f"V ds [kjkc gksus dh laHkkouk dks de djus ds fy, dksbZ Hkh lqjf{kr fodYi ekStwn ugha gSaA vxj ugha fd;k tkrk rks eSa le>rk gwa fd vka[kds vanj jDrlzko vkSj LdSj Ård fuekZ.k ls n`f"V dh LFkk;h gkfu dk c<+k gqvk tksf[ke gSA

5- izksfyQjsfVo oSLdqyj jsfVuksiSFkh esa fØ;ks dk vuqiz;ksxA vPNs QksVksdksvkxqys'ku ds ckotwn Mk;fcfVd jsfVuksFksjsih ;k ,Yl chekjh ds dqN ekeyksaesa fu;ks&oSLdqyjkbts'ku ;k vkorhZ foVfjvl jDrlzko gks ldrk gSA fygktk] vkxs vkSj leL;k ugha gksus nsus gsrq ifj/kh; jsfVuk dks dkV djvyx djus ds fy, fØ;ksFksjsih dk mi;ksx fd;k tkrk gSA

6- ystj mipkj u;h okfgdkvksa dh xaHkhjrk vkSj gn vkSj mipkj ds fy, esjh lgu'khyrk ds vk/kkj ij ,d ;k vf/kd mipkj l=ksa esa fd;k tkldrk gSA tc yksdy ,usLFkhfl;k ds fy, isfjcqyckj ;k jsVªkscqyckj batsD'ku fn;k tkrk gS rks n`f"V laca/kh Hksnu dh cgqr gh de xaqtkb'k gksrhgSA

7- mipkj ds ckn mipkj ds izfr izfrfØ;k vkSj jsfVuksFksjsih dh fLFkfr esa fdlh cnyko] [kkldj ,sls cnyko dk irk yxkus ds fy, le;≤ij iqu% ijh{k.k vko';d gksrk gS] ftlds fy, vfrfjDr mipkj dh t:jr gksxhA eSa le>rk gwa fd ;g jksxh dh ftEesnkjh gS fd og ystj mipkjds ckn vko';d QkWyksvi eqykdkrksa dks cuk;s j[ksA

eSa Lohdkj djrk gwa fd bl dk;Zfof/k dh izÑfr vkSj mís';] blls tqM+s tksf[keksa] fodYiksa vkSj laHkkfor tfVyrkvksa ds ckjs esa esjs MkWDVj }kjk eq>s le>kfn;k x;k gS vkSj ;g fd esjs lHkh iz'uksa ds larks"ktud mÙkj ns fn;s x;s gSaA eSa bl ckr ls voxr gwa fd MkWDVjh vkSj ltZjh lVhd foKku ugha gS vkSjeSa Lohdkj djrk gwa fd izkIr gksus okys ifj.kkeksa ds ckjs esa dksbZ Hkh xkjaVh ugha nh tk ldrhA bl lcdks eq>s ,slh Hkk"kk esa crk fn;k x;k gS ftls fdeSa le>rk gwaA

mi;qZDr tkudkjh dks eSaus i<+ fy;k gS ;k eq>s i<+dj lquk fn;k x;k gS vkSj eSa mipkj ls tqM+s laHkkO; tksf[keksa dks tkurs gq, blds fy, vuqefr iznkudjrk gwaA


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

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


( 42 )




MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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

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

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

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

( 11 )

( 43 )

Laser Photocoagulation for MaculopathyCourtesy: Shroff Eye Centre, New Delhi


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

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

I hereby authorize Dr. ......................................................... to perform upon me Laser Photocoagulation in the Right / Left eye for changes inthe Macula (which is the vital region of the retina for clear central vision) caused by Diabetes / Age Related Macular Degeneration /Venous Blocks / ......................................................................................

In diabetes / venous blocks the aim of treatment is to close the blood vessels and capillary abnormalities which leak fluid and cause waterlogging seen in this region. In age related macular degeneration the purpose is to destroy sub retinal neovascular membrane.

Following photocoagulation it is possible that there may be a slight improvement and you may be able to read a line or two more on thevision test chart. Laser photocoagulation helps in maintaining your existing vision and to a certain extent prevents worsening at a laterdate. In some insances vision may worsen despite photocoagulation due to unpreventable changes developing in this region.

In case of age - related macular degeneration, if the laser has to be applied to the centre of macula or very close to it, there can be animmediate drop of vision. In these cases, long term visual prognosis is better if laser is done. When a peribulbar or retrobulbar injectionis given for local anesthesia there is an extremely small chance of ocular penetration.

One or more sessions of laser may be required. During follow up, more photocoagulation may have to. be done for changes in the maculaor for other changes that might have developed during this period.

After treatment, periodic re-examination is necessary to monitor the response to treatment and detect any changes in the status of theretinopathy, especially any change that would require additional treatment. I understand that it is the patient’s responsibility to maintainfollow up appointment necessary after laser treatment. I acknowledge that the nature and the purpose of this procedure, the risks involved,alternatives and the possible complications have been explained to me by my doctor, that all my questions, if any, have been answered tomy satisfaction. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantee can bemade as to the results that may be obtained. All this has been explained to me in the language I understand.

I have read, or had read to me, the above information and I consent to treatment, recognizing the potential risks that are involved.



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

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

( 44 )




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 45 )

eSdqyksiSFkh ds fy, ystj QksVksdksvkxqys'kuJkWQ vkbZ lsaVj] u;h fnYyh ds lkStU; ls



eSa blds }kjk MkW- ------------------------------------dks vius Åij nk;h@ck;ha vka[k esa e/kqesg@mez ls tqM+s eSdqyj fodkj@ulksa ds vo#) gksus@----------------------------------- ls mRiUu eSdqyk ¼tks fd Li"V e/;orhZ n`f"V ds fy, jsfVuk dk egRiw.kZ {ks= gS½ esa ifjorZuksa ds fy, ystj QksVksdksvkxqys'ku dks lEiUu djusds fy, vf/kÑr djrk gwaA

e/kqesg@ulksa ds vojks/k esa mipkj dk mís'; jDr okfgdkvksa vkSj dSfiyjh vlkekU;rkvksa dks can djuk gS tks fd nzo dk fjlko djrh gSa vkSj bl {ks=esa ns[ks tkus okys ikuh ds teko dks mRiUu djrh gSaA mez ls tqM+s gq, eSdqyj fodkj esa mís'; mi jsfVuy fu;ksoSLdqyj f>Yyh dks u"V djuk gksrkgSA

QksVksdksvkxqys'ku ds mijkar ;g laHko gS fd fdafpr lq/kkj gks vkSj vki utj ijh{k.k pkVZ ij ,d ;k nks ykbu vkSj i<+ ldrs gSaA ystj QksVksdksvkxqys'kuvkidh orZeku n`f"V dks cuk;s j[kus esa enn djrk gS vkSj ,d gn rd ckn dh rkjh[k esa blds cnrj gksus dks jksdrk gSA dqN ekeyksa esa bl {ks=esa fodflr gksus okys nqfuZokj ifjorZuksa ds pyrs QksVksdksvkxqys'ku ds ckotwn n`f"V cnrj gks ldrh gSA

mez ls tqM+s eSdqyj fodkj ds ekeys esa vxj eSdqy ds e/; esa ;k mlds cgqr gh djhc ystj dks iz;ksx esa yk;k tkuk gS rks n`f"V esa QkSju fxjkoVvk ldrh gSA bu ekeyksa esa vxj ystj dk mi;ksx fd;k tkrk gS rks nwjxkeh pk{kq"k jksx funku csgrj gksrk gSA tc yksdy ,usLFkhfl;k ds fy,isfjcqyckj ;k jsVªkscqyckj batsD'ku fn;k tkrk gS rks n`f"V laca/kh Hksnu dh cgqr gh de xaqtkb'k gksrh gSA

ystj ds ,d ;k vf/kd l=ksa dh vko';drk iM+ ldrh gSA eSdqyk esa ifjorZu ds fy, ;k ,sls vU; ifjorZuksa ds fy, QkWyks&vi ds nkSjku T;knkQksVksdksvkxqys'ku djuk iM+ ldrk gS tks fd bl vof/k ds nkSjku fodflr gq, gks ldrs gSaA

mipkj ds ckn mipkj ds izfr izfrfØ;k vkSj jsfVuksFksjsih dh fLFkfr esa fdlh cnyko] [kkldj ,sls cnyko dk irk yxkus ds fy, le;≤ ij iqu%ijh{k.k vko';d gksrk gS] ftlds fy, vfrfjDr mipkj dh t:jr gksxhA eSa le>rk gwa fd ;g jksxh dh ftEesnkjh gS fd og ystj mipkj ds ckn vko';dQkWyksvi eqykdkrksa dks cuk;s j[ksA eSa Lohdkj djrk gwa fd bl dk;Zfof/k dh izÑfr vkSj mís';] blls tqM+s tksf[keksa] fodYiksa vkSj laHkkfor tfVyrkvksads ckjs esa esjs MkWDVj }kjk eq>s le>k fn;k x;k gS vkSj ;g fd esjs lHkh iz'uksa ds larks"ktud mÙkj ns fn;s x;s gSaA eSa bl ckr ls voxr gwa fd MkWDVjhvkSj ltZjh lVhd foKku ugha gS vkSj eSa Lohdkj djrk gwa fd izkIr gksus okys ifj.kkeksa ds ckjs esa dksbZ Hkh xkjaVh ugha nh tk ldrhA bl lcdks eq>s ,slhHkk"kk esa crk fn;k x;k gS ftls fd eSa le>rk gwaA



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

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


( 46 )




MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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

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

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

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

( 47 )

Fundus Fluorescein Angiography / Ophthalmoscopy/Indocyanine Green Angiography

Courtesy: Shroff Eye Centre, New Delhi


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

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

This investigation procedure comprises of injection of a dye- fluorescein or Indocyanine green into one of your veins in the arm andeither taking rapid serial photographs of its passage within the inner structures of the eye, the retina and choroid or examining the insideof your eye with an instrument called the indirect ophthalmoscope with appropriate filters. The information obtained from a study of thisprocedure aids your doctor in either making a diagnosis, planning your treatment or assessing the results of treatment particularlyphotocoagulation. There is no discomfort from this test apart from the needle prick and the flash of the camera which is harmless. You mayhave nausea (sensation of vomiting) a minute or so after the injection. This usually passes off in about 30 seconds. Remaining calm andbreathing deeply helps in overcoming this difficulty. You are advised to be on an empty stomach three hours prior to this test. Your usualdiet can be taken soon after the procedure. Fluorescein is a highly non toxic drug and only rarely produces a mild aleergic reaction whichresponds rapidly to appropriate medication. Serious life threatening reactions are exceptionally rare but can however occur. This is notdifferent from what can occur with any other medication. The skin and urine stain yellow for about 36 hours with fluorescein and is of noconsequence. You must be accompanied by an adult attendant during this test.

Informed ConsentThe pamphlet on Fundus Fluorescein Angiography / Ophthalmoscopy / Indocyanine Green Angiography has been read by me/ out to meand having understood the content, I give my consent to the performance of this on me.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 48 )

QaMl yqvksjlhu ,aft;ksxzkQh@vkFkSyeksLdksihbaMksfl,ukbu xzhu ,aft;ksxzkQh

JkWQ vkbZ lsaVj] u;h fnYyh ds lkStU; ls



vUos"k.k dh bl dk;Zfof/k esa ckagksa esa vkidh fdlh ul esa Mkb&ywvksjlhu ;k baMksflvukbu xzhu dk batsD'ku vFkok vka[k ds vkarfjd <kaps] jsfVuk vkSjdksjksbM ds vanj mlds ekxZ dh Rofjr <ax ls Øfed rLohjsa mrkjuk ;k mi;qDr fQYVjksa ds lkFk buMk;jsDV vkFkSyeksLdksi uked midj.k ds lkFkvkidh vka[k ds Hkhrj ijh{k.k djuk 'kkfey gksrk gSA bl izfØ;k ds v/;;u ls izkIr tkudkjh vkids MkWDVj dh funku djus ;k vkids mipkj dh ;kstukcukus vFkok mipkj ds ifj.kkeksa [kkldj QksVksdksvkxqys'ku dk vkdyu djus esa enn djrh gSA lqbZ dh pqHku vkSj dSejs dh ped] tks fd gkfujfgrgksrh gS] ds flok; bl ijh{k.k ls dksbZ vlqfo/kk ugha gksrh gSA vkidks batsD'ku ds ckn ,d feuV ds vklikl feryh dh vuqHkwfr gks ldrh gSA ;g izk;%yxHkx 30 lsdsaM esa [kRe gks tkrh gSA 'kkar jgdj xgjh lkal ysus ls bl dfBukbZ ls ikj ikus esa enn feyrh gSA vkidks lykg nh tkrh gS fd blijh{k.k ls igys rhu ?kaVksa rd isV dks [kkyh j[ksaA vki viuh jkstejkZ dh [kqjkd dks izfØ;k ds rqjar ys ldrs gSaA ywvksjlhu ,d vR;f/kd xSj fo"kkDrnok gS vkSj eqf'dy ls gh gYdh ,yftZd izfrfØ;k mRiUu djrh gS] tks fd mi;qDr nokbZ ds izfr Rofjr xfr ls izfrfØ;k nsrh gSA xaHkhj tkuysok izfrfØ;k,aeqf'dy ls gh gksrh gSa ij fQj Hkh mifLFkr gks ldrh gSaA ;g mlls fHkUu ugha gS tks fd fdlh Hkh nwljh nok ds lkFk mifLFkr gks ldrk gSA ywvksjlhuds lkFk rdjhcu 36 ?kaVksa rd Ropk vkSj is'kkc xans ihys jax dh gksrh gS vkSj blls dksbZ QdZ ugha iM+rkA bl ijh{k.k ds nkSjku vkids lkFk dksbZ o;Ldrhekjnkj gksuk pkfg,A

lwfpr lgefrQaMl ywvksjlhu ,aft;ksxzSQh@vkFkSyeksLdksih@baMksfl;kukbu xzhu ,aft;ksxzSQh ij ijps dks esjs }kjk i<+ fy;k x;k gS@eq>s i<+dj lquk fn;k x;k gS vkSjeSaus mldh varoZLrq dks le> fy;k gS] eSa vius Åij bls lEiUu djus ds fy, lgefr iznku djrk gwaA


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 %. ............................................................................................

( 49 )

Photodynamic Therapy (PDT)Courtesy: Shroff Eye Centre, New Delhi


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

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

I hereby authorize Dr................................................................. to perform upon me Photodynamic Therapy (PDT) in Right/Left eye for neovascularchanges in the Macula (which is the vital region of the retina for clear central vision) caused by Age Related Macular Degeneration /Pathologic Mypia/other causes..........................................................................................................................

Photodynamic Therapy (PDT) is a type of laser therapy designed for the treatment of subretinal new-vessel formation especially whenthese new vessels involve the subfoveal region. These new vessels most commonly develop in i) Aging Macular Degeneration ii) Myopia,iii) Post inflammatory and iv) Idiopathic causes. When the fovea (the vital region of the retina for fine central reading and colour vision)is not involved, these vessels can be destroyed by laser photocoagulation. However there is also simultaneous destruction of the retinalcells overlying these abnormal new vessels. This loss of function of retinal cells is usually acceptable in other areas but not at the fovea.Hence the search for alternative therapies which can destroy these abnormal vessels without destroying the overlying foveal retinal cells.The various alternatives tried for this are:

1) Surgery 2) Photodynamic Therapy (PDT) 3) TTT 4) Radiation 5) Anti-angiogenic factors.

1. Surgery : Results especially in Aging Macular Degeneration have been poor because in removing the membrane retinal pigmentepithelial cells are also lost and vision usually does not improve. There is also a risk of significant vision loss if complications occur.

2. Photodynamic Therapy : Verteporfin “Visudyne” dye is injected into a vein in the arm and after that a contact lens is placed on theeye and laser treatment is applied to the area of neovascularization. After the treatment the entire body has to be protected fromsunlight and strong light. For a few hours after treatment you will have blurred vision because of drops and the laser light exposure.Treatment results have been encouraging.

Most patients have stabilization of vision. A very small number may have actual improvement in vision. Some patients may experiencereduction in central vision after the treatment. PDT treatment may need to be repeated depending on the progress seen on follow upexaminations and fluorescein/indocyanine green angiograms/OCT results.

3. Radiation - Results have not been encouraging.4. Anti-angiogenic factors :- Definitive results are not available so far.5. Trans Pupillary Thermo Therapy:- Large spot of diode laser 810 nm with relatively low energy is applied to the area of new-vessels.

This therapy has shown encouraging results in some cases, especially occult new-vessels.

You do not have to agree to have this therapy and, if you wish, we will continue to monitor your progress even if you choose not to tryPhotodynamic Therapy (PDT).

Post-Treatment RegimeAfter treatment you should not bend down and lift weights, and you should sleep with head up with 2 pillows. You must not be exposedto sunlight and very bright light as mentioned earlier.

After treatment, periodic re-examination is necessary to monitor the response to treatment and detect any changes in the status of theretinopathy, especially any change that would require additional treatment. I understand that it is the patient’s responsibility to maintainfollow up appointments necessary after laser treatment. I acknowledge that the nature and the purpose of

this procedure, the risks involved, alternatives and the possible complications have been explained to me and that all my questions, if any,have been answered to my satisfaction. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledgethat no guarantee can be made as to the results that may be obtained. All this has been explained to me in the language I understand.

( 50 )

I have read, or had read to me, the above information, and I consent to treatment, recognizing the potential risks that are involved.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 51 )

QksVksMk;ufed Fksjsih ¼ihMhVh½JkWQ vkbZ lsaVj] u;h fnYyh ds lkStU; ls



eSa blds }kjk MkW- ------------------------------------dks vius Åij nk;h@ck;ha vka[k esa mez ls tqM+s eSdqyj fodkj@iSFkksykWftd ekbfivk@vU; dkj.kksa ---------------------------------- ls mRiUu eSdqyk ¼tks fd Li"V e/;orhZ n`f"V ds fy, jsfVuk dk egRiw.kZ {ks= gS½ esa ifjorZuksa gsrq QksVksMk;ufed Fksjsih ¼ihMhVh½ dks lEiUudjus ds fy, vf/kÑr djrk gwaA

QksVksMk;ufed Fksjsih ¼ihMhVh½ lcjsfVuy u;h&okfgdk fuekZ.k ds mipkj ds fy, [kkldj ml le; tc ;s u;h okfgdk,a lcQksohy {ks= dks lEc)djrh gSa] rS;kj fd;k x;k ,d izdkj dk mipkj gSA ;s u;h okfgdk,a lokZf/kd vkerkSj ij 1½ c<+rh mez ds eSdqyj fodkj] 2½ de ns[kus dh chekjh]3½ lwtu ds ckn vkSj 4½ bfM;ksiSfFkd dkj.kksa esa fodflr gksrh gSaA tc Qksfovk ¼mRÑ"V e/;orhZ ikBu vkSj jaxksa dh n`f"V ds fy, jsfVuk dk egRoiw.kZHkkx½ lEc) ugha gksrk gS rks bu okfgdkvksa dks ystj QksVksdksvkWxqys'ku ds }kjk u"V fd;k tk ldrk gSA fQj Hkh] bu vlkekU; u;h okfgdkvksa dks <adusokyh jsfVuy dksf'kdkvksa dk Hkh lkFk gh esa fouk'k gks tkrk gSA jsfVuy dksf'kdkvksa ds izdk;Z dh ;g gkfu izk;% vU; {ks=ksa esa Lohdk;Z gksrh gS ysfdu Qksfovkesa ughaA fygktk] oSdfYid mipkjksa dh [kkst dh x;h tks fd <adus okyh Qksfovy jsfVuy dksf'kdkvksa dks u"V fd;s fcuk bu vlkekU; okfgdkvksa dksu"V dj ldsA blds fy, vktek;s x;s fofHkUu fodYi gSa %

1½ ltZjh 2½ QksVksMk;ufed mipkj ¼ihMhVh½ 3½ VhVhVh 4½ fofdj.k 5½ ,aVh&,aft;kstsfud dkjdA1½ ltZjh % fo'ks"k :i ls c<+rh mez esa eSdqyj fodkj esa ifj.kke [kjkc gksrs gSa D;ksafd fNYyh dks gVkus esa jsfVuy fixesaV ,fiFksfy;y dksf'kdk,a

Hkh gV tkrh gS vkSj nf"V izk;% csgrj ugha gksrh gSA blds vykok tfVyrk ds mRiUu gksus ij nf"V dh dkQh vf/kd gkfu dk Hkh tksf[ke jgrk gSA2½ QksVksMk;ukfed mipkj % ckag dh ul esa osVsZiksfQZu ^^folqMkbu** Mkb dk batsD'ku fn;k tkrk gS vkSj blds ckn vka[k esa dkaVSDV ysal dks Mkyk

tkrk gS vkSj fu;ksoSLdqyjkbts'ku ds fgLls esa ystj mipkj dk vuqiz;ksx fd;k tkrk gSA mipkj ds ckn lewps 'kjhj dh /kwi vkSj rst izdk'kls j{kk djuh gksrh gSA mipkj ds ckn dqN ?kaVksa rd vkidks MªkIl vkSj ystj izdk'k ds laidZ esa gksus ls /kqa/kyk fn[kk;h nsxkA mipkj ds ifj.kkemRlkgtud jgs gSaA

vf/kdrj jksfx;ksa dh n`f"V fLFkj gks tkrh gSA cgqr FkksM+h lh la[;k esa n`f"V esa okLrfod lq/kkj gks ldrk gSA dqN jksxh mipkj ds ckn e/;LFk n`f"V esadeh eglwl dj ldrs gSaA QkWyks&vi ds ijh{k.kksa vkSj ywvksjlhu@baMksfl;kukbu xzhu ,aft;ksxzSQh@vkslhVh ifj.kkeksa esa ns[kh x;h izxfr ds vk/kkj ijihMhVh mipkj dks nksgjk;s tkus dh t:jr iM+ ldrh gSA

3- fofdj.k & ifj.kke mRlkgtud ugha jgs gSaA4- ,aVh&,aft;kstsfud dkjd % vHkh rd fuf'pr ifj.kke miyC/k ugha gSaA5- Vªkal&I;wiyjh FkeksZ mipkj % vis{kr;k de ÅtkZ okyk fMvksM ystj 810 ,u,e dk cM+k LikWV u;h okfgdkvksa ds {ks= esa iz;ksx fd;k tkrk gSA

bl mipkj ds dqN ekeyksa esa] [kkldj vdYV u;h okfgdkvksa esa] mRlkgtud ifj.kke ns[ks x;s gSaA

bl mipkj dks djokus ds fy, vki lgefr nsa ;g t:jh ugha vkSj vxj vki pkgsaxs rks ge ml n'kk esa vkidh izxfr ij utj j[kuk tkjh j[ksaxs tcfdvki QksVksMk;ufed mipkj ¼ihMhVh½ ugha vktekus dk fodYi pqurs gSaA

mipkj&ckn dh O;oLFkkmipkj ds ckn vkidks uhps ugha >qduk vkSj otu mBkuk ugha pkfg, vkSj vkidks nks rfd;ksa ds lkFk flj ds Åij djds lksuk pkfg,A tSlk fd igyscrk;k x;k gS vkidks /kwi vkSj cgqr rst jks'kuh ds laidZ esa ugha vkuk pkfg,A


( 52 )



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 %. ............................................................................................

( 53 )

Trans Pupillary Thermotherapy (TTT)Courtesy: Shroff Eye Centre, New Delhi


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

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

I hereby authorize Dr. ......................................................................................... to perform upon me Trans-Pupillary Thermotherapy in Right /Left eye for neovascular changes in the Macula (which is the vital region of the retina for clear central vision) caused by Age RelatedMacular Degeneration / Pathologic Mypia / other causes .......................................................................

Transpupillary thermotherapy (TTT) is a type of laser therapy designed for the treatment of sub retinal new-vessel formation especiallywhen these new vessels involve the subfoveal region. These new vessels most commonly develop in i) Aging Macular Degeneration ii)Myopia, iii) Post inflammatory and iv) Idiopathic causes. TTT is also used in the treatment of certain tumours. When the fovea (the vitalregion of the retina for fine central reading and colour vision) is not involved, these vessels can be destroyed by laser photocoagulation.However there is also simultaneous destruction of the retinal cells overlying these abnormal new vessels. This loss of function of retinalcells is usually acceptable in other areas but not at the fovea. Hence the search for alternative therapies which can destroy these abnormalvessels without destroying the overlying foveal retinal cells. The various alternatives tried for this are:-

1) Surgery 2) Photodynamic therapy (PDT) 3) TTT 4) Radiation 5) Anti-angiogenic factors.

1. Surgery : Results especially in Aging Macular Degeneration have been poor because in removing the membrane retinal pigmentepithelial cells are also lost and vision usually does not improve. There is also a risk of significant vision loss if complications occur.

2. Photodynamic Therapy : This is applicable only to certain specific types of new-vessels. The cost of treatment is very high becauseof high cost of dye. The treatment may need to be repeated depending on the progress seen on follow up examinations.

3. Radiation - Results have not been encouraging.4. Anti-angiogenic factors :- Results have not been encouraging.5. Trans Pupillary Thermo Therapy :- Large spot of diode laser 810 nm with relatively low energy is applied to the area of new-vessels.

Treatment results have been encouraging. About two-thirds of patients have stabilization of vision. A very small number may haveactual improvement in vision. Some patients may experience reduction in central vision after the treatment. TTT treatment mayneed to be repeated depending on the progress seen on follow up examinations and fluorescein/indocyanine green angiograms.

For the laser treatment, local anaesthetic drops are put into the eye and a contact lens is used. After treatment you should not bend down,lift weight and you should sleep with head up with 2 pillows. For a few hours after the treatment, you will have some blurred vision becauseof the drops used to prepare your eye for the treatment. You should also wear dark sunglasses to protect your eye from the light. During thistime, you must not drive any vehicles. You do not have to agree to have this therapy and, if you wish, we will continue to monitor yourprogress even if you choose not to try Transpupillary Thermotherapy (TTT).

After treatment, periodic re-examination is necessary to monitor the response to treatment and detect any changes in the status of theretinopathy, especially any change that would require additional treatment. I understand that it is the patient’s responsibility to maintainfollow up appointments necessary after laser treatment. I acknowledge that the nature and the purpose of this procedure, the risksinvolved, alternatives and the possible complications have been explained to me and that all my questions, if any, have been answered tomy satisfaction. I am aware that the practice of medicine & surgery is not an exact science, and I acknowledge that no guarantee can bemade as to the results that may be obtained. All this has been explained to me in the language I understand.

I have read, or had read to me, the above information, and I consent to treatment, recognizing the potential risks that are involved.

( 54 )



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 55 )

Vªkal I;wfiyjh FkeksZFksjsih ¼VhVhVh½JkWQ vkbZ lsaVj] u;h fnYyh ds lkStU; ls



eSa blds }kjk MkW- ------------------------------------dks vius Åij nk;h@ck;ha vka[k esa mez ls tqM+s eSdqyj fodkj@iSFkksykWftd fefivk@vU; dkj.kksa -------------------------------------------------------------- ls mRiUu eSdqyk ¼tks fd Li"V e/;orhZ n`f"V ds fy, jsfVuk dk egRiw.kZ {ks= gS½ esa fu;ksoSLdqyj ifjorZuksa ds fy, esa ifjorZuksagsrq QksVksMk;ufed Fksjsih ¼ihMhVh½ dks lEiUu djus ds fy, vf/kÑr djrk gwaA

Vªkal I;wfiyjh FkeksZFksjsih ¼VhVhVh½ lc&jsfVuy u;h&okfgdk fuekZ.k] [kkldj ml le; tcfd bu u;h okfgdkvksa ls lcQksfovy {ks= lEc) gksrk gS]ds mipkj ds fy, rS;kj fd;k x;k ystj mipkj dk ,d izdkj gSA;s u;h okfgdk,a lokZf/kd vkerkSj ij 1½ c<+rh mez ds eSdqyj fodkj] 2½ de ns[kus dh chekjh] 3½ lwtu ds ckn vkSj 4½ bfM;ksiSfFkd dkj.kksa esa fodflrgksrh gSaA VhVhVh dk mi;ksx dqN V~;wejksa ds mipkj esa Hkh fd;k tkrk gSA tc Qkfovk ¼mRÑ"V e/;orhZ ikBu vkSj jaxksa dh n`f"V ds fy, jsfVuk dkegRoiw.kZ Hkkx½ lEc) ugha gksrk gS rks bu okfgdkvksa dks ystj QksVksdksvkWxqys'ku ds }kjk u"V fd;k tk ldrk gSA fQj Hkh] bu vlkekU; u;h okfgdkvksadks <adus okyh jsfVuy dksf'kdkvksa dk Hkh lkFk gh esa fouk'k gks tkrk gSA jsfVuy dksf'kdkvksa ds izdk;Z dh ;g gkfu izk;% vU; {ks=ksa esa Lohdk;Z gksrh gSysfdu Qksfovk esa ughaA fygktk] oSdfYid mipkjksa dh [kkst dh x;h tks fd <adus okyh Qksfovy jsfVuy dksf'kdkvksa dks u"V fd;s fcuk bu vlkekU;okfgdkvksa dks u"V dj ldsA blds fy, vktek;s x;s fofHkUu fodYi gSa %

1½ ltZjh 2½ QksVksMk;ufed mipkj ¼ihMhVh½ 3½ VhVhVh 4½ fofdj.k 5½ ,aVh&,aft;kstsfud dkjdA

1½ ltZjh % fo'ks"k :i ls c<+rh mez esa eSdqyj fodkj esa ifj.kke [kjkc gksrs gSa D;ksafd fNYyh dks gVkus esa jsfVuy fixesaV ,fiFksfy;y dksf'kdk,aHkh gV tkrh gS vkSj nf"V izk;% csgrj ugha gksrh gSA blds vykok tfVyrk ds mRiUu gksus ij nf"V dh dkQh vf/kd gkfu dk Hkh tksf[ke jgrk gSA

2½ QksVksMk;ukfed mipkj % ;g u;h okfgdkvksa ds dqN fof'k"V izdkjksa ij gh ykxw gksrk gSA mipkj dh ykxr Mkb dh Åath ykxr dh otg lscgqr vf/kd gksrh gSA QkWyks&vi ds ijh{k.kksa esa ns[kh x;h izxfr ds vk/kkj ij ihMhVh mipkj dks nksgjk;s tkus dh t:jr iM+ ldrh gSA

3- fofdj.k & ifj.kke mRlkgtud ugha jgs gSaA4- ,aVh&,aft;kstsfud dkjd % ifj.kke mRlkgtud ugha jgs gSaA5- Vªkal&I;wiyjh FkeksZ mipkj % vis{kr;k de ÅtkZ okyk fMvksM ystj 810 ,u,e dk cM+k LikWV u;h okfgdkvksa ds {ks= esa iz;ksx fd;k tkrk gSA

bl mipkj ds mRlkgtud ifj.kke ns[ks x;s gSaA yxHkx nks&frgkbZ jksfx;ksa dh n`f"V fLFkj gqbZ gSA cgqr gh FkksM+h la[;k esa n`f"V esa okLrfodlq/kkj gks ldrk gSA mipkj ds ckn dqN jksxh e/;LFk n`f"V esa deh dk vuqHko dj ldrs gSaA QkWyks&vi ijh{k.kksa vkSj ywvkslhZu@baMksflvkukbuxzhu ,aft;ksxzkEl esa ns[kh x;h izxfr ds vk/kkj ij VhVhVh mipkj dks nksgjk;s tkus dh vko';drk iM+ ldrh gSA

ystj mipkj ds fy, yksdy ,usLFksfVd MªkIl dks vka[k esa Mkyk tkrk gS vkSj dkaVSDV ysal dk bLrseky fd;k tkrk gSA mipkj ds ckn vkidks uhps>qduk] otu mBkuk ugha pkfg, vkSj vkidks nks rfd;k j[kdj flj dks Åij dh vksj j[kdj lksuk pkfg,A mipkj ds ckn dqN ?kaVksa rd vkidh n`f"Vmipkj ds fy, vkidh vka[kksa dks rS;kj djus ds fy, mi;ksx esa yk;s x;s MªkIl dh otg ls /kqa/kyh jgsxhA blds vykok jks'kuh ls viuh vka[kksa dks cpkusds fy, vkidks dkys jax dk /kwi dk p'ek iguuk pkfg,A bl le; ds nkSjku vkidks dksbZ okgu ugha pykuk gSA t:jh ugha fd vki bl mipkj dsfy, lgefr iznku djsa vkSj vxj vki pkgsaxs rks ge ml n'kk esa Hkh vkidh izxfr dks ekWfuVj djuk tkjh j[ksaxs tcfd vkius Vªkal&I;wiyjh FkeksZ mipkj¼VhVhVh½ dk fodYi ugha pquk gSA



( 56 )


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 %. ............................................................................................

( 57 )

Intravitreal Injection for EndophthalmitisJatin Ashar, Subrata Mandal


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

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

I have been explained in the language I best understand that drugs would be injected into the vitreous cavity of my eye after appropriateanesthesia to treat and limit the infection in my eye. I have been explained I may or may not regain vision after the procedure and may needa repeat injection or surgery in future. Possible complications of the procedure include retinal detachment, glaucoma, hypotony, cataract,and bleeding. I may also experience side effects such as eye pain, subconjunctival hemorrhage, swelling of the cornea and inflammationof the eye. As with any medication, there is a risk of causing allergic reactions in a small number of patients. Symptoms of allergicreactions include rash, hives, itching and shortness of breath.

I also understand that my eye condition may not get better or may worsen. Any or all the complications explained to me may cause afurther deterioration in vision or have a possibility of blindness. Additional procedure may be required for management of the complications.

The nature of my eye condition has been explained to me and the proposed treatment has been described. The risks, benefits, alternatives,and limitations of treatment have been discussed with me. All my questions have been answered.

I here by authorize the doctor to administer intravitreal antibiotics in my R/L eye.

This consent is valid until I revoke it or my condition changes to a point that the risks and benefits of the injection are significantlydifferent from this date.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 58 )

,aMksFkSyfefVl ds fy, baVªkfoVfj;y batsD'kutfru v'kkj] lqczr eaMy



eq>s ml Hkk"kk esa] ftls fd eSa vPNh rjg le>rk gwa] HkyhHkkafr le>k fn;k x;k gS fd esjh vka[k dk mipkj djus vkSj laØe.k dks lhfer djus ds fy,mi;qDr ,usLFksfl;k ds ckn esjh vka[k dh foVfjvl dsfoVh esa nokvksa dks batsD'ku ds tfj;s Mkyk tk,xkA eq>s le>k fn;k x;k gS fd bl izfØ;k dsckn eSa n`f"V dks iqu% izkIr dj ldrk gwa vkSj ugha Hkh dj ldrk vkSj Hkfo"; esa fQj ls batsD'ku ;k ltZjh dh t:jr iM+ ldrh gSA bl dk;Zfof/k dhlaHkkfor tfVyrkvksa esa jsfVuy vyxko] Xywdksek] gkbiksVskuh] eksfr;kfcan vkSj jDrlzko 'kkfey gSA blds vykok eSa vka[k esa nnZ] lc datfDVoy jDrlzko]dkfuZ;k dh lwtu vkSj vka[kksa dh tyu dk vuqHko dj ldrk gwaA

tSlk fd fdlh Hkh nokbZ ds lkFk gksrk gS jksfx;ksa dh FkksM+h la[;k esa ,yftZd izfrfØ;k,a mRiUu gks ldrh gSaA ,yftZd izfrfØ;kvksa ds y{k.kksa esa nnksjs]gkbOt] [kqtyh vkSj lkalksa dk m[kM+uk 'kkfey gSA

eSa ;g Hkh le>rk gwa fd esjh vka[k dh voLFkk csgrj ugha Hkh gks ldrh ;k cnrj gks ldrh gSA eq>s le>k;h x;h dksbZ ;k lHkh tfVyrk,a n`f"V ds vkSjHkh [kjkc gksus dk dkj.k cu ldrh gSa ;k mudh otg ls eSa n`f"Vghu gks ldrk gwaA tfVyrkvksa ds izca/ku ds fy, vfrfjDr dk;Zfof/k dh vko';drkiM+ ldrh gSA esjh vka[k dh voLFkk dh izÑfr eq>s le>k nh x;h gS vkSj izLrkfor mipkj dks of.kZr dj fn;k x;k gSA mipkj ds tksf[keksa] ykHkksa] fodYiksavkSj lhekvksa dh esjs lkFk ppkZ dh x;h gSA esjs lHkh iz'uksa ds mÙkj fn;s x;s gSaA

blds }kjk eSa MkWDVj dks viuh nk;ha@ck;ha vk[ka esa baVªkfoVfj;y ,aVhckW;ksfVDl dks Mkyus ds fy, vf/kÑr djrk gwaA;g vuqefr ml le; rd oS/k gS tc rd fd eSa bls jí ugha djrk ;k esjh vka[k dh voLFkk ml fcanq rd cny ugha tkrh gS tgka ij batsD'ku dstksf[ke vkSj ykHk bl rkjh[k ls mYys[kuh; :i ls fHkUu gksaA


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MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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( 59 )

Electrophysiological TestsCourtesy: Shroff Eye Centre, New Delhi


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

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

Electro-Retinogram (ERG)This investigation procedure comprises of electrodes, which are put on the cornea and on the skin with which a signal is generated fromthe retina in response to a flast of light. This tells us,the gross retinal function. The test takes about 45 minutes to 1 hour and includes 30minutes of dark adaptation (sitting in a dark room) which can be a little tiring. Very rarely the contact lens electrodes can cause cornealdiscomfort or abrasion which can be managed by proper medication. For this test, the pupils need to be dilated after which you may notbe able to drive or do near work for atleast 3-4 hours. Sometimes, in cases of very small children or uncooperative patients the test needsto be carried out under anesthesia.

