GLAUCOMA SURGERY CONSENT FORM

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TUCSON EYE CARE, PC. GLAUCOMA SURGERY CONSENT FORM. Dr. Kaye has determined that your pressure is too high for the health of your eye.

TUCSON EYE CARE, PC GLAUCOMA SURGERY CONSENT FORM Dr. Kaye has determined that your pressure is too high for the health of your eye and unless it is lowered further, you will experience further damage to your optic nerve and loss of peripheral vision. Dr. Kaye is recommending a surgical procedure to create a new drain for the eye to allow fluid to escape to lower the eye pressure and to protect the eye against further damage. The procedure is performed in a surgical facility as an outpatient. Numbing medication is placed around the eye and the operation takes approximately 30 to 45 minutes to perform. To improve the success rate of the surgery, a medication called Mitomycin C may be used. This works to decrease scarring and to ensure that the new drain remains open after surgery. You will have a patch on the eye for the night of the surgery and you will be examined by Dr. Kaye the next day when the patch will be removed and you will be started on eye drops. Your vision may be blurred for up to one month following the surgery and you may have to have some stitches removed, cut or lasered within the first post-operative month. There is an 80% chance that the pressure will be controlled with this procedure, a 15% chance you will still need medications to help control your eye pressure after surgery, and a 15% chance the surgery will be unsuccessful and may need to be repeated. Glaucoma surgery, like surgery anywhere else on the body, has some risks involved. The risks include, but are not limited to, bleeding, infection, swelling of the front or back of the eye, leakage of fluid from the eye, low pressure and cataract formation. In the worst-case scenario, these complications may lead to blindness and loss of the eye. I, the undersigned, have read this statement and understand the risks, benefits, alternatives and complications of glaucoma surgery and am giving my consent to proceed.

Patient: _____________________

Witness:_________________________

Surgeon: ____________________

Date: ___________________________