This information is to help you make an informed decision about having Laser Assisted in-situ Keratomileusis surgery to treat your nearsightedness, farsightedness, or astigmatism. Take as much time as you wish to make a decision about signing this form. You are encouraged to ask any questions and have them answered to your satisfaction before giving your permission for surgery. Every surgery has flaws as well as benefits and each person must evaluate this risk/benefit ratio for himself/ herself in light of the information presented in this consent form.
Spectacles and contact lenses are the most common method of correcting nearsightedness (myopia), farsightedness (hyperopia) and astigmatism. When tolerated well, they are likely to be a good alternative to LASIK surgery. Refractive surgery is continually evolving and other refractive procedures may be available as an alternative to LASIK. You should also be aware that having any refractive procedure could potentially disqualify you from some professions, including the military and certain law enforcement agencies.
LASIK permanently changes the shape of the cornea. The surgery is performed under a topical anesthetic (drops in the eye.) A one-quarter thickness corneal flap is created with an instrument called a microkeratome. The microkeratome is a specialized instrument, which is used to perform partial thickness separation of corneal tissue. The flap is then placed back and the laser is performed inside the cornea. The flap is replaced and bonds back into place without the need for stitches. The result of removing thin layers of tissue causes the center of the cornea to flatten in the case of nearsightedness, or steepen in the case of farsightedness, or become more rounded in the case of astigmatism, which changes the focusing power of the cornea. Although the goal of LASIK is to improve vision to the point of not being dependent on glasses or contact lenses, or to the point of wearing thinner (or weaker) glasses, this result is not guaranteed.
You should understand that LASIK surgery would not prevent you from developing naturally occurring eye problems such as glaucoma, cataracts, retinal degeneration or detachment. After the procedure you should avoid rubbing the eye. Your eyes may be more susceptible to traumatic injury after LASIK and protective eye wear is recommended for all contact and racquet sports where a direct blow to the eye could occur. Also, LASIK does not correct the condition known as presbyopia (or aging of the eye), which occurs to most people around age 40 and may require them to wear reading glasses for close-up work. People over 40 that have their nearsightedness corrected may find they need reading glasses for clear, close vision. LASIK does not correct double vision. If you currently wear glasses with prism to correct double vision (strabismus), or have double vision without glasses, you will still have this condition after having LASIK surgery. It is possible, however, to improve double vision with a separate surgery.
During pregnancy, your refractive error can fluctuate which could influence your results. If you know you are pregnant or attempting to become pregnant, it is important you advise your doctor immediately.
POTENTIAL RISKS OF LASIK INCLUDE:
In signing this form, you are stating that you have read this consent form, and although it may contain medical terms that you do not completely understand, you have had the opportunity to ask questions and have had them answered to your satisfaction.
To assure you have understood the information presented, please copy the following statement in your own handwriting:
“I understand the information presented and am willing to accept the fact that I may need glasses or contact lenses or further surgery following LASIK to achieve my best possible level of vision.”
True/False: I may have glare in the evening, which may make it difficult for me to function at night.
True/False: I may not be able to have 20/20 vision after the procedure even with glasses or contact lenses.
I am making an informed decision in giving my permission to have Laser Assisted In-Situ Keratomileusis (LASIK) surgery performed on my right eye; left eye; both eyes.