Visual Evoked Potential (VEP)This investigation procedure comprises of electrodes, which are put on the skin with which a signal is generated from visual pathway inresponse to a flash of light. This tells us the gross visual pathway function. The test takes about 30-45 minutes to perform. For this test, thepupils need not be dilated. Sometimes, in cases of very small children or uncooperative patients, the test needs to be carried out underanesthesia.

Electro - Oculogram (EOG)This investigation procedure comprises of electrodes which are put on the skin, with which a signal is generated from the retina inresponse to successive movements of the eye in opposite directions. This tells us the gross retinal function. The test takes about 30-45minutes to perform. The pupils need not be dilated for this test.

Informed ConsentThe information on ERG/EOG/VEP has been read by me / out to me and having understood the content, I give my consent to theperformance of this test on me.



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

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

( 60 )




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 61 )

bysDVªksfQft;ksykWftdy ijh{k.kJkWQ vkbZ lsaVj] u;h fnYyh ds lkStU; ls



bysDVªks&jsfVuksxzke ¼bZvkjth½tkap&iM+rky dh bl dk;Zfof/k esa bysDVªksM~l lekfgr gksrs gSa] ftUgsa fd dkfuZ;k ij vkSj Ropk ij j[kk tkrk gS ftlls izdk'k dh ped dh izfrfØ;kesa jsfVuk ls flXuy mRiUu gksrk gSA ;g gesa laiw.kZ jsfVuy izdk;Z ds ckjs esa crkrk gSA ijh{k.k esa rdjhcu 45 feuV ls ysdj 1 ?kaVs rd dk le; yxrkgS vkSj blesa va/ksjs esa vuqdwyu ¼va/ksjs dejs esa cSBuk½ dk 30 feuV 'kkfey gksrk gS] tks fd FkksM+k Fkdk nsus okyk gks ldrk gSA cgqr gh fojys rkSj ijbysDVªksM~l dkuhZy cspSuh ;k [kjksap dk dkj.k cu ldrs gSa] ftldk fd leqfpr nokbZ ls izca/k fd;k tk ldrk gSA bl ijh{k.k ds fy, iqrfy;ksa dksQSykus dh t:jr iM+rh gS] ftlds ckn de ls de 3&4 ?kaVksa ds fy, vki okgu ugha pyk ldrs ;k fudV dk dke ugha dj ldrs gSaA dbZ ckj] cgqrgh NksVs cPpksa ;k lg;ksx ugha nsus okys jksfx;ksa ds ekeyksa esa csgks'kh dh n'kk esa bl ijh{k.k dks djus dh t:jr iM+ ldrh gSA

fotqvy ,oksDM iksVsa'ky ¼ohbZih½tkap&iM+rky dh bl dk;Zfof/k esa bysDVªksM~l lekfgr gksrs gSa] ftUgsa fd Ropk ij j[kk tkrk gS ftlls izdk'k dh ped dh izfrfØ;k esa pk{kq"k jkLrs dsizdk;Z flXuy mRiUu gksrk gSA ;g gesa laiw.kZ pk{kq"k jkLrs ds izdk;Z ds ckjs esa crkrk gSA ijh{k.k esa rdjhcu 30 ls 45 feuV rd dk le; yxrk gSAbl ijh{k.k ds fy, iqrfy;ksa dks QSykus dh t:jr iM+rh gSA dbZ ckj] cgqr gh NksVs cPpksa ;k lg;ksx ugha nsus okys jksfx;ksa ds ekeyksa esa csgks'kh dhn'kk esa bl ijh{k.k dks djus dh t:jr iM+ ldrh gSA

bysDVªks&vksdqyksxzke ¼bZvksth½tkap&iM+rky dh bl dk;Zfof/k esa bysDVªksM~l lekfgr gksrs gSa] ftUgsa fd Ropk ij j[kk tkrk gS ftlls fd foijhr fn'kkvksa esa vka[kksa dh Øfed gypydh izfrfØ;k esa jsfVuk ls flXuy mRiUu gksrk gSA ;g gesa laiw.kZ jsfVuy izdk;Z ds ckjs esa crkrk gSA ijh{k.k esa rdjhcu 30&35 feuV rd dk le;yxrk gSA bl ijh{k.k ds fy, iqrfy;ksa dks QSykus dh ugha t:jr iM+rh gSA

lwfpr lgefrbZvkjth@bZvksth@ohbZih ij tkudkjh eSa i<+ yh gS@eq>s i<+dj lquk nh x;h gS vkSj varoZLrq dks le>dj eSa bl ijh{k.k dks vius Åij djus ds fy,lgefr iznku djrk gwaA


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( 62 )




MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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OCULOPLASTY&

ORBIT

( 63 )

EnucleationNoornika Khuraijam


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

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

I have been informed in my own language that my right/ left eye may be harboring a tumor/ disease which if not removed may result inloss of vision in the same eye and may lead to spread of the disease to other parts of the body and cause risk to my life.

It has been explained to me that the exact confirmation of diagnosis can be obtained only after microscopic examination after removal ofthe eye.

The option of removing a piece of tissue through surgery or with the help of a needle for the purpose of diagnosis and its risks involved havebeen explained and given to me.

I understand that the entire eye along with its coverings and part of the nerve attached to it will be removed and replaced by an artificialprosthesis. I also understand that I will have to wear prosthetic eye for cosmetic purpose after the surgery.

I understand that in spite of the best efforts by the operating surgeons, there may be incomplete removal which may require additionalsurgery or treatment.

I hereby authorize …………………………..and those he/ the institute may designate as staff, associates or assistants to perform surgeryfor removal of my right/left eye.

It has been explained to me that during the course of treatment, unforeseen conditions may be revealed or encountered which maynecessitate surgical and emergency procedures in addition to or different from those contemplated at the time of initial diagnosis. I,therefore, further request and authorize the above designated staff to perform such additional surgical or other procedures as they deemnecessary or desirable.

I consent to the use of anesthesia and to use of anesthetics as may be deemed necessary or desirable.

I further consent to the administration of such drugs, infusions, plasma or blood transfusion or any other treatment or procedures deemednecessary.

I consent to the observing, photographing or televising of the procedure to be performed for medical, scientific or educational purposeprovided my identity is not revealed by the pictures or by descriptive text accompanying them.

I have been given the opportunity to ask all/any questions and I have also been given the option to ask for any second opinion.

I am fully aware that the surgery is being performed in good faith and that no guarantee or assurance has been given as to the result thatmay be obtained.

Any tissues or parts surgically removed may be disposed off by the institution in accordance with customary practice.



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

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

( 64 )




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 65 )

,U;wfDy,'kuuwjfudk [kqjStke



eq>s esjh viuh Hkk"kk esa lwfpr dj fn;k x;k gS fd esjh nk;ha@ck;ha vka[k esa ,sls V~;wej@chekjh iSnk gks jgh gks ldrh gS ftls ugha gVk;s tkus ds QyLo:iml vka[k dh jks'kuh tk ldrh gS vkSj 'kjhj ds nwljs fgLlksa esa chekjh QSy ldrh gS vkSj esjh tku tk ldrh gSA

eq>s ;g ckr le>k nh x;h gS fd funku dks lVhd iqf"V vka[kksa dks fudkyus ds ckn ekbØksLdksfid ijh{k.k ls gh izkIr fd;k tk ldrk gSA

funku ds mís'; ls ltZjh ds tfj;s ;k lqbZ dh enn ls Ård ds VqdM+s dk fudkyus dk fodYi vkSj blls tqM+s tksf[keksa dks eq>s le>k fn;k x;k gSA

eSa le>rk gwa fd viuh dofjax ds lkFk&lkFk lewph vka[k vkSj mlls tqM+h ul ds ,d fgLls dks gVk;k tk,xk vkSj mldh txg ij udyh vka[k yxknh tk,xhA eSa ;g Hkh le>rk gwa fd eq>s ltZjh ds ckn lqanj yxus ds fy, udyh vka[k iguuh iM+sxhA

eSa le>rk gwa fd vkWijs'ku djus okys ltZuksa ds loZJs"B iz;klksa ds ckotwn gks ldrk gS fd iwjh fudklh ugha gks ik;s ftlds fy, vfrfjDr ltZjh ;kmipkj dh vko';drk iM+sA

eSa blds }kjk ------------------------------------------------------------------------ vkSj mu yksxksa dks nk;ha@ck;ha vka[k dks fudkyus ds fy, ltZjh djus gsrq vf/kÑr djrk gwa]ftUgsa fd mlus@laLFkku us LVkQ] ,lksfl,V ;k lgk;d dsd :i esa fu;qDr fd;k gksA

eq>s ;g ckr le>k nh x;h gS fd mipkj dh vof/k ds nkSjku vizR;kf'kr n'kk,a mRiUu gks ldrh gSa ;k mudk lkeuk djuk iM+ ldrk gS tks fd mllsfHkUu lftZdy ;k vkikrdkyhu dk;Zfof/k;ksa dh vko';drk dks mRiUu djsa] ftudh fd 'kq#vkrh funku ds le; vis{kk dh x;h FkhA vr%] eSa mi;qZDrfufnZ"V LVkQ ls vuqjks/k djrk gwa vkSj mls vf/kÑr djrk gwa fd og bl izdkj dh vfrfjDr lftZdy ;k vU; dk;Zfof/k;ksa dks lEiUu djs tSlk fd osvko';d ;k okaNuh; le>rs gksaA

eSa ,usLFksfl;k vkSj ,usLFksfVDl dk mi;ksx djus ds fy, lgefr iznku djrk gwa tSlk fd vko';d ;k okaNuh; le>k x;k gSA

eSa bl izdkj dh nokvksa] batsD'kuksa] IykTek ;k jDRk vk/kku ;k fdlh vU; mipkj ;k dk;Zfof/k dks fd;s tkus dh Hkh vuqefr iznku djrk gwa tSlk fdvko';d le>k x;k gksA

eSa fpfdRldh;] oSKkfud ;k 'kS{kf.kd mís'; ls dk;Zfof/k ds voyksdu] QksVksxzkQh ;k Vsyhfotu ij izlkfjr djus dh vuqefr iznku djrk gwa c'krsZ fdrLohjksa }kjk ;k muds lkFk okys fooj.kkRed ikB ds }kjk esjh igpku ugha tkfgj gksrh gksA

eq>s lHkh@dksbZ Hkh iz'u iwNus dk volj fn;k x;k gS vkSj eq>s dksbZ f}rh;d iz'u iwNus dk Hkh fodYi iznku fd;k x;k gSA

eSa bl ckr ls iwjh rjg ls voxr gwa fd ltZjh lfnPNk ds lkFk dh tk jgh gS vkSj ;g fd mu ifj.kkeksa dks ysdj dksbZ xkjaVh ;k oknk ugha fd;k x;kgS tks fd izkIr gks ldrs gSaA

ltZjh ls vyx fd;s x;s fdUgha Årdksa ;k vaxksa dks pkyw ifjikVh ds vuqlkj laLFkku }kjk fuLrkfjr fd;k tk ldrk gSA


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( 66 )




MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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

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( 67 )

EviscerationNoornika Khuraijam


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

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

I have been informed in my mother tongue that my right/ left eye may be harboring a disease which if not removed may result in loss ofvision in the same eye and may lead to spread of the disease to other parts of the body and cause risk to my life and a painful blind eye.

I understand that the total contents of the eyeball will be removed and an artificial prosthesis may have to be implanted to maintain theshape of the eye. I also understand that I will have to wear prosthetic eye for cosmetic purpose after surgery.

I understand that in spite of the best efforts by the operating surgeons, there may be incomplete removal which may require additionalsurgery or treatment. I also understand that the other eye may be affected after surgery, which may require additional treatment.

I hereby authorize …………………………..and those he/ the institute may designate as staff, associates or assistants to perform surgeryfor removal of my right/left eye.

It has been explained to me that during the course of treatment, unforeseen conditions may be revealed or encountered which maynecessitate surgical and emergency procedures in addition to or different from those contemplated at the time of initial diagnosis. I,therefore, further request and authorize the above designated staff to perform such additional surgical or other procedures as they deemnecessary or desirable.

I consent to the use of anesthesia and to use of anesthetics as may be deemed necessary or desirable.

I further consent to the administration of such drugs, infusions, plasma or blood transfusion or any other treatment or procedures deemednecessary.

I consent to the observing, photographing or televising of the procedure to be performed for medical, scientific or educational purposeprovided my identity is not revealed by the pictures or by descriptive text accompanying them.

I have been given the opportunity to ask all/any questions and I have also been given the option to ask for any second opinion.

I am fully aware that the surgery is being performed in good faith and that no guarantee or assurance has been given as to the result thatmay be obtained.

Any tissues or parts surgically removed may be disposed off by the institution in accordance with customary practice.



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

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

( 68 )




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 69 )

,folfljs'kuuwjfudk [kqjStke



eq>s esjh viuh Hkk"kk esa lwfpr dj fn;k x;k gS fd esjh nk;ha@ck;ha vka[k esa ,sls V~;wej@chekjh iSnk gks jgh gks ldrh gS ftls ugha gVk;s tkus ds QyLo:iml vka[k dh jks'kuh tk ldrh gS vkSj 'kjhj ds nwljs fgLlksa esa chekjh QSy ldrh gS vkSj esjh tku tk ldrh gS vkSj va/kh vka[k esa nnZ jg ldrk gSA

eSa le>rk gwa fd us=xksyd dh lewph lkexzh dks fudkyk tk,xk vkSj vka[kksa dh vkÑfr dks cuk;s j[kus ds fy, udyh vka[k dks yxkuk iM+ ldrk gSA

eSa le>rk gwa fd vkWijs'ku djus okys ltZuksa ds loZJs"B iz;klksa ds ckotwn gks ldrk gS fd iwjh fudklh ugha gks ik;s ftlds fy, vfrfjDr ltZjh ;kmipkj dh vko';drk iM+sA

eSa ;g Hkh le>rk gwa fd ltZjh ds ckn nwljh vka[k izHkkfor gks ldrh gS] ftlds fy, vfrfjDr mipkj dh vko';drk iM+ ldrh gSA

eSa blds }kjk ------------------------------------------------------------------------ vkSj mu yksxksa dks nk;ha@ck;ha vka[k dks fudkyus ds fy, ltZjh djus gsrq vf/kÑr djrk gwa]ftUgsa fd mlus@laLFkku us LVkQ] ,lksfl,V ;k lgk;d ds :i esa fu;qDr fd;k gksA

eq>s ;g ckr le>k nh x;h gS fd mipkj dh vof/k ds nkSjku vizR;kf'kr n'kk,a mRiUu gks ldrh gSa ;k mudk lkeuk djuk iM+ ldrk gS tks fd mllsfHkUu lftZdy ;k vkikrdkyhu dk;Zfof/k;ksa dh vko';drk dks mRiUu djsa] ftudh fd 'kq#vkrh funku ds le; vis{kk dh x;h FkhA vr%] eSa mi;qZDrfufnZ"V LVkQ ls vuqjks/k djrk gwa vkSj mls vf/kÑr djrk gwa fd og bl izdkj dh vfrfjDr lftZdy ;k vU; dk;Zfof/k;ksa dks lEiUu djs tSlk fd osvko';d ;k okaNuh; le>rs gksaA

eSa ,usLFksfl;k vkSj ,usLFksfVDl dk mi;ksx djus ds fy, lgefr iznku djrk gwa tSlk fd vko';d ;k okaNuh; le>k x;k gSA

eSa bl izdkj dh nokvksa] batsD'kuksa] IykTek ;k jDRk vk/kku ;k fdlh vU; mipkj ;k dk;Zfof/k dks fd;s tkus dh Hkh vuqefr iznku djrk gwa tSlk fdvko';d le>k x;k gksA

eSa fpfdRldh;] oSKkfud ;k 'kS{kf.kd mís'; ls dk;Zfof/k ds voyksdu] QksVksxzkQh ;k Vsyhfotu ij izlkfjr djus dh vuqefr iznku djrk gwa c'krsZ fdrLohjksa }kjk ;k muds lkFk okys fooj.kkRed ikB ds }kjk esjh igpku ugha tkfgj gksrh gksA

eq>s lHkh@dksbZ Hkh iz'u iwNus dk volj fn;k x;k gS vkSj eq>s dksbZ f}rh;d iz'u iwNus dk Hkh fodYi iznku fd;k x;k gSA

eSa bl ckr ls iwjh rjg ls voxr gwa fd ltZjh lfnPNk ds lkFk dh tk jgh gS vkSj ;g fd mu ifj.kkeksa dks ysdj dksbZ xkjaVh ;k oknk ugha fd;k x;kgS tks fd izkIr gks ldrs gSaA

ltZjh ls vyx fd;s x;s fdUgha Årdksa ;k vaxksa dks pkyw ifjikVh ds vuqlkj laLFkku }kjk fuLrkfjr fd;k tk ldrk gSA


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( 70 )




MkWDVj dk gLrk{kj %

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rkjh[k %

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( 71 )

OrbitotomyRachna Meel


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

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

I have been explained in my mother tongue that a mass has grown adjacent to my left/ right eye. The growth is causing the following:

Displacement and/ protrusion of the eye ball Yes/No

Decrease vision (Which is due to globe distortion Yes/Noand/or compression of the optic nerve)

Restriction of the movements of the eyeball Yes/No

Abnormal deviation of the eyeball Yes/No

Drooping of the eyelid Yes/No

Altered sensations in the area surrounding the eye (forehead/ nose/ cheek) Yes/No

Incomplete closure of the eye Yes/No

I understand that I need to undergo orbitotomy in order to remove this mass. It is a surgical procedure that involves entering and/oropening up the orbit that is the bony compartment within which the eye is placed. The mass that is removed will then be examined by thepathologist. The histopathological diagnosis will guide further treatment that may involve no further management/ local radiotherapy/chemotherapy.

I fully understand that it may not be possible to remove the mass completely. The vision, eyeball and eyelid movements, deviation of theeyeball and the sensations around the eye may not recover completely and may even deteriorate due to surgical manipulation.

The surgery has a risk of post operative bleeding and infection in the orbit that may need further treatment in the form of medication orsurgery. I also understand the risks of general anesthesia under which this surgery will be done.

Having clearly understood all that is stated above I hereby authorize the doctors to carry out orbitotomy on the right /left side.



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

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

( 72 )




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 73 )

vksfcZVksVksehjpuk ehy



eq>s esjh ekr`Hkk"kk esa ;g ckr le>k nh x;h gS fd esjh ck;ha@nk;ha vka[k ds fudV ekal c<+ x;k gSA

;g o`f) fuEufyf[kr dks tUe ns jgh gS %

us=xksyd dk foLFkkiu vkSj mHkkj gka@ugha

?kVh gqbZ n`f"V ¼tks fd Xyksc fo:i.k vkSj@ gka@ugha

;k izdkf'kd ul ds laihM+u ds pyrs gS½

us=xksyd dh gypyksa dh lhek gka@ugha

us=xksyd dk vlkekU; fopyu gka@ugha

iydksa dh Mªwfiax gka@ugha

vka[kksa ds bnZfxnZ ¼eLrd] ukd] xky½ esa cnyh gqbZ laosnuk gka@ugha

vka[kksa dk vk/kk&v/kwjk can gksuk gka@ugha

eSa le>rk gwa fd eq>s bl ekal dks gVokus ds fy, vkWjfcVksVkseh djokus dh t:jr gSA ;g lftZdy dk;Zfof/k gS ftlls fd vksfcZV esa izos'k djuk vkSj@;k[kksyuk tqM+k gqvk gksrk gS] tks fd gfì;ksa dk [kkuk gksrk gS ftlds vanj vka[k fLFkr gksrh gSA gVk;s tkus okys ekal fiaM dk blds ckn iSFkksykWftLV }kjkijh{k.k fd;k tk,xkA fgLVksiSFkksykWftdy funku vkxs ds mipkj dks funsZf'kr djsxk ftlls fd vkxs dk dksbZ izca/ku@yksdy jsfM;ksFksjsih@dheksFksjsih tqM+hgqbZ ugha gks ldrhA

eSa iwjh rjg ls bl ckr dks le>rk gwa fd ekal ds fiaM dks iwjh rjg ls fudkyuk laHko ugha Hkh gks ldrk gSA n`f"V] us=xksyd vkSj iqryh dh gypyksa]us=xksyd ds fopyu vkSj vka[kksa ds bnZfxnZ dh laosnuk dh gks ldrk gS fd iwjh rjg ls Hkjik;h ugha gks vkSj gks ldrk gS fd og ltZfdy gLr{ksi dspyrs vkxs vkSj [kjkc gks tk;sA

ltZjh esa vkWijs'ku ds ckn ds jDrlzko vkSj vksfcZV esa laØe.k dk tksf[ke gksrk gS ftlds fy, nokbZ ;k ltZjh ds :i esa vkxs ds mipkj dh t:jriM+ ldrh gSA blds vykok eSa lkekU; csgks'kh ds tksf[keksa dks Hkh le>rk gwa ftlds rgr ;g ltZjh dh tk,xhA

ml lc dks Li"V :i ls le> ysus ds ckn ftls fd Åij crk;k x;k gS eSa blds }kjk MkWDVjksa dks nk;ha@ck;ha rjQ vksfcZVksVkseh dks lEiUu djusds fy, vf/kÑr djrk gwaA


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( 74 )




MkWDVj dk gLrk{kj %

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( 75 )

EntropionPrashant Yadav


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

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

I have been explained in my own language the risks and complications of surgery. I have also been fully explained the surgery is beingdone to correct my lid deformity and there will be no improvement in my vision.

The complications which may occur are enumerated below:

• Infection and gape of the surgical wound• Suture erosion, infection and granuloma formation• Lid edema and scar of the incision• Risks of corneal irritation, injury and ulceration• Hemorrhage and haematoma formation• Excessive watering / dry eye,• Damage to the lid margin• Loss of eyelashes• Ptosis and lid retraction.• A skin graft may be required to correct the deformity. I have been explained that:

a. The skin graft site maybe post auricular or the anterior forearmb. Graft rejection, infection, contracture or fibrosis may occurc. It has been explained to me that regular aseptic cleaning of the graft has to be done. It also has been explained to me that the

donor site in case of a skin graft may gape or get infected and regular aseptic cleaning of the donor site is required.d. A tarsorrhaphy may have to be in place for 3-6 months to prevent contracture of the graft.

• Chances of under correction overcorrection and resurgery have been fully explained.



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 name

Date

Witness 1 Witness 2Signature: ............................................................................................. Signature: .............................................................................................Name: ................................................................................................... Name: .....................................................................................................Address: .............................................................................................. Address: ................................................................................................Tel: ....................................................................................................... Tel: .........................................................................................................

( 76 )

,aVªksfiuiz'kkar ;kno



eq>s esjh viuh Hkk"kk esa ltZjh ds tksf[keksa vkSj tfVyrkvksa dks le>k fn;k x;k gSA eq>s ;g ckr Hkh iwjh rjg ls le>k nh x;h gS fd esjh iiksV dhdq:irk dks Bhd djus ds fy, ltZjh dh tk jgh gS vkSj esjh n`f"V esa dksbZ lq/kkj ugha gksxkA mRiUu gks ldus okyh tfVyrkvksa dks uhps of.kZr fd;kx;k gS %Û Vkads dk {kj.k] laØe.k vkSj xzsuqyksek fuekZ.kÛ iiksVs dk ,fMek vkSj phjs dk ?kkoÛ dkuhZy [kqtyh] pksV vkSj QksM+s dk tksf[keÛ jDrlzko vkSj gSekVksek dk fuekZ.kÛ vR;f/kd iuhyh@'kq"d vka[kÛ iiksVk ekftZu dks {kfrÛ cjkSfu;ksa dks uqdlkuÛ iksfll vkSj iiksVk izR;kgkjA

dq:irk dks Bhd djus ds fy, fLdu xzkV dh vko';drk iM+ ldrh gSA eq>s le>k fn;k x;k gS fd %,- fLdu xzkV dh txg iksLV vkSfjdqyj ;k 'kjhj dk vxz Hkkx ;k vxzckgq gks ldrh gSch- xzkV dk udkjk tkuk] laØe.k] vodqapu ;k Qkbczksfll mRiUu gks ldrk gSlh- eq>s ;g ckr le>k nh x;h gS fd xzkV dh fu;fer dhVk.kqghu lQkbZ djuh gksxhA eq>s ;g Hkh le>k fn;k x;k gS fd fLdu xzkV dh n'kk

esa nkrk LFky [kqy ;k laØfer gks ldrk gS vkSj nkrk LFky dh fu;fer dhVk.kqghu lQkbZ vko';d gSAMh- xzkV ds vodqapu dks jksdus ds fy, VklksZjgkQh dks 3&6 eghuksa ds fy, dke esa ykuk iM+ ldrk gSA

Û vaMj djsD'ku] vksoj djsD'ku vkSj fQj ls ltZjh dh xqatkb'kksa dks iwjh rjg ls le>k fn;k x;k gSA


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MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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( 77 )

EctropionPrashant Yadav


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

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

I have been explained in my own language the risks and complications of surgery. I have also been fully explained the surgery is beingdone to correct my lid deformity and there will be no improvement in my vision.

The complications which may occur are enumerated below:

• Infection and gape of the surgical wound• Suture erosion, infection and granuloma formation• Lid edema and scar of the incision• Risks of corneal irritation, injury and ulceration• Hemorrhage and haematoma formation• Excessive watering / dry eye• Damage to the lid margin• Loss of eyelashes• Ptosis and lid retraction• A mucous membrane graft/ nasal septal/ aural cartilage maybe required to correct the deformity. Graft rejection, infection,

contracture and/or fibrosis may occur. Regular aseptic cleaning of the graft site has to be done. It also has been explained to me thatthe donor site (buccal mucosa) of the mucous membrane graft may get infected and I have been explained the importance of regularoral hygiene

• Chances of undercorrection, overcorrection and resurgery have been fully explained



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 78 )

,DVªksfivuiz'kkar ;kno



eq>s esjh viuh Hkk"kk esa ltZjh ds tksf[keksa vkSj tfVyrkvksa dks le>k fn;k x;k gSA eq>s ;g ckr Hkh iwjh rjg ls le>k nh x;h gS fd esjh iiksV dhdq:irk dks Bhd djus ds fy, ltZjh dh tk jgh gS vkSj esjh n`f"V esa dksbZ lq/kkj ugha gksxkA mRiUu gks ldus okyh tfVyrkvksa dks uhps of.kZr fd;kx;k gS %Û laØe.k vkSj lftZdy ?kko dk [kqyk gksukÛ Vkads dk {kj.k] laØe.k vkSj xzsuqyksek fuekZ.kÛ iiksVs dk ,fMek vkSj phjs dk ?kkoÛ dkuhZy [kqtyh] pksV vkSj QksM+s dk tksf[keÛ jDrlzko vkSj gSekVksek dk fuekZ.kÛ vR;f/kd iuhyh@'kq"d vka[kÛ iiksVk ekftZu dks {kfrÛ cjkSfu;ksa dks uqdlkuÛ iksfll vkSj iiksVk izR;kgkjAÛ dq:irk dks Bhd djus ds fy, 'ys"ek dh f>Yyh xzkV@uty lsIVy@vkSjy dkfVZyst dh vko';drk iM+ ldrh gSA xzkV dk udkjk tkuk]

laØe.k] vodqapu vkSj@;k Qkbczksfll mRIkUu gks ldrk gSA xzkV okyh txg dh fu;fer dhVk.kqghu djuh gksxhA eq>s ;g Hkh le>k fn;k x;kgS fd 'ys"ey f>Yyh xzkV dk nkrk LFky ¼cqDdy eqdkslk½ laØfer gks ldrk gS vkSj eq>s fu;fer ekSf[kd lkQ&lQkbZ ds egRo dks le>k fn;kx;k gSA

Û vaMj djsD'ku] vksoj djsD'ku vkSj fQj ls ltZjh dh xqatkb'kksa dks iwjh rjg ls le>k fn;k x;k gSA


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MkWDVj dk gLrk{kj %

MkWDVj dk uke %

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( 79 )

PtosisDinesh Shrey


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

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

I have been explained in the language that I understand, that the surgery is being done for drooping of my Rt/ Lt/ Both eyelids under LocalAnaesthesia.

During the course of the surgery, there are chances of:

• Undercorrection / Overcorrection after surgery that may require resurgery• Lid edema, lid swelling and infection• Inability to fully close the eye (lagophthalmos)• Lid lag during down gaze leading to scleral show• Corneal exposure and keratopathy• Injury to the surface of the eyeball/ globe• Misdirection of the eyelashes that may point towards the eyes instead of away from it• Blurred vision or double vision for one or two days postoperatively• Watering of the eyes for the first few days after surgery• Scarring at the incision siteKnowing the above mentioned facts, I give my consent for my Rt/ Lt/ Both eyelids ptosis surgery.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 80 )

iksfllfnus'k Js;



eq>s esjs le> esa vkus okyh Hkk"kk esa ;g crk fn;k x;k gS fd yksdy ,usLFkslhfl;k ds rgr esjh nk;ha@ck;ha@nksuksa iydksa dh Mªwfiax ds fy, ltZjh dhtk jgh gSAltZjh dh vof/k ds nkSjku] bl ckr dh xqatkb'k gS fd %Û ltZjh ds ckn vaMjdjsD'ku@vksojdjsD'ku ftlds fy, fQj ls ltZjh dh vko';drk iM+ ldrh gSÛ iiksV dh ,fMek] iiksV dh lwtu vkSj laØe.kÛ vk[kksa dks iwjh rjg ls can djus esa v{ke gksuk ¼ySxvkFkSyeksl½Û uhps utj gksus ds nkSjku iiksV dk ihNs jg tkuk ftlls us=xksyd dh lQsn ckgjh iyd fn[krh gSÛ dkWuhZy dk vjf{kr gksuk vkSj dsjSVksiSFkhÛ us=xksyd@Xyksc dh lrg dks pksVÛ cjkSfu;ksa dh xyr fn'kk tks fd vka[kksa ls nwj gksus dh ctk; mldh vksj tk ldrh gSÛ vkWijs'ku ds ckn ,d ;k nks fnuksa ds fy, /kqa/kyh n`f"V ;k nksgjh n`f"VÛ phjs okyh txg ij t[eÅij crk;s x;s rF;ksa dks tkurs gq, eSa viuh nk;ha@ck;ha@nksuksa iiksVksa dh iksfll ltZjh ds fy, viuh vuqefr iznku djrk gwaA


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MkWDVj dk gLrk{kj %

MkWDVj dk uke %

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xokg 1 xokg 2

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( 81 )

Syringing and ProbingDinesh Shrey


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

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

I have been explained in the language that I understand that I / my son / daughter has a block in the passage which is responsible fordrainage of tears from eyes to nose. An attempt will be made to open the passage whereby a fine metal probe will be inserted so as toovercome the blockage. The procedure will be done under General Anaesthesia.

• Syringing and Probing is successful in 95% of cases of nasolacrimal duct blockage that are caused by a simple duct blockage.• The procedure needs to be repeated sometimes if the blockage is not relieved.• The tear duct may have a complicated type of obstruction or the tear duct might not have developed completely. These complications

may be noticed at the time of surgery during probing. Further surgery may be required consequently.• Bleeding from the nose can occur for upto three days after surgery.• Lid swelling can occur due to false passage and extravasation of saline.

Knowing the above mentioned facts, I give my consent for my/ my son/ daughter’s surgery.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 82 )

fipdkjh ls lQkbZ vkSj tkap&iM+rkyfnus'k Js;



eq>s esjs }kjk le> esa vkus okyh Hkk"kk esa ;g crk fn;k x;k gS fd eSa@esjk csVk@csVh ds vk[kksa ds fudklh ds ekxZ esa vojks/k gS ftldh otg ls vka[kksals ukd vkalw cgrk gSA fudklh ds bl ekxZ dks [kksyus ds fy, iz;kl fd;k tk,xk] ftlds }kjk /kkrq dh fpduh NM+ Mkyh tk,xh rkfd fudklh ds ekxZds vojks/k ls futkr ik;h tk ldsA ;g dk;Zfof/k lkekU; csgks'kh dh n'kk esa lEiUu dh tk,xhAÛ fipdkjh ls lQkbZ vkSj tkap&iM+rky uSlksySfØey uyh vojks/k ds 95 izfr'kr ekeyksa esa lQy gS] tks fd ljy uyh vojks/k ls mRiUu gksrk gSAÛ vojks/k ls vxj eqfDr ugha feyrh rks dbZ ckj bl dk;Zfof/k dks nksgjkus dh t:jr iM+rh gSAÛ vkalw dh uyh esa tfVy fdLe dh ck/kk gks ldrh gS vFkok vkalw dh uyh gks ldrh gS fd iwjh rjg ls fodflr ugha gqbZ gksA fipdkjh ls lQkbZ

ds nkSjku ltZjh ds le; esa ;s tfVyrk,a utj vk ldrh gSaA blds QyLo:i vkxs vkSj ltZjh dh t:jr iM+ ldrh gSAÛ ltZjh ds ckn rhu fnuksa rd ukd ls jDrlzko gks ldrk gSAÛ fudklh ds xyr ekxZ vkSj lsykbu dh fudklh ds pyrs iiksVs esa lwtu vk ldrh gSA

Åij crk;s x;s rF;ksa dks tkurs gq, eSa viuh nk;ha@ck;ha@nksuksa iiksVksa dh iksfll ltZjh ds fy, viuh vuqefr iznku djrk gwaA


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MkWDVj dk gLrk{kj %

MkWDVj dk uke %

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( 83 )

Punctal PlugsPrakashchand Agarwal, Bhavna Chawla


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

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

I have been informed in the language I best understand that I am/ my child is suffering from dry eye syndrome due to inadequateproduction of tears. Blocking the tear drainage system with artificial punctal plugs may improve my symptoms by retaining more tears inthe eye. This is a temporary procedure and may be reversible. I have been explained that alternative treatment options include the frequentuse of artificial tears or ointment depending on severity of the condition, topical cyclosporine eyedrops or a permanent closure of thepunctum and canaliculus by thermal cautery or ligation.

Risks associated with this procedure include infection, excessive tearing, irritation and foreign body sensation, loss of the plug and rarely,lodging of the plug in the tear drainage pathway (canaliculus) leading to scarring. In such cases, surgery may be necessary to re-establishtear drainage. The plugs may require replacement or removal. I have been fully explained the permanent nature of the disease and that thistreatment might give symptomatic relief by retaining the tears to moisten the ocular surface. This procedure will not cure the primarycause of dry eye syndrome. Regular follow up may be required to assess the ocular surface status and modify medications accordingly.

I certify that I have fully understood the implications of the above consent and authorise the doctors to insert punctal plugs in my/ mychild’s

RIGHT lower upper LEFT lower upper eyelid(s)



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 84 )

iadVy IyXlizdk'kpan vxzoky] Hkkouk pkoyk



eq>s ,slh Hkk"kk esa] ftls fd eSa le>rk gwa] lwfpr dj fn;k x;k gS fd eSa@esjk cPpk vkalqvksa ds de cuus ds dkj.k 'kq"d vka[k flaMªkse ls =Lr gSA udyhiaDVy IyXl ls vkalw fudlh ekxZ dks vo#) dj nsus ls vka[kksa esa T;knk vkalw jksdus ds }kjk esjs y{k.kksa esa lq/kkj gks ldrk gSA ;g vLFkk;hdk;Zfof/k gS vkSj bls myVk tk ldrk gSA eq>s ;g ckr le>k nh x;h gS fd mipkj ds oSdfYid fodYiksa esa udyh vkalqvksa vFkok voLFkk dh xaHkhjrkds vk/kkj ij eyge] VkWfidy lkbDykstiksjkbu vkbZMªkIl dk vDlj iz;ksx ;k FkeZy dkSVjh ;k fyxs'ku ds }kjk iaDVe vkSj dSukfydqyl dks ges'kkds fy, can djuk 'kkfey gSA

bl dk;Zfof/k ls tqM+s tksf[keksa esa laØe.k] vR;f/kd vkalw] [kqtyh vkSj ckgjh pht iM+s gksus dh vuqHkwfr] Iyx dh gkfu vkSj dHkh&dHkkj vkalw fudklh dsekxZ ¼dSukfydqyl½ esa Iyx dk vkuk ftlls fu'kkuk iM+ tkrs gSaA bl rjg ds ekeyksa esa vkalw ds cgko ds ekXkZ dks fQj ls dk;e djus ds fy, ltZjhvko';d gks ldrh gSA eq>s chekjh dh LFkk;h izÑfr ds ckjs esa le>k fn;k x;k gS vkSj ;g fd ;g mipkj vksdqyj lrg dks ue j[kus ds fy, vkalqvksadks jksddj y{k.k ls jkgr iznku dj ldrk gSA ;g dk;Zfof/k 'kq"d vka[kksa ds flaMªkse ds izkFkfed dkj.k dks Bhd ugha djsxhA vksdqyj lrg dh fLFkfrdk vkdyu djus vkSj mlds vuqlkj nokbZ dks ifjof)Zr djus ds fy, fu;fer QkWyks&vi dh vko';drk iM+ ldrh gSA

eSa izekf.kr djrk gwa fd eSaus mi;qZDRk lgefr ds fufgrk'k;ksa dks iwjh rjg ls le> fy;k gS vkSj MkWDVjksa dks esjh@esjh cPps dh nk;ha fupyh@Åijh]ck;ha fupyh@Åijh iydksa esa iaDVy Iyx Mkyus ds fy, vf/kÑr djrk gwaA


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MkWDVj dk gLrk{kj %

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( 85 )

Dacryocystorhinostomy (DCR)Rachna Meel


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

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

I have been informed in my mother tongue that the natural passage for tear drainage from my eye (right/ left) is blocked. I understand thatin order to overcome the problem of tearing in my eye because of the blockade I need to undergo dacryocystorhinostomy. This surgeryinvolves by-passing the normal drainage system by making a direct communication between this passage and the nose. This will be doneby making a bony opening in the adjacent wall of the nose, through a skin incision on the nose. A nasal pack would be kept in the nosefor 24 hours post-operatively. Syringing of the passage created by the surgery may be required post-operatively.

