Consent
Philadelphia LASIK – Bucks County, Elkins Park, Phoenixville, Warminster
Dr. James S. Lewis
Introduction
You probably have friends, relatives, and co-workers who have had successful LASIK surgery. In their eagerness to recommend this procedure they may not have mentioned that all refractive surgery has risks. It is the duty of all responsible LASIK providers to carefully delineate these risks.
The intent of these pages is not to dissuade you from LASIK. It is to temper your enthusiasm for this procedure with a careful and thorough review of the potential complications.
Most of the problems described have not occurred in any of our cases; some have not occurred in any LASIK patient worldwide. Nevertheless, our policy is to provide full disclosure.
I Hate My Glasses employs an extremely talented and experienced staff, the best materials, and the most technologically advanced lasers and surgical instrumentation. A refined system of checks and balances minimizes the likelihood of surgical complications.
We feel our surgical success and patient satisfaction is second to none. Furthermore, we believe our complication rate is as low if not lower than any other provider.
Count on us to remain supportive throughout your visual rehabilitation. We will work with you to achieve the visual result you desire and to preserve your ophthalmic health.
Sincerely,
James S. Lewis, MD
[The term LASIK in this document refers to LASIK and its related refractive procedures including LASEK, PRK, PTK, and Enhancement]
Informed Consent for LASIK, LASEK and Enhancements
1) There is a balance between the risks of LASIK and its benefits. For a successful experience you must accept responsibility for this decision. The only way to avoid surgical risk is to refuse surgery.
2) No one should undergo medical or surgical intervention without informed consent. Informed consent does not protect you from complications nor release your doctor from his/her obligation to maintain the standard of care. It serves to certify, educate, and counsel you regarding the intervention you are contemplating.
3) Read this document carefully. When all your questions and concerns have been adequately addressed sign and date each section. If you are not comfortable with this process or doubt your understanding of this material you must cancel your procedure. We will be happy to schedule another consultation with your doctor.
4) LASIK is a very exciting development both for our patients and for our practice. This exercise is part of the educational process. Those who elect to continue will be better prepared for the experience.
5) LASIK is an elective surgical procedure involving a microkeratome and an excimer laser for the treatment of your nearsightedness, farsightedness, and/or astigmatism. Read the materials provided. Watch the video tapes and other multimedia presentations describing this surgery before you continue. These supplement but do not substitute for personal discussion with your doctor.
Alternatives
6) There are other methods of correcting your refractive error. These alternatives may include, among others, eyeglasses, contact lenses, PRK (photorefractive keratectomy), intra-corneal rings, clear lensectomy (lens removal before cataract development) with intraocular lens insertion, intraocular lens insertion without lensectomy, thermal keratoplasty, incisional keratotomy, orthokeratology, or simply tolerating vision without correction.
History
7) LASIK is a highly evolved procedure with roots in corneal surgery performed decades ago. Improvements to the technique are ongoing and should be considered part of the art and practice of medicine. Application of an excimer laser to corneal stroma (central layer) has been in existence less than fifteen years. Consequently, we can not guarantee or assure the long-term consequences of this intervention.
8) The FDA evaluates medical and surgical drugs and devices in the United States. In the opinion of many experts both here and abroad this government agency has extended its authority beyond its scope by approving LASIK for some laser manufacturers and some refractive errors. You should not assume any assurances nor is there any guarantee regarding the long term safety and effectiveness of LASIK simply because the FDA has approved a laser system. LASIK has been practiced in the United States for nearly ten years. The FDA approved the first excimer for LASIK a few years ago. Thus almost all LASIK procedures performed in this country prior to mid-1998 were performed without FDA approval.
9) The FDA evaluates medical and surgical drugs and devices in the United States. We exclusively use the NIDEK EC-5000 laser, which in our opinion represents superior technology. The FDA has approved our laser for LASIK in myopia and myopic astigmatism. Some refractive errors like hyperopia (farsightedness) and hyperopic-astigmatism are still in FDA-sponsored clinical trials. We prefer to use our surgical judgement and expertise in the interim. Your optimal treatment plan may include off-label or non-sanctioned techniques. Feel free to discuss this further if you have concerns.