I have been explained the risks of this surgery involving: failure ( approx 10%), excessive bleeding during the surgery or postoperatively,infection at the site of surgery and a potential risk of loss of vision due to any of the above reasons. I also understand the risks of localanesthesia under which this surgery will be performed.

Having completely understood the implications of the consent I hereby authorize the doctors to perform dacryocystorhinostomy on myleft /right side.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 86 )

MSfØvksflLVksjfuksLVkseh ¼Mhlhvkj½jpuk ehy



eq>s esjh ekr`Hkk"kk esa lwfpr dj fn;k x;k gS fd esjh vka[k ¼nk;ha@ck;ha½ ls vkalqvksa ds cgko ds fy, LokHkkfod ekxZ vo#) gSA eSa le>rk gwa fdvojks/k dh otg ls esjh vka[k esa vkalw cgus dh leL;k ls futkr ikus ds Øe esa eq>s MSfØvksflLVksjfuksLVkseh djokus dh t:jr gSA bl ltZjh ls fudklhdh lkekU; O;oLFkk vkSj ukd ds chp lh/kk laidZ cukdj mls ckgj&ckgj ls fudkyk tkrk gSA bl dke dks ukd ij Ropk ds phjs ds tfj;s ukd lsyxh nhokj esa gfì;ksa esa lqjk[k djds fd;k tk,xkA vkWijs'ku ds ckn pkSchl ?kaVksa rd ukd esa uty iSd dks j[kk tk,xkA ltZjh ds }kjk rS;kj fd;sx;s cgko ekxZ dh fipdkjh ls lQkbZ vkWijs'ku ds ckn t:jh gks ldrh gSA

eq>s bl ltZjh ls tqM+s gq, tksf[keksa ds ckjs esa le>k fn;k x;k gS % foQyrk ¼rdjhcu 10 izfr'kr½] ltZjh ds nkSjku ;k vkWijs'ku ds ckn vR;f/kd jDrlzko]ltZjh dh txg ij laØe.k vkSj mi;qZDr dkj.kksa esa ls fdlh ds Hkh pyrs n`f"V dh gkfuA blds vykok eSa yksdy ,usLFksfl;k ds tksf[keksa dks Hkh le>rkgwa ftlds rgr ;g ltZjh dh tk,xhA

lgefr ds fufgrk'k;ksa dks iwjh rjg ls le> pqdus ds ckn eSa blds }kjk MkWDVjksa dks viuh ck;ha@nk;ha rjQ MSfØvksflLVksjfuksLVkseh lEiUu djus dsfy, vf/kÑr djrk gwaA


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MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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

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( 87 )

Contracted SocketPrashant Yadav


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

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

I have been explained in my own language the risks and complications of surgery which is being performed to relieve my orbital socketcontracture. These are enumerated below:

• The surgery is being done to correct my contracted socket and there will be no gain in my vision.• Infection and hemorrhage and gape of the surgical wound may occur.• Suture erosion, infection and granuloma formation may occur.• I may require a mucous membrane graft/ amniotic membrane graft or dermis fat graft. I have been explained that:

a. Graft rejection, infection, contracture or fibrosis may occur.b. It has been explained to me that regular aseptic cleaning of the graft has to be done and that the donor site in case of a mucous

membrane graft is buccal mucosa. I have also been explained the importance of regular oral hygiene.c. In case of dermis fat graft, the graft site will be my gluteal region and I been fully explained the importance of donor site

hygiene.• I will require fornix formation sutures which will be removed after 3 weeks• I will be required to wear a conformer for 2 months• I will be given an artificial eye after 2 months. There is a risk of inadequate fitting of the artificial eye. There will only be minimal

ocular movements.• There is a high risk of failure of the socket reconstruction and I may require multiple surgeries.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 88 )

vodqafpr lkWdsViz'kkar ;kno



eq>s esjh viuh Hkk"kk esa ltZjh ds tksf[keksa vkSj tfVyrkvksa ds ckjs esa le>k fn;k x;k gS] ftls fd esjs vkfcZVu lkWdsV vodqapu ls futkr fnykus dsfy, lEiUu fd;k tk jgk gSA bUgsa uhps fn;k x;k gS %Û esjs vodqafpr lkWdsV dks Bhd djus ds fy, ltZjh dh tk jgh gS vkSj esjh n`f"V esa blls dksbZ lq/kkj ugha gksxkA

Û laØe.k vkSj jDrlzko gks ldrk gS rFkk lftZdy ?kko [kqy ldrk gSA

Û eq>s 'ys"ek f>Yyh xzkV@,fefu;ksfVd fNYyh xzkV ;k MfeZl QSV xzkV dh t:jr iM+ ldrh gSA eq>s le>k fn;k x;k gS %

,- eq>s ;g ckr crk nh x;h gS fd xzkV dh fu;fer dhVk.kqghu lQkbZ djuh gksxh vkSj ;g fd 'ys"ek f>Yyh xzkV dh n'kk esa nkrk LFky cqDdyeqdkslk gSA eq>s fu;fer ekSf[ke lQkbZ ds egRo ds ckjs esa Hkh crk fn;k x;k gSA

ch- MfeZl QSV xzkV dh n'kk esa xzkV okyh txg esjk XywVhy {ks= gksxk vkSj eq>s nkrk LFky dh lQkbZ ds egRo ds ckjs esa iwjh rjg ls le>kfn;k x;k gSA

Û eq>s QksfuZDl cukus okys ?kko lhus ds /kkxksa dh t:jr iM+sxh ftUgsa fd rhu grksa ckn fudkyk tk,xk

Û eq>s nks eghuksa rd dkWuQkeZj /kkj.k djus dh t:jr iM+sxh

Û eq>s nks eghuksa ckn udyh vka[k iznku dh tk,xhA udyh vka[k dh vi;kZIr fQfVax dk tksf[ke gSA dsoy U;wure vksdqyj xfrfof/k gksxhA

Û lkWdsV iqufuekZ.k dh foQyrk dk dkQh tksf[ke gS vkSj eq>s vusd ltZfj;ksa dh vko';drk iM+ ldrh gSA


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MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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OCULAR SURFACE,CORNEA & REFRACTIVE

SURGERY

( 89 )

Optical Penetrating KeratoplastyGaurav Prakash


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

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

I have been informed in my mother tongue that I/ my child is suffering from whitening of the cornea (Corneal opacity) /other diseaseinvolving the cornea and that a surgery to remove this along with some normal cornea will be done. A donor cadaveric cornea will be usedto replace this and will be placed with help of sutures.

I have been fully explained regarding the permanent nature of the opacity/ lesion and that it has to be removed to enhance vision. I havebeen explained the risk of infection, graft rejection, suture loosening and replacement, no improvement or worsening of Best correctedvisual acuity, glaucoma secondary to surgery or to medications, cataract formation and high astigmatism after surgery. There may be aneed for repeat surgery which may or may not lead to improvement of vision. I have been explained the need for follow up as frequentlyas advised by the doctors that may span upto years, with multiple investigations at each visit. I have been explained that using medicationsproperly is required for success of the graft. I have been explained that I will need to urgently come for follow-up to ophthalmic casualtyif there is a sudden onset of redness, photophobia, foreign body sensation, pain or detoriation of vision as these may be early signs of graftinfection or rejection. I understand that inspite of all efforts, there is a possibility that there may be worsening of the visual acuity or thecosmetic appearance of the eye.

I certify that I have fully understood the implications of the above consent and authorise the doctors to perform Penetrating Keratoplastyon my / my child’s right / left eye.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 90 )

vkfIVdy isusVªsfVax dsjSVksIykLVhxkSjo izdk'k



eq>s esjh ekr` Hkk"kk esa lwfpr dj fn;k x;k gS fd eSa@esjk cPpk dkfuZ;k ds lQsn gksuk ¼dkWuhZy vkWikflVh½@dkWfuZ;k ls tqM+h vU; chekjh ls ihfM+r gSvkSj ;g fd dqN lkekU; dkfuZ;k ds lkFk&lkFk bl fudkyus ds fy, ltZjh dh tk,xhA bls fjIysl djus ds fy, nkrk dSMkosfjd dkWfuZ;k dk mi;ksxfd;k tk,xk vkSj mls Vkadksa dh enn ls LFkkfir fd;k tk,xkA

eq>s vkWikflVh@phjs dh LFkk;h izÑfr dh ckcr iwjh rjg ls le>k fn;k x;k gS vkSj ;g fd n`f"V dks c<+kus ds fy, bls fudkyuk gksxkA eq>s laØe.k]xzkV ds udkj] Vkads ds <hyk iM+us vkSj iqu%LFkkiu] dksbZ lq/kkj ugha gksus ;k lcls vPNs <ax ls Bhd dh x;h pk{kq"k rh{.krk ds cnrj gksus] ltZjh ;knokb;ksa ds ckn ds Xywdksek] eksfr;kfcan fuekZ.k vkSj ltZjh ds ckn mPp ,LfVxeSfVTe ds ckjs esa le>k fn;k x;k gSA ltZjh nksgjkus dh t:jr iM+ldrh gS tks fd nf"V dks lq/kkj dks tUe ns Hkh ldrk gS vkSj ugha HkhA eq>s le>k fn;k x;k gS fd MkWDVj ftruh ckj dgsxk mruh ckj QkWyks&vi foftVds fy, vkuk gksxk vkSj ;g Øe o"kksZa rd py ldrk gS vkSj gjsd foftV ij dbZ rjg dh tkapsa dh tka,xhA eq>s ;g ckr le>k nh x;h gS fd lefprrjhds nokbZ dk mi;ksx djuk xzkV dh lQyrk ds fy, vko';d gSA eq>s ;g ckr crk nh x;h gS fd vxj ykyh] QksVksQksfc;k] ckgjh d.k dh vuqHkwfr]nnZ ;k nf"V fcxM+us dh vdLekr 'kq#vkr gksrh gS rks vkikrdkyhu us= fpfdRlk ds fy, QkSju vkuk iM+sxk D;ksafd ;s xzkV laØe.k ;k udkj ds 'kq#vkrhfpUg gks ldrs gSaA eSa le>rk gwa fd leLr iz;klksa ds ckotwn bl ckr dh laHkkouk gS fd pk{kq"k rh{.krk ;k vka[kksa dh lqanjrk cnrj gks tk;sA

eSa izekf.kr djrk gwa fd eSaus mi;qZDr lgefr ds fufgrk'k;ksa dks iwjh rjg ls le> fy;k gS vkSj MkWDVjksa dks esjh@esjs cPps dh nk;ha@ck;ha vka[k ijisusVªsfVax dsjSVksiSFkh dks lEiUu djus ds fy, vf/kÑr djrk gwaA


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MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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

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( 91 )

Therapeutic KeratoplastyAnand Agarwal, Shalini Mohan


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

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

Therapeutic keratoplasty is an ocular surgical procedure which is carried out in patients having infections involving the transparent outercoat of the eye ie cornea. The procedure is usually undertaken in cases with impending corneal perforation or frank perforation orsometimes in cases which are not responding to conventional medical therapy and cases with infection spreading onto deeper layers ofthe cornea. The procedure is usually carried out under general anesthesia but can be performed under local anesthesia as well dependingupon the condition of the patient’s eye and systemic status of the patient.

Post operative careThe eye may be red, swollen and painful following the procedure for which pain relieving oral medications and some eyedrops are givento bring about relief. Out patient visits are done on first day post operatively, day three, day seven and then after every two weeks. It is veryimportant for you to realize that the primary motive of the surgical procedure is salvaging of the eye, and prevention of spread of infectioninto the eye which can be devastating. Attainment of useful vision is only a secondary objective of the procedure for which additionalprocedures including a repeat corneal replacement may be required at a later date once the infection gets controlled.

Post operative course and complications1. Corneal wound healing problems including persistent epithelial defect2. Secondary glaucoma3. Graft rejection and opacification of the donor cornea4. Suture related problems including loose, broken sutures, suture abscess5. Recurrence of original infection in the graft6. Endophthalmitis and shrinkage of globe- these are rare

It is very important for the patient to realize that you have to be on certain topical medications in the form of antibiotics, local antiinflammatory agents, lubricants etc. for a prolonged period of time to bring about an optimal graft and visual acuity outcome. Also, theimportance of regular follow up as decided by the treating physician cannot be over emphasized. Needless to say that you are activelyinvolved in the care of the graft to ensure success.

I have been made aware of the above mentioned facts and I have been counseled about the potential benefits and possible side effects ofthe procedure and by thoroughly going through all of the above, I give my full informed consent for the above procedure.



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

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

( 92 )




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 93 )

FksjSfIVd dsjSVksIykLVhvkuan vxzoky] 'kkfyuh eksgku


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

FksjSfIVd dsjSVksIykLVh vksdqyj lftZdy dk;Zfof/k gS ftls fd mu jksfx;ksa esa lEiUu fd;k tkrk gS ftUgsa fd vka[k dh ckgjh ikjn'khZ ijr vFkkZr dkWfuZ;kls tqM+k laØe.k gksrk gSA bl dk;Zfof/k dks izk;% vklUu dkWuhZy Nsn ;k Li"V Nsn vFkok dbZ ckj ,sls ekeyksa] tks fd ikjaifjd fpfdRlk mipkj ls Bhdugha gksrs] vkSj dkfuZ;k dh T;knk xgjh ijrksa esa QSyus okys laØe.k esa lEiUu fd;k tkrk gSA bl dk;Zfof/k dks lkekU;r% lkeku; csgks'kh dh gkyr esalEiUu fd;k tkrk gS ij bls jksxh dh vka[k dh voLFkk vkSj jksxh ds iwjs 'kjhj dh fLFkfr ds vk/kkj ij yksdy ,usLFksfl;k ds rgr Hkh lEiUu fd;k tkrk gSA

vkWijs'ku ds ckn dh ns[kHkkydk;Zfof/k ds ckn vka[kksa esa ykyh] lwtu vkSj nnZ gks ldrk gS ftlds fy, nnZ fuokjd ekSf[kd nokb;ka vkSj dqN vkbZMªkIl fn;s tk ldrs gSa rkfd vkjkeigqapsA vkWijs'ku ds ckn igys fnu] rhljs fnu] lkrosa fnu vkSj fQj gjsd nks grksa ij cká jksxh foftV gksrh gSA vkidks fy, ;g le>uk t:jh gS fdlftZdy dk;Zfof/k dk izkFkfed mís'; vka[kksa dh j{kk djuk vkSj vka[k esa laØe.k ds QSyko dks jksduk gksrk gS] tks fd fouk'kdkjh gks ldrk gSA mi;ksxhn`f"V dh izkfIr dk;Zfof/k dk dsoy xkS.k y{; gksrk gS ftlds fy, fjihV dkWuhZy iqu%LFkkiu lesr vfrfjDr dk;Zfof/k;ksa dh ,dckj laØe.k ds fu;af=r gks tkuss ij ckn esa pydj vko';drk iM+ ldrh gSA

vkWijs'ku ckn dk dkslZ vkSj tfVyrk,a1- LFkk;h ,fiFksfy;y [kjkch lesr dkWuhZy dk ?kko Hkjus esa vkuh okyh leL;k,a

2- f}rh;d Xywdksxk

3- xzkV dk udkj vkSj nkrk dkfuZ;k dk vkSiSflfQds'ku

4- <hys] VwVs gq, Vkaxksa] Vkaxs ds QksM+ks lesr Vkads ls tqM+h gqbZ leL;k,a

5- xzkV esa ewyHkwr laØe.k dk fQj ls gks tkuk

6- Xyksc dh ,aMksFkSyfefVl vkSj fldqM+u & ;s eqf'dy ls gh gksrk gSjksxh ds fy, bl ckr dks le>uk cgqr t:jh gS fd vki yacs le; rd ,aVhck;ksfVDl] lwtu jks/kh yksdy ,tsaVksa] yqfczØSaV~l vkfn ds :i esa dqN VkWfidynokb;ksa dk iz;ksx djsaxs rkfd vf/kdre xzkV vkSj pk{kq"k rh{.krk izkIr gks ldsA blds vykok] mipkj djus okys MkWDVj ds fu.kZ; ds vuqlkjfu;fer QkWyksvi ds egRo dks le>uk cgqr t:jh gSA dgus dh t:jr ugha fd lQyrk dks lqfuf'pr djus ds fy, vki ns[kHkkyls lfØ; :i ls tqM+s gq, gSaA

eq>s Åij crk;s x;s rF;ksa ls HkyhHkkafr voxr djk fn;k x;k gS vkSj eq>s dk;Zfof/k ds laHkkO; ykHkksa vkSj laHkkfor ik'oZ&izHkkoksa ds ckjs esa ijke'kZ fn;ktk pqdk gS vkSj bu lHkh ckrksa dks dk;ns ls le>&cw> dj eSaus mi;qZDr dk;Zfof/k ds fy, viuh iwjh lwfpr lgefr iznku dh gSA


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( 94 )




MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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

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( 95 )

Automated Lamellar Therapeutic Keratoplasty (ALTK)Gaurav Prakash


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

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

I have been informed in my mother tongue that I/ my child is suffering from whitening of the cornea (Corneal opacity) / corneal ectasia(keratoconus) / other disease involving anterior part of the cornea (specify ...................................................) and that a surgery to remove uptoanterior, middle and deep part of the cornea (epithelium, basement membrane & upto mid stroma) will be done. A part of a donorcadaveric cornea will be used to replace this and will be placed with the help of sutures.

I have been fully explained regarding the permanent nature of the opacity/ lesion and that it has to be removed to enhance vision. I havebeen explained the risk of perforation of the host eye, leading to the need for a full thickness corneal transplant. There is risk of infection,graft rejection, suture loosening and replacement , increased blood vessels in interface possibly leading to haemorrhage, no improvementor worsening of Best corrected visual acuity, glaucoma secondary to surgery or to medications, cataract formation and high astigmatismafter surgery. There may be a need for repeat surgery which may or may not lead to improvement of vision. I have been explained the needfor follow up as frequently as advised by the doctors that may span upto years, with multiple investigations at each visit. I have beenexplained that using medications properly is required for success of the graft. I have been explained that I will need to urgently come forfollow-up to ophthalmic casualty if there is sudden onset of redness, photophobia, foreign body sensation, pain or detoriation of vision asthese may be early signs of graft infection or rejection. I understand that inspite of all efforts, there is a possibility that there may beworsening of the visual acuity or the cosmetic appearance of the eye.

I certify that I have fully understood the implications of the above consent and authorise the doctors to perform Automated LamellarTherapeutic Keratoplasty on my/ my child’s right / left eye.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 96 )

vkVësVsM Y©esYkj F¨jkiqfVd dsjkVÏYkkLVh ¼,,yVhds½x©jo Ádk'k



eq>s esjh ekr`Òk"kk esa crk;k x;k gS fd eSa@esjk cPpk dkfuZ;k ds 'osru ¼dkfuZ;k dh vikjnf'kZrk@d‚fuZ;Yk bDVsfl;k ¼dsjkV¨dül½@dkfuZ;k ds vxzÒkx ¼Li"V djsa --------------------------------------------------------------------------------½ esa güs okY¨ fdlh vU; j¨x ls ihfM+r gS v©j ;g Òh fd d‚fuZ;k ds vxz] e/; ;k fupY¨fgLls ¼bfifFkfYk;e] cslesaV esacjsu v©j e/; LVëk rd½ d¨ fudkYkus ds fYk, 'kY;fØ;k dh tk,xhA bls ÁfrLFkkfir djus ds fYk, nkrk ds dsMsofjddkfuZ;k ds fdlh fgLls dk mi;¨x fd;k tk,xk v©j bls Vkad a dh enn ls ÁfrLFkkfir fd;k tk,xkA

eq>s vikjnf'kZrk@{kfr dh LFkkbZ ÁÑfr ds ckjs esa iwjh rjg le>k;k x;k gS v©j ;g Òh crk;k x;k gS fd n`f"V ¼'kfä½ c<+kus ds fYk, bls fudkYkk tkukgSA eq>s gksLV dh vka[k esa fNæ güs ds t¨f[ke ds ckjs esa crk;k x;k gS ftlds dkj.k iwjh e¨VkbZ ds dkfuZ;k ds ÁR;kjï.k dh t:jr iM+ ldrh gSAlaØe.k] fujï ds vLohdj.k] Vkad a ds <hYkk güs v©j ÁfrLFkkiu] varjkQYkd esa jäokfgfu; a ds c<+ tkus ls jälzko güs] n`f"V dh rh{.krk esa d¨bZlq/kkj u vkus ;k Bhd dh xbZ loZJs"B n`f"V rh{.krk ds v©j Òh [kjkc güs tkus] 'kY;fØ;k ds x©.k ÁÒko ds :i esa XYkkdëk güs ds t¨f[ke d¨ ÒhLi"V fd;k x;k gSA nqckjk 'kY; fØ;k djus dh vko';drk iM+ ldrh ftlls n`f"V 'kfä c<+ Òh ldrh gS v©j ugÈ Òh c<+ ldrhA eq>s ;g Òh crk;kx;k gS fd M‚DVj ftruh ckj cqYkk,xk eq>s mruh ckj Q‚Yk¨vi ds fYk, tkuk g¨xk v©j ÁR;sd eqYkkdkr ij cgqr&lh tkapsa djkuh iM+ ldrh gSaA eq>s;g Òh Li"V fd;k x;k gS fd ;fn vka[k vpkud YkkYk g¨ tkrh gS] Ádk'k Òhfr g¨rh gS vka[k esa dqN iM+s güs] nnZ ;k n`f"V 'kfä ds vogzkl dh vuqÒwfrg¨rh gS r¨ esjk rqjar us"k fpfdRlk vkikr d{k esa Q‚Yk¨vku ds fYk, vkuk vko';d g¨xk D; afd ;g fujï ds laØe.k ;k vLohdj.k dk 'kq#vkrh ladsrg¨ ldrk gSA eSa le>rk gwa fd lkjh d¨f'k'k a ds ckotwn laÒo% gS fd vka[k dh n`f"V dh rhozrk ;k vka[k dh Álk/kd okákÑfr v©j Òh [kjkc g¨ tk,A

eSa Áekf.kr djrk gwa fd eSa mi;qZä lgefr ds fufgrkFk ± d¨ iwjh rjg le>rk gwa] v©j fpfdRld a d¨ viuh@vius cPps dh nkb±@ckb± dh vkVësVsMY©esYkj F¨jkiqfVd dsjkVÏYkkLVh djus ds fYk, Ákf/kÑr djrk gwaA


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

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MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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

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( 97 )

Deep Anterior Lamellar Keratoplasty (DALK)Gaurav Prakash


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

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

I have been informed in my mother tongue that I/ my child is suffering from whitening of the cornea (Corneal opacity) / corneal ectasia(keratoconus) / other disease involving anterior part of the cornea (specify ...................................................) and that a surgery to remove uptoanterior, middle and deep part of the cornea (epithelium, basement membrane & stroma upto or just before Descemets) will be done. Apart of a donor cadaveric cornea will be used to replace this and will be placed with the help of sutures.

I have been fully explained regarding the permanent nature of the opacity/ lesion and that it has to be removed to enhance vision. I havebeen explained the risk of perforation of the host eye, leading to the need for a full thickness corneal transplant. There is risk of infection,graft rejection , suture loosening and replacement , increased blood vessels in interface possibly leading to haemorrhage, no improvementor worsening of Best corrected visual acuity, glaucoma secondary to surgery or to medications, cataract formation and high astigmatismafter surgery. There may be a need for repeat surgery which may or may not lead to improvement of vision. I have been explained the needfor follow up as frequently as advised by the doctors that may span upto years, with multiple investigations at each visit. I have beenexplained that using medications properly is required for the success of the graft. I have been explained that I will need to urgently comefor follow-up to ophthalmic casualty if there is a sudden onset redness , photophobia, foreign body sensation , pain or detoriation of visionas these may be early signs of graft infection or rejection. I understand that inspite of all efforts, there is a possibility that there may beworsening of the visual acuity or the cosmetic appearance of the eye.

I certify that I have fully understood the implications of the above consent and authorise the doctors to perform Deep Anterior LamellarKeratoplasty on my / my child’s right / left eye.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 98 )

Mhi ,aVhfj;j Y©esYkj dsjkVÏYkkLVh ¼Mh,,yds½x©jo Ádk'k



eq>s esjh ekr`Òk"kk esa crk;k x;k gS fd eSa@esjk cPpk dkfuZ;k ds 'osru ¼dkfuZ;k dh vikjnf'kZrk @ d‚fuZ;Yk bDVsfl;k ¼dsjkV¨dül½/dkfuZ;k ds vxzÒkx ¼Li"V djsa ---------------------------------------------------------------------------------------------------½ esa güs okY¨ fdlh vU; j¨x ls ihfM+r gS v©j~ ;g Òh fd d‚fuZ;k ds vxz]e/; ;k fupY¨ fgLls ¼bfifFkfYk;e] cslesaV esacjsu v©j e/; LVª ek rd½ d¨ fudkYkus ds fYk, 'kY;fØ;k dh tk,xhA bls ÁfrLFkkfir djus ds fYk, nkrkds dsMsosfjd dkfuZ;k ds fdlh fgLls dk mi;¨x fd;k tk,xk v©j bls Vkad a dh enn ls ÁfrLFkkfir fd;k tk,xkA

eq>s vikjnf'kZrk@{kfr dh LFkkbZ ÁÑfr ds ckjs esa iwjh rjg le>k;k x;k gS v©j ;g Òh crk;k x;k gS fd n`f"V ¼'kfä½ c<+kus ds fYk, bls fudkYkk tkukgSA eq>s gksLV dh vka[k esa fNæ güs ds t¨f[ke ds ckjs esa crk;k x;k gS ftlds dkj.k iwjh e¨VkbZ ds dkfuZ;k ds ÁR;kjï.k dh t:jr iM+ ldrh gSAlaØe.k] fujï ds vLohdj.k] Vkad a ds <hYkk güs v©j ÁfrLFkkiu] varjkQYkd esa jäokfgfu; a ds c<+ tkus ls jälzko güs] n`f"V dh rh{.krk esa d¨bZlq/kkj u vkus ;k Bhd dh xbZ loZJs"B n`f"V rh{.krk ds v©j Òh [kjkc güs tkus] 'kY;fØ;k ds x©.k ÁÒko ds :i esa XYkkdëk güs ds t¨f[ke d¨ ÒhLi"V fd;k x;k gSA nqckjk 'kY; fØ;k djus dh vko';drk iM+ ldrh ftlls n`f"V 'kfä c<+ Òh ldrh gS v©j ugÈ Òh c<+ ldrhA eq>s ;g Òh crk;kx;k gS fd M‚DVj ftruh ckj cqYkk,xk eq>s mruh ckj Q‚Yk¨vi ds fYk, tkuk g¨xk v©j ÁR;sd eqYkkdkr ij cgqr&lh tkapsa djkuh iM+ ldrh gSaA eq>s;g Òh Li"V fd;k x;k gS fd ;fn vka[k vpkud YkkYk g¨ tkrh gS] Ádk'k Òhfr g¨rh gS vka[k esa dqN iM+s güs] nnZ ;k n`f"V 'kfä ds vogzkl dh vuqÒwfrg¨rh gS r¨ esjk rqjar us"k fpfdRlk vkikr d{k esa Q‚Yk¨vku ds fYk, vkuk vko';d g¨xk D; afd ;g fujï ds laØe.k ;k vLohdj.k dk 'kq#vkrh ladsrg¨ ldrk gSA eSa le>rk gwa fd lkjh d¨f'k'k a ds ckotwn laÒo% gS fd vka[k dh n`f"V dh rhozrk ;k vka[k dh Álk/kd okákÑfr v©j Òh [kjkc g¨ tk,A

eSa Áekf.kr djrk gwa fd eSa mi;qZä lgefr ds fufgrkFk ± d¨ iwjh rjg le>rk gwa] v©j fpfdRld a d¨ viuh@vius cPps dh nkb±@ckb± dh vkVësVsMY©esYkj F¨jkiqfVd dsjkVÏYkkLVh djus ds fYk, Ákf/kÑr djrk gwaA


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

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





MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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

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

( 99 )

Descemet’s Stripping Endothelial Keratoplasty(DSEK/DSAEK)

Bhavna Chawla


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

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

I have been informed in the language I best understand that I am suffering from an ocular condition (specify ________________ such asFuchs’ Corneal Dystrophy, trauma, previous intraocular surgery, failed graft) in which a critical number of endothelial cells (inner layerof the cornea) have been lost because of which the cornea has become swollen and cloudy. The remainder of the corneal layers, the stromaand the outer epithelium, are healthy.

An operation known as Descemet’s Stripping Endothelial Keratoplasty (DSEK/DSAEK) will be carried out in which a thin button ofdonor tissue containing the endothelial cell layer will be inserted onto the back surface of my eye.

Advantages of DSEK over full thickness corneal transplantation are that it is faster to perform, the wound is smaller, more stable and lesslikely to break open from inadvertent trauma. Because the technique requires very few sutures, there is negligible postoperative astigmatismwhich can otherwise delay visual recovery. Since only the thin inner layer of the cornea is replaced, over 90% of the patient’s own cornearemains behind contributing to greater structural integrity and a reduced incidence of rejection.

Risks and complications of DSEK/DSAEKThese include general risks similar to those of a full thickness corneal transplantation such as hemorrhage in the eye, infection, a retinaldetachment, rejection of the transplanted tissue, chronic inflammation, double vision, loss of corneal clarity, no improvement in visionor worsening of BCVA, glaucoma secondary to surgery or to medications and cataract formation.

Risks specific to DSEK include displacement of the thin button of endothelium within the first few days or weeks after surgery requiringa repeat surgery to reposition it. If the DSEK operation fails, the operation can be repeated with another button of donor endothelium.Alternatively, a traditional corneal transplant operation can also be performed. Repeat surgery may or may not lead to improvement ofvision.

Other complications from the local anesthesia include perforation of the eyeball, damage to the optic nerve, a droopy eyelid, interferencewith the circulation of the blood vessels in the retina, respiratory depression, and hypotension.

I have been explained the need for follow up as frequently as advised by the doctors that may span upto years, with multiple investigationsat each visit. I have been explained that using medications properly is essential for the success of the graft. I have been explained that I willneed to urgently come for follow-up to ophthalmic casualty if there is a sudden onset redness, photophobia, pain or deterioration of visionas these may be early signs of graft infection or rejection.

I understand that there may be other unexpected risks or complications that can occur that are not listed here. I also understand thatduring the course of the proposed operation, unforeseen conditions may be revealed that require the performance of additional procedures,and I authorize such procedures to be performed. I further acknowledge that no guarantees or promises have been made to me concerningthe results of any procedure or treatment.

This consent form has also educated me about the various options available to me.

I certify that I have fully understood the implications of the above consent and authorize the doctors to perform endothelial keratoplastyon my right / left eye.

( 100 )



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 101 )

MhLlhesV~l fLVªfiax baM¨F¨fYk;Yk dsjkVÏYkkLVh¼Mh,lbZds@Mh-,l-,-bZ-ds½

Òkouk pkoYkk



eq>s ml Òk"kk esa ftls eSa lcls vPNh rjg le>rk gwa lwfpr fd;k x;k gS fd eSa vka[k dh fdlh voLFkk ¼Li"V djsa-------------------------------------------------------------------------------------------------------------------------------------tSls QqDl dkfuZ;Yk fMLVª Qh] ?kko] iqjkuh var% us"kh; 'kY;fpfdRlk] vlQYk fujï½ ls ihfM+r gwa ftlesaegRoiw.kZ la[;k esa dkfuZ;k dh baM¨fFkfYk;eh d¨f'kdk,a u"V g¨ xbZ gSa ftlds dkj.k dkfuZ;k esa lwtu vk xbZ gS v©j og efYku g¨ xbZ gSA dkfuZ;k dh'¨"k ijrsa] LVª ek v©j ckgjh bfifFkfYk;eh d¨f'kdk,a LoLFk gSaA

,d 'kY;fØ;k dh tk,xh ftls fMLlsesV~l fLVªfiax baM¨fFkfYk;Yk dsjsVÏYkkLVh dgk tkrk gS] ftlesa bfifFkfYk;eh d¨f'kdkv a dh ijr ;qä nkrk ds Ård adk ,d irYkk lk cVu esjh vka[k ds ihNs dh lrg ds Òhrj ?kqlk fn;k tk,xkA

iwjh e¨VkbZ ds dkfuZ;k ds ÁR;kjï.k dh rqYkuk esa Mh,lbZds dk YkkÒ ;g gS fd ?kko N¨Vk g¨rk gS] ;g vf/kd fVdkÅ v©j vlko/kkuh ls Ykxus okYkh p¨Vls blds VwVus dk [krjk de jgrk gSA pwafd bl rduhd esa Vkads cgqr de Ykxkus iM+rs gSa blfYk, 'kY;fØ;k ds ckn dk n`f"VoS"kE; u ds cjkcj g¨rkgS t¨ vU;Fkk n`f"V ds iquYkkZÒ esa nsj dj ldrk gSA pwafd dkfuZ;k dh dsoYk irYkh lh Òhrjh ijr dk ÁR;kjï.k fd;k tkrk gS] blfYk, 90% ls vf/kdj¨fx; a dk dkfuZ;k ihNs cuk jgrk gS t¨ vf/kd lajpukRed v{krrk Ánku djrk gS v©j vLohdj.k dh ?kVukv a d¨ de dj nsrk gSA

Mh,lbZds@Mh,l,bZds ds t¨f[ke v©j tfVYkrk,abuesa vka[k esa jälzko] laØe.k] jsfVuk dk foYkxko] ÁR;kjïf.kr Ård a dk vLohdj.k] iqjkuk Ánkg] nqgjh n`f"V] d‚fuZ;k dh Li"rk dk vÒko] n`f"V 'kfäesa d¨bZ lq/kkj u gük ;k chlhoh, dk v©j Òh [kjkc g¨ tkuk] 'kY;fØ;k ;k mipkj ds x©.k ÁÒko ds :i esa e¨fr;kfcan ;k XYkkdëk ;k e¨fr;kfcan dscuus tSls iwjh e¨VkbZ ds dkfuZ;Yk ÁR;kjï.k tSls lkekU; t¨f[ke 'kkfeYk g srs gSaA

Mh,lbZds ds fof'k"V t¨f[ke a esa ÁkjaÒ ds dqN gh fnu a ;k gr a ds Òhrj baM¨fFk;e dh irYkh cVu dk viuh txg ls f[kld tkuk 'kkfeYk gS ftls mldhtxg ij j[kus ds fYk, nqckjk 'kY;fØ;k djuh iM+rh gSA ;fn Mh,lbZds ÁfØ;k vlQYk g¨ tkrh gS r¨ nkrk ds baM¨fFkfYk;e ds nwljs cVu ds lkFk nqckjk'kY;fØ;k djuh iM+ ldrh gSA vU;Fkk] dkfuZ;k ds ÁR;kjï.k dh ijaijkxr 'kY;fØ;k Òh dh tk ldrh gSA nqckjk 'kY;fØ;k djus ls vka[k a dh n`f"Vesa lq/kkj g¨ Òh ldrk gS v©j ugÈ ÒhA

LFkkfud laosnukgj.k ls güs okYkh vU; tfVYkrkv a esa us"kxŸkd esa fNæ] n`d~ raf"kdkv a d¨ {kfr] >qdh iYkdsa] jsfVuk dh jäokfgfu; a esa jä Áokg esaO;o/kku] 'olu laca/kh volkn] v©j fuEu jä pki 'kkfeYk gSaA

eq>s Li"V :i ls crk;k x;k gS fd eq>s fpfdRld a ds lq>k, vuqlkj ckj&ckj Q‚Yk¨vi ds fYk, vkuk g¨xk t¨ o"k ± pYk ldrk gS v©j ÁR;sd eqYkkdkrij cgqr&lh tkapsa djkuh g axhA eq>s crk;k x;k gS fd fujï dh lQYkrk ds fYk, lgh <ax ls nokv a dk mi;¨x vfuok;Z gSA eq>s crk;k x;k gS fd;fn vka[k vpkud YkkYk g¨ tkrh gS] Ádk'k Òhfr] vka[k esa dqN iM+s güs] nnZ ;k n`f"V 'kfä ds vogzkl dh vuqÒwfr g¨rh gS r¨ esjk rqjar us"k fpfdRlkvkikr~ d{k esa Q‚Yk¨vi ds fYk, vkuk vko';d g¨xk D; afd ;g fujï ds laØe ;k vLohdj.k dk ÁkjafÒd Yk{k.k g¨ ldrk gSA

eSa le>rk gwa fd vU; vuisf{kr t¨f[ke v©j tfVYkrk,a g¨ ldrh gSa ftudh lwph ;gka ugÈ nh xbZ gSA eSa ;g Òh le>rk gwa fd ÁLrkfor 'kY;fØ;k dsn©jku vÁR;kf'kr voLFkkv a dk irk pYk ldrk gS ftuds fYk, vfrfjä ÁfØ;k,a djus dh vko';drk iM+ ldrh gS v©j bl rjg dh ÁfØ;k,a djusdk vf/kdkj Ánku djrk gwaA eSa ;g Òh Lohdkj djrk gwa fd eq>ls fdlh Òh ÁfØ;k ;k mipkj ds ifj.kke ds ckjs esa fdlh rjg dh xkjaVh ;k okns ugÈfd, x, gSaA

bl lgefr Ái= us eq>s nwljs miYkC/k fodYi a ds fYk, eq>s f'kf{kr fd;k gSA

eSa Áekf.kr djrk gwa fd eSaus mi;qZä lgefr fufgrkFk ± d¨ vPNh rjg le> fYk;k gS v©j viuh nkb±@ckb± vka[k esa baM¨fFkfYk;eh dsjkVÏYkkLVh djus dkÁkf/kdkj nsrk gwaA

( 102 )


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MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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

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( 103 )

Phototherapeutic Keratectomy (PTK)Chandrashekhar


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

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

Patient ConsentIn giving my permission for excimer laser surgery, I understand the following:

1. The surgical removal of the superficial layers of my cornea using the excimer laser has been elected by me as an alternative to otherforms of corneal surgery.

2. As with all surgery, I understand the results cannot by guaranteed.3. I understand that my vision may be made worse by this procedure. Complications could include: Loss of sharp vision, increased

corneal scarring, increased night glare or corneal infection. Any pre-existing viral infections may reappear with the use of post-operative drops. If the cornea has extensive scars, it is possible that a corneal perforation may occur that could produce otherchanges such as infections, cataracts or the need for additional surgery. I understand that I must be examined closely to ensureproper healing of the treated eye.

4. I understand Phototherapeutic Keratectomy (PTK) with the excimer laser may increase my need for glasses and may require the useof corrective lenses to achieve my best vision.

5. I understand that although sharper vision and less glare are anticipated, it is possible that glare and clarity may be made worsefollowing this procedure.

6. I understand that for those severe corneal problems, where the surgical option for me is a corneal transplant, excimer laser PTKmay not eliminate the need for a corneal transplant.

7. I understand it is impossible to state every possible complication that may occur as a result of this surgical procedure.8. I understand that not all the beneficial effects of PTK are currently known.9. I also understand that all the risks and complications are not known.10. I acknowledge this disclosure of information has been made to me and that all my questions have been answered to my satisfaction.

I have read this form (or it has been read to me) and I fully understand the complications, risks and benefits that can result from PTKSurgery. I realize there are no guarantees with PTK Surgery.

I still however elect to have PTK laser treatment in my R/L / both eye(s).



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

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

( 104 )




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 105 )

Q¨V¨F¨jkI;qfVd dsjkVsDVëh ¼ihVhds½paæ'¨[kj



j¨xh dh lgefr,Dllkbej Y¨tj 'kY;fØ;k djus dh vuqefr%1- eSaus ,Dllkbej Y¨tj dk mi;¨x djds viuh d‚fuZ;k dh Åijh ir ± ds 'kY;fØ;kRed fu"dklu d¨ d‚fuZ;k dh 'kY;fØ;k ds nwljs :i a ds

fodYi ds :i esa pquk gSA

2- eSa le>rk gwa fd nwljh lÒh 'kY;fØ;kv a dh rjg ifj.kke a dh xkajVh ugÈ nh tk ldrhA

3- eSa le>rk gwa fd bl ÁfØ;k ls esjh n`f"V v©j Òh [kjkc g¨ ldrh gSA tfVYkrkv a esa n`f"V rh{.krk dk gzkl] of/kZr dkfuZ;Yk oz.kfPkUg] vkof/kZrjkf"k p©a/k] ;k dkfuZ;k dk laØe.k 'kkfeYk gSaA 'kY;fØ;k ds ckn vka[k esa VidkbZ tkus okYkh nokv as ds mi;¨x ls igY¨ ls e©twn d¨bZ fo"kk.kq laØe.knqckjk mÒkj dj ldrk gSA ;fn dkfuZ;k esa cgqr ls oz.kfpUg gSa r¨ dkfuZ;k esa fNæ g¨ ldrk gS t¨ laØe.k] e¨fr;kfcan tSls nwljs ifjorZu Ykkldrk gS v©j vfrfjä 'kY;fØz;k dh vko';drk iM+ ldrh gSA eSa le>rk gwa fd ;g lqfuf'pr djus ds fYk, mipkfjr vka[k dk ?kko ,d lgh<ax ls Òjs] ckjhdh ls esjh tkap dh tkuh pkfg,A

4- eSa le>rk gwa fd ,Dlkbe Y¨tj ls Q¨V¨F¨jkI;qfVd dsjkVsDVëh ¼ihVsds½ p'es] dh esjh vko';drk c<+k ldrh gS v©j esjh vf/kdre n`f"V dsfYk, lq/kkjd Y al a dh vko';drk iM+ ldrh gSA

5- eSa le>rk gwa fd gkYkkafd vis{kkÑr rh{.k n`f"V v©j de p©a/k visf{kr gS Y¨fdu ;g Òh laÒo gS fd bl ÁfØ;k ds ckn p©a/k v©j n`f"V nü a v©jÒh [kjkc g¨ tk,aA

6- eSa le>rk gwa fd dkfuZ;k dh mu xaÒhj leL;kv a ds fYk,] ftuds fYk, esjs fYk, dkfuZ;k ds ÁR;kjï.k dk fodYi miYkC/k gS] ,Dllkbej Y¨tjihdsVh dkfuZ;k ds ÁR;kjï.k dh vko';drk [kRe u dj ldsA

7- eSa le>rk gwa fd bl 'kY;fØ;kRed ÁfØ;k ds QYkLo:i güs okYkh ÁR;sd tfVYkrk dk o.kZu dj ikuk vlaÒo gSA

8- eSa le>rk gwa fd ihdsVh ds lÒh ykÒnk;d ÁÒko vÒh Kkr ugÈ gSaA

9- eSa ;g Òh le>rk gwa fd lÒh t¨f[ke v©j tfVYkrk,a Kkr ugÈ gSaA

10- eSaus ;g QkseZ i<+ fYk;k gS ¼;k bls i<+ dj eq>s lquk;k x;k gS½ v©j eSa ihdsVh 'kY;fØ;k dh lÒh tfVYkrkv a] t¨f[ke a v©j YkkÒ a d¨ iwjh rjgle>rk gwaA eSa le>rk gwa fd ihdsVh 'kY;fØ;k dh d¨bZ xkjaVh ugÈ gSA

eSa fQj Òh viuh nkb±@ckb± vka[k@nüä vka[kä dh ihdsVh Y¨tj fpfdRlk djkus dk pquko djrk gwaA


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( 106 )




MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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( 107 )

Photorefractive Keratectomy (PRK)Chandrashekhar


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

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

In giving my permission for PRK, I understand the following:

The long-term risks and effects of PRK surgery are unknown. The goal of PRK with the excimer laser is to reduce dependence upon orneed for contact lenses and/or eyeglasses; however, I understand that as with all forms of treatment, the results in my case cannot beguaranteed. For example:

1. I understand that an overcorrection or undercorrection could occur, causing me to become farsighted or nearsighted or increasemy astigmatism and that this could be either permanent or treatable. I understand an overcorrection or undercorrection is morelikely in people over the age of 40 years and may require the use of glasses for reading or for distance vision some or all of the time.

2. If I currently need reading glasses, I will likely still need reading glasses after this treatment. It is possible that dependence onreading glasses may increase or that reading glasses may be required at an earlier age if I have PRK surgery.

3. Further treatment may be necessary, including a variety of eye drops, the wearing of eyeglasses or contact lenses (hard or soft), oradditional PRK or other refractive surgery.

4. My best vision, even with glasses or contacts, may become worse.5. There may be a difference in spectacle correction between eyes, making the wearing of glasses difficult or impossible. Fitting and

wearing contact lenses may be more difficult.6. I have been informed, and I understand, that certain complications and side effects have been reported in the post-treatment period

by patients who have had PRK, including the following:A. Possible short-term effects of PRK surgery: The following have been reported in the short- term post treatment period and

are associated with the normal post-treatment healing process: mild discomfort or pain (first 72 to 96 hours), cornealswelling, double vision, feeling something is in the eye, ghost images, light sensitivity, and tearing.

B. Possible long-term complications of PRK surgery:Haze: Loss of perfect clarity of the cornea, usually not affecting vision, which usually resolves over time.Starbursting: After refractive surgery, a certain number of patients experience glare, a “starbursting” or halo effect aroundlights, or other low-light vision problems that may interfere with the ability to drive at night or see well in dim light.Although there are several possible causes for these difficulties, the risk may be increased in patients with large pupils or highdegrees of correction. For most patients, this is a temporary condition that diminishes with time or is correctable by wearingglasses at night or taking eye drops. For some patients, however, these visual problems are permanent. I understand that myvision may not seem as sharp at night as during the day and that I may need to wear glasses at night or take eye drops. Iunderstand that it is not possible to predict whether I will experience these night vision or low light problems, and that I maypermanently lose the ability to drive at night or function in dim light because of them. I understand that I should not driveunless my vision is adequate. These risks in relation to my particular pupil size and amount of correction have beendiscussed with me.Loss of Best Vision: A decrease in my best vision even with glasses or contacts.IOP Elevation: An increase in the inner eye pressure due to post-treatment medications, which is usually resolved by drugtherapy or discontinuation of post-treatment medications.Mild or severe infection: Mild infection can usually be treated with antibiotics and usually does not lead to permanent visualloss. Severe infection, even if successfully treated with antibiotics, could lead to permanent scarring and loss of vision thatmay require corrective laser surgery or, if very severe, corneal transplantation.Keratoconus: Some patients develop keratoconus, a degenerative corneal disease affecting vision that occurs in approximately1/2000 in the general population. While there are several tests that suggest which patients might be at risk, this condition can

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develop in patients who have normal preoperative topography (a map of the cornea obtained before surgery) and pachymetry(corneal thickness measurement) . Since keratoconus may occur on its own, there is no absolute test that will ensure apatient will not develop keratoconus following laser vision correction. Severe keratoconus may need to be treated with acorneal transplant while mild keratoconus can be corrected by glasses or contact lenses.

C. Infrequent complications. The following complications have been reported infrequently by those who have had PRKsurgery: itching, dryness of the eye, or foreign body feeling in the eye; double or ghost images; patient discomfort; inflammationof the cornea or iris; persistent corneal surface defect; persistent corneal scarring severe enough to affect vision; ulceration/infection; irregular astigmatism (warped corneal surface which causes distorted images); cataract; drooping of the eyelid;loss of bandage contact lens with increased pain (usually corrected by replacing with another contact lens); and a slightincrease of possible infection due to use of a bandage contact lens in the immediate post-operative period.

I understand there is a remote chance of partial or complete loss of vision in the eye that has had PRK surgery.

I understand that it is not possible to state every complication that may occur as a result of PRK surgery. I also understand that complicationsor a poor outcome may manifest weeks, months, or even years after PRK surgery.

I understand this is an elective procedure and that PRK surgery is not reversible.

For women only: I am not pregnant or nursing. I understand that pregnancy could adversely affect my treatment result.

I have spoken with my physician, who has explained PRK, its risks and alternatives, and answered my questions about PRK surgery. Itherefore consent to having PRK surgery on:



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 109 )

Q¨V¨fjÝSfDVo dsjkVsDVëh ¼ihvkjds½paæ'ks[kj



ihvkjds ds fYk, viuh vuqefr nsrs le; eSa fuEufYkf[kr d¨ le>rk gwa%ihvkjds 'kY;fpfdRlk ds nh?kZdkfYkd t¨f[ke v©j ÁÒko vKkr gSaA ,Dllkbej ds lkFk ihvkjds dk Yk{; dkaVSDV Y al a ;k p'es ij fuÒZjrk ;k vko';drkde djuk gSA cgjgkYk] eSa le>rk gwa fd tSlk fd lÒh rjg ds mipkj a ds lkFk g¨rk gS] esjs ekeY¨ esa ifj.kke dh xkjaVh ugÈ nh tk ldrhA mnkgj.kds fYk,%1- eSa le>rk gwa fd vfr la'k¨/ku ;k vYi la'k¨/ku g¨ ldrk gS ftlesa eSa fudV n`f"Vn¨"k ;k nwj n`f"Vn¨"k dk f'kdkj g¨ ldrk gwa ;k esjk n`f"V

oS"kE; c<+ ldrk gS v©j ;g Òh fd ;g vLFkk;h ;k mipkj;¨X; g¨ ldrk gSA eSa le>rk gwa fd 40 lkYk ls Åij ds Yk¨x a esa vfrla'k¨/ku ;kvYila'k¨/ku dh laÒkouk vf/kd jgrh gS v©j cgqr a d¨ i<+us ds fYk, ;k dh nf"V ds fYk, dqN le; ds fYk, ;k gj le; ds fYk, p'es dh vko';drkg¨rh gSA

2- ;fn bl le; eq>s i<+us ds fYk, p'es dh vko';drk gS r¨ g¨ ldrk gS fd eq>s mipkj ds ckn Òh p'es dh t:jr iM+sA3- laÒo gS fd ;fn eSa ihvkjds 'kY; fpfdRlk djkrk gwa r¨ i<+us ds p'es ij fuÒZjrk v©j c<+ tk, ;k de mez esa p'es dh t:jr iM+ ldrh

gSA4- esjh loZJs"B n`f"V] p'es ;k dkaVSDV Y©al a ds ckn Òh [kjkc g¨ ldrh gSA5- vka[k a ds chp p'es ds lq/kkj esa varj g¨ ldrk gS] ftlls vka[k a dk p'ek Ykxkuk dfBu ;k vlaÒo g¨ ldrk gSA dkaVSDV Y al Ykxkuk ;k iguuk

vf/kd dfBu g¨ ldrk gSA6- eq>s lwfpr fd;k x;k gS] v©j eSa le>rk gwa fd ihvkjds djkus okY¨ j¨fx; a esa mipkj¨Ùkj vof/k esa fuEufYkf[kr lfgr dqN tfVYkrkv a v©j nq"ÁÒko a

dh fji¨Vs± vkbZ gSa%,- ihvkjds 'kY; fpfdRlk ds laÒkfor vYidkYkhu ÁÒko% mipkj¨Ùkj vof/k esa fuEufYkf[kr dh fji¨Vs± vkbZ gSa v©j mÙkjïpkj dh

lkekU; YkkÒdkjh ÁfØ;k ls tqM+h gSaA gYdk d"V ;k nnZ ¼igY¨ 72 ls 96 ?kaVs½ dkfuZ;k dh lwtu] nqgjh n`f"V] vka[k esa dqN iM+s güs dhvuqÒwfr] vkÒklh Áfrfcac] Ádk'k ds Áfr laosnu'khYkrk] v©j vkalw vkukA

ch- ihvkjds dh laÒkfor nh?kZdkfYkd tfVYkrk,a%?kqa/k% d‚fuZ;k dh iwjh Li"Vrk dk vÒko] t¨ vker©j ij n`f"V d¨ ÁÒkfor ugÈ djrk] v©j lkekU;r;k le; ds lkFk vius&vki Bhd g¨tkrk gSArkjkfoLQ¨V% viorZd 'kY; fpfdRlk ds ckn j¨fx; a dh ,d fuf'pr rknkn p©a/k] Þrkjk foLQ¨Vß ;k Ádk'k ds fxnZ ÁÒkeaMYk ;k dqN j¨xhde j¨'kuh esa ns[kus dh leL;k vuqÒo djrs gSa t¨ jkr esa okgu pYkkus ;k /kqa/kYkh j¨'kuh esa vPNh rjg ns[k ikus dh leL;k iSnk djrhgSA gkYkkafd bu ijs'kkfu; a ds cgqr ls laÒkfor dkj.k g¨ ldrs gSaA Y¨fdu cM+h iqrfYk; a okY¨ ;k mPp va'k a ds la'k¨/ku ds f'kdkj j¨fx; aesa t¨f[ke c<+ tkrk gSA vf/kdrj j¨fx; a ds fYk, ;g vLFkk;h voLFkk g¨rh gS t¨ le; ds lkFk Bhd g¨ tkrh gS ;k p'es Ykxkuk ;k vka[kesa Vidkus okYkh nok ls Bhd g¨ ldrh gSA Y¨fdu dqN ejht a ds fYk, n`f"V laca/kh ;s leL;k,a LFkk;h g¨rh gSaA eSa le>rk gwa fd g¨ ldrkgS fd esjh utj jkr esa fnu ftruh rst ugÈ Árhr g¨ v©j ;g Òh fd eq>s jkr esa p'ek Ykxkus ;k vka[k esa Vidkus okYkh nok Yüh iM+sAeSa le>rk gwa fd bldh Òfo";ok.kh djuk laÒo ugÈ gS fd eSa jkr dh ;k de j¨'kuh dh ;s leL;k,a vuqÒo d:axk ;k ugÈ] v©j ;g Òhfd muds dkj.k eSa jkr esa okgu pYkkus ;k de j¨'kuh esa dke djus dh lkeF;Z LFkk;h :i ls [k¨ ldrk gwaA eSa le>rk gwa fd esjh n`f"Vi;kZIr u g¨ r¨ eq>s okgu ugÈ pYkkuk pkfg,A esjh vka[k dh iqrYkh dh fo'¨"k eki v©j lq/kkj dh ek"kk laca/kh bu t¨f[ke a ds ckjs esa esjslkFk ppkZ dh xbZ gSAloZJs"B n`f"V dk gzkl% p'es v©j dkaVSDV Y al¨ ds ckotwn esjh loZJs"B n`f"V esa dehAvkbZvïh dk cguk% mipkj¨Ùkj nh tkus okYkh nokv a ds dkj.k vka[k ds vkarfjd ncko esa o`f) g¨ ldrh gS] t¨ lkekU;r;k v©"kf/k mipkj;k mipkj¨Ùkj nokv a ds can djus ls Bhd g¨ tkrk gSAgYdk ;k xaÒhj laØe.k% gYds laØe.k dk lkekU;r;k ,aVh c‚;¨fVDl ls bYkkt fd;k tk ldrk gS v©j lkekU;r;k muls nf"V dh dkLFkk;hgzkl ugÈ g¨rkA xaÒhj laØe.k] pkgs ,saVhc‚;¨fVDl ls lQYkrkiwoZd mudk mipkj g¨ Òh tk, rc Òh LFkk;h oz.kfpUg N¨M+ ldrs gSa v©jn`f"V gzkl iSnk dj ldrs gSa ftlds fYk, lqjk/kkRed Y¨tj 'kY;fØ;k dh vko';drk g¨rh gS] ;k cgqr xaÒhj güs ij dkfuZ;k ds ÁR;kjï.kdh t:jr iM+ ldrh gSAdsjkV¨dül% dqN j¨fx; a esa n`f"V d¨ ÁÒkfor djus okYkk dkfuZ;k dk ,d {k;dkjh j¨x dsjkVsdül fodflr g¨ tkrk gSA ;g j¨x vke

( 110 )

vkcknh esa 2000 esa ls fdlh ,d O;fä d¨ g¨rk gSA gkYkkafd dbZ tkapsa gSa t¨ crk ldrh gSa fd d©u&ls j¨xh d¨ bldk t¨f[ke g¨ ldrkgS] Y¨fdu ;g voLFkk mu j¨fx; a esa Òh fodflr g¨ ldrh gS] 'kY;fØ;k ls igY¨ ftudh Vï¨xzkQh ¼'kY;fØ;k ds igY¨ rS;kj fd;k tkusokYkk d‚fuZ;k dk uD'kk½ v©j iSfdesVªh ¼d‚fuZ;k dh e¨VkbZ dh eki½ lkekU; g¨rh gSA pwafd dsjkV¨dül vius vki g¨ ldrk gS] blfYk,;g lqfuf'pr djkus okYkh d¨bZ iq[rk tkap ugÈ gS fd j¨xh esa Y¨tj n`f"V la'k¨/ku ds ckn dsjkV¨dül fodflr ugÈ g¨xkA xaÒhjdsjkV¨dül ds mipkj ds fYk, d‚fuZ;k ds ÁR;kjï.k dh t:jr iM+ ldrh gS tcfd gYdk dsjkV¨dül p'es ;k d‚VSDV Y al a ls Bhdg¨ ldrk gSA

lh- vÁkf;d tfVYkrk,aA ihvkjds 'kY;fØ;k djkus okYk a us fuEufYkf[kr vÁkf;d tfVYkrkv a dh lwpuk nh gS% [kqtYkh vka[k dk lw[kkiu(;k vka[k esa fdlh ckgjh pht ds iM+s güs dh vuqÒwfr( nqgjs ;k vLi"V Áfrfcac] j¨xh d¨ d"V( d‚fuZ;k ;k vkbfjl dk Ánkg( dkÆu;k dhlrg dh fpj LFkk;h foÑfr( dkfuZ;k ij n`f"V d¨ ÁÒkfor djus ds fYk, i;kZIr LFkk;h o`.k fpUg( ?kko@laØe.k( vfu;fer n`f"V oS"kE;¼dkfuZ;k dh <adh gqbZ lrg t¨ Áfrfcac a d¨ fo:fir dj nsrh gS½( e¨fr;kfcan( iYkd a dk >qdko( nnZ c<+ tkus ds lkFk cSaMst dkaVSDV Y©aldh {kfr ¼t¨ lkekU;r;k nwljk dkaVSDV Y©al Ykxkus ls Bhd g¨ tkrh gS½( v©j 'kY;fØ;k ds ckn dh vof/k esa cSaMst dkaVSDV Y al ds mi;¨xds dkj.k laØe.k dh laÒkouk esa ekewYkh o`f)A

eSa le>rk gwa fd ftl vka[k esa ihvkjds 'kY;fØ;k gqbZ Fkh mlds vkaf'kd ;k iw.kZ n`f"V gzkl dh gYdh lh laÒkouk jgrh gSAeSa le>rk gwa fd ihvkjds 'kY;fØ;k ds ifj.kke Lo:i güs okYkh lÒh tfVYkrkv a dk Li"Vhdj.k laÒo ugÈ gSA eSa ;g Òh le>rk gwa fd ihvkjds 'kY;fØ;kds g¶r a] eghu a ;k o"k ± ckn Òh tfVYkrk,a ;k [kjkc urhts lkeus vk ldrs gSaAeSa le>rk gwa fd ;g fuokZfpr ÁfØ;k gS v©j ihvkjds 'kY;fØ;k fjoZfloy ugÈ gSAdsoYk efgYkkvä ds fYk,% eSa xÒZorh ugÈ gwa ;k Lruiku ugÈ djk jgh gwaA eSa le>rh gwa fd xÒZ esjs mipkj ds ifj.kke a d¨ ÁfrdwYk :i ls ÁÒkfordj ldrk gSAeSaus vius fpfdRld ls ckr dj Ykh gS ftlus ihvkjds] blds t¨f[ke a v©j fodYi a d¨ Li"V fd;k gS v©j ihvkjds 'kY;fØ;k laca/kh esjs Á'u a ds mÙkjfn, gSaA blfYk, eSa ihvkjds 'kY;fØ;k djus dh lgefr nsrk gwa%


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( 111 )

LASIKPrakashchand Agarwal, Reena Sharma


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

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

LASIK reshapes the cornea, it involves raising a thin flap of corneal tissue using a blade/ femtosecond laser and remodelling of cornealshape using excimer laser.

During the procedure the patient is required to fix his / her gaze at the blinking light, to ensure proper centration. Clicking sound is heardand a smell similar to that of charring of hair is perceived.

Expected BenefitsI understand the purpose of LASIK is to reduce short sightedness , long sightedness and /or astigmatism to provide me much betterunaided vision that I presently have without spectacles or/ and contact lenses. However I understand that an excellent unaided vision maynot be guaranteed

Alternative TreatmentsI understand that continuous use of spectacles and / or contact lenses can provide excellent vision and LASIK is an alternative to decreasethe dependence on spectacles and / or contact lenses.

Possible Side Effects, Risks and Complications

Undercorrection or Over CorrectionI understand that calculations used in this surgery are based on previous experience on large number of patients and they use averagevalues. Thus depending on the individual variations in response to the procedure, there might be some undercorrection or over correction.As a result, I may require some spectacles to achieve best possible vision for distance and /or near. If treatment may be required, a periodof 6 months must elapse between it and the original surgery.

PresbyopiaI understand that as I get older (45 yrs or older), there is a likelihood of requiring spectacles for reading which is based on natural agerelated changes in the eye on which there is no direct bearing of the LASIK procedure.

Decrease of Best Corrected VisionDecrease of Best Corrected VisionDecrease of Best Corrected VisionDecrease of Best Corrected VisionDecrease of Best Corrected Vision

I understand that post-LASIK, best spectacle correction may not be as good as before the procedure.

Glare, Starbursts and Double VisionThese may occur, more so in the first 24 hours. In most cases, they disappear in 1-4 weeks.

Rare ComplicationsInfection, inflammation, corneal oedema, loss or damage to the corneal flap.

Long Term ChangesThere may be alteration in power requiring spectacles or contact lenses.

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Technical FailureIt may lead to abandoning the procedure and performing a repeat procedure at a later date.

I certify that I have fully understood the implications of the above consent and authorize the doctors to perform the procedure on my R/L Eye. I have had all the questions answered to my satisfaction.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 113 )

YkkfldÁdk'kpan vxzokYk] jhuk 'kekZ



Ykkfld d‚fuZ;k d¨ fQj ls x<+rh gS] blds varxZr fdlh CY¨M@QseV¨ lsdaM Y¨tj dk mi;¨x djds d‚fuZ;k ds Ård a ds ,d irY¨ iÍs d¨ mBk;ktkrk gS v©j ,Dllkbej Y¨tj dk mi;¨x djds d‚fuZ;k d¨ fQj ls x<+k tkrk gSA

mfpr ,dkxzrk lqfuf'pr djus ds fYk, j¨xh d¨ ÁfØ;k ds n©jku j¨xh d¨ tYkrh&cq>rh j¨'kuh ij viuh utj fVdk, j[kuh g¨rh gSA fVd&fVd dh

vkokt vkrh gS v©j ckYk a ds tYkus tSlh xa/k dh vuqÒwfr g¨rh gSA

visf{kr YkkÒ

eSa le>rk gwa fd Ykkfld dk mÌs'; fcuk p'es ;k dkaVSDV Y al a ds esjh orZeku n`f"V ls csgrj vleÆFkr n`f"V Ánku djus ds fYk, nwjnf"V n¨"k] fudV

n`f"Vn¨"k v©j@;k n`f"VoS"kE; d¨ de djuk gSA cgjgkYk eSa le>rk gwa fd mRÑ"V vleÆFkr n`f"V dh xkjaVh ugÈ nh tk ldrhA

oSdfYid mipkj

eSa le>rk gwa fd Ykxkrkj p'es v©j@;k dkaVSDV Y al a dk mi;¨x eq>s mRÑ"V n`f"V Ánku dj ldrk gSa v©j Ykkfld p'es ;k dkaVSDV Y al a ij fuÒZjrkde djus dk ,d fodYi gSA

laÒkfor nq"ÁÒko t¨f[ke v©j tfVYkrk,a

vYi la'k¨/ku ;k vfr la'k¨/ku

eSa le>rk gwa fd bl 'kY;fØ;k esa Á;qä güs okY¨ vkdYku ejht a dh cM+h la[;k ds fiNY¨ vuqÒo a ij vk/kkfjr g¨rs gSa v©j Yk¨x v©lr eku a dk mi;¨xdjrs gSaA blfYk, ÁfØ;k ds Áfr vuqfØ;k esa O;fäxr fofÒérkv a ds vk/kkj ij dqN vYila'k¨/ku ;k vfrla'k¨/ku g¨ ldrs gSaA urhtru eq>s loZJs"BlaÒkfor nwj@;k fudV n`f"V ÁkIr djus ds fYk, dqN p'es dh t:jr iM+ ldrh gSA ;fn mipkj dh vko';drk gqbZ r¨ ewYk 'kY;fØ;k v©j mipkj

ds chp 6 eghus dk varj vo'; gük pkfg,A

çsLok;ksfi;k

eSa le>rk gwa fd eSa tSls&tSls esjh mez ¼45 lkYk ;k mlls vf/kd½ c<+rh tk;sxh] i<+us ds fYk, p'es dh vko';drk iM+ ldrh gSA t¨ vka[k esa mez

ls lacaf/kr ÁkÑfrd cnYkko a ij vk/kkfjr g¨rk gS v©j ftldk Ykkfld ÁfØ;k ls d¨bZ lh/kk laca/k ugÈ g¨rkA

loZJs"B la'k¨f/kr n`f"V esa deh

eSa le>rk gwa fd Ykkfld ds ckn p'es ls la'k¨f/kr loZJs"B n`f"V ÁfØ;k ls igY¨ dh esjh n`f"V ls vPNh ugÈ Òh g¨ ldrhA

p©a/k] rkjk foLQ¨V v©j n¨gjh n`f"V

;s g¨ ldrs gSa] 'kq#vkrh 24 ?kaVs ds Òhrj ,slk güs dh laÒkouk vf/kd jgrh gSA vf/kdrj ekeYk a esa 1&4 g¶rs ds Òhrj [kRe g¨ tkrs gSaA

nqYkZÒ tfVYkrk,a

laØe.k] Ánkg] d‚fuZ;k dh lwtu] dkfuZ;k dh iÍh dk {k; ;k {kfrA

nh?kZdkfYkd ifjorZuvko';d p'es ;k dkaVSDV Y al a ds ikoj esa ifjorZuA

( 114 )

rduhdh vlQYkrkbldh otg ls ÁfØ;k N¨M+us v©j vkxs fdlh frfFk ij nqckjk djus dh t:jr iM+ ldrh gSA

eSa Áekf.kr djrk gwa fd eSaus mi;qä lgefr ds fugrkFk ± d¨ iwjh rjg le> fYk;k gS v©j fpfdRld a d¨ nkb±@ckb± vka[k ij ;g ÁfØ;k djus dkvf/kdkj nsrk gwaA eq>s esjs lÒh Á'u a ds lar¨"ktud mÙkj fn, x, gSaA


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( 115 )

Astigmatic Keratotomy (AK)Asim K. Kandar


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

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

IntroductionAstigmatic keratotomy (AK) is a surgical procedure which consists of making fine microscopic arcuate (curved) incisions, either singlyor as a pair, at optical zones of either 6 or 7 mm, or relaxing incisions at the limbus, which is the junction of the clear part of the eye (cornea)with the white (sclera) of the eye. These cuts are made for the purpose of flattening the steepest part of the cornea in an attempt to obtaina more spherical cornea. AK permanently changes the shape of the cornea. Although the goal of AK is to improve vision to the point ofnot wearing glasses, this result is not guaranteed.

AK is an elective procedure: There is no emergency condition or other reason that requires or demands that you have it performed. Youcould continue wearing contact lenses or glasses and have adequate visual acuity. This procedure, like all surgery, presents some risks,many of which are listed below. You should also understand that there might be other risks not known to your doctor that may becomeknown later. Despite the best of care, complications and side effects may occur; should this happen in your case, the result might beaffected even to the extent of making your vision worse.

Alternatives to AKIf you decide not to have AK, there are other methods of correcting your astigmatism. These alternatives include, among others,eyeglasses, contact lenses, and other refractive surgical procedures such as PRK or LASIK.

Patient ConsentI give my consent to my ophthalmologist to perform AK, and I declare that I have received no guarantee as to the success of my particularcase. I understand that the following risks are associated with the procedure:

Potential Risks and Complications1. I understand that there is a possibility that my vision may not improve with this surgery or that the desired results of surgery may not

be obtained. It is possible that I may require additional surgery at a later date or that I could still need glasses after surgery. It ispossible that I may not be able to wear contact lenses after having this surgery.

2. As a result of the surgery, it is possible that I could lose vision or best-corrected vision. This could happen as a result of infection thatcould not be controlled with antibiotics or other means, which could even cause loss of my eye.

3. Irregular healing of incisions may cause the corneal surface to be distorted. In that case, it may be necessary for me to wear a contactlens to affect useful vision, and there is a possibility that this may not restore useful vision.

4. I understand that I may experience incapacitating light sensitivity from sunlight or other bright light sources for a varying lengthof time, or possibly permanently.

5. I understand that I may experience incapacitating glare or halos from oncoming headlights or other bright light sources, particularlyin the evening or at nighttime, for a varying length of time or possibly permanently. I am aware that this may interfere with drivingfor an indefinite period both during day and night, and I understand that I am not to drive until I am certain that my vision isadequate both during day and night.

6. I understand that fluctuations or variation in vision may occur during the day during the initial stabilization period (up to threemonths or longer).

7. As occurs in all surgical procedures, scarring is the result of making incisions in living tissue. This particular surgery is noexception.

8. My eye will be more susceptible to a blow to the eye during the healing phase and possibly somewhat after healing as the microscopicscar tissue may not be as strong as the normal tissue. Protective eyewear is recommended for all contact and racquet sports wherea direct blow to the eye could cause permanent injury to the eye.

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9. Additional reported complications include corneal perforation, which could possibly require sutures; incisional inclusions, cornealvascularization, corneal ulcer formation, endothelial cell loss, epithelial healing defects, and very rarely, endophthalmitis (internalinfection of the eye, which could lead to permanent loss of vision).

10. I understand that, as with all types of surgery, there is a possibility of complications due to anesthesia, drug reactions or other factorsthat may involve other parts of my body. I understand that, since it is impossible to state every complication that may occur as a resultof any surgery, the list of complications in this form may not be complete.

Patient’s Statement of Acceptance and UnderstandingThe details of the procedure known as AK have been presented to me in detail in this document and explained to me by my ophthalmologist.My ophthalmologist has answered all my questions to my satisfaction. I have read this informed consent form (or it has been read to me),and I fully understand it and the possible risks, complications, and benefits that can result from surgery. I therefore consent to AK surgery.

I wish to have AK performed on my R/L/Both eye(s).