Research
10) A number of practices as well as several corporate entities are performing LASIK in this area. We encourage you to investigate this procedure and decide if it is appropriate for your needs. While the press and the Internet are valuable resources (example: www.ihatemyglasses.com) there is no substitute for an evaluation and consultation with your doctor.
11) We are happy to provide a list of local surgeons and surgical centers so that you can make an educated decision regarding LASIK. We will facilitate the scheduling of additional evaluations prior to surgery if you request . We will also arrange referrals or second opinions postoperatively if you find them desirable or necessary.
12) LASIK educational materials are also available from several non-profit agencies. Many can be obtained in this office. Copious links are available on our website.
Advertisement and Guarantees
13) LASIK is a medical procedure. Although we have engaged in advertising campaigns, the foundation for a successful surgery lies in the doctor-patient relationship. It is vital that you establish this relationship before your operation. Furthermore, you have a right to meet with your surgeon at a mutually convenient time without cost or obligation. There is no penalty for canceling surgery.
14) While several corporate entities and even a few surgeons promise 20/20 vision, we will not make that guarantee. Over the centuries physicians and surgeons have recognized biological variation and the lack of predictability in virtually all surgical and medical procedures. We respect this cumulative wisdom and instead offer excellent and responsible care. We strive for an optimal visual result without violating the basic tenet… first, do no harm.
15) In our opinion there is no place for a surgical guarantee in LASIK or in any other field of medicine. Refractive surgery is not a commodity.
Costs
16) The cost of LASIK at James S. Lewis, MD includes your pre-surgical evaluations, surgical procedure, post-operative examinations and any enhancements for one year following your procedure.
17) You and your health insurance provider are responsible for any related or non-related problems that may occur. While many insurance companies cover the cost of complications arising after elective surgery you should consult your carrier or benefits counselor to determine their policy regarding LASIK.
18) On occasion, pre-operative or post-operative clinical management may require the use of special tests or procedures. We may ask you to submit these to your health insurance company. If you belong to an HMO you may require a referral.
19) Routine eye care should continue indefinitely following refractive surgery. This is not included in the cost of the procedure.
20) LASIK is an elective procedure. Nevertheless, the obligations of your surgeon are no different than those that govern standard surgical procedures. The bond between patient and physician is fundamental. This begins with an understanding of risks and benefits.
Presbyopia
21) LASIK can not address the changes that occur in the human crystalline lens. Aging progressively decreases the amplitude of accommodation (close focus) making it more difficult to see near objects (without glasses) despite a clear view of distance objects. While this does not usually become problematic before the age of 40 it will occur and warrants careful consideration before having LASIK. If you demand bilateral clear vision both far and near regardless of age and will not wear reading glasses then LASIK is not for you.
22) Alternatives exist such as monovision, purposeful undercorrection, and clear lensectomy with multifocal intraocular lens insertion. These options should be addressed during your evaluation.
Recovery
23) It is not possible to estimate how quickly you will heal. The rate of visual recovery can not be predicted or guaranteed. This includes when you can safely drive, use a computer, return to work, etc. There is considerable fluctuation during the first weeks following surgery. In successful cases recovery can take six months or more.
Pregnancy
24) The cornea changes during pregnancy and lactation (nursing). The fluctuation of hormones may lead to a sub-optimal visual result. We will not knowingly operate on anyone who is pregnant, lactating, or planning pregnancy within six months. If relevant, these issues should be discussed during your evaluation. We strongly recommend consultation with your gynecologist or family physician. If you could be pregnant at the time of surgery postpone your LASIK procedure.
25) Fortunately, most patients who inadvertently become pregnant soon after LASIK enjoy excellent visual results.
Disease, Allergy and Medication Usage
26) LASIK can be performed on patients with a variety of serious medical conditions. You are responsible to be forthcoming during your evaluation. You must describe all medication and drug use, all health history, all relevant conditions including chronic diseases. Alert us to any allergies.
Dry Eye
27) LASIK can exacerbate or induce a temporary and very rarely a permanent dry eye state. This may cause discomfort and blurred vision. Effective interventions exist and will be utilized to maintain ocular health and comfort.