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 117 )

,fLVXesfVd dsjkV¨Vëh ¼,ds½vkfle ds- daanj



ifjp;,fLVXesfVd dsjkV¨Vëh ¼,ds½ ,d 'kY;fØ;kRed ÁfØ;k gS ftlesa 6 ;k 7 feeh ds n`DeaMYk ij ;k r¨ ,dYk ;k t¨M+s esa lw{en'kÊ ls fn[kus okY¨ pkikdkj¼oØ½ phjs Ykxk, tkrs gSa ;k fyEol ij f'kfFkYkdkjh phjs Ykxk, tkrs gSa t¨ vka[k ds LoPN Òkx ¼dkÆu;k½ v©j 'osr iVYk ¼LDYkhjk½ dh laf/k ij g¨rk gSA;s phjs v©j Òh xŸkkdkj dkfuZ;k ÁkIr djus ds Á;kl esa dkfuZ;k ds lcls <Ykoka fgLls d¨ piVk djus ds mÌs'; ls Ykxk, tkrs gSaA gkYkkafd ,ds dk Yk{;n`f"V esa bl foanq rd lq/kkj Ykkuk gS fd p'es u Ykxkus iM+sa Y¨fdu bl ifj.kke dh xkjaVh ugÈ g¨rhA

,ds ,d fuokZfpr ÁfØ;k gS% ,slh d¨ vkikr~ voLFkk ;k nwljk dkj.k ;k vko';drk ugÈ g¨rh ftldh otg ls vkid¨ ;g ÁfØ;k djkuh iM+rh gSA vkip'ek ;k dkaVSDV Y al igu dj i;kZIr n`"; xfrfof/k;ka dj ldrs gSaA lÒh 'kY;fØ;kv a dh rjg ;g ÁfØ;k Òh dqN t¨f[ke iSnk djrh gS ftudh lwphuhps nh xbZ gSA vkid¨ ;g Òh le>uk pkfg, fd nwljs t¨f[ke Òh g¨ ldrs gSa] vkidk fpfdRld ftuds ckjs esa u tkurk g¨ vkxs pYk dj ftudkirk pYk ldrk gSA vPNh ls vPNh ifjp;kZ ds ckotwn tfVYkrk,a v©j nq"ÁÒko g¨ ldrs gSaA ;fn vkids lkFk g¨rk gS r¨ ifj.kke bl gn rd ÁÒkforg¨ ldrs gSa fd vkidh n`f"V cn ls cnrj g¨ tk,A

,ds ds fodYi;fn vki ,ds u djkus dk fu'p; djrs gSa r¨ Òh vkids n`f"V oS"kE; d¨ Bhd djus ds fodYi gSaA buesa vU; fodYi a ds vfrfjä p'es] dkaVSDV Y al]v©j vU; viorZd 'kY;fØ;kRed ÁfØ;k,a tSls ihvkjds ;k Ykkfld 'kkfeYk gSaA

j¨xh dh lgefreSa vius us"k fo'¨"kK r¨ ,ds djus dh lgefr nsrk gwa] v©j ?k¨"k.kk djrk gwa fd eq>s esjs fo'¨"k ekeY¨ dh lQYkrk dh d¨bZ xkjaVh ugÈ nh xbZ gSA eSa le>rkgwa fd ÁfØ;k ls fuEufYkf[kr t¨f[ke tqM+s gSa%

laÒkfor t¨f[ke v©j tfVYkrk,a1- eSa le>rk gwa fd bl 'kY;fØ;k ls esjh n`f"V esa lq/kkj u güs dh laÒkouk gS ;k ;g Òh g¨ ldrk gS fd 'kY;fØ;k ds okafNr ifj.kke u ÁkIr

g aA ;g Òh laÒo gSa fd vkxs fdlh fnu eq>s fdlh vfrfjä 'kY;fØ;k dh vko';drk iM+s ;k ;g Òh g¨ ldrk gS fd eq>s 'kY;fØ;k ds ckn p'esYkxkus dh vko';drk iM+sA ;g laÒo gS fd ;g 'kY;fØ;k djus ds ckn eSa dkaVSDV Y al u igu ldwaA

2- laÒo gS fd 'kY;fØ;k ds ifj.kke Lo:i esjh n`f"V ;k loZJs"B la'k¨f/kr n`f"V pYkh tk,A ;g fdlh laØe.k ds ifj.kke Lo:i g¨ ldrk gS ftls,aafVck;kfV~Dl ;k nwljs lk/ku a ls fu;af"kr u fd;k tk lds] ftldh otg ls esjh vka[k Òh tk ldrh gSA

3- dVku a ds vfu;fer :i ls Òjus ds dkj.k dkfuZ;k dh lrg foÑr g¨ ldrh gSA ml fLFkfr esa eq>s mi;¨xh n`f"V ikus ds fYk, dkaVSDV Yäliguus dh vko';drk iM+ ldrh gS v©j ;g Òh laÒo gSa fd ;g esjh mi;¨xh n`f"V d¨ Yk©Vk u ldsA

4- eSa le>rk gwa fd eSa fofÒé le;kof/k; a ds fYk, ;k LFkk;h :i ls lwjt dh j¨'kuh ;k rst j¨'kuh ds nwljs lz r aa ls v{ke cuk nsus okYkh Ádk'klaosnu'khYkrk vuqÒo dj ldrk gwaA

5- eSa le>rk gwa fd eSa fofÒé le;kof/k; a ;k laÒor% LFkk;h :i ls 'kke ds le; ;k jkr esa vkus okYkh gsMYkkbV ;k rst Ádk'k ds vU; lz r a lsv{ke dj nsus okYkh p©a/k vuqÒo dj ldrk gwaA eSa tkurk gwa fd ;g vfuf'pr vof/k ds fYk, fnu v©j jkr nü a le; esa esjh okgu pkYku {kerkd¨ ÁfrdwYk :i ls ÁÒkfor dj ldrk gS] v©j eSa le>rk gwa fd eq>s rc rd okgu ugÈ pYkkuk pkfg, tc rd fd eSa vk'oLr u g¨ tkÅa fdfnu v©j jkr nü a ds n©jku esjh n`f"V i;kZIr gSA

6- eSa le>rk gwa fd ÁkjafÒd LFkkf;Ro vof/k ds n©jku fnu ds le; esjh nf"V esa ¼rhu eghus ;k blls vf/kd le; rd½ mrkj&p<+ko vk ldrs gSaA

7- tSlk fd lÒh 'kY;fØ;kRed ÁfØ;kv a esa g¨rk gS] oz.k fpUg thfor Ård a esa phjs Ykxkus ls curs gSaA ;g fo'¨"k 'kY;fØ;k d¨bZ viokn ugÈ gSA

8- esjh vka[k ?kko Òjus dh voLFkk ;k laÒor% ?kko Òjus ds ckn Òh vk?kkr ds Áfr vf/kd lqxzká g¨xh D; afd lw{en'kÊ oz.k Ård lkekU; Ård aftrus n`<+ ugÈ g axs lÒh laidZ v©j jSdsV ls [Ÿ¨ tkus okY¨ [Ÿk a ds n©jku lqj{kkRed us= igukos dh lYkkg nh tkrh gSA D; afd vka[k d¨ YkxusokYkk lh/kk vk?kkr vka[k d¨ {kfr igqapk ldrk gSA

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9- vfrfjä Áfrosfnr tfVYkrkv a esa dkfuZ;k ds fNæ 'kkfeYk gSa ftuds fYk, laÒor% Vkads Ykxkus dh vko';drk iM+ ldrh gS( phjs ls lacaf/kr varosZ'ku]dkfuZ;k dk okfgdko/kZu] dkfuZ;k esa oz.k cuus] bihfFkfYk;eh d¨f'kdkv a dk {k;] bihfFkfYk;eh ?kko ds Òjus esa foÑfr] v©j cgqr gh fojY¨ ekeYk aesa ,aMÏF©YkekbfVl ¼vka[k dk van:uh laØe.k ftlds dkj.k LFkk;h :i ls n`f"V tk ldrh gS½ 'kkfeYk gSaA

10- lÒh 'kY;fØ;kv a dh rjg blesa Òh laKkgj.k] nokv a ds ÁfrdwYk ÁÒko a ;k nwljs dkjd a ls ftlesa esjs 'kjhj ds nwljs fgLls 'kkfeYk g¨ ldrs gSa]tfVYkrk,a g a ldrh gSaA eSa le>rk gwa fd pwafd fdlh Òh 'kY;fØ;k ds ifj.kke Lo:i güs okYkh ÁR;sd tfVYkrk d¨ Lo"V djuk vlaÒo gS blfYk,g¨ ldrk gS fd bl Ái"k dh tfVYkrkv a dh lwph iwjh u gÄ

j¨xh dh LohÑfr v©j le>nkjh dk c;kueq>s bl nLrkost esa ,ds ds uke ls tkuh tkus okYkh ÁfØ;k dk foLr`r fooj.k fn;k x;k gS v©j esjs us= fpfdRld }kjk eq>s le>k;k x;k gSA esjs us=fpfdRld us esjs Á'u a ds lar¨"ktud mÙkj fn, gSaA eSaus ;g lwfpr lgefr Ái"k i<+ fYk;k gS ¼;k eq>s i<+ dj lquk;k x;k gS½ v©j eSa bls v©j laÒkfort¨f[ke a] tfVYkrkv a] v©j bl 'kY;fØ;k ds ifj.kke Lo:i güs okY¨ YkkÒ a d¨ iwjh rjg le>rk gwaA blfYk, eSa ,ds ltZjh dh lgefr nsrk gwaA

eSa nkb±@ckb± vka[k@nü a vka[k a ij ,ds djkuk pkgrk gwaA


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 %. ............................................................................................

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IntacsRashim Mannan, J. S. Titiyal


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

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

Nature of the Intacs ProcedureIntacs® is a non-laser procedure with FDA approval for use in patients with myopia and astigmatism. Intacs are intrastromal corneal ringsegments in the shape of a semi-circle which an ophthalmologist inserts into the non-seeing periphery of the cornea through a tinyincision. These segments flatten the central cornea without removing tissue to better focus light. The segments are made of the samematerial that’s been implanted in human eyes after cataract surgery, called PMMA (polymethylmethacrylate). The procedure is performedunder local anesthesia, peri-bulbar block or topical (eye drops) anesthesia. During the procedure, if performed under topical anesthesia,patient has to fix his or her gaze on the bright light of the operating microscope or as instructed by the operating ophthalmologist.

Expected benefits: Intacs® have the advantage of removability or exchangeability for different sized segments, and maintaining a morenatural corneal shape. Intacs cannot be felt by the patient, require no maintenance, and are probably less visible than a contact lens to thenaked eye. Patients who elect to have Intacs® are not “locked in” to the procedure forever, as are patients who undergo other refractiveprocedures such as LASIK or PRK.

Alternative treatments: I understand that continuous use of spectacles and / or contact lenses can provide good vision and Intacs® is analternative to decrease the dependence on glasses and / or contact lenses.

Possible Side Effects, Risks and Complications1. OVER/UNDER-CORRECTION: I understand that calculations used in this surgery are based on previous experience on large

number of patients and these use average values. I understand that Intacs® do not provide a full correction or a full reversal back toeye’s normal refractive state. Rather, the goal is to reduce myopia and astigmatism and /or to alter the shape of the cornea so thatcontact lenses can have a better fit. Thus depending on individual variations in response to the procedure, there may be someunder-correction or over-correction.

2. VISUAL ACUITY FLUCTUATION: I may have blurred vision or fluctuating vision following the procedure, this is due tomodulation in the corneal tissue in response to Intacs® in the corneal stroma.

3. LIGHT SENSTIVITY: I may experience glare or halos form light sources, more so during night time. These tend to disappear withtime but glare may persist for a long time particularly at night.

4. INDUCED ASTIGMATISM: I understand that I may experience a temporary blurring or distortion of vision for several days afterthe procedure. This type of visual distortion is normal during the healing process and, in most cases, it decreases over time.However, in rare instances, it may be permanent.

5. PRESBYOPIA AND OTHER OCULAR CONDITIONS: I understand that Intacs® will NOT prevent the development of naturallyoccurring eye problems such as glaucoma, cataracts, retinal degeneration, or detachment. Further Intacs® do not correct thecondition known as presbyopia (or aging of the eye), which may require reading glasses for close work at about age 40.

6. OTHER COMPLICATIONS: Like any other surgical procedure of the eye, insertion of Intacs® can lead to trauma to corneal tissueleading to corneal edema, perforation, infection, which if severe could result in the loss of the eye or, rarely, a cataract. I understandthat stromal thinning may occur due to shallow placement, which would require removal of the Intacs®. Further I have been madefully aware that if there are complications or problems during the surgery, the surgeon may not be able to insert Intacs®, and thesurgery may have to be cancelled.

There are other risks associated with any surgery. Since it is impossible to state every risk or complication that may occur as a result of anysurgery, the possible risks and complications listed in this informed consent may be incomplete. There may be risks or complicationsassociated with this surgery that are unknown because this is a relatively new procedure.

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I hereby give permission to release/publish medical data and/or video/audio record/photograph the current procedure and the proceduresperformed in subsequent/ follow up visits for the advancement of medical knowledge.

In signing this consent form for insertion of Intacs® I am stating that I have read this consent form (or it has been read to me) and I fullyunderstand the nature and the purpose of and the possible side effects, risks and complications of this procedure. Although it is impossiblefor the doctor to inform me of every possible complication that may occur, the doctor has answered all my questions to my satisfaction.

I give permission to perform Intacs® insertion on my R/L/Both eye(s).



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

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baVSDljkf'ke eéku] ts- ,l- frfr;kYk



baVSDl ÁfØ;k dh ÁÑfrbaVSDl® ek;¨fi;k v©j n`f"V oS"kE; ds j¨fx; a ds mi;¨x ds fYk, ,QMh, LohÑr ,d xSj Y¨tj ÁfØ;k gSA baVSDl v)Zo`Ùkkdkj var% ihfBdh; dkfuZ;kfjax flXesaV g¨rs gSa ftUgsa d¨bZ us"k fpfdRld ,d N¨Vs&ls phjs esa ls dkfuZ;k dh u fn[kus okYkh ifjf/k ds Òhrj ?kqlk nsrk gSA ;s flxesaV fcuk ÅrdfudkY¨ dkfuZ;k ds e/;Òkx d¨ piVk dj nsrs gSa ftlls Ádk'k csgrj <ax ls dsafær g¨rk gSA ;s flxesaV ih,e,e, i‚fYkesFkkbYk&esFkkØkbY¨V uked mlhinkFkZ ls cus g srs gSa ftls e¨fr;kfcan ds v‚ijs'ku ds ckn bulku dh vka[k esa ÁR;kj¨fir fd;k tkrk gSA ;g ÁfØ;k Yk¨dYk ,susLFkhfl;k] isjh cYcj CYk‚d;k V‚fidYk ¼vkbZMª‚i½ ,usLFkhfl;k ds varxZr fd;k tkrk gSA ÁfØ;k ds n©jku] ;fn V‚fidYk ,usLF¨fl;k ds varxZr fd;k tkrk gS r¨ j¨xh d¨ 'kY;fØ;kdj jgs us=fo'¨"kK ds funsZ'kkuqlkj v‚ijsfVax ekbØ¨Ldï dh rst j¨'kuh esa VdVdh Ykxk dj ns[kuk g¨rk gSA

visf{kr YkkÒ% baVSDl ds lkFk YkkÒ ;g g¨rk gS fd mUgsa fudkYkk tk ldrk gS ;k fofÒé eki ds [kaM+ a ds fYk, ijLij cnYkk tk ldrk gS] v©j dkfuZ;kdk vf/kd LokÒkfod vkdkj cuk, j[kk tk ldrk gSA j¨xh baVSDl® dh vuqÒwfr ugÈ dj ldrs] mudk d¨bZ vuqj{k.k ugÈ djuk g¨rk] v©j laÒor% dkaVSDVY al ds eqdkcY¨ uaxh vka[k a d¨ de fn[krs gSaA t¨ j¨xh baVSDl Ykxokus dk pquko djrs gSa mUgsa Ykkfld ;k ihvkjds tSlh nwljh viorZd ÁfØ;k,a djkusokY¨ j¨fx; a dh rjg ges'kk ds fYk, ÁfØ;k ds lkFk ûgÈ ca/¨ j[kuk* g¨rkA

oSdfYid mipkj% eSa le>rk gwa fd Ykxkrkj p'es v©j@;k dkaVSDV Y al dk mi;¨x vPNh n`f"V Ánku dj ldrk gS v©j baVSDl® p'es ;k dkaVSDV Y al aij fuÒZjrk de djus okY¨ fodYi gSaA

laÒkfor nq"ifj.kke] t¨f[ke v©j tfVYkrk, a1- vfr@vYi la'k¨/ku% eSa le>rk gwa fd bl 'kY;fpfdRlk esa Á;¨x güs okY¨ vkdYku j¨fx; a dh cM+h la[;k ds vuqÒo a ij vk/kkfjr g¨rs gSa v©j

os v©lr eku a dk mi;¨x djrs gSaA eSa le>rk gwaa fd baVSDl iwjk la'k¨/ku ugÈ djrs ;k vka[k a dh lkekU; viorÊ voLFkk d¨ iwjh rjg okilugÈ Y¨ vkrsA blds ctk; budk Yk{; fudV nf"Vn¨"k v©j nf"V oS"kE; d¨ de djuk v©j@;k dkfuZ;k ds vkdkj d¨ cnYkuk g¨rk gS rkfd dkaVSDVY al vPNh rjg fQV g aA blfYk, ÁfØ;k ds Áfr O;fäxr vuqfØ;kv a dh fofÒérk ds vk/kkj ij dqN vfrla'k¨/ku ;k vYi la'k¨/ku g¨ ldrs gSaA

2- n`f"V dh rhozrk esa mrkj&p<+ko% ÁfØ;k ds ckn esjh n`f"V /kqa/kYkh g¨ ldrh gS ;k esjh n`f"V esa mrkj&p<+ko vk ldrs gSaA ;g dkfuZ;k ds LVëkesa Ykxs baVSDl® dh vuqfØ;k es d¨fuZ;k ds Ård a esa e‚MÓwYku ds QYkLo:i g¨ ldrk gSA

3- Ádk'k laosnu'khYkrk% eSa Ádk'k ds lz r ls Ykacs le; rd p©a/k ;k ÁÒkeaMYk vuqÒo dj ldrk gwa] jkr ds le; ,slk v©j Òh g¨ ldrk gSA4- Ásfjr n`f"VoS"kE;% eSa le>rk gwa fd eSa ÁfØ;k ds ckn dbZ fnu rd vLFkk;h :i ls /kqa/kYkh ;k foÑfr n`f"V dh vuqÒwfr dj ldrk gwaA ?kko Òjus

ds n©jku bl rjg dh n`f"V laca/kh foÑfr lkekU; g¨rh gS] v©j vf/kdrj ekeYk a esa le; chrus ds lkFk ;g de g¨rh tkrh gSA Y¨fdu fojYëkeYk a esa ;g LFkkbZ g¨ ldrh gSA

5- tjk nwjn`f"V v©j n`f"V laca/kh voLFkk,a% eSa le>rk gwa fd baVSDl XYkkdëk] e¨fr;kfcan] jsfVuk ds vi{k; ;k foYkxko tSlh lkekU; r©j ij güsokYkh leL;kv a d¨ ugÈ j¨dsaxsA blds vfrfjä baVSDl Áslck;¨fi;k ¼;k vka[k a dk cq<+kik½ ds uke ls tkuh tkus okYkh voLFkk d¨ Bhd ugÈ djsxkftlesa YkxÒx 40 o"kZ dh mez esa utnhd ds dke ds fYk, i<+us dk p'ek vko';d g¨ tkrk gSA

6- vU; tfVYkrk,a% vka[k dh fdlh nwljh 'kY;fØ;kRed ÁfØ;k dh rjg baVSDl dk lféos'k dkfuZ;k ds Ård a d¨ vk?kkr igqapk ldrk gS ftllsdkfuZ;k esa lwtu vk ldrh gS] laØe.k g¨ ldrs gSa] t¨ ;fn xaÒhj gq, r¨ vka[k tk ldrh gS ;k fojY¨ ekeYk a esa e¨fr;kfcan g¨ ldrk gSA eSale>rk gwwa fd mFkY¨ LFkkiu ds dkj.k LVª ek irYkk g¨ ldrk gS ftlls baVSDl® dk fudkYkuk vko';d g¨ tkrk gSA blds vfrfjä eq>s bldsckjs esa iwjh tkudkjh nh xbZ gS fd ;fn 'kY;fØ;k ds n©jku d¨bZ tfVYkrrk,a ;k leL;k,a iSnk gqb± r¨ g¨ ldrk gS fd 'kY;fpfdRld baVSDlu ?kqlk lds v©j 'kY; fØ;k jÌ djuh iM+sA

'kY;fØ;k ds lkFk v©j Òh t¨f[ke tqM+s gSaA pwafd fdlh Òh 'kY;fØ;k ds ifj.kke Lo:i güs okY¨ ÁR;sd t¨f[ke ;k tfVYkrk dk [kqYkklk djuk vlaÒogS] blfYk, bl lgefr Ái= esa nh xbZ laÒkfor t¨f[ke a v©j tfVYkrkv a dh lwph viw.kZ g¨ ldrh gSA ;g Òh g¨ ldrk gS fd bl 'kY;fØ;k ls tqM+sdqN ,sls t¨f[ke ;k tfVYkrk,a g a t¨ vÒh rd vKkr g a D; afd ;g vis{kkÑr ubZ ÁfØ;k gSA

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eSa ,rn}kjk fpfdRlh; Kku dh Áxfr ds fYk, orZeku ÁfØ;k v©j vkxeh@Q‚Yk¨vi eqYkkdkr a ds n©jku dh tkus okYkh ÁfØ;kv a ls lacaf/kr fpfdRlh;vkadM+ a v©j@;k ohfM;¨ fjd‚MZ@fp"k tkjh djus@Ádkf'kr djus dh vuqefr nsrk gwaA baVSDl® ds lféos'k dh vuqefr nsrk gwaA

baVSDl® ds lféos'k dh vuqefr nsrs gq, eSa ?k¨"k.kk djrk gwa fd eSaus ;g lgefr Ái= i<+ fYk;k gS ¼;k eq>s i<+ dj lquk;k x;k gS½ v©j eSa ÁfØ;k dhÁÑfr v©j mÌs'; v©j laÒkfor nq"ÁÒko a] t¨f[ke sa v©j tfVYkrkv a d¨ le>rk gwaA gkYkkafd fpfdRld ds fYk, eq>s ÁR;sd laÒkofr tfVYkrk ds ckjs esalwfpr dj ikuk laÒo ugÈ gS Y¨fdu fpfdRld us esjs lÒh Á'u a ds lar¨"ktud mÙkj fn, gSaA

eSa viuh nkb±@ckb± vka[k@nü a vka[k a esa baVSDl® Ykxkus dh vuqefr nsrk gwaA


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 %. ............................................................................................

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Phakic IOLRashim Mannan, J. S. Titiyal


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

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

Nature Of The Phakic Iol ProcedureSurgical implantation of a phakic intraocular lens is one of a number of alternatives for correcting nearsightedness. In phakic implantsurgery, an artificial lens (such as the ICL or Verisyse phakic intraocular lens) is surgically placed inside your eye. The lens is made frommaterial similar to the type used for intraocular lenses currently being implanted in the eye to correct vision after cataract surgery. Thedifference between phakic implant surgery and other intraocular lens implants is that your natural lens is not removed during phakicimplant surgery. The phakic lens is inserted in addition to your natural lens. The procedure is performed under local anesthesia, peri-bulbar block.

The surgeon will make two small holes in the colored portion of your eye (the iris) to help ensure that intraocular fluid does not build upbehind the phakic lens; this procedure is called an iridotomy. It will take place either at the time of surgery by using an instrument (asurgical iridotomy) or within two weeks before the placement of the phakic implant by using a laser (YAG-laser iridotomy).

Indications & Expected Benefits If you have myopia, hyperopia or astigmatism, phakic implant surgery may improve your natural vision without the use of glasses orcontacts. Further they have the advantage of removability and maintaining a more natural corneal shape. Phakic IOL cannot be felt by thepatient, require no maintenance, and are less visible than a contact lens to the naked eye. Patients who elect to have Phakic IOL implantsare not “locked in” to the procedure forever, as are patients who undergo other refractive procedures such as LASIK or PRK.

Alternative TreatmentI understand that continuous use of spectacles and / or contact lenses can provide good vision and Phakic IOL is an alternative to decreasethe dependence on glasses and / or contact lenses.

Possible Side Effects, Risks And Complications

Vision Threatening Complications:ANAESTHETIC COMPLICATIONS: In most cases, the surgery will be accomplished with use of an injection around the eye foranesthesia. Very rare complications from injections include damage to the eye muscles, perforation of the eye, and damage to the retinaor optic nerve leading to loss of vision.

INFECTION: I understand that mild or severe infection is possible. Mild infection can usually be treated with antibiotics and usually doesnot lead to permanent visual loss. Severe infection, even if treated with antibiotics, could lead to permanent scarring and loss of vision.

IRIS ATROPHY: I understand that I could experience damage to the iris (the colored portion of the eye) leading to iris atrophy or developa rise in the pressure in my eye (secondary glaucoma). I may require another iridotomy if this occurs or eye drops to control the pressure.

RETINAL DETATCHMENT: I understand that I could develop a retinal detachment, a separation of the retina from its adhesion at theback of the eye, which usually results from a tear in the retina and could lead to vision loss. Patients with moderate to high levels ofnearsightedness have a higher risk of retinal detachment when compared to the general population. This risk level may be increased withimplantation of the phakic IOL.

CATARACT: I understand that I may develop a cataract, or a clouding of the eye’s natural lens, which impairs normal vision, and mayrequire removal of the lens, the phakic implant, and insertion of an artificial lens.

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CORNEAL INVOLVEMENT: I understand that I may develop corneal swelling (edema) and/or ongoing loss of cells lining the innersurface of my cornea (endothelial cells). These cells play a role in keeping the cornea healthy and clear. Corneal edema and loss ofendothelial cells may result in a hazy and opaque appearance of the cornea, which could reduce vision and may require a cornealtransplant.

GLAUCOMA: I understand that I may develop glaucoma, which is an increase in the pressure of the eye caused by slowed fluid drainage.Glaucoma can lead to vision loss, and may require treatment with long-term medications or surgery.

I understand that other complications could threaten my vision, including, but not limited to, iritis or inflammation of the iris (immediateand persistent), uveitis, bleeding, swelling in the retina (macular edema), and other visual complications. Though rare, certain complicationsmay result in total loss of vision or even loss of the eye. Complications may develop days, weeks, months, or even years later.

Non-vision-threatening Side EffectsGLARE OR HALOS: I understand that there may be increased sensitivity to light or night glare. I also understand that at night there maybe a “starbursting” or halo effect around lights. The risk of this side effect may be related to the size of my pupil, and larger pupils may putme at increased risk.

UNDER/OVER CORRECTION: I understand that an over-correction or under-correction could occur, causing me to become farsighted,remain nearsighted, or increase my astigmatism and that this could be either permanent or treatable with either glasses, contact lenses, oradditional surgery.

REPEAT SURGERY: I understand that the phakic lens may need to be repositioned, removed surgically, or exchanged for another lensimplant. The lens may change position (de-centration), or I may require a different size or power of lens than that of the implanted lens.Potential complications of additional surgery include all of the complications possible from the original surgery.

PROTECTIVE GLASSES: I understand that, after phakic implant surgery, the eye may be more fragile to trauma from impact. Iunderstand that the treated eye, therefore, is somewhat more vulnerable to all varieties of injuries. I understand it would be advisable forme to wear protective eyewear when engaging in sports or other activities in which the possibility of a ball, projectile, elbow, fist, or othertraumatizing object contacting the eye may be high.

PRESYOPIA: I understand that if I currently need reading glasses, I will still likely need reading glasses after this treatment. It is possiblethat dependence on reading glasses may increase or that reading glasses may be required at an earlier age if I have this surgery.

I understand that the correction that I can expect to gain from phakic implant surgery may not be perfect. I understand that it is notrealistic to expect that this procedure will result in perfect vision, at all times, under all circumstances, for the rest of my life. I understandI may need glasses to refine my vision for some purposes requiring fine detailed vision after some point in my life, and that this mightoccur soon after surgery or years later.

I understand that, since it is impossible to state every complication that may occur as a result of any surgery, the list of complications in thisform may not be complete.

I understand that because I have a phakic lens, it is important for me to be seen at all follow-up visits as felt necessary by my surgeon.

I hereby give permission to release/publish medical data and/or video/audio record/photograph the current procedure and the proceduresperformed in subsequent/ follow up visits for the advancement if medical knowledge.

In signing this consent form for insertion of Phakic IOL I am stating that I have read this consent form (or it has been read to me) and Ifully understand the nature and the purpose of and the possible side effects, risks and complications of this procedure. Although it isimpossible for the doctor to inform me of every possible complication that may occur, the doctor has answered all my questions to mysatisfaction.

I give permission to perform phakic IOL insertion on my R/L/Both eye(s).

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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

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( 127 )

dkfuZ;k dk buoksyesUV eSa le>rk gwa fd esjh dkfuZ;k esa lwtu ¼'k¨Fk½ vk ldrk gS v©j@;k esjh dkfuZ;k dh fupYkh lrg ds vLrj dh d¨f'kdkv a¼baM¨fFkfYk;eh d¨f'kdkv a½ dk {k; g¨ ldrk gSA ;s d¨f'kdk,a dkfuZ;k d¨ LoLFk v©j LoPN j[kus esa Òwfedk fuÒkrh gSaA d¨fuZ;k esa lwtu vkus v©jbaM¨fFkfYk;eh d¨f'kdkv a ds {k; ls dkfuZ;k /kqa/kYkh v©j vikjn'kÊ g¨ ldrh gS ftlls nf"V det¨j iM+ ldrh gS v©j dkfuZ;k ds ÁR;kjï.k dh vko';drkiM+ ldrh gSA

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nqckjk 'kY;fpfdRlk% eSa le>rk gwa fd Qsfdd Y¨l a d¨ iquLFkkZfir djuk iM+ ldrk gSA 'kY;fØ;k }kjk fudkYkuk ;k nwljs Y al ls iqujizR;kjï.k djukiM+ ldrk gSA Y al a dh fLFkfr cnYk ldrh gS ¼MhlsaVªs'ku½] ;k ÁR;kj¨fir Y al ds ikoj ls vYkx eki v©j ikoj okY¨ Y al dh vko';drk iM+ ldrh gSAvfrfjä 'kY;fpfdRlk dh laÒkfor leL;kv a esa ewYk 'kY;fpfdRlk dh lÒh laÒkfor leL;k,a 'kkfeYk g¨rh gSaA

lqj{kkRed p'ek% eSa le>rk gwa fd Qsfdd ÁR;kjï.k 'kY;fpfdRlk ds ckn esjh vka[k Vôj ls Ykxus okYks vk?kkr ds Áfr vf/kd uktqd g¨ ldrh gSAeSa le>rk gwa fd mipkfjr vka[k gj rjg dh p¨V a ds fYk, dqN vf/kd vk?kkr ;¨X; g¨rh gSA eSa el>rk gwa fd eq>s ,sls [Ÿk a ;k nwljh xfrfof/k; a esaÒkx Y¨rs le; lqj{kkRed p'es Ykxkus dh lYkkg nh tk,xh ftlesa vka[k ls xsan] xŸkh] dqguh] ?kwalk ;k vk?kkrdkjh nwljh oLrqv a ds Vdjkus dh vk'kadkvf/kd g¨ ldrh gSA

tjk nwjnf"V% eSa le>rk gwa fd ;fn bl le; eq>s i<+us ds p'es dh vko';drk gS r¨ g¨ ldrk gS fd bl mipkj ds ckn Òh i<+us ds p'es dh vko';drkiM+sA ;g Òh g¨ ldrk gS fd ;fn eSa ;g 'kY;fpfdRlk djkrk gwa r¨ i<+us ds p'es ij esjh fuÒZjrk v©j c<+ tk, ;k de mez esa gh i<+us ds p'es dht:jr iM+ tk,A

eSa le>rk gwa fd eSa Qsfdd vkbZvks,y ÁR;kjï.k ls ftl la'k¨/ku dh vis{kk djrk gwa 'kY;fpfdRlk ls og la'k¨/ku ÁkIr u gÄ eSa le>rk gwa fd ;gvis{kk djuk ;FkkZFkokn ugÈ gS fd bl ÁfØ;k ds QYkLo:i gj le;] v©j gj ifjfLFkr esa '¨"k thou Òj ds fYk, esjh n`f"V fcYkdqYk lgh g¨ tk,xhAlw{e foLr`r n`f"V dh ekax djus okY¨ Á;¨tu a ds fYk, viuh n`f"V ds ifjektZu ds fYk, p'es dh t:jr iM+ ldrh gS v©j ;g Òh fd 'kY;fpfdRlkds rqjar ckn ;k cjl a ckn bldh t:jr iM+ ldrh gSA

eSa le>rk gwa fd pwafd fdlh Òh 'kY;fpfdRlk dh lÒh leL;kv a d¨ O;ä djuk laÒo ugÈ g¨rk blfYk, g¨ ldrk gS fd bl Ái"k esa of.kZr leL;kv adh lwph iwjh u gÄ

eSa le>rk gwa fd pwafd eSaus Qsfdd Y©al Ykxok;k gS blfYk, esjk mu lÒh QkYk¨vi eqYkkdkr a ij tkap djkuk egRoiw.kZ gS ftUgsa esjk 'kY;fpfdRld vko';dle>rk gSA

,rn}kjk eSa fpfdRlh; Kku dh Áxfr ds fYk, orZeku ÁfØ;k v©j vkxs pYkdj@Q‚Yk¨vi ds n©jku dh tkus okYkh ÁfØ;kv a ds vkadM+s v©j@;kohfM;¨@v‚fM;¨ tkjh@Ádkf'kr djus dh vuqefr nsrk gwaA

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eSa viuh nkb±@ckb± vka[k@nü a vka[k a esa Qsfdd vkbZv¨,Yk bulVZ djus dh vuqefr nsrk gwaA

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Conductive KeratoplastyChandrashekhar


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

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

In giving my permission for Conductive Keratoplasty (CK) I understand the following:

The long-term risks and effects of CK are unknown. I have received no guarantee as to the success of my particular case. I understand thatthe following risks are associated with the procedure:

1. I understand that the visual acuity I initially gain from CK could regress, and that my vision may go partially or completely back tothe level it was immediately prior to having the procedure

2. I understand that it is possible that damage to my cornea could also be caused by scarring, ulceration, or an eye infection that couldnot be controlled with antibiotics or other means

3. I understand that I may not get a full correction from my CK procedure and this may require future enhancement procedures or theuse of glasses or contact lenses. This procedure may also cause an increase in my astigmatism, which may cause blurred vision

4. I understand that an over-correction could occur, causing me to become nearsighted, and that this nearsightedness could be eitherpermanent or treatable

5. I understand that the correction that I can expect to gain from CK may not be perfect and it is not realistic to expect that thisprocedure will result in perfect vision, at all times, under all circumstances, for the rest of my life. I understand I may need glassesto refine my vision for some purposes requiring fine detailed vision after some point in my life, and that this might occur soon aftersurgery or years later

6. I understand that there may be pain, scratchiness, a foreign body sensation, or slight dryness in my eye, particularly during the first48 hours after surgery

7. I understand that there may be increased sensitivity to light. I understand this condition usually resolves within the first few weeksfollowing treatment, but it may also be permanent

8. I understand that there may be a “balance” problem between my two eyes after CK has been performed on one eye, but not the other.This phenomenon is called anisometropia. I understand this would cause eyestrain and make judging distance or depth perceptionmore difficult. I understand that my first eye may take longer to heal than is usual, prolonging the time I could experienceanisometropia

9. I understand I may temporarily experience corneal haze, small round hazy areas where the cornea was heated during the CKtreatment. This haze will usually fade over time and may only be visible with a microscope within 3 months following surgery

10. I understand that if I currently need reading glasses, I will still likely need reading glasses after this treatment11. Even 90% clarity of vision is still slightly blurry. Enhancement surgeries can be performed when vision is stable UNLESS it is

unwise or unsafe. An assessment and consultation will be held with the surgeon at which time the benefits and risks of anenhancement surgery will be discussed

12. I understand that there is a natural tendency of the eyelids to droop with age and that eye surgery may hasten this process.13. I understand that the follow-up effects of CK are unknown and that CK has not been in use long enough to measure long-term

effects (those occurring after 10 years or more) following the procedures, and that unforeseen complications or side effects couldoccur

14. I understand that I may be given medication in conjunction with the procedure. I understand that I must not drive for at least oneday following the procedure and not until I am certain that my vision is adequate for driving

15. I understand that, as with all types of surgery, there is a possibility of complications due to anesthesia, drug reactions, or other factorsthat may involve other parts of my body. I understand that, since it is impossible to state every complication that may occur as a resultof any surgery, the list of complications in this form may not be complete

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The details of the procedure known as CK have been presented to me in detail and explained to me by my ophthalmologist. Myophthalmologist has answered all my questions to my satisfaction. I therefore consent to CK surgery my R/L eye.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 131 )

daMfDVo dsjkVÏYkkLVhpaæ'¨[kj



daMfDVo dsjkVÏYkkLVh ¼lhds½ ds fYk, vuqefr nsrs gq, eSa fuEufYkf[kr d¨ le>rk gwa%lhds ds nh?kZdkfYkd t¨f[ke v©j ÁÒko vKkr gSaA eq>s vius fo'¨"k ekeY¨ dh lQYkrk dh d¨bZ xkjaVh ugÈ feYkh gSA eSa le>rk gwa fd ÁfØ;k ds lkFkfuEufYkf[kr t¨f[ke tqM+s gSa%1- eSa le>rk gwa fd lhds ls ÁkjaÒ esa eq>s t¨ n`f"V laca/kh xfrfof/k ÁkIr g¨xh og i'pxeu dj ldrh gS v©j vkaf'kd :i ls ;k iwjh rjg ls ÁfØ;k

djkus ls Bhd igY¨ ds Lrj ij okil tk ldrh gS

2- eSa le>rk gwa fd laÒo gS fd oz.k fpUg] oz.k] ;k vka[k ds fdlh laØe.k ds dkj.k esjs dkfuZ;k d¨ {kfr igqap ldrh gS] ftls ,saVhck;¨fVDl ;knwljs lk/ku a ls dUVªksy ugÈ fd;k tk ldrk

3- eSa le>rk gwa fd g¨ ldrk gS fd viuh lhds ÁfØ;k ls eq>s iwjk la'k¨/ku u ÁkIr g¨ v©j g¨ ldrk gS fd Òfo"; esa lao`f) ÁfØ;k dh vko';drkiM+sA ;g ÁfØ;k esjs n`f"V oS"kE; d¨ c<+k ldrh gS] t¨ /kqa/kYkh n`f"V dk dkj.k cu ldrk gS

4- eSa le>rk gwa fd vfrla'k¨/ku g¨ ldrk gS t¨ eq>s fudV n`f"Voku cuk ldrk gS v©j ;g fudVn`f"VoÙkk ;k r¨ LFkk;h ;k mipkj ;¨X; g¨ ldrhgSA

5- eSa le>rk gwa fd eSa lhds ls t¨ la'k s/ku ÁkIr djus dh vis{kk djrk gwa og iwjh rjg lgh ugÈ g¨ ldrk v©j ;g vis{kk djuk ;FkkFkZokn ugÈg¨xk fd bl ÁfØ;k ds QYkLo:i esjh n`f"V '¨"kthou Òj ds fYk, gj le;] gj ifjfLFkfr esa iwjh rjg lgh g¨ tk,xhA eSa le>rk gwa fd viusthou ds fdlh eqdke ij dqN Á;¨tu a ds fYk, t¨ lw{e foLrr nf"V dh ekax djrs gSa] eq>s viuh nf"V ds ifjektZu ds fYk, p'es dh vko';drkiM+ ldrh gS] v©j 'kY;fpfdRlk ds rqjar ckn ;k o"k ± ckn ,slk g¨ ldrk gS

6- eSa le>rk gwa fd esjh vka[k a esa nnZ] fdjfdjkgV] dqN iM+s güs ;k gYds ls lw[ïu dh vuqÒwfr g¨ ldrh gS] fo'¨"kr;k 'kY;fpfdRlk ds igY¨48 ?kaVs ds n©jku

7- eSa le>rk gwa fd Ádk'k ds Áfr laosnu'khYkrk esa o`f) g¨ ldrh gSA eSa el>rk gwa fd mipkj ds 'kq#vkrh dqN g¶r a ds n©jku ;g j¨x Bhd g¨tkrk gS Y¨fdu ;g LFkk;h Òh g¨ ldrk gSA

8- eSa le>rk gwa fd esjh nü a vka[k a esa ugÈ] cfYd ,d vka[k esa lhds güs ds ckn esjh nü a vka[k a ds chp larqYku dh leL;k iSnk g¨ ldrh gSAbl x¨pj rF; d¨ n`f"V fo"kerk dgk tkrk gSA eSa le>rk gwa fd blls vka[k ij ruko iM+sxk v©j nwjh dk vuqeku Ykxkus v©j xgjkbZ d¨ le>usesa dfBukbZ g¨ ldrh gSA eSa le>rk gwa fd esjh igYkh vka[k dk ?kko Òjus esa lkekU; ls vf/kd le; Ykx ldrk gSA bl le; ds Ykack f[kapusls eSa n`f"V fo"kerk vuqÒo dj ldrk gwa

9- eSa le>rk gwa fd eSa vLFkk;h :i ls dkfuZ;k dk /kqa/kYkkiu vuqÒo dj ldrk gwa] N¨Vs&N¨Vs /kqa/kY¨ fgLls tgka ij lhds mipkj ds n©Sjku dkfuZ;kxeZ dh xbZ FkhA ;g /kqa/kYkkiu le; ds chrus ij lkekU;r;k [kRe g¨ tk,xk v©j 'kY;fpfdRlk ds rhu eghus ds Òhrj dsoYk lw{en'kÊ ls ns[kktk ldsxkA

10- eSa le>rk gwa fd ;fn eq>s bl le; i<+us dk p'ek Ykxrk gS r¨ bl mipkj ds ckn Òh eq>s p'es dh t:jr iM+ ldrh gSA

11- oLrqr% nf"V dh 90% Li"Vrk vÒh rd dqN /kqa/kYkh gSA nf"V ds fLFkj g¨ tkus ds ckn laof) 'kY;fpfdRlk dh tk ldrh gS] c'krsZ fd ;g vfoosdiw.kZv©j vlqjf{kr u gÄ 'kY;fpfdRld ds lkFk ewY;kadu v©j ijke'kZ fd;k tk,xk v©j mlh le; lao`f) 'kY;fpfdRlk ds YkkÒ a v©j t¨f[ke a ijppkZ dh tk,xh

12- eSa le>rk gwa fd iYkd a dh LokÒkfod Áo`fÙk g¨rh gS fd mez c<+us ds lkFk os >qdrh tkrh gSa v©j ;g Òh fd vka[k dh 'kY;fpfdRlk bl ÁfØ;kd¨ rst dj ldrh gS

13- eSa le>rk gwa fd lhds ds QkYk¨vi ÁÒko vKkr gSa v©j lhds brus Ykacs le; ls pYku esa ugÈ gS fd ÁfØ;kv sa ds ckn ds nh?kZdkfYkd ÁÒko ekistk ldsa ¼,sls ÁÒko t¨ 10 o"kZ ;k blls Òh vf/kd le; ckhn fn[krs gSa½ v©j ml rjg dh vuisf{kr leL;k,a ;k nq"ÁÒko g¨ ldrs gSa

14- eSa le>rk gwa fd eq>s ÁfØ;k ds lkFk&lkFk nok,a Òh nh tk ldrh gSaA eSa le>rk gwa fd eq>s ÁfØ;k ds de ls de ,d fnu ckn rd okgu ugÈpYkkuk pkfg, v©j rc rd ugÈ pYkkuk pkfg, tc rd fd eSa vk'oLr u g¨ tkÅa fd esjh n`f"V okgu pYkkus ds fYk, i;kZIr gS

15- eSa le>rk gwa fd tSlk fd lÒh rjg dh 'kY;fpfdRlkv a ds lkFk g¨rk gS] laosnukgj.k] nokv a ds ÁfrdwYk ÁÒko a] ;k esjs 'kjhj ds nwljs fgLl als tqM+s vU; dkjd a ds dkj.k leL;k,a iSnk g¨ ldrh gSaA eSa le>rk gwa fd fpfdRld ds fYk, fdlh Òh 'kY;fpfdRlk dh lÒh laÒkfor leL;kv adk O;¨jk ns ikuk vlaÒo g¨rk gS blfYk, g¨ ldrk gS fd bl Ái= esa nh xbZ leL;kv a dh lwph iwjh u gÄ

( 132 )

eq>s esjs us"k fo'¨"kK }kjk lhds ds uke ls tkuh tkus okYkh ÁfØ;k dk foLr`r O;¨jk fn;k x;k gSA esjs us"kfpfdRld us esjs lÒh Á'u a ds lar¨"ktudmÙkj fn, gSaA blfYk, eSa viuh nkb±@ckb± vka[k esa lhds 'kY;fpfdRlk djus dh vuqefr nsrk gwaA


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

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MkWDVj dk gLrk{kj %

MkWDVj dk uke %

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xokg 1 xokg 2

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( 133 )

Pterygium SurgerySaurbhi Khurana


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

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

I have been explained in the language that I understand that I have a fold of conjunctiva enroaching upon the cornea in my R/L eye, whichis to be surgically removed. The following has been explained to me:

• Corneal opacity would persist after surgery• Risk of recurrence of fold and need for repeat surgery• Visual prognosis remains guarded in view of persisting astigmatism, hence vision may / may not improve after removal of the

lesion• A piece of conjunctiva from the same / other eye may be required to prevent recurrence of the fold if an autoconjunctival graft is

planned after excision• If Mitomycin C is applied after excision to decrease the incidence of recurrence, risk of scleral thinning has been explained• Redness, irritation, watering may persist for a few days after surgery• In case of autograft, sutures will be applied and may lead to irritation. Risk of infection of the graft has been explained• Additional laser procedure may be required for removal of corneal opacity after surgery• Surgery would be done under local infiltration/ anesthetic drops

After knowing all this, I give my free and voluntary consent to undergo pterygium excision i.e. removal of conjunctival fold from my eye.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 134 )

Vsfjft;e 'kY;fpfdRlkl©jfÒ [kqjkuk



eSa t¨ Òk"kk le>rk gwa ml Òk"kk esa eq>s le>k x;k gS fd esjh dUtaDVªkbZok dh ,d ijr esjh dkfuZ;k ij vfrØe.k dj jgh gS ftls 'kY;fpfdRld}kjk gVk;k tkuk gS- eq>s fuEufYkf[kr ckrsa le>kbZ xbZ gSa%Û 'kY;fpfdRlk ds ckn Òh dkfuZ;k dh vikjnf'kZrk cuh jg ldrh gSÛ ijr ds nqckjk cu tkus dk t¨f[ke jgsxk v©j nqckjk mldh 'kY;fpfdRlk dh vko';drk iM+ ldrh gSÛ oZreku n`f"VoS"kE; ds eÌsutj n`"; iwZokuqeku lqjf{kr jgrk gS blfYk, ?kko d¨ fudkYk fn, tkus ds ckn n`f"V esa lq/kkj g¨ Òh ldrk gS v©j

ugÈ ÒhÛ ijr ds nqckjk vkus ls j¨dus ds fYk, mlh vka[k@nwljh vka[k ls dUtaDVªkbZok ds ,d VqdM+s dh t:jr g¨xh] ;fn ?kko fudkYkus ds ckn viuh

gh dUtaDVªkbZok ds mijï.k dh ;¨tuk ckukbZ tkrh gS r¨Û ;fn nqckjk ijr d¨ vkus ls j¨dus ds fYk, ?kko fudkY¨ tkus ds ckn ekbV¨flu&lh Ykxk;k tkrk gS r¨ LDY¨jk ds irY¨ güs ds t¨f[ke dk Li"Vhdj.k

fd;k tk pqdk gSÛ YkYkkbZ] Ánkg] v©j ikuh dk vkuk 'kY;fpfälk ds dqN fnu ckn rd cuk jg ldrk gSÛ viuh gh vka[k ds 'Y¨"ek ds mijï.k ds ekeY¨ esa Vkads Ykxk, tka,xs v©j mudh otg ls {k¨Ò g¨ ldrk gSA mijï.k esa laØe ds t¨f[ke d¨

Li"V fd;k tk pqdk gSÛ 'kY;fpfdRlk ds ckn dkfuZ;k dh vikjnf'kZrk d¨ fudkYkus ds fYk, vfrfjä Y¨tj ÁfØ;k dh vko';drk g¨xhÛ 'kY;fpfdRlk LFkkuh; var%lj.k@laosnuk gj.k Mª‚Il MkYk dj dh tk,xh

;g lc tkuus ds ckn esSa Vsfjft;e ,Dlfltu] ;kuh viuh vka[k ls 'Y¨"ek dh ijr d¨ fudkYkus dh Lora"k v©j LosZfPNd vuqefr nsrk gwaA


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( 135 )

Corneal ScrapingSaurbhi Khurana


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

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

I have been explained in my own language thah I am suffering from an ocular infection i.e. a corneal ulcer in my R/L eye. I am to undergoa diagnostic procedure in the form of a corneal scraping for the same. The following has been explained to me:

• After topical anaesthesia, material would be taken from the ulcerated area with the help of a needle and sent for investigations.• The procedure is being done to isolate the organisms responsible for the infection in order to start appropriate treatment for the

same.• This is not a therapeutic procedure and will not lead to improvement in symptoms/ healing of the lesion or in visual recovery.• There is a risk of corneal perforation during the procedure for which surgical intervention may be required.• This procedure may/ may not isolate the organism responsible for the infection and accordingly may have to be repeated.

After knowing all this, I give my free and voluntary consent to undergo corneal scraping from my R/L eye.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 136 )

dkfuZ;y LØsfixlqjfÒ [kqjkuk



eq>s esjh Òk"kk esa le>k;k x;k gS fd eSa us"k ds ,d laØe.k] ;kuh viuh nkb±@ckb± vka[k dh dkfuZ;y vylj ls ihfM+r gwaA eq>s blds funku ds fYk,dkfuZ;y LØsfix ds :i esa ,d uSnkfud ÁfØ;k djkuh gSA eq>s fuEufYkf[kr ds ckjs esa crk;k x;k gS%Û LFkkfud laosnukgj.k ds oz.k Q¨M+s okYkh txg ls ,d lwbZ dh lgk;rk ds dqN æO; fudkYkk tk,xk v©j mls tkap ds fYk, Òstk tk,xkA

Û ;g ÁfØ;k ml laØe.k ds fYk, ftEesnkj tho dk irk Ykxkus ds fYk, dh tk jgh gS rkfd mlds fYk, mi;qä mipkj 'kq: fd;k tk ldsA

Û ;g mipkjkRed ÁfØ;k ugÈ gS v©j blls Yk{k.k a esa lq/kkj ugÈ g¨xk@?kko ugÈ Òjsxk ;k n`f"V dh fjdojh ugÈ g¨xhA

Û ÁfØ;k ds n©jku dkfuZ;k esa fNæ güs dk t¨f[ke gS ftlds fYk, gLr{ï dh vko';drk iM+ ldrh gSA

Û g¨ ldrk gS fd ÁfØ;k ls laØe.k ds fYk, ftEesnkj tho u feY¨ v©j bls fQj ls djuk iM+sA

;g lc tkuus ds ckn eSa viuh nkb±@ckb± vka[k ds dkfuZ;k ls [kqjpu fudkYkus dh Lora"k v©j LosZfPNd lgefr nsrk gwa


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( 137 )

Fibrin Glue Adhesive for Corneal PerforationKiran G.


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

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

I have been clearly explained in the language I best understand that in view of my (diagnosis-corneal perforation), application of fibringlue will be attempted to seal the defect.

I have also been informed of the fact that this procedure is being attempted because the tissue defect in my cornea is less than 2 mm indiameter.

I am fully aware of the risk of failure of the procedure which may necessitate reapplication of the glue or alternate treatment modalities likecorneal patch grafting.

I am also aware of the fact that glue may produce inflammation of varying intensities in the eye and that the risk of endophthalmitis isgreater with this procedure than a patch graft.

Nevertheless, I wish to have the procedure performed in my R/L eye and I am willing to accept the potential risks that my doctor hasdiscussed with me.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 138 )

Qk;fczu XYkw v<sflo Q‚j dkfuZ;Yk iQ¨Zjs'kufdju th-



eq>s ml Òk"kk esa ftls eSa lcls vPNh rjg le>rk gwa] Li"V :i ls le>k;k x;k gS fd esjs ¼funku&dkfuZ;k ds fNæ½ d¨ ns[krs gq, bl [kkeh d¨ candjus ds fYk, Qk;fczu XYkw Ykxkus Ykxkus dk Á;kl fd;k tk,xkA

eq>s bl rF; ls Òh voxr djk;k x;k gS fd bl ÁfØ;k dk Á;kl blfYk, fd;k tk jgk gS fd esjh dkfuZ;k dh Ård foÑfr dk O;kl 2 feeh ls de gSA

eSa ÁfØ;k dh ukdkeh ds t¨f[ke ls Òh iwjh rjg voxr gwa ftlds fYk, XYkw ;k dkfuZ;k ds VqdM+s ds jï.k tSlh oSdfYid mipkj dh vko';drk g¨xhA

eSa bl rF; ls Òh voxr gwa fd XYkw vka[k esa vYkx&vYkx rhczrkv a ds Ánkg iSnk dj ldrk gS v©j ;g Òh fd bl ÁfØ;k ds lkFk baMÏF©YekbfVl dkt¨f[ke VqdM+s ds jï.k ls vf/kd g¨rk gSA

fQj Òh eSa viuh nkb±@ckb± vka[k esa ;g ÁfØ;k djkus dk bPNqd gwa v©j eSa mu laÒkfor t¨f[ke a d¨ Lohdkj djus d¨ rS;kj gwa ftuds ckjs esa fpfdRldus esjs lkFk ppkZ dh gSA


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( 139 )

Symblepharon ReleaseReena Sharma


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

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

I have been informed in my mother tongue that I/ my child is suffering from adhesion of ocular surface and lids (Symblepharon) due todisease involving the conjunctiva and cornea and that a surgery to remove this will be done. An amniotic membrane graft (humanplacental tissue) or mucous membrane graft may be applied to the ocular surface with the help of sutures. Bandage contact lens will beapplied after the surgery.

I have been fully explained regarding the permanent nature of the lesion and that it has to be released to improve the ocular surface. Thisprocedure primarily will not improve vision. I have been explained the risk of inadvertent perforation of the eye during the surgery,infection, inadequate release or reformation of adhesions. There may be a need for repeat surgery which may or may not lead toimprovement of vision. I have been explained the need for follow up as frequently as advised by the doctors that may span upto years, withmultiple investigations at each visit. I have been explained that proper use of medications is required for success of the treatment. Iunderstand that inspite of all efforts, there is a possibility that there may be no improvement or worsening of the visual acuity or thecosmetic appearance of the eye.

I certify that I have fully understood the implications of the above consent and authorise the doctors to perform symblepharon releasewith/ without AMT on my/ my child’s right / left eye.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 140 )

flaCY¨Qsj‚u fjYkhtjhuk 'kekZ



eq>s esjh ekr`Òk"kk esa crk;k x;k gS eSa@esjk cPpk datafDVok v©j dkfuZ;k ls lac) j¨x ds dkj.k vkdqyj ljQsl v©j iYkd ds fpidkYk ¼flaCY¨Qsj‚u½ls ihfM+r gS v©j ;g Òh fd bls Bhd djus ds fYk, 'kY;fpfdRlk dh tk,xhA Vkad a dh enn ls vkdqyj ljQsl ij ,fEuv‚fVd esacjsu ¼ekuo IY¨lsaVdsÅrd½ ;k 'Y¨"ek dYkk dk jï.k Ykxk;k tk,xkA 'kY;fpfdRlk ds ckn cSaMst dkaVSDV Y al Ykxk;k tk,xkA

eq>s ?kko dh LFkkbZ ÁÑfr ds ckjs esa iwjh rjg le>k;k x;k gS v©j ;g Òh fd vkdqyj ljQsl d¨ lq/kkjus ds fYk, bls [kŸkuk gSA ;g ÁfØ;k ewYkr%n`f"V ugÈ lq/kkjsxhA eq>s 'kY;fpfdRlk ds n©jku vlko/kkuh o'k vka[k esa fNæ] laØe.k] vi;kZIr eqfä] ;k vklatu a ds iqufuZeku dh vk'kadk ds ckjs esacrk;k x;k gSA nqckjk fpfdRlk dh vko';drk iM+ ldrh gS ftlls nf"V esa lq/kkj g¨ ldrk gS ;k ugÈ Òh g¨ ldrkA eq>s le>k;k x;k gS fd fpfdRldds lq>k, vuqlkj eq>s ckj&ckj Q‚Yk¨vi ds fYk, vkuk g¨xk t¨ cjl a pYk ldrk gS v©j ÁR;sd eqYkkdkr ij vusd tkapsa dh tk ldrh gSaA eq>s le>kx;k gS fd bYkkt dh lQYkrk ds fYk, nokv a dk Á;¨x vko';d gSA eSa le>rk gwa fd lÒh Á;kl a ds ckotwn laÒkouk gS fd n`f"V dh rh{.krk ;k vka[kdh Álk/kd cká vkÑfr esa d¨bZ lq/kkj u g¨ ;k v©j Òh [kjkc g¨ tk,A

eSa Áekf.kr djrk gwa fd eSaus mi;qZä lgefr ds fufgrkFk ± d¨ iwjh rjg le> fYk;k gS v©j fpfdRld d¨ ,,eVh ds lkFk@mlds fcuk viuh@vius cPpsdh nkb±@ckb± vka[k dh flaCY¨Qsj‚u fjYkht djus ds fYk, vf/kÑr djrk gwaA


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( 141 )

Amniotic Membrane Transplantation (AMT)Asim K. Kaudar


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

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

I have been informed in my mother tongue that I/ my child is suffering from a disease involving the ocular surface(specify ....................................) and that a surgery will be performed in which an amniotic membrane (covering of the foetal sac) will beused to cover the ocular surface. The amniotic membrane will be sutured into place with circumferential interrupted sutures with 10-0monofilament nylon sutures and the peripheral edge of the membrane will be sutured to the conjunctiva with 8-0 polyglactin interruptedsutures. The excess membrane will be trimmed and a bandage contact lens will be put after surgery.

I have been fully explained regarding the permanent nature of the opacity/ lesion. I have been explained the risk of perforation of the hosteye, leading to the need for a full thickness corneal transplant. There is risk of infection, suture loosening and replacement , increasedblood vessels in interface possibly leading to haemorrhage, no improvement or worsening of best corrected visual acuity and pain,glaucoma secondary to surgery or to medications after surgery. The membrane may shed off prematurely leading to repeat surgery whichmay or may not lead to improvement of vision. I have been explained the need for follow up as frequently as advised by the doctors that mayspan upto years, with multiple investigations at each visit. I have been explained that use of medications properly is required for successof the surgery. There is chance of falling of the bandage contact lens and it may require replacement. I have been explained that I will needto urgently come for follow-up to ophthalmic casualty if there is sudden onset redness, photophobia, pain or detoriation of vision as thesemay be early signs of amniotic membrane infection. I understand that inspite of all efforts, there is a possibility that there may beworsening of the visual acuity or the cosmetic appearance of the eye.

I certify that I have fully understood the implications of the above consent and authorise the doctors to perform Amniotic MembraneTransplantation on my right / left eye.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 142 )

,fEuv‚fVd esaczsu VªkalIYkkaVs'ku ¼,,eVh½vklhe ds- danj



eq>s esjh ekr`Òk"kk esa lwfpr fd;k xk;k gS fd eSa@esjk CkPpk vkdqyj ljQsl ls lac) j¨x ¼Li"V djsa----------------------------------------------------------------½ ls ihfM+rgS v©j ;g Òh ,d 'kY;fpfdRlk dh tk,xh ftlesa vkdqyj ljQsl d¨ <adus ds fYk, ,d ,fEuv‚fVd esacjsu ¼Òzw.kh; F©Ykh ds vkoj.k½ dk mi;¨x fd;ktk,xkA ,fEuv‚fVd esacjsu d¨ 10&0 eü¨fQYkkesaV uk;Yk‚u Vkad a dh enn ls ÒXuØe ifj/kh; Vkad a ls flYkk tk,xk v©j esaczsu ds ifj/kh; fdukjs d¨ÒXuØe 8&0 i‚fYkXY©fDVu Vkad a dh enn ls datafDVuk ds lkFk flYkk tk,xkA vfrfjä esaczsu d¨ rjk'k fn;k tk,xk v©j 'kY;fpfdRlk ds ckn cSaMstdkaVSDV Y al Ykxk;k tk,xkA

eq>s vikjnf'kZrk@?kko dh LFkkbZ ÁÑfr ds ckjs esa iwjh rjg le>k;k x;k gSA eq>s nkrk dh vka[k esa fNæ güs ds t¨f[k.k ds ckjs esa crk;k x;k gSA ftldhotgls iwjh e¨VkbZ dh dkfuZ;k ds ÁR;kjï.k dh vko';drk iM+ ldrh gSA laØe.k] Vkads ds <hYkk iM+ tkus v©j ÁfrLFkkiu] varjkQYkd esa jäokfgfu; ads c<+ tkus v©j laÒor% mldh otg ls jälzko güs] loZJs"V la'k¨f/kr n`'; xfrfof/k; a esa d¨bZ lq/kkj u güs ;k v©j Òh [kjkc g¨ tkus] v©j nZn] ltZjh;k nokv a ds x©.k ÁÒko ds :i esa XYkkdëke g¨ tkus dk t¨f[ke gSA esaczsu le; ls igY¨ fxj ldrh gS ftlds dkj.k nqckjk ltZjh djuh iM+ ldrhgS ftlls n`f"V esa lq/kkj g¨ Òh ldrk gS v©j ugÈ ÒhA eq>s crk;k x;k gS fd fpfdRld ds lq>k, vuqlkj esjk ckj&ckj QkYk¨vi ds fYk, vkuk vko';dg¨xk t¨ cjl a pYk ldrk gS v©j ÁR;sd QkYk¨vi ds le; dbZ tkapsa dh tk ldrh gSaA eq>s crk;k x;k gS fd ltZjh dh lQYkrk ds fYk, mfprvkS’kf/k ds Á;¨x vko';d gSA cSaMst dkaVSDV Y al ds fxjus dh Òh laÒkouk gS v©j mlds ÁfrLFkkiu dh vko';drk iM+ ldrh gSA eq>s crk;k x;k gSfd ;fn esjh vka[k esa vpkud YkYkkbZ vk tkrh gS] Ádk'k Òhfr] nnZ güs Ykxrh gS ;k n`f"V v©j Òh [kjkc güs Ykxrh gS r¨ eq>s rqjar us=fpfdRld vkikrd{k esa Q‚Yk¨vi ds fYk, vkuk g¨xk D; afd ;g ,fEuv¨fVd esacjsu esa laØe.k dk ÁkjafÒd ladsr g¨ ldrk gSA eSa le>rk gwa fd lÒh Á;kl a ds ckotwnlaÒo gS fd n`'; xfrfof/k ;k vka[k dh Álk/kd oká vkÑfr v©j Òh [kjkc g¨ tk,A

eSa Áekf.kr djrk gwa fd eSaus mi;qZä vuqÁ;¨x a ds fufgRkkFk ± d¨ iwjh rjg le> fYk;k gS v©j fpfdRldd a d¨ viuh nkb±@ckb± vka[k esa ,fEuv‚fVd esaczsuÁR;kjï.k dk vf/kdkj Ánku djrk gwaA


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 %. ............................................................................................

( 143 )

Limbal Stem Cell Transplantation (LSCT)Asim K. Kaudar, Bhavna Chawla


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

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

I have been informed in the language I best understand that I/ my child is suffering from an ocular surface disease with conjunctivalizationof the cornea (specify .........................................) and that a surgery to improve the ocular surface will be done along with removal of thesuperficial part of the cornea depending upon depth of involvement. A part (limbal tissue) of a donor cadaveric cornea / from oppositenormal eye / from live related donor will be used either directly or after expansion in tissue culture media to replace the diseased tissuewith the help of sutures.

I have been fully explained regarding the permanent nature of the disease and that this treatment is intended to improve the ocular surface.I have been explained the risk of perforation of the host eye, leading to full thickness corneal transplant. There is a risk of infection, graftrejection, suture loosening and replacement, increased blood vessels possibly leading to haemorrhage, no improvement or worsening ofbest corrected visual acuity. The opacity may increase after the surgery. There may be a need for repeat surgery which may or may not leadto improvement of vision. I have been explained the need for follow up as frequently as advised by the doctors that may span upto years,with multiple investigations at each visit. I have been explained that using medications properly is required for success of the graft. I havebeen explained that I will need to urgently come for follow-up to ophthalmic casualty if there is a sudden onset of redness, photophobia,foreign body sensation, pain or detoriation of vision as these may be early signs of infection or rejection. I understand that inspite of allefforts, there is a possibility that there may be worsening of the visual acuity or the cosmetic appearance of the eye.

I certify that I have fully understood the implications of the above consent and authorise the doctors to perform Limbal Stem CellTransplantation on my right / left eye.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 144 )

fYkacYk LVse lsYk VªkalIYkkaVs'ku ¼,y,llhVh½vlhe ds- danj] Òkouk pkoYkk



eq>s ml Òk"kk esa ftls eSa lcls vPNh rjg le>rk gwa le>k;k x;k gS fd eSa@esjk cPpk dkfuZ;k esa datafDVoYkkbts'ku ¼Li"V :i ls O;¨jk nsa----------------------------------------------------------½ ds lkFk vkD;wYkj lQsZl fMtht ls ihfM+r gS v©j ;g Òh fd tfVYkrk dh xgjkbZ ds vk/kkj ij dkfuZ;k ds ÅijhfgLls d¨ fudkYkus ds lkFk&lkFk us= dh lrg d¨ lq/kkjus ds fYk, ,d 'kY;fpfdRlk dh tk,xhA nkrk ds dsMkosfjd dkfuZ;k nwljh lkekU; vka[k@fj'rsds thfor nkrk ds dkfuZ;k ds ,d Òkx ¼fYkacYk Ård½ dk lh/¨ ;k Ård lao/kZu ek/;e esa foLrkj ds ckn Vkad a dh lgk;rk ls j¨xh Ård a d¨ ÁfrLFkkfirdjus ds fYk, mi;¨x fd;k tk,xkA

eq>s j¨x dh LFkk;h ÁÑfr ds ckjs esa iwjh rjg crk;k x;k gS v©j ;g Òh fd bYkkt dk mns'; us= dh lrg d¨ lq/kkjuk gSA eq>s nkrk dh vka[k esa fNæg¨ tkus ds t¨f[ke ds ckjs esa Òh crk;k x;k gS ftldh otg ls iwjh e¨VkbZ ds dkfuZ;k dk ÁR;kjï.k djuk iM+ ldrk gSA laØe.k] fujï dh vLohÑfr]Vkads ds <hYkk güs v©j ÁfrLFkkiuk] jä okfgfu; a dh la[;k ds c<+ tkus v©j QYkLo:i jälzko] loZJs"B n`f"V rh{.krk esa d¨bZ lq/kkj u güs ;k mldsv©j Òh [kjkc g¨ tkus dk t¨f[ke gSA nqckjk 'kY;fpfdRlk djus dh vko';drk iM+ ldrh gS ftlls esa lq/kkj g¨ ldrk gS ;k ugÈ Òh g¨ ldrkA eq>sfpfdRld dh lYkkg ds vuqlkj ckj&ckj Q‚Yk¨vi ds fYk, vkus dh vko';drk ds ckjs esa crk;k x;k gS t¨ cjl a pYk ldrk gS v©j ÁR;sd eqYkkdkrij dbZ tkapsa dh tk ldrh gSaA vpkud YkYkkbZ vk tkus] Ádk'k Òhfr güs d¨bZ pht iM+s güs dh vuqÒwfr güs] nnZ gS ;k n`f"V v©j [kjkc g¨ tkus ijeq>s rqjar us"kfpfälk vkikr d{k esa Q‚Yk¨vi ds fYk, vkus dh t:jr ds ckjs esa crk;k x;k gS D; afd ;s laØe.k ;k vLohÑfr ds ÁkjafÒd Yk{k.k g¨ldrs gSaA eSa le>rk gwa fd lÒh Á;kl a ds ckotwn laÒkouk gS fd vka[k dh n`'; rh{k.rk ;k Álk/kd okáÑfr v©j Òh [kjkc g¨ ldrh gSA

eSa Áekf.kr djrk gwa fd eSaus mi;qZä lgefr ds fufgrkFk ± d¨ iwjh rjg le> fYk;k gS v©j fpfdRld a d¨ viuh nkb±@ckb± vka[k esa fYkacYk LVse lsYkVªkalIYkkaVs'ku dsjus dk vf/kdkj Ánku djrk gwaA


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 %. .............................................................................................

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( 145 )

Osteo-odonto Keratoprosthesis (OOKP)Noopur Gupta, Radhika Tandon


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

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

I have been informed in my mother tongue that I will need a specially designed keratoprosthesis where the artificial cornea is embeddedin a biological frame made of the canine tooth to enhance support and long-term stability of the visual aid to treat my blind eye/eyes as thisis the last option of restoring vision in my present condition and no other surgical procedure e.g. keratoplasty will be successful as I havesevere dry eyes also.

I understand that Keratoprosthesis will replace my opaque, white cornea and act like a telescope, so that the light rays can go in the eye andreach the retina (back of the eye which is the seeing machinery of the eye) and I will be able to see.

I have been fully explained that for osteo-odonto-keratoprosthesis (OOKP), one of my healthy canine tooth/teeth will be harvested forthe surgery and a layer of the inner lining of the cheek will also be taken to cover the surface of the eye. The surgery will be done in twostages which will be two months apart, so it may take a long time to gain vision after the first stage of the surgery.

I have been explained the potential benefits and risks of the procedure and that there is a possibility of no visual gain after surgery. Theremay be potential complications like extrusion or necrosis of the OOKP lamina, infection in the eye and increased pressure in the eye.There may be need of further surgeries if tissue grows over the OOKP cylinder or a membrane forms behind the cylinder, both of whichwill need to be removed.

I certify that I have fully understood the implications of the above consent and authorize the doctors to perform OOKP surgery in my right/left eye.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 146 )

vk¡fLVvks&v¨MäV¨ dsjkV¨Á¨LF¨fll ¼vksvksdsih½uwiqj xqIrk] jkf/kdk VaMu



eq>s esjh ekr`Òk"kk esa crk;k x;k gS fd eq>s fo'¨"k :i ls fMtkbu fd, x, ,d dsjkV¨Á¨LF¨fll dh vko';drk g¨xh] ftlesa esjh va/kh vka[k@vka[k a dkbYkkt djus ds fYk, n`'; lgkjs ds leFkZu v©j nh?kZ dkfYkd LFkkf;Ro d¨ c<+kus ds fYk, jnu ds nar ds tho oSKkfud <kaps esa Ñf"ke dkfuZ;k tM+h tkrhgS] D; afd esjh orZeku voLFkk esa esjh nf"V cpkus dk vafre fodYi ;gh gS v©j dsjkVÏYkkLVh lQYk ugÈ g axh D; afd esjh vka[ a xaÒhj :i ls lw[kh Òh gSaA

eSa le>rk gwa fd dsjkV¨Á¨LF¨fll esjs vikjn'kÊ lQsn dkfuZ;k d¨ ÁfrLFkkfir dj nsxk v©j fdlh nwjn'kÊ dh rjg dke djsxk rkfd Ádk'k dh fdj. alh/¨ esjh vka[k esa tk,a v©j esjh vka[k dh jsfVuk ¼vka[k dk fiNYkk fgLlk t¨ vka[k dh ns[kus okYkh e'khujh gS½ rd igqapsa v©j eSa ns[kus esa l{ke g¨ ldwaA

eq>s iwjh rjg le>k;k x;k gS fd vk¡fLVvks&v¨M aV¨ dsj¨V¨Á¨LF¨fll ¼v¨v¨dsih½ ds fYk, esjk ,d LoLFk jnud nar fudkYkk tk,xk v©j esjh vka[kdh lrg d¨ <adus ds fYk, xkYk dh van:uh ijr dk ,d irYkk vLrj Òh fYk;k tk,xkA 'kY;fpfdRlk n¨ pj.k a esa dh tk,xh t¨ n¨ eghus ds varjij g axsA blfYk, 'kY;fpfdRlk ds igY¨ pj.k ds ckn esjh n`f"V ds okil vkus essa Ykack le; Ykx ldrk gSA

eq>s laÒkfor YkkÒ a v©j t¨f[ke a ds ckjs esa crk;k x;k gS v©j laÒkouk ;g Òh gS fd 'kY;fpfdRlk ds ckn d¨bZ n`"; YkkÒ u gÄ v¨v¨dsih Y©feuk dsofgosZ/ku] ;k foxYku] vka[k esa laØe.k v©j vka[k esa ncko c<+us tSlh laÒkfor leL;k,a Òh g¨ ldrh gSaA ;fn v¨v¨dsih flfyaMj ij Ård c<+ vkrs gSa;k flfyaMj ds ihNs esEcjsu cu tkrh gS r¨ nü a d¨ fudkYkuk g¨xkA

eSa Áekf.kr djrk gwa fd eSaus mi;qZä lgefr ds fufgrkFk ± d¨ iwjh rjg le> fYk;k gS v©j fpfdRld a d¨ viuh nkb±@ckb± vka[k esa v¨v¨dsih djus dkvf/kdkj nsrk gwaA


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

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MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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

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SQUINT

( 147 )

Squint SurgeryShailesh G.M, Rohit Saxena


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

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

Information about SquintAdults & children of any age with eye deviation may benefit from eye muscle surgery to make both eyes look straight. This will helpmaximizing the chance of binocular fusion (3-D vision/depth perception) and normalizing the field of vision. Apart from making themlook cosmetically better, squint surgery may also allow patients to see more comfortably with a relaxed head position.

Events during surgery• General anesthesia is given in children & some special squint cases.• Local anesthesia in the form of injections around the eye is given in adults.• During surgery, one eye or both eye muscles are either tightened or loosened & the positions of the eye muscles are changed to

make eyes look straight.

Risks associated with Squint surgeryWhile we are unable to list every possible complication, the following are some potential risks.

Major risks1) Due to anesthesia (both general & local) – includes breathing difficulties, vomiting, sore throat, or even risk of heart attack or

death. Local complications of anesthesia injections around the eye can be in the form of perforation of eyeball, destruction of opticnerve, interference with circulation of retina, drooping of eyelid, hypotension & respiratory depression.

2) Need for reoperation – Over- and under-correction after surgery is common. A reoperation may be necessary because a totallypredictable response is not possible in every case. Need for reoperation may be high in cases where prior surgery has beenperformed, when the squint is complicated, in cases of a slipped or lost muscle, excessive hemorrhage, or fat exposure. Reoperationin some cases may be needed in the other (normal) eye also later to fine tune the surgical results.

3) Loss of vision – is quite rare but can be associated with anesthesia or other causes like hemorrhage, retinal detachment (after needleperforation), infection, or change in blood supply to the eye.

Minor risks: include inflammation of the eye (conjunctivitis), reaction to the sutures, pain, temporary double vision, temporary blurryvision, alteration of the eyelid position and scar tissue formation including implantation cysts.

General information• Discomfort of eyes, redness & swollen eyelids for the first few days after surgery is common.• If child wears glasses, they will likely continue to wear glasses after the surgery.• Eyes are not patched after surgery & usually there is no permanent scar.• Eye drops are given 3 to 6 times a day for up to 1 month after surgery.• Temporary double vision after surgery is common.• Absorbable sutures are used & need not be removed after surgery.

Additional comments: ....................................................................................................................................................................................................

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

I have read & understand the consent form including potential risks & benefits of the squint surgery. I have discussed with my treating eye

( 148 )

surgeons & am satisfied with the explanation provided & I authorize them to proceed with my/child’s surgery. Occasionally a different,unsuspected condition may arise at the time of surgery requiring immediate attention, and I authorize my surgeon to do what he/shedeems necessary.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 149 )

fLdfoUV ltZjh'©Y¨'k th,e] j¨fgr lDlsuk



fLdfoUV ds ckjs esa tkudkjhfolkekU;rk xzLr fdlh Òh mez ds o;Ld v©j cPps nü a vka[k a ds lh/kk fn[kus ds fYk, dh tkus okYkh vka[k dh is'kh dh 'kY;fpfdRlk ls YkkÒkfUor g¨ldrs gSaA ;g f}us=h; lesdu ¼3&Mh n`f"V@xgjkbZ dk Kku½ dh laÒkoukv a d¨ vf/kdre djus esa enn djsxh v©j n`f"V d¨ lkekU; djsxhA vka[k ad¨ Álk/kd okáÑfr dh n`f"V ls fn[kus esa csgrj cukus ds vYkkok fLdfoUV 'kY;fpfdRlk flj dh f'kfFkYk voLFkk esa j¨xh d¨ vf/kd vkjke ls ns[kusdh Òh lgwfYk;r ns ldrh gSA

ltZjh ds n©jku dh ?kVuk,aÛ cPp a v©j fLdfoUV ds dqN fo'¨"k ekeYk a esa lkekU; ,susLFkhfl;k nh tkrh gSA

Û o;Ld a esa vka[k ds vkl&ikl lwbZ Ykxk dj LFkkuh; ,susLFkhfl;k nh tkrh gSA

Û 'kY;fpfdRlk ds n©jku ,d vka[k ;k nüä vka[k¨ a dh isf'k; a d¨ ;k r¨ dlk ;k <hYkk fd;k tkrk gS v©j vka[k dh isf'k; a dh fLFkfr cnYkhtkrh gS rkfd vka[ a lh/kh fn[ aA

fLdfoUV ltZjh ls tqM+s t¨f[kegkYkkafd ge ÁR;sd laÒkfor tfVYkrk dh lwph nsus esa v{ke gSa Y¨fdu dqN laÒkfor t¨f[ke fuEufYkf[kr gSA

Áeq[k t¨f[ke1½ ,susLFkhfl;k ds dkj.k ¼lkekU; v©j LFkkuh; nü a ½ buesa 'kkfeYk gSa% lkal Yüs esa dfBukbZ] xY¨ esa Ánkg ;k fnYk dk n©jk iM+uk ;k e`R;q g¨

tkukA vka[k ds vkl&ikl YkxkbZ tkus okYkh ,susLFkhfl;k dh lwbZ dh LFkkuh; tfVYkrk,aa us= xŸkd esa fNæ g sus] n`'; raf"kdk ds /oal] jsfVuk dsjälapkj esa cka/kk] vka[k dh iYkd a ds >qd tkus] mPpjäpki v©j 'olu laca/kh volkn ds :i esa lkeus vk ldrh gSaA

2½ iqu% 'kY;fØ;k dh vko';drk&'kY;fpfdRlk ds ckn vfr@vYi la'k¨/ku lkekU; g¨rk gSA iqu% 'kY;fpfdRlk vko';d g¨ ldrhgS D; afd ÁR;sd ekeY¨ esa iwjh rjg iwokZuqekus; vuqfØ;k laÒo ugÈ g¨rhA mu ekeYk a esa iqu% 'kY;fpfdRlk dh vko';drk g¨ ldrh gS] igY¨Òh ftudh 'kY;fpfdRlk g¨ pqdh g¨rh gS] tc fLdfoUV tfVYk g¨rk gS] isf'k; a ds f[kld tkus ;k is'kh; {k; ds ekeYk a esasa] vR;f/kd jälzko ;ko'kk dk [kqYk tkukA dqN ekeYk a esa 'kY;fpfdRlk ifj.kke a d¨ lw{e la’kks/ku djus ds fYk, iqu% 'kY;fpfdRlk dh vko';drk iM+ ldrh gSA

3½ n`f"V dk {k;& cgqr gh fojY¨ ekeYk a esa g¨rk gS Y¨fdu ,susLFkhfl;k ;k jälzko] jsfuuk dk foYkxko] ¼lwbZ ls fNæ g¨ tkus ds ckn½ ;k vka[k dhjä vkiwfrZ esa cnYkko tSls nwljs dkj.k a ls tqM+k g¨ ldrk gSA

N¨Vs t¨f[ke% esa 'kkfeYk gSa vka[k dk Ánkg ¼datfDVovkbfVl½] Vkad a ds Áfr ÁfrfØ;k] nnZ] vLFkkbZ nqgjh n`f"V] vLFkkbZ /kqa/kYkh n`f"V] vka[k dh iYkddh fLFkfr esa cnYkko] ÁR;kjï.k flLV cuus lfgr oz.kfpUg Ård a dk cuukA

lkekU; tkudkfj;kaÛ 'kY;fpfdRlk ds ckn ds dqN ÁkjafÒd fnu a ds fYk, vk[k a dh rdYkhQ] YkYkkbZ] v©j lwth gqbZ iYkdsaA

Û ;fn cPpk p'ek Ykxkrk gS r¨ og 'kY; fpfdRlk ds ckn Òh p'ek Ykxkuk tkjh j[k ldrk gSA

Û 'kY;fpfdRlk ds ckn vka[k a esa t¨M+ ugÈ Ykxk;k tkrk v©j lkekU;r;k d¨bZ fu'kku ugÈ iM+rkA

Û 'kY;fpfdRlk ds ckn 1 eghus rd fnu esa 3 ls 6 ckj vkbZ Mª‚Il MkY a tkrs gSaA

Û 'kY;fpfdRlk ds ckn vLFkkbZ nqgjh n`f"V lkekU; gSA

Û vo'k¨"; Vkads Ykxk, tkrs gSa v©j 'kY;fpfdRlk ds ckn fudkYkus dh vko';drk ugÈ iM+rhA

vfrfjä fVIif.k;ka%. .............................................................................................................................................................................. ............................................................................................................................................................................................................eSaus laÒkfor t¨f[ke a v©j YkkÒ a lfgr lgefr Ái= d¨ i<+ v©j le> fYk;k gSA eSaus viuk bYkkt dj jgs us"k 'kY;fpfdRld ls ppkZ dh gS v©j fn,

( 150 )

x, Li"Vhdj.k a ls larq"V gwa v©j mUgsa viuh@vius cPps dh 'kY;fpfdRlk djus dk vf/kdkj nsrk gwaA dÒh dÒkj 'kY;fpfdRlk ds le; ,d vYkx]vuisf{kr voLFkk,a mÒj dj lkeus vk ldrh gSa t¨ vfoYkac /;ku nsus dh ekax dj ldrh gSa v©j eSa vius 'kY;fpfdRld d¨ og djus dk vf/kdkj nsrkgwa t¨ og vko';d lerk@le>rh 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 %. .............................................................................................

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( 151 )

Botox (Botulinum Toxin) InjectionShailesh G.M, Rohit Saxena


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

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

I .............................................................................. have discussed my illness with my treating eye surgeon and I consent to having Botoxtreatment carried out upon myself for the improvement of .......................................................................................

Botox is injected with a small needle into the skin/muscle, with the aim of inhibiting the underlying muscle contraction, thereforeimproving my underlying muscle spasms/illness. In squint cases, the injection will weaken the overacting muscle & help in making theeye look straight. Botox injection also gives additional information about squint and can be used instead of performing surgery.

I have been informed about the indications, treatment procedure, expected results & possible side effects. I understand that I mayexperience swelling, redness, tenderness, flu-like syndrome, temporary muscle aching, as well as paralysis of a nearby muscle (which cancause droopy eyelids, double vision, droopy mouth, or neck weakness), slight headache, pain and/or bruising that may occur for severaldays after my treatment, however these symptoms will resolve.

Although the results are usually dramatic, I have been informed that the practice of medicine is not an exact science and that no guaranteescan be made concerning the expected results in my case. The injection will take 3-4 days to start acting & will usually last for up to 3months. Repeated injections may be required as the effect starts decreasing from 3-months onwards.

I understand that I am required to have a follow-up consultation at 2 weeks, and that I am required to have photographs taken before,during and after treatment for my medical records.

ContraindicationsYou should not have Botox if you are pregnant; nursing; allergic to albumin; have an infection, skin condition, or muscle weakness at thesite of the injection; or have Eaton-Lambert syndrome, Lou Gehrig’s disease, or myasthenia gravis. Botox contains human-derivedalbumin and carries a theoretical risk of virus transmission.

I understand that whilst every precaution will be taken to prevent complications and that whilst complications from this procedure arerare, they can and sometimes do occur. I certify that I have read, and fully understand the above paragraphs and that I have had sufficientopportunity for discussion to have any questions answered.



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

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

( 152 )




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 153 )

c¨V¨Dl ¼c¨VqfYkue V‚fDlu½ batsD'ku'©Y¨'k th,e] j¨fgr lDlsuk



eSaus---------------------------------------------------------------------------------------------------------------------------------------------------------------- viuk bYkkt dj jgs 'kY;fpfdRld ls ppkZ dh gSv©j ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ds lq/kkj ds fYk, vius Åij c¨V¨Dl fpfdRlkdjkus ds fYk, lger gwaA vk/kkjÒwr is'kh ladqpu ds voj¨/ku] blfYk, esjh vk/kkjÒwr is'kh esa vkdqapu@chekjh esa lq/kkj Ykkus ds mÌs'; ls ,d N¨Vh lhlwbZ ls Ropk@is'kh esa c¨V¨Dl dh lwbZ YkxkbZ tkrh gSA fLdfoUV ds ekeYk a esa lwbZ vfr lfØ; isf'k; a d¨ det¨j djsxh v©j vka[k dss lh/kk fn[kus esaenn djsxhA c¨V¨Dl dk batsD'ku fLdfoUV ds ckjs esa vfrfjä tkudkjh nsrk gS v©j 'kY;fpfdRlk djus dh txg Á;¨x fd;k tk ldrk gSA

eq>s fpfdRlk l>ko a] fpfdRlk ÁfØ;k] visf{kr ifj.kke a v©j laÒkfor nq"ifj.kke a ds ckjs esa lwpuk nh xbZ gSA eSa le>rk gwa fd eSa lwtu] YkYkkbZ]laosnu'khYkrk] ¶Ykw tSls flaMª e] vLFkkbZ is'kh; nnZ ds lkFk&lkFk vkl&ikl dh isf'k; a dk Ykdok ¼t¨ >qdh iYkd a] nqgjh n`f"V] >qds eqag ;k xnZu dhdet¨jh dk dkj.k curk gS½] gYdk ljnnZ] nnZ ;k xweM+ vuqÒo dj ldrk gwa t¨ bYkkt ds dbZ fnu ckn rd g¨ ldrk gSA cgjgkYk ;s Yk{k.k [kReg¨ tk,axsA

gkYkkafd urhts vker©j ij ukVdh; g¨rs gSa] Y¨fdu eq>sa crk;k x;k gS fd fpfdRlk dk is'kk lVhd foKku ugÈ gS v©j ;g Òh fd fdlh Òh ekeY¨ esavisf{kr ifj.kke dh d¨bZ xkjaVh ugÈ nh tk ldrhA batsD'ku ds dke djuk 'kq: djus esa 3&4 fnu Ykxsaxs v©j rhu eghus rd dke djrs jgsaxsA rhueghus ckn tc mudk ÁÒko de güs Ykxsxk r¨ fQj ls batsD'ku Ykx ldrs gSaA

eSa le>rk gwa fd eq>s 2 g¶rksa ij ijke'kZnkrk fpfdRld ls Q‚Yk¨vi ds fYk, feYkuk g¨xk v©j eq>s vius fpfdRlh; vfÒY¨[k ds fYk, bYkkt ls igY¨]mlds n©jku v©j mlds ckn vius Q¨V¨ f[kapokus g axsA

dUVªkbafMds’ku

;fn vki xÒZorh gSa( Lruiku djkrh gSa( ,Ycqfeu dh ,YktÊ gS( d¨bZ laØe.k gqvk gS( Ropk dk d¨bZ j¨x gS( ;k batsD'ku dh txg ij is'kh; det¨jhgS( ;k bZVü&ywxSfjl fMthu j¨x] ;k ek;kLF¨fu;k xzsfol gSa r¨ vkid¨ c¨V¨Dl ugÈ Yük pkfg,A c¨V¨Dl esa ekuo O;wRié ,Ycqfeu g¨rh gS v©j fo"kk.kqÁlkj.k ds lS)kafrd [krjs dk okgd g¨rh gSA

eSa le>rk gwa fd gkYkkafd tfVYkrkv a d¨ j¨dus ds fYk, gj lko/kkuh cjrh tk,xh] v©j gkYkkafd bl ÁfØ;k ls cgqr de tfVYkrk,a iSnk g¨rh gS] fQjÒh os g¨ ldrh gSa v©j dÒh&dÒkj g¨ tkrh gSaA eSa Áekf.kr djrk gwa fd eSaus mi;qZä iSjs i<+ v©j iwjh rjg le> fYk, gSa v©j eq>s ppkZ djus v©j d¨bZÁ'u mBus ij muds mÙkj ikus dk i;kZIr volj feYkk gSA


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

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


( 154 )




MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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

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

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

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

GLAUCOMA

( 155 )

Trabeculectomy With / Without Anti-Fibroblastic AgentsMunish Dhawan, Ramanjit Sihota


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

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

Indications, Benefits, and AlternativesI have been informed by my treating doctor that I have been diagnosed with glaucoma and if it is left untreated, it is very likely that I willexperience loss of vision which could end up in blindness. Glaucoma means rise in pressure of the eye which can sometimes be treatedsuccessfully with medications, or if medications are not effective, laser and other surgical procedures may be of value in controlling thepressure and preventing further vision loss.

My doctor has informed me that an operation called trabeculectomy is necessary to help control the pressure in my eye(s) becauseprolonged rise of this pressure can damage my optic nerve leading to loss of vision and eventual blindness. When successful, thisprocedure will lower the pressure in my eye, minimizing the risk of further vision loss from glaucoma. The purpose of the operation is tocontrol the pressure and preserve my vision; any vision lost to glaucoma cannot be restored.

ComplicationsAs with any surgical procedure, there are risks associated with glaucoma drainage surgery. For example, there is always the possibility thatthe surgery cannot control my eye pressure, for which medications or more procedures may be needed after surgery. Not every possiblecomplication can be covered in this form but the following are examples of risk encountered with glaucoma drainage surgery. Thesecomplications can occur days, weeks, months, or years later. They can result in loss of vision or blindness. So frequent follow-up ismandatory after surgery.

After complete healing also, regular eye examination is necessary to monitor eye pressure and to look for other problems.

Complications of the surgery1. Failure to control eye pressure, with the need for another operation (early or late)2. Generally vision might decrease for 2 months or so. There may be development of cataract which can reduce vision but it can be

treated with cataract surgery3. There might be too high or too low pressure after glaucoma surgery for which other necessary treatment or operation might be

needed.4. Bleeding in the eye5. Pronged redness and mild pain resulting in chronic inflammation6. Irritation or discomfort in the eye that may persist7. In spite of surgery, vision could become worse from continuing degenerative changes in the eye8. Infection resulting in pain, redness and decrease in vision which can occur early or much later9. In rare cases, there could be total loss of vision

Operation will be done under local or general anesthesia which also includes complications of anesthesia.

Complications of anesthesia injections around the eye

10. Perforation of eyeball11. Needle damage to the optic nerve, which could destroy vision12. Interference with circulation of the retina13. Possible drooping of eyelid14. Systemic effects that have the potential for life-threatening complications and death

( 156 )

Patient ConsentThere may arise unwanted situation during surgery. In that situation I give my full authority to my treating doctor to take any necessarydecision. In 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 haveread and understood the consent form, and all my queries have been answered, and I authorize my surgeon to proceed with the operationon my .............................. (indicate “right” or “left” eye).



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 157 )

,saVh&Qkbcz¨ CYkkfLVd ,tsaVä ds lkFk@muds fcuk VªscsdqY¨DVëhequh'k /kou je.kthr flg¨Vk



fpfdRlk lq>ko] YkkÒ] v©j fodYiesjk bYkkt dj jgs fpfdRld us eq>s crk;k gS fd funku gqvk gS fd eq>s XYkkdëk gSA cgqr laÒo gS fd eSa n`f"V gzkl dk vuqÒo d:a] g¨ ldrk gS bldklekiu va/ïu esa gÄ XYkkdëk dk vFkZ gS vka[k ds ncko esa o`f)A dÒh&dÒh nokv as ls lQYkrkiwoZd bldk bYkkt fd;k tk ldrk gS] ;fn nok,a ÁÒkohu g a r¨ ncko fu;af=r djus v©j vf/kd n`f"V gzkl d¨ j¨dus ds fYk, Y¨tj ;k vU; 'kY;fpfdRlk ÁfØ;k,a mi;¨xh g¨ ldrh gSaA

esjs fpfdRld us eq>s crk;k gS fd esjh vka[k ¼vka[k a½ dk ncko fu;af=r djus ds fYk, Vªscs dqY¨DVëh uke dk ,d v‚ijs'ku vko';d gS D; afd bl nckods Ykacs le; rd c<+rs tkus ls n`f"V gzkl g¨rk gS v©j varr% va/kkiu vk tkrk gSA lQYk güs ij ;g v‚ijs'ku esjh vka[k dk ncko de dj nsxk v©jXYkkdëk ds dkj.k v©j n`f"V gzkl d¨ de djsxkA bl v‚ijs'ku dk mÌs'; ncko fu;af"kr djuk] v©j esjh n`f"V d¨ v{kq..k j[kuk gS]XYkkdëk dh otg ls [k¨bZ n`f"V Yk©VkbZ ugÈ tk ldrhA

leL;k,atSlk fd fdlh Òh 'kY;fpfälh; ÁfØ;k ds lkFk g¨rk gS] XYkkdëk Mªsust ltZjh ds lkFk Òh t¨f[ke tqM+s gSaA mnkgj.k ds fYk, bldh laÒkouk ges'kk jgrhgS fd 'kY;fpfdRlk esjh vka[k ds ncko d¨ fu;af=r u dj lds] ftlds fYk, 'kY;fpfdRlk ds ckn nokv a ;k v©j ÁfØ;kv a dh vko';drk iM+ ldrhgSA bl Ái= esa laÒkfor lÒh leL;kv a d¨ 'kkfeYk djuk laÒo ugÈ gS Y¨fdu XYkkdëk Mªsust ltZjh djus ij lkeus vkus okYkh leL;kv a ds mnkgj.kfuEufYkf[kr gSa- ;s leL;k,a fnu a] g¶r a] eghu a v©j o"k ± ckn g¨ ldrh gSaA os n`f"V dk gzkl ;k va/kkiu iSnk dj ldrh gSaA blfYk, 'kY;fpfdRlkds ckn Ák;% Q‚Yk¨vi ds fYk, tkuk vfuok;Z g¨rk gSA

?kko ds iwjh rjg Òj tkus ds ckn Òh vka[k a ds ncko dh fuxjkuh djus v©j nwljh leL;kv a dk irk Ykxkus ds fYk, vka[k a dh fu;fer tkap vko';dgSA

'kY;fpfdRlk dh leL;k,a1- ¼tYnh ;k nsj ls½ nwljs v‚ijs'ku dh vko';drk ds lkFk vka[k dk ncko fu;af=r djus esa vlQYkrk]

2- lkekU;r;k n¨ eghus ds fYk, n`f"V de g¨ ldrh gS] e¨fr;kfcan g¨ ldrk gS t¨ n`f"V de dj ldrk gS Y¨fdu dVSjSDV ltZjh ls mldk bYkktfd;k tk ldrk gS

3- XYkkdëk ltZjh ds ckn ncko cgqr de ;k cgqr vf/kd g¨ ldrk gS ftlds fYk, nwljs vko';d bYkkt a ;k v‚ijs'ku a dh t:jr iM+ ldrh gS

4- vka[k esa jälzko

5- Ykacs le; rd YkYkkbZ v©j gYdk nnZ ftlds QYkLo:i nh?kZdkfYkd Ánkg g¨ ldrk gS

6- vka[k esa bfjVs”ku ;k fMldEQZV t¨ cuk jg ldrk gS

7- 'kY;fpfdRlk ds ckotwn vka[k esa tkjh vigzklh ifjorZu a ds dkj.k n`f"V v©j [kjkc g¨ ldrh gS

8- laØe.k] ftuds dkj.k YkYkkbZ vk ldrh gS] n`f"V de g¨ ldrh gS t¨ tYnh ;k dkQh nsj ls Òh g¨ ldrk gS

9- fojY¨ ekeYk a esa iwjh rjg ls n`f"V dk gzkl g¨ ldrk gS

v‚ijs'ku Yk¨dYk ;k tujYk&,susLFkhfl;k nsdj fd;k tk,xk] ftlesa ,susLFkhfl;k dh leL;k,a Òh 'kkfeYk g¨ ldrh gSaA

vka[k ds vkl&ikl ,susLFkhfl;k dh lwbZ Ykxkus dh leL;k,a

10- us=xŸkd esa fNæ g¨ tkuk

11- lwbZ ls n`'; raf=dk d¨ {kfr igqapuk t¨ n`f"V d¨ u"V dj ldrk gS

12- jsfVuk esa jä lapkj esa ck/kk

13- laÒkfor iYkd Mwfiax

14- flLVesfVd ÁÒko t¨ tkuYök leL;k,a iSnk dj ldrs gSa ;k e`R;q dk dkj.k cu ldrs gSa

( 158 )

j¨xh dh lgefr'kY;fpfdRlk ds n©jku vokafNr fLFkfr;ka iSnk g¨ ldrh gSaA ml fLFkfr esa viuk bYkkt dj jgs fpfdRld d¨ d¨bZ Òh vko';d fu.kZ; Yüs dk iwjkvf/kdkj nsrk gwaA mi;qZä t¨f[ke a ds ckotwn eSa le>rk gwa fd ;fn eSa vkijs'ku ugÈ djkrk r¨ esjh n`f"V d¨ v‚ijs'ku djkus ls dgÈ vf/kd [krjk jgsxkAeSaus lgefr Ái= d¨ i<+ v©j le> fYk;k gS v©j esjs lÒh Á'u a ds mÙkj fn, x, gSa v©j eSa vius 'kY;fpfdRld d¨ viuh ---------------------------------------¼**nkb±** ;k **ckb±** vka[k dk fufnZ"V djsa½ v‚ijs'ku djus dk vf/kdkj nsrk gwaA


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

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MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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

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( 159 )

Diode Laser Cyclo-photocoagulation (DLCP)Anand Agarwal, Shalini Mohan


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

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

DLCP is an ocular surgical procedure which is usually carried out in people with advanced, recalcitrant glaucoma who have uncontrolledhigh intra ocular pressures (IOPs) inspite of use of medications and repeated glaucoma filtration surgeries and used of glaucoma drainagedevices (GDDs). This procedure is effective in bringing down IOPs and relieving ocular pain if the cause of pain is high IOP. Theprocedure is usually carried out under local peribulbar anesthesia and sometimes more than one sitting needs to be given ie the proceduremay have to be repeated to bring about clinical success.

Post operative careThe eye may be red, swollen and painful following the procedure for which pain relieving oral medications and some drops are given tobring about relief. Out patient visits are done on first day post operatively, day seven and then after every two weeks.

The need for repeat procedure is decided by the treating physician after evaluating patient’s symptoms and IOP.

The usual side effects encountered are:

1. Ocular pain2. Redness3. Peri ocular swelling4. Need for repeat treatments5. The procedure may be able to bring down the need for IOP lowering medications although some of them may be required to

maintain optimal IOP5. Rarely the eye may become smaller i.e. progress to atrophic bulbi

IT IS VERY IMPORTANT FOR THE PATIENT TO UNDERSTAND THAT THE PROCEDURE IS NOT MEANT TO IMPROVE THEVISION OVER & ABOVE WHAT HE/SHE HAS ALREADY GOT.

I have been made aware of the above mentioned facts and I have been counseled about the potential benefits and possible side effects ofthe procedure and by thoroughly going through all of the above, I give my full informed consent for the above procedure.



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

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

( 160 )




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 161 )

Mk;¨M Y¨tj lkbDYk¨&Q¨V¨d‚xqY¨'ku ¼Mh ,y lh ih½vkuan vxzokYk] 'kkfYkuh e¨gu



Mh,Yklhih ,d us= 'kY;fpfdRlk ÁfØ;k gS t¨ mér] nqnZE; XYkkdëk ls ihfM+r mu Yk¨x a ij dh tkrh gS ftuds mPp var% usf=; nkc ¼vkbZvïh½ nokv av©j ckj&ckj XYkkdëk fQYVjs'ku ltZjh djus v©j XYkkdëk Mªsust Msokbl a ¼thMhMh½ ds mi;¨x ds ckn Òh fu;af=r ugÈ g¨rsA ;g ÁfØ;k var% usf=;nkc ¼vkbZvïh½ de djus v©j vka[k ds nnZ ls jkgr fnYkkus esa ÁÒkoh g¨rh gS] c'krsZ fd nnZ mPp vkbZvïh ds dkj.k g¨ jgk gÄ lkekU;r;k ;g ÁfØ;kisjhcYcj ,susLFkhfl;k nsdj dh tkrh gS v©j dÒh&dÒh ,d ls vf/kd ckj djuh iM+rh gS] ;kuh fpfdRlh; lQYkrk ds fYk, ÁfØ;k nqgjkuh iM+ ldrhgSA

'kY;fpfdRl¨Ùkj ifjp;kZÁfØ;k ds ckn vka[k YkkYk g¨ ldrh gS] lwtu ;k ldrh gS ;k nnZ g¨ ldrk gS] ftlls jkgr fnYkkus ds fYk, [kkus v©j vka[k esa Vidkus dh nok,a nhtk ldrh gSaA cfgjax j¨xh foÒkx esa v‚ijs'ku ds ckn igY¨ v©j~ lkrosa fnu v©j mlds ckn gj n¨ g¶rksa ij eqYkkdkrsa dh tkrh gSaA

nqckjk ÁfØ;k djus dh vko';drk j¨xh ds Yk{k.k a v©j vkbZvïh tkapus ds ckn bYkkt djus okYkk fpfdRld r; djrk gSA

lkekU;r% lkeus vkus okY¨ nq"ÁÒko gSa%

1- vka[k esa nnZ

2- YkYkkbZ

3- isfjvk¡dwyj lwtu

4- iqu% fpfdRlk dh vko';drk

5- ÁfØ;k vkbZvïh de djus okYkh nokv a dh vko';drk de dj ldrh gS gkYkkafd ;F¨"V vkbZvïh cuk, j[kus ds fYk, dqN nokv a dh t:jriM+ ldrh gSA

5- fojY¨ ekeYk a esa vka[k N¨Vh g¨ ldrh gS] ;kuh ,VªksfQd oYokbZ

j¨xh ds fYk, ;g le>uk cgqr egRoiw.kZ gS fd ÁfØ;k dk mÌs'; mldh orZeku n`f"V esa lq/kkj Ykkdj mlls vf/kd ;k mlls Åij dh n`f"V Ánku djukugÈ gS

eq>s mi;qZä rF; a ls voxr djk;k x;k gS v©j eq>s ÁfØ;k ls j¨xh d¨ güs okY¨ YkkÒ a v©j laÒkfor nq"ÁÒko a ds ckjs esa lYkkg nh xbZ gS v©j mi;qZälkjh ckr a d¨ xaÒhjrk ls i<+us ds ckn eSa miq;Zä ÁfØ;k ds fYk, viuh iwjh lwfpr lgefr nsrk gwaA


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

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( 162 )




MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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

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

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

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

( 163 )

Argon Laser Trabeculoplasty (ALT)Manoj Gupta


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

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

The argon laser causes photocoagulation of tissue. Thermal disruption of structural molecules, especially protein denaturation, results intissue changes that are observed such as contraction, condensation, and separation. Formation of amorphous gels as well as clot formationcan also occur. Higher temperatures result in non-selective coagulation necrosis of the target tissue and will lead to the burning of tissue.

Argon Laser TrabeculoplastyLaser trabeculoplasy (LTP) is indicated for the treatment of open-angle glaucomas and is particularly effective in the treatment ofpigmentary and pseudoexfoliation glaucomas. LTP causes alteration of the TM by photocoagulation and a greater effect is seen with moreheavily pigmented TM. The precise mechanism of action is unknown but it relates to the change in conformation of the TM by collagenshrinkage leading to the opening of meshwork in adjacent, nontreated regions.

ProcedureA slit lamp-mounted argon laser is usually used with the laser beam focused at the outflow angle with a contact lens such as a Goldmannthree-mirror lens. The laser settings are typically 800 mW to 1200 mW for 0.1 second and a 50-µm spot size. The laser is focused on theTM and the power adjusted to cause a slight focal bubble or blanching of the TM. The TM is treated for 180º to 360º with a total of 50 to100 spots. Treatment complications include elevation of IOP, inflammation, inadvertent treatment of the cornea or ciliary body, hemorrhage,and pain.

Antiglaucoma Medication HistoryI have been explained about the procedure and the risk involved in the procedure in my own language. I have been explained that theremight be decrease in vision, corneal burn, raised IOP, and IOP may not decrease to desired level. Knowing all these inadvertentcomplications, I am willing to undergo the above procedure and I give my consent for the procedure .



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

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

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Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 165 )

vkxZu Y¨tj VªscsdqYkÏYkkLVh ¼,,yVh½eu¨t xqIrk



vkxZu Y¨tj Ård a ds Q¨V¨dkxqY¨'ku dk dkj.k curk gSA lajpukRed v.kqv a dk rkih; fo?kVu] [kkl dj Á¨Vhu foÑfrdj.k ds dkj.k Ård ifjorZug¨rs gSa t¨ ladqpu] la?kuu] v©j vYkxko ds :i esa lkeus vkrs gSaA vfØLVYkh; tSYk ;k Fkôk Òh cu ldrk gSA Åaps rkieku ds dkj.k vfÒYkf{kr Ård adk vp;fur Ldanu foxYku g¨rk gS v©j Ård tYk tkrs gSaA

vkxZu Y¨tj VªscsdqYkÏYkkLVhY¨tj VªscsdqYkÏYkkLVh dk lq>ko vksiu ,saxy ds XYkkdëk ds bYkkt ds fYk, fn;k tkrk gS v©j fiXesaVjh v©j L;wM¨,DlQ¨fYk,'ku XYkkdëk ds bYkkt esaÁÒkoh gSA ,YkVhih Q¨V¨dkxqY¨'ku }kjk Vh,e dk ,dkarj.k djrh gSA bl fØ;k dh lVhd ;kaf=dh vKkr gS Y¨fdu ;g dkY©tu ds ladqpu ls Vh,edh jpuk esa cnYkko ls lacaf/kr gS ftlls ikl ds vuqipkfjr es”kodZ dh tkYkh [kqYk tkrh gSA

ÁfØ;klkekU; :i ls Y¨tj fdj.k ds lkFk fLyV Y©ai ij LFkkfir vkxZu Y¨tj d¨ xŸMeSu Fkzh fejWj Y al tSls dkaVSDVY al ds lkFk oká Áokg d¨.k ij dsafærfd;k tkrk gSA Y¨tj dh Áokg fn'kk Á:ih r©j ij 0-1 lsdaM ds fYk, 800 ,eMCY;w ls 1200 ,eMCY;w v©j 50 E;w,l ds fcanqeki ij g¨rh gSA Y¨tjd¨ Vh,e ij dsafær fd;k tkrk gS v©j gYdk&lk ukÒh; cqYkcqYkk mRié djus ds fYk, ikoj leaftr fd;k tkrk gSA 180 ls 360 rd dqYk 50 ls 100fcanqv a ij Vh,e dk mipkj fd;k tkrk gSA bYkkt dh leL;kv sa esa vkbZvïh dk c<+uk] Ánkg] dkfuZ;k ;k flfYk;jh c‚Mh dk vufÒÁsr mipkj] jälzkov©j nnZ 'kkfeYk g¨ ldrs gSaA

,saVhXYkkdëk ds v©"kf/kÁ;¨x dk bfrgkleq>s esjh viuh Òk"kk esa ÁfØ;k v©j ÁfØ;k ds lkFk tqM+s t¨f[ke a ds ckjs esa le>k;k x;k gSA eq>s crk;k x;k gS fd g¨ ldrk gS fd n`f"V de g¨ tk,]dfuZ;k tYk tk,] vkbZvïh c<+ tk, v©j vkbZvïh okafNr Lrj rd de u gÄ bu lÒh vufÒÁsr leL;kv a ds ckotwn eSa mi;qZä ÁfØ;k djkuk pkgrkgwa v©j ÁfØ;k ds fYk, viuh lgefr nsrk gwa-


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

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


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MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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

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

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

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

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Laser IridotomyDeepankur Mahajan


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

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

Laser iridotomy is a procedure used for patients with narrow angle glaucoma in which a laser is used to make a small hole in the iris(colored part of the eye) to allow free movement of fluid from posterior to anterior chamber of the eye which might help to control theintraocular pressure and hopefully prevent scar formation between the iris and cornea which can check progression of the glaucoma.

Risks associated with this procedure include transient blurring of vision, post laser IOP spike, anterior uveitis, pupillary distortion,corneal epithelial defects and corneal burns, bleeding/hyphema, cataract, diplopia, late iridotomy closure, retinal/macular burns, malignantglaucoma, sterile hypopyon, cystoid macular edema and pupillary pseudomembrane. Additional medical or surgical intervention mightbe required for these complications.

The procedure may require more than on sitting for completion in some cases. Some individuals respond only partially or not at all to theprocedure and may require additional medication/surgical intervention to check progression of glaucoma.

Post procedure topical medication including glaucoma medication might have to be continued/ changed.

I, ................................................................... have been fully explained in the best understood language (.............................................) that I haveRE/LE ........................................................ and have to undergo right/left eye laser iridotomy for the same.

The details of the procedure, alternatives and their risks and benefits have been explained to my satisfaction. I hereby give my full, free andvoluntary informed consent for right/left eye laser iridotomy.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

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Y¨tj vkbfjM¨Vëhnhiadj egktu



Y¨tj vkbfjM¨Vëh ,d ÁfØ;k gS t¨ ladh.kZ d¨.k XYkkdëk ds j¨fx; a esa Á;qä g¨rh gS] ftlesa vka[k ds fiNY¨ Ád¨"B ls vxY¨ Ád¨"B esa eqä :i lsrjYk ds Áokg dh lqfo/kk nsus ds fYk, vkbfjl ¼vka[k ds jaxhu Òkx½ esa ,d N¨Vk&lk fNæ djus ds fYk, Y¨tj dk Á;¨x fd;k tkrk gS] t¨ var%usf=;ncko fu;af=r djus esa enn dj ldrk gS v©j mEehn dh tkrh gS fd vkbfjl v©j dkfuZ;k ds chp LdkWj cuus ls j¨d ldrh gS t¨ XYkkdëk ds fodkld¨ j¨d ldrk gSA

bl ÁfØ;k ls tqM+s t¨f[ke a esa 'kkfeYk gSa n`f"V dk vLFkk;h /kqa/kYkkiu] Y¨tj ds ckn vkbZvïh Likbd] ,saVsfj;j ;wfo;kl¨Fk] I;wiykjh dk fo:i.k] dkfuZ;kds bfifFk;e dh foÑfr] dkfuZ;k dk tYk tkuk] jälzko@gkbQsek] e¨fr;kÇcan] fMIYk¨fi;k] vkbfjM¨Vëh dk nsj ls can gük] jsfVuYk@esdqyj cuZ] dSaljhXYkkdëk] thok.kqjfgr gkbiïk;ü] flLV‚;M ekdqYkj ,fMek v©j I;wfiYkjh L;wMësaczsuA bu leL;kv a ds fYk, vfrfjä fpfdRlh;@'kY;fpfdRlh; gLr{ïdh t:jr iM+ ldrh gSA

dqN ekeYk a esa g¨ ldrk gS fd ÁfØ;k ,d ls vf/kd ckj esa iwjh gÄ dqN O;fä ÁfØ;k ds Áfr vkaf'kd vuqfØ;k nsrs gSa ;k fljs ls vuqfØ;k ugÈ nsrsv©j muds fYk, XYkkdëk d¨ c<+us ls j¨dus ds fYk, vfrfjä v©"kf/k Á;¨x@'kY;fpfdRlh; gLr{ï dh vko';drk iM+ ldrh gSAv‚ijs'ku ds ckn dh LFkkfud nok,a] XYkkdëk dh nokv a lfgr] tkjh j[kuh@cnYkuh iM+ ldrh gSaA

eq>s]----------------------------------------------------------------------------------------------------------------------------------------------------------- t¨ Òk"kk lcls vPNh rjg le> esa vkrh gS ml Òk"kk¼--------------------------------------------------------------------------------------------------½ esa le>k;k x;k gS fd eq>s nkbZ vk¡[k@ckbZ vk¡[k----------------------------------------------- v©j eq>smlds fYk, nkb±@ckb± vk[k dk Y¨tj vkbfjM¨Vëh djkuk 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 %. ............................................................................................

CATARACT

( 169 )

Cataract Surgery With / Without Implantation ofIntraocular Lens

Courtesy: Shroff Eye Centre, New Delhi


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

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

Introduction :A cataract is opacity of the lens. Cataract operation is indicated only when you cannot function adequately due to poor sight produced bythe cataract. Maturity of cataract is no longer a criterion for surgery. The natural lens within your eye with a slight cataract, although notperfect, has distinct advantages over an artificial lens.

In giving permission for cataract extraction with / without implantation of an intraocular lens in my eye, I declare that I understand thefollowing information

1. Alternative Treatments :There are three methods of restoring vision after cataract surgerya) Cataract Spectacles b) Contact Lens c) Intraocular LensCataract spectacles increase image size by 30%. They cannot be used if there is cataract in only one eye (the other is normal) becausethey may cause double vision. A contact lens increases image size by 8%. However, it is difficult to handle and may not be toleratedby everyone. Intraocular lens does not increase image size. It is surgically placed inside the eye permanently

2. An intraocular lens is implanted by surgery (not by laser). The implanted lens will be left in the eye permanently. At the time ofsurgery the doctor may decide not to implant an intraocular lens in the eye, if for any reason he feels that the lens implantation isnot indicated or may prove deleterious to the well being of the eye, even though permission may have been given to do so

3. Though the intraocular implant power is calculated by utilizing a computerised Biometer (A-scan), a small correction in thespectacles is to be considered inevitable postoperatively and this may be more in specific cases. An astigmatism (number with axis)which may reduce with time, is to be taken as inevitable and normal. Therefore, a small power is to be expected in the spectacles fordistance and near for clear vision after the operation. In any case, the aim of cataract surgery is to remove the cloudy lens from theeye and replace it with a plastic lens and not to rid the patient of his spectacles

4. The calibre of vision obtained after a successful cataract surgery/lens implantation depends upon the retina behind. In an advancedcataract even with the most sophisticated instruments (Ultrasound Scan etc.), it is not possible to be certain that the retina inside isnormal. Removal of cataract is like opening a door to a room. If the retina is normal, you will see well, but it is not possible in amajority of advanced cataract cases to ascertain the visual status of the retina before operation

5. With modern instrumentation and micro surgical techniques, the rate of complications in cataract surgery with/without intraocularlens implantation is very low. Complications can usually be managed by medical and/or surgical treatment. The chances of totalloss of vision are less than 0.5%. However, the following complications can occur and are mentioned in standard text books ofcataract and lens implantation surgerya) It is possible that vision may drop after surgery due to thickening/opacification of the posterior capsule. This is not a

complication but a sequelae to Extra Capsular Cataract Extraction. The condition is treated with the “Yag Laser”b) Complications may include haemorrhage (bleeding), posterior capsule rupture, nucleus drop, vitreous loss, wound leakage,

uveitis, cornea! decompensation, glaucoma, cystoid macular oedema or retinal detachment. In addition lens implantationmay be complicated by severe reaction to the lens (Toxic Lens Syndrome) or dislocation of the lens. The implanted lens mayhave to be repositioned or removed surgically if it is likely to damage the eye. Though every effort is made to minimize thechances of infection, it cannot be eliminated altogether. Loss of vision is a risk common to any intraocular surgery

c) Although you may have opted for phacoemulsification surgery and the same may have been planned by your surgeon after

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pre operative examination, if during surgery phacoemulsification is found to be unsafe or not feasible. your surgeon willhave the liberty to perform surgery by the conventional technique in the interest of patient safety

d) Complications of surgery in general:- As the procedure is generally done under local anaesthesia the risk to life is less than0.5%. Risk is greater in patients with Diabetes, Hypertension, Cardiac ailments and other systemic disorders & when surgeryis performed under general anaesthesia. There is a possibility of drug reaction, brain damage or risk to life

Since it is impossible to state every complication that may occur as a result of surgery, the list of complications in this form is notexhaustive.

Consent for Operation1. I hereby authorize Dr. .................................................................................... and those whom he may designate as associates or assistants to

perform cataract operation with an intraocular lens / without an intraocular lens / as a secondary procedure on my left / right eyeIt has been explained to me that during the course of operation/ procedure, unforeseen conditions may be revealed or encounteredwhich necessitate surgical or other procedures in addition to or different from those contemplated. I, therefore, further request andauthorize the above named Physician/Surgeon or his designates to perform such additional surgical or other procedures as he orthey deem necessary or desirable

2. The nature and purpose of the operation, the necessity thereof, the possible alternative methods of treatment of my condition havebeen fully explained to me and I understand the same

3. I am fully aware that the surgery is being performed in good faith and that no guarantee or assurance has been given as to the resultthat may be obtained

4. I consent to the administration of anesthesia and to the use of such anesthetics as may be deemed necessary or desirable5. I further consent to the administration of such drugs or infusions deemed necessary in the judgement of the medical staff6. I consent to the observing, photographing or televising of the procedure to be performed for medical, scientific or education

purpose provided my identity is not revealed by the pictures or by descriptive text accompanying them7. Any tissues or parts surgically removed may be disposed off by the institution in accordance with customary practice

Informed Consent for Operation on Patients With Guarded / Poor Visual PrognosisI have been explained by the attending surgeon/Designated Assistant prior to the operation that visual prognosis after surgery isguarded/uncertain/poor/very poor. The reasons for this have been explained to me. The reasons are: (to be signed by the patient /person authorised to consent for the patient.)Trauma / Diabetic Retinopathy / Myopia / Glaucoma / Uveitis /Age Related Macular Degeneration / PVR / Complex TractionRetinal Detachment/Combined tractional rhegmatogenous retinal detachment /Dislocated lens or IOL / Endophthalmitis (Severeeye infection)............................................................................................................................................................................................................................

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

Signature of patient / person authorised to

consent for patient: ........................................................

I THE UNDERSIGNED (THE PATIENT OR NEAREST RELATIVE) HEREBY GIVE MY CONSENT FOR THE OPERATION OFLEFT EYE / RIGHT EYE WITH THE FULL KNOWLEDGE OF POSSIBLE COMPLICATIONS AND GUARDED / POOR VISUALPROGNOSIS. I CERTIFY THAT I HAVE READ THIS INFORMED CONSENT / IT HAS BEEN READ OVER TO ME AND EXPLAINEDTO ME IN MY MOTHER TONGUE AND ALL BLANKS OR STATEMENTS REQUIRING INSERTION OR COMPLETION WEREFILLED IN AND ANY INAPPLICABLE PARAGRAPHS STRICKEN OFF BEFORE I SIGNED. THE DOCTOR HAS ANSWEREDALL MY QUESTIONS TO MY SATISFACTION.

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

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Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 172 )

baVªkvkD;wYkj Yälä ds lkFk@muds fcukdSVjSDV ltZjh

lkÒkj%: J‚Q vkbZ lsaVj] u;h fnYYkh



ifjp;%dSVjSDV Y al dh vikjnf'kZrk gSA dSVjSDV ds v‚ijs'ku dk lq>ko rÒh fn;k tkrk gS tc vki e¨fr;kfcan tU; [kjkc n`f"V ds dkj.k ;F¨"kzV :i ls dkeugÈ dj ikrsA e¨fr;kfcan dk id tkuk vc 'kY;fpfdRlk dh dl©Vh ugÈ gSA gYds e¨fr;kfcan ds lkFk vka[k esa vka[k ds ÁkÑfrd Y al ds Ñf"ke Y alds jgus ds eqdkcY¨ vusd YkkÒ gSaA

viuh vka[k esa baVªkv‚D;wYkj Y al ds lkFk@;k mlds fcuk e¨fr;kfcan ds fu"d"kZ.k dh vuqefr nsrs gq, eSa ?k¨"k.kk djrk gwa fd eSa fuEu lwpukv a d¨ le>k gwa

1- oSdfYid fpfdRlk,a%

dSVjSDV ltZjh ds ckn n`f"V dh okilh d¨ rhu fof/k;ka gSa

v½ dSVjSDV p'ek c½ dkaVSDVY al l½ baVªkvkD;wYkj Y al

dSVjSDV p'ek fp= d¨ 30% c<+k nsrk gSA ;fn dsoYk ,[k vka[k esa e¨fr;kfcan g¨ r¨ p'ek ugÈ iguk tk ldrk D; afd og nqgjh n`f"V iSnkdj ldrk gSA dkaVSDV Y al fp= dk vkdkj 8% c<+krk gSA Y¨fdu mldk j[k&j[kko dfBu g¨rk gS v©j gj fdlh ls lgu ugÈ g¨rkA baVªkvkD;wYkjY al fp"k dk vkdkj ugÈ c<+krkA 'kY;fpfdRlk ls bls LFkkbZ :i ls vka[k ds Òhrj Ykxk;k tkrk gSA

2- d¨bZ var% us=h; Y al 'kY;fpfdRlk }kjk ¼Y¨tj }kjk ugÈ½ vka[k esa Ykxk;k tkrk gSA ÁR;kj¨fir Y al d¨ LFkkbZ :i ls vka[k esa N¨M+ fn;k tkrkgSA 'kY;fpfdRlk ds le; fpfdRld var% us=h; Y al u Ykxkus dk QSlYkk dj ldrs gS]A c'krsZ fd fdlh dkj.ko'k mls Ykxrk gS fd ÁR;kjï.kugÈ fd;k tk ldrk ;k vka[k ds LokLF; ds fYk, gkfudkjd lkfcr g¨ ldrk gS] pkgs mls ,slk djus dh vuqefr feYkh g¨ rc ÒhA

3- gkYkkafd var% us=h; ÁR;kjï.k ds ikoj dk vkdYku daI;wVjhÑr ck;ëhVj ¼,&LdSu½ dk mi;¨x djds fd;k tkrk gS] Y¨fdu v‚ijs'ku ds cknp'es esa ekewYkh la'k¨/ku d¨ vifjgk;Z le>k tkrk gS v©j fo'¨"k ekeYk a esa ;g vf/kd Òh g¨ ldrk gSA n`f"VoS"kE; ¼,fDll ds lkFk uacj½ d¨vo';aÒkoh v©j lkekU; ekuk tk ldrk gSA blfYk, v‚ijs'ku ds ckn nwj v©j utnhd ds fYk, p'es esa Fk¨M+k lk ikoj güs dh vis{kk dh tkldrh gSA t¨ Òh g¨ dSVjsDV ltZjh dk mÌs'; vka[k ls /kqa/kYkk Y al fudkYk dj mldh txg IYkkfLVd dk Y al Ykxkuk g¨rk gS] j¨xh d¨ p'esls futkr fnYkkuk ugÈA

4- lQYk dSVjSDV ltZjjh@Y al ds ÁR;kjï.k ds ckn ÁkIr n`f"V dh {kerk ihNs dh jsfVuk ij fuÒZj djrk gSA c<+ pqds e¨fr;k fcan esa] vk/kqfudremidj.k a ¼vYVªklkmaM LdSu bR;kfn½ ds lkFk Òh fuf'pr :i ls dguk laÒo ugÈ gS g¨rk fd Òhrj jsfVuk lkekU; gSA e¨fr;kfcan dk fudkYkukfdlh dejs dk njoktk [kŸkus tSlk gSA ;fn jsfVuk lkekU; gS r¨ vki vPNh rjg ns[ axs Y¨fdu e¨fr;kfcan dh c<++h voLFkk esa v‚ijs'ku ls igY¨jsfVuk dh n`'; fLFkfr dk r; g¨ ikuk laÒo ugÈ g¨rkA

5- vk/kqfud midj.k a v©j lw{e 'kY;fpfdRlh; rduhd ds lkFk var%us=h; Y al ds ÁR;kjï.k ds lkFk@mlds fcuk e¨fr;kfcan dh 'kY;fpfdRlkesa tfVYkrkv a dh nj cgqr de g¨rh gSA tfVYkrkv a d¨ fpfdRlh; v©j@;k 'kY;fpfdRlh; bYkkt ls fu;af=r fd;k tk ldrk gSA iwjh rjgn`f"V gzkl dh laÒkouk,a 0-5% ls Hkh de jgrh gSaA Y¨fdu fuEufYkf[kr tfVYkrk,a iSnk g¨ ldrh gSa v©j e¨fr;kfcan v©j Y al ÁR;kjï.k laca/khekud iqLrd a esa mudk mYY¨[k fd;k x;k gSA

,½ laÒo gS fd 'kY;fpfdRlk ds ckn i'p dSilwYk ds e¨Vk güs@vikjn'kÊ güs ds dkj.k n`f"V det¨j iM+ tk,A ;g tfVYkrk ugÈ] cfYd,DLVªk dSIlqYkj dSVjSDV ,DlVªSD'ku dk ifj.kke gSA bl voLFkk dk bYkkt **okbZ,th Y¨tj** ls fd;k tkrk gS

ch½ tfVYkrkv a esa 'kkfeYk gS] gSejst ¼jälzko½] i¨LVsfj;j dSIlwYk dk QV tkuk] U;wfDYk;l Mª‚i] iksLVhfj;j dsiLyw dk VwVuk] ?kko dk fjluk];wfo;k'k¨Fk dkfuZ;k! dk fMdWEisals'ku] XYkkdëk] flLV‚;M ekD;wYkj ,fMek ;k jsfVuk dk foYkxkoA blds vfrfjä Y al ds Áfr xaÒhj ÁfrfØ;k¼V‚fDld Y al flaMª e½ ls Y al ÁR;kjï.k tfVYk g¨ ldrk gSA ÁR;kj¨fir Y al d¨ iqu% LFkkfir djuk iM+ ldrk gS ;k ;fn mlds vka[kd¨ {kfr igqapkus dh vk'kadk g¨ r¨ mls 'kY;fpfdRlk ls fudkYkuk iM+ ldrk gSA gkYkkafd laØe.k de djus ds lÒh Á;kl fd, tkrs gSaY¨fdu mldh laÒkouk d¨ iwjh rjg [kRe ugÈ fd;k tk ldrkA

lh½ gkYkkafd g¨ ldrk gS fd vkius Qkd¨beY'ku ltZjh ilan dh g¨ v©j 'kY;fpfdRlk ls igsYk dh xbZ tkap ds ckn vkids 'kY;fpfdRld

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us ogh djus dh ;¨tuk cukbZ g¨xh Y¨fdu ;fn Qkd¨beY'ku ltZjh vlqjf{kr ;k vO;kogkfjd ikbZ tkbZ gS r¨ vkidk 'kY;fpfdRld j¨xhds fgr esa ijaijkxr rduhd ls 'kY;fpfdRlk djus ds fYk, Lora= g¨xk

Mh½ 'kY;fpfdRlk dh lkekU; tfVYkrk,a] pwafd ÁfØ;k lkekU;r;k Yk¨dYk ,susLFkhfl;k nsdj dh tkrh gS blfYk, tku dk t¨f[ke 0-5% ls dejgrk gSA tc 'kY;fpfdRlk tujYk ,susLFkhfl;k nsdj dh tkrh gS r¨ Mk;kfcVht] mPpjäpki] fnYk ds j¨x a] v©j nwljs nSfgd fodkj a dsj¨fx; a d¨ t¨f[ke vf/kd jgrk gSA nok dh ÁfrfØ;k] efLr"d {kfr ;k tku t¨f[ke dh Òh laÒkouk jgrh gSA

pwafd 'kY;fpfdRlk ds QYkLo:i güs okYkh ÁR;sd tfVYkrk ds ckjs esa crkuk vlaÒo gS blfYk, bl Ái= esa nh xbZ tfVYkrkv a dh lwph laiw.kZ ugÈ g¨ldrhA

v‚ijs'ku ds fYk, lgefr1- eSa ,rn~ }kjk M‚------------------------------------------------------------------------------------------------------------------------------------------------- v©j mUgsa ftud¨ og vius lg;¨fx;ä

;k lgk;d a ds :i esa fu;qä djrs gSa] viuh ckb±@nkb± vka[k esa baVªkv‚D;wYkj Y al ds lkFk@baVªkv‚D;wYkj Y al ds fcuk dSVjsDV v‚ijs'ku djusdk vf/kdkj nsrk gwa

eq>s le>k;k x;k gS fd v‚ijs'ku@ÁfØ;k ds n©jku vuisf{kr voLFkkv a dk irk pYk ldkr gS ;k lkeus vk ldrh gSa t¨ visf{kr v‚ijs'ku lsvfrfjä ;k vYkx nwljh 'kY;fpfdRlh; ;k vU; ÁfØ;kv a d¨ vko';d cuk ldrh gSaA blfYk, eSa mi;qZä uke ds vfrfjä 'kY;fpfdRlk ;knwljh ÁfØ;k,a djus dk vuqj¨/k djrk v©j vf/kdkj Ánku djrk gwa ftUgsa og ;k os vko';d ;k okafNr le>rs g a

2- v‚ijs'ku dh ÁÑfr v©j mÌs';] mldh vko';drk] esjh voLFkk ds bYkkt ds vU; laÒkfor rjhd a ds ckjs esa eq>s iwjh rjg crk;k xk;k gS v©jeSa mUgsa le>rk ga

3- eSa iwjh rjg voxr gwa fd 'kY;fØ;k usduh;rh ls dh tk jgh gS v©j ÁkIr g¨ ldus okY¨ ifj.kke a ds ckjs esa d¨bZ xkjaVh ;k vk'oklu ugÈ fn;kxk; gS

4- eSa ,susLF¨fl;k v©j ,sls ,usLF¨fVDl ds mi;¨x ls lger gwa ftls vko';d okafNr le>k tk,

5- eSa fpfdRlh; dfeZ; a dh utj esa vko';d v©j okafNr nokv as v©j bu¶;wtu fn, tkus ls lger gwa

6- eSa fpfdRlh;] oSKkfud ;k '©{kf.kd mÌs'; ls ÁfØ;k ds voYk¨du] Q¨V¨ mrkjus ;k VsfYkfotu ls Álkfjr djus dh lgefr nsrk gwa c'krsZ fdfp= ;k muds lkFk fn, tkus okY¨ o.kZukRed ikB ls esjk ifjp; ÁdV u gÄ

7- 'kY;fpfdRlk }kjk fudkY¨ x, d¨bZ Òh Ård ;k vax a d¨ laLFkku ijaijkxr pYku ds vuq:i fBdkus Ykxk ldrk gS

jf{kr@[kjkc n`'; iwokZuqeku okY¨ j¨fx;ä ds v‚ijs'ku ds fYk, lwfpr lgefreq>s ifjp;kZ djus okY¨ ltZu@ukfer lgk;d }kjk v‚ijs'ku ls igY¨ crk;k x;k gS fd 'kY;fpfdRlk ds ckn n`'; iwokZuqeku jf{kr@vfuf'pr@cgqr[kjkc gSA eq>s blds dkj.k crk, x, gSaA dkj.k gSa% ¼j¨xh@j¨xh ds fYk, lgefr nsus ds fYk, Ákf/kÑr O;fä }kjk gLrk{kj djus ds fYk,A½vk?kkr] Mk;kcsfVd jsfVuïSFkh] ek;¨fi;k@XYkkdëk@;wfo;k'k¨Fk@mez laca/kh us"kh; {k;@ihohvkj@daIY¨Dl VªSD'ku jsfVuYk fMVSpesaV@dackbaM VªSD'kuYkjsXesV¨tsul jsfVuYk fMVSpesaVA LFkkarfjr Y al ;k vkbZv¨,Yk@,aMÏF©YkekbfVl ¼vka[k dk xaÒhj laØe.k½. ............................................................................................................................................................................................................

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

j¨xh@j¨xh ds fYk, lgefr ds fYk,Ákf/kÑr O;fä ds gLrk{kj ---------------------------------------------

eSa v/k¨gLrk{kj drkZ ¼j¨xh ;k fudVre laca/kh½ ,rn~}kjk laÒkfor tfVYkrkv a v©j lajf{kr@[kjkc n`f"V ds iwokZuqeku ds ckjs esa iwjh tkudkjh ds lkFkviuh ckb±@nkb± vka[ka ds v‚ijs'ku dh lgefr nsrk gwwaA eSa Áekf.kr djrk gwa fd eSaus ;g lwfpr lgefr i<+ Ykh gS ;g eq>s i<+ dj lqukbZ xbZ gS v©jesjh ekr`Òk"kk esa eq>s le>kbZ xbZ gSA v©j lkjh [kkYkh txgsa ;k fuos'ku ;k iwfrZ dh ekax djus okYks lÒh dFku esjs gLrk{kj djus ls igY¨ Òjs x, F¨v©j Ykkxw u güs okY¨ iSjs dkV fn, x, FÄ fpfdRld us esjs lÒh Á'u a ds lar¨"ktud mÙkj fn, gSaA

( 174 )


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MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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( 175 )

Pediatric CataractShalini Mohan, Anand Aggarwal


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

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

Pediatric cataract may affect one or both eyes of children in any age group. Some children have cataract at birth where as some can get itduring their developing years. The need for surgery is undertaken on the discretion of the ophthalmologist after a thorough assessment ofchild’s visual behaviour. If the cataract is visually significant, then early surgery is the best option for improving visual outcome and givingthe child binocular vision. The surgery is performed under general anesthesia and whether or not the intra ocular lens is placed at the timeof primary surgery, depends on the age of the child and the laterality of cataract whether unilateral or bilateral. If both the eyes need to beoperated, then two separate requirements for anesthesia are needed and the time for second eye is decided by the ophthalmologist afterseeing the response of the first eye. It is very critical that clear ocular media is ensured so that the child can develop full visual potential.

Post operative careThe eye may be red, swollen and painful following the procedure for which pain relieving oral medications and some eyedrops are givento bring about relief. The medications may need to be used for a prolonged period after the procedure to ensure maximal efficacy of theprocedure. It is very im portant for the child’s parents / legal guardians to understand that their role in the optim al visual outcom e is asparam ount as the ophthalm ic physician. They need to ensure regular follow up of the child, to make note of abnorm al visual behaviour,the need for regular examinations under anesthesia due to the changing refractive errors as the pediatric eye grows over time. Sometimeschildren may have other associated ocular and systemic abnormalities accompanying their cataract which might need additional surgicalinterventions/ systemic pediatric evaluation.

Post operative course & complications1. After cataract and membrane formation: The incidence has decreased in recent years with the availability of modern techniques of

surgery but can still occur especially in small children under the age of one year.2. Changing refractive errors and the frequent need of glasses: Periodic assessment of child’s refractive status is a must for which

repeated examinations under anesthesia are needed to ensure proper refraction. It is also important for the parents/ legal guardiansto realize that they ensure that the proper refractive correction in the form of glasses/ contact lenses is worn by the child duringwaking hours.

3. Amblyopia (lazy eye) treatment: This is the single most important factor in the success of unilateral cataract cases. The parents/legal guardians need to ensure that the child is on proper occlusion therapy, the frequency of which is decided by the treatingophthalmologist.

4. Glaucoma: This is the single most important cause of late onset visual loss after successful pediatric cataract surgery. The rate of thiscomplication varies widely. To ensure safety, it is very important for the parents’/ legal guardians to ensure that periodic Intra ocularpressure of the child’s eye is monitored so that early detection is possible and remedial measures can be undertaken.

5. Retinal detachment/ endophthalmitis: These are rare complications.6. Strabismus (squint) and nystagmus: These may sometimes be present at the time of presentation. Both of these require separate

surgical intervention usually at a later date.

It is very important for you to realize that meticulous regular life long follow up is very important on your part so that the treatingphysician is able to assess your child’s visual function and early detection of any complication as listed above is possible.

I have been made aware of the above mentioned facts and I have been counseled about the potential benefits and possible side effects ofthe procedure and by thoroughly going through all of the above, I give my full informed consent for the above procedure on my child.

( 176 )

Signature / Thumb Impression of Patient/ Parent / Guardian: ............................................................................................................................



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 177 )

ihfM,sfVªd dSVjSDV'kkfYkuh e¨gu] vkuan vxzokYk



ihfM,sfVªd dSVjSDV lÒh vk;qox ± ds cPp a dh ,d ;k nü a vka[k a d¨ ÁÒkfor dj ldrk gSA dqN cPp a d¨ tUe ls gh e¨fr;kfcan jgrk gS v©j dqNd¨ mudh c<+us dh mez ds n©jku dÒh Òh g¨ ldrk gSA us= fo'¨"kK cPps ds n`'; vkpj.k ds xgu vkdYku ds ckn vius foosd ls 'kY;fpfdRlk dkfu.kZ; Y¨rk gSA ;fn e¨fr;kfcan ns[kus esa mYY¨[kuh; gS r¨ n`'; ifj.kke lq/kkjus v©j cPps d¨ f}us=h; n`f"V Ánku djus ds fYk, ;Fkk le; 'kY;fpfdRlklcls vPNk fodYi g¨rh gSA 'kY;fpfdRlk csg¨'k djds dh tkrh gS v©j 'kY;fpfdRlk ds le; var%us=h; Y al Ykxk;k tk,xk ;k ugÈ] bldk QSlYkkcPps dh mez v©j e¨fr;kfcan dh ik'oÊ;rk ij fuÒZj djrk gS] ;kuh bl ij fd e¨fr;kfcan ,d vka[k esa gS ;k nü a vka[k a esaA ;fn nü a vka[k a ds v‚ijs'kudh vko';drk g¨rh gS n¨ vYkx&vYkx ckj csg¨'k djus dh t:jr iM+rh gS D; afd v©j nwljh vka[k ds v‚ijs'ku dk le; us"kfpfdRld igYkh vka[kdh vuqfØ;k ns[kus ds ckn r; djrk gSA ;g cgqr egRoiw.kZ gS fd Li"V us=h; ehfM;k lqfuf'pr fd;k tk, rkfd cPpk iw.kZ n`f"V {kerk fodflr djldsA

'kY;fpfdRl¨Ùkj ifjp;kZÁfØ;k ds ckn vka[k YkkYk] lwth gqbZ g¨ ldrh gS v©j mlesa nnZ g¨ ldrk gS ftlds fYk, dqN [kkus dh nnZ fuokjd nok,a v©j jkgr nsus ds fYk, vka[kesa VidkbZ tkus okYkh nok,a nh tkrh gSaA ÁfØ;k dh vf/kdre ÁÒkodkfjrk lqfuf'pr djus ds fYk, ÁfØ;k ds ckn Ykach vof/k rd nokv a dk Á;¨x fd;ktkrk gSA cPps ds ekrk&firk@dkuwuh vfÒÒkodä dk ;g le>uk cgqr egRoiw.kZ gS fd n`f"V laca/kh ;F¨"Vre ifj.kke esa mudh Òwfedkus"kfo'¨"kKA fpfdRld ftruh gh vge g¨rh gSA muds fu;fer :i ls cPps dk Q‚Yk¨vi lqfuf'pr djus] vlkekU; n`'; crkZo ij/;ku nsus dh t:jr g¨rh gS] ,susLFkhfl;k nsdj cnYkrh viorZukRed [kkfe;ä ds fYk, fu;fer :i ls tkap dh vko';drk g¨rhgS D;äfd cPpä dh vka[ksa le; ds lkFk c<+rh jgrh gSaA dÒh&dÒh cPp a d¨ muds e¨fr;kfcan ds lkFk vka[k dh nwljh ;k nSfgd foÑfr;ka g¨ldrh gSa t¨ vfrfjä 'kY;fpfdRlh; gL{ï@nSfgd fcekfj;ksa ds boSY;w”ku dh t:jr iM+ ldrh gSA

'kY;fpfdRl¨Ùkj dk;Zfof/k v©j tfVYkrk,a1- vkQVj dSVjsDV o eSEojsu Qkjes”ku 'kY;fpfdRlk dh vk/kqfud rduhd a dh miYkC/krk ds lkFk bl rjg dh ?kVuk,a de güs Ykxh gSa Y¨fdu

vc Òh g¨ ldrh gSa] fo'¨"kdj ,d lkYk ls de mez ds cPp a esaA

2- cnYkrh viorZukRed [kkfe;ka v©j p'esa dh Ákf;d vko';drk% cPps dh viorZukRed fLFkfr dk fu;rdkfYkd ewY;kadu vfuok;Z g¨rk gS] ftldsfYk, ,susfLFkhfl;k nsdj mi;qZä viorZu lqfuf'pr djus ds fYk, ckj&ckj tkap djus dh vko';drk g¨rh gSA ekrk&firk@dkuwuh vfÒokod ads fYk, ;g Òh egRoiw.kZ g¨rk gS fd os lqfuf'pr djsa fd cPpk tkxrs le; p'es@dkaVSDV Y al a ds :i esa mi;qä viorZukRed la'k¨/ku igusA

3- ,Eoyk;ksfi;k ¼lqLr vka[k½ dk bYkkt% ;g ,d vka[k ds e¨fr;kfcan ds ekeYk a esa lQYkrk dk vdsYkk lcls egRoiw.kZ dkjd gSA ekrk&firk@dkuwuhvfÒÒkod a dk ;g lqfuf'pr djkuk vko';d gS fd cPps d¨ mi;qä voj¨/k fpfälk feYk jgh gS] ftldh vkofÙk bYkkt djus okYkk us=fpfdRldr; djrk gSA

4- XYkkdëk% lQYk ckYk e¨fr;kÇcn v‚ijs'ku ds ckn nsj ls n`f"V gzkl ds ÁkjaÒ dk ;g vdsYkk lcls egRoiw.kZ dkj.k gSA bl tfVYkrk dh nj esaO;kid fofÒérk gSA lqj{kk lqfuf'pr djus ds fYk, ekrk&firk@dkuwuh vfÒÒkod a dk ;g lqfuf'pr djuk cgqr egRoiw.kZ gS fd fu;r le;karjkYkij cPps dh vka[k ds var%us=h; ncko dh fuxjkuh dh tk, rkfd le; jgrs irk Ykx lds v©j mipkjkRed mik; fd, tk ldsaA

5- jsfVuk dk foYkxko@,aMÏFŸkekbfVl% ;s fcjYk tfVYkrk,a gSaA

6- HkSaxkiu ¼HkSaxk½ v©j fuLVSXel ¼vf{knŸku½% dÒh&dÒh ;s tfVYkrk,a ÁLrqfrdj.k ds le; e©twn g¨ ldrh gSaA buesa ls nü a lek;U;r% vkxs dhfdlh frfFk ij vYkx ls 'kY;fpfdRlh; gLr{ï dh ekax djrh gaSA

vkids fYk, ;g vuqÒo djuk egRoiw.kZ gS fd thou Òj vR;ar lko/kkuh ds Q‚Yk¨vi djuk cgqr egRoiw.kZ g¨rk gS rkfd bYkkt djus okYkk fpfdRldvkids cPps ds n`'; dk; ± dk ewY;kadu dj lds v©j mi;qZä tfVYkrkv a esa fdlh tfVYkrk dk le; jgrs irk Ykx ldsA

eq>s mi;qZä rF; a ls voxr djk;k x;k gS v©j ÁfØ;k ls laÒkfor YkkÒ a v©j nq"ÁÒko a ds ckjs esa eq>s lYkkg nh xbZ gS v©j mi;qZä lÒh pht a d¨ iwjhrjg i<+ Yüs ds ckn eSa vius cPps ij mi;qZä ÁfØ;k djus dh iw.kZ lwfpr lgefr nsrk gwaA

( 178 )


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MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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( 179 )

YAG CapsulotomyDeepankur Mahajan


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

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

Posterior capsular opacification (PCO) is a condition which develops due to clouding of back membrane of the lens left behind followingmodern cataract surgery to support the intraocular lens. Such a membrane causes blurring and dimunition of vision and occasionallystreaks or haloes around light.

Laser capsulotomy involves using Nd-Yag laser to make a central hole within the PCO when it is causing significant complaints to thepatient thereby providing a clear central visual axis to the patient.

Complications of the procedure include: Damage to IOL optic, IOL pitting, IOL subluxation, IOL dislocation, postoperative intraocularpressure elevation, new floaters/ spots, cystoid macular edema, retinal swelling, retinal detachment and exacerbation of localizedendophthalmitis. Additional medical/surgical intervention may be required for these

Alternative treatment options include surgical posterior capsulotomy whereby eye has to be opened to remove opacified posterior capsule.

I, ................................................................... have been fully explained in the best understood language (.............................................) that I haveRE/LE posterior capsular opacification and have to undergo right/left eye Yag laser posterior capsulotomy for the same.

The details of the procedure and alternate treatments and their risks and benefits have been explained to my satisfaction. I hereby give myfull, free and voluntary informed consent for a posterior capsulotomy in my right/left eye with the YAG laser.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 180 )

okbZ,th dSIlwYk¨Vëhnhiadj egktu



i¨LVsfj;j dSIlwYkj vïkflfQds'ku ¼ihlhv¨½ ,d voLFkk gS t¨ var% us=h; Y al d¨ leFkZu nsus ds fYk, vk/kqfud dSVjSDV ltZjh ds ckn N¨M+h xbZ Y aldh dYkk ds /kqa/kYkh g¨ tkus ls g¨rh gSA esEojsu dk bl rjg dk /kqa/kkYkkiu] n`f"V gzkl v©j Ádk'k ds bnZ&fxnZ ÁÒkeaMYk ;k /kfj;k iSnk djrk gSA

Y¨tj dSIlwYk¨Vëh ds varxZr ml le; ,uMh okbZ,th Y¨tj dk mi;¨x djds ihlhv¨ ds Òhrj ,d dsaæh; fNæ fd;k tkrk gS] tc og j¨xh d¨ mYY¨[kuh;d"V nsus Ykxrh gS v©j bl rjg j¨xh d¨ us= dk Li"V dsaæh; v{k Ánku fd;k tkrk gSA

ÁfØ;k dh tfVYkrkv a esa 'kkfeYk gSa% vkbZv¨,Yk v‚fIVd d¨ {kfr] vkbZv¨,Yk dk fifVax] vkbZv¨,Yk dk foLFkkiu] 'kY;fpfdRl¨Ùkj var%us=h; ncko esa of)]u, ¶yksVlZ@/kCcs] flLV‚;M ekD;wYkj ,fMek] jsfVuk dh lwtu] jsfVuk dk foYkxko v©j LFkkfud ,aMÏF©YkekbfVl dk vR;f/kd c<+ tkuk buds fYk, vfrfjänokbZ ls mipkj@'kY;fpfdRlh; gLr{ï dh vko';drk iM+ ldrh gSA

bYkkt ds oSdfYid fodYi a esa lftZdYk i¨LVsfj;j dSIlwYk¨Vëh 'kkfeYk gS ftlds varxZr vikjn'kÊ g¨ pqds i¨LVsfj;j dSIlwYk d¨ fudkYkus ds fYk, vka[k[kŸkuh iM+rh gSA

eq>s] --------------------------------------------------------------------------------------------------------------------------- ml Òk"kk esa ftls eSa lcls vPNh rjg le>rk gwa iwjh rjg le>k;k x;kgS fd esjh nkb± vka[k@ckb± vka[k esa i¨LVsfj;j dSIlwYkj vïkflfQds'ku gS v©j mlds fYk, esjk nkb±@ckb± vka[k dh okbZ,thY¨tj i¨LVsfj;j dSIlwYk¨Vëhdh tkuh gSA

ÁfØ;k ds O;¨js v©j oSdfYid bYkkt a v©j muds t¨f[ke a v©j YkkÒ a dk eq>s lar¨"ktud fooj.k fn;k x;k gSA ,rn~}kjk eSa viuh nkb±@ckb± vka[k esa okbZ,thY¨tj i¨LVsfj;j dSIlwYk¨Vëh djus ds fYk, viuh iwjh] Lora"k] v©j LoSfPNd lwfpr lgefr nsrk gwaA


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

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MkWDVj dk gLrk{kj %

MkWDVj dk uke %

rkjh[k %

xokg 1 xokg 2

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

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MISCELLANEOUS

( 181 )

Examination Under Anesthesia (EUA)Chaitali Basu


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

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

I have been informed in the language I understand best, that my daughter/son/…….. is to undergo Examination Under Anaesthesia (EUA) , and that :

• The procedure is being done to thoroughly examine the patient who is not otherwise co-operative for normal examination.• During examination, if any need for an intervention is felt by my doctor, I give my consent for performing any procedure as may

be deemed advisable. I hereby certify that I have fully understood the reasons why the above procedure is considered necessary, itsadvantages and possible alternative modes of treatment. I also hereby certify that no guarantee or assurance has been made as to theresult that may be obtained.

• The procedure carries all the inherent risks of General Anaesthesia. The risk of complication with serious after effects and/or death,though small is always present.

Knowing this I give my full, free and voluntary consent.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 182 )

,sfuLFkhfl;k nsdj tkap ¼b;w,½pSrkYkh clq



eq>s ml Òk"kk esa ftls eSa lcls vPph rjg le>rk gwa] lwfpr fd;k x;k gS fd esjh csVh@csVs dh ,susLFkhfl;k nsdj ¼bZ;w,½ tkap dh tkuh gS] v©j ;gÒh fd%Û ;g ÁfØ;k j¨xh dh vPNh rjg tkap djus ds fYk, dh tk jgh gS t¨ vU;Fkk lkekU; tkap esa lg;¨x ugÈ dj jgk gSAÛ tkap ds n©jku ;fn fpfdRld fdlh gLr{ï dh t:jr vuqÒo djsxk r¨ og ftl fdlh Òh ÁfØ;k d¨ mfpr le>sxk mls djus dh viuh lgefr

nsrk gwaA eSa ,rn~}kjk Áekf.kr djrk gwa fd eSa mi;qZä ÁfØ;k d¨ vko';d le>us ds dkj.k a] blds YkkÒ a v©j bYkkt dh laÒo oSdfYid fof/k; ad¨ iwjh rjg le>rk gwaA eSa ,rn~}kjk ;g Òh Áekf.kr djrk gwa fd ÁkIr g¨ ldus okY¨ ifj.kke ds ckjs esa eq>s d¨bZ vk'oklu ;k xkjaVh ugÈ nhxbZ gSA

Û ÁfØ;k ds lkFk tujYk ,susLFkhfl;k ds lÒh varfuZfgr t¨f[ke tqM+s gSaA xaÒhj mÙkj ÁÒko v©j@;k e`R;q ds lkFk tfVYkrkv a ds t¨f[ke] gkYkkafdde] Y¨fdu ges'kk e©twn jgrs gSaA

;g tkurs gq, eSa viuh iwjh] Lora= v©j LoSfPNd lgefr nsrk gwaA


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MkWDVj dk gLrk{kj %

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rkjh[k %

xokg 1 xokg 2

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( 183 )

Optical IridectomyAsim K. Kandar


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

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

I have been informed in my mother tongue that I/ my child is suffering from whitening of the cornea (Corneal opacity) with some cleararea remaining (specify .........................................) and that a surgery will be performed to enhance the passage of light through the clear area.A part of the iris (diaphragm of the eye) will be excised during the surgical procedure.

I have been fully explained regarding the permanent nature of the opacity/ lesion and that it may increase after the surgery and cornealtransplant may be required. I have been explained the risk of development of cataract, leading to cataract surgery and lens implantation.There is risk of infection, hyphema due to haemorrhage from iris vessels leading to secondary rise of intraocular pressure. There is chanceof no improvement or worsening of best corrected visual acuity, glaucoma secondary to surgery or to medications, and high astigmatismafter surgery. There may be a need for repeat surgery which may or may not lead to improvement of vision. I have been explained the needfor follow up as frequently as advised by the doctors that may span upto years, with multiple investigations at each visit. I have beenexplained that using medications properly is required for success of the procedure. I have been explained that I will need to urgently comefor follow-up to ophthalmic casualty if there is sudden onset of redness, photophobia, pain or detoriation of vision as these may be signsof endophthalmitis. I understand that inspite of all efforts, there is a possibility that there may be worsening of the visual acuity or thecosmetic appearance of the eye.

I certify that I have fully understood the implications of the above consent and authorise the doctors to perform Optical Iridectomy on my/my child’s right / left eye.



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

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




Doctor’s name

Date

Witness 1 Witness 2


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

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

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

( 184 )

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Consent Forms in Ophthalmic Practice - dosonline.orgdosonline.org/consent_form.pdf · Consent Forms in Ophthalmic Practice in Hindi ... I understand the procedure has the following