Trauma
28) Trauma, especially during the first week following your surgery, can severely compromise your long term visual results. Caution around small children is emphasized. Safety glasses are always recommended for racquet or contact sports.
Peoperative and Postoperative Instructions
29) Follow all instructions and restrictions given pre-operatively and post-operatively. Failure to comply can jeopardize the final visual results and your ocular health. You must absolutely refrain from soft contact lens wear for no less than 2 weeks before LASIK. Gas permeable lenses must be strictly discontinued one or more months prior to surgery. You must adhere to the specific recommendations made at the time of your evaluation. Do not restart your lenses after your evaluation if you plan to have LASIK.
Long-Term Risks
30) In giving permission for LASIK, you understand that the long-term risks and effects of LASIK are unknown. You have received no guarantee.
Vision Threatening Complications
31) Understand that the microkeratome or the excimer laser can malfunction (for a variety of reasons), requiring the procedure be stopped before completion. Depending on the type of malfunction, this may or may not be accompanied by temporary or permanent visual loss.
32) Understand that decentration of the laser energy can result in a sub-optimal result. This can cause regular and irregular astigmatism, glare, halos, double vision, and other serious visual distortions. Additional procedures or interventions may be required to ameliorate these symptoms.
33) Understand that unwanted material such as fibers and/or epithelial cells (epithelial ingrowth) and/or inflammatory cells can accumulate inadvertently beneath the corneal flap. This may require one or more additional procedures for adequate removal. This can delay visual recovery and possibly cause temporary or permanent visual loss.
34) Understand that inflammation and edema of the cornea can occur for a variety of reasons. This may require prolonged use of topical anti-inflammatory agents with their inherent risks (glaucoma, cataracts, infection). Additional surgical procedures may be required. This can result in temporary or permanent visual loss.
35) Understand that inflammation of the vascular tissues of the eye (iritis) can occur after LASIK. This will usually respond to anti-inflammatory agents with their inherent risks (glaucoma, cataracts, infection). This will delay visual recovery and may result in temporary or permanent visual loss. The pupil may develop an irregular shape.
36) Understand that, after LASIK, the eye may be more susceptible to trauma from impact. Understand that eyes treated with LASIK are more vulnerable to all kinds of injuries for at least one year and possibly indefinitely. Understand the need to wear protective eyewear while engaging in sports or other activities in which the possibility of a ball, projectile, elbow, fist, or other traumatizing object contacting the eye exists. Atmospheric extremes (high altitudes, underwater diving, etc) and exposure to noxious materials have not been adequately investigated. Caution must be exercised in these conditions. Commercial airline travel is allowed.
37) Understand that a corneal flap could be lost intra-operatively or post-operatively. This will result in temporary and possibly permanent visual loss. It is also possible that the flap could be inadequate. In such cases laser application for that eye will be postponed for several months. This will result in a temporary visual compromise and significant inconvenience. . Additional procedures or interventions may be required.
38) Understand that irregular healing of the flap, injury to the flap (intra-operatively or post-operatively), or loss of the flap could yield a distorted and scarred cornea. The resultant visual acuity, despite the use of glasses and/or contact lenses, can be less than that achieved pre-operatively. This is called loss of best corrected visual acuity. If the visual distortion is sufficiently severe, a partial or complete corneal transplant may be necessary to recover acuity.
39) Understand that rarely, perforations of the cornea occur causing devastating complications, including loss of some or all vision in that eye. A similar loss can be caused by an internal or external ocular infection that does not adequately respond to antibiotics or other interventions. This can occur even when the diagnosis is made promptly and a full therapeutic regimen is applied.
40) Understand that other uncommon complications can occur after LASIK. These include, but are not limited to, corneal decompensation (swelling), corneal ectasia (bulging), corneal melt (thinning w/o perforation ), corneal haze, corneal scarring, loss of endothelial cells or reduced endothelial cell function, cataract formation, chronic ocular dilation, glaucoma, optic nerve injury, ptosis (drooping lid), retinal detachment, hemorrhage, venous and/or arterial occlusion, chronic pain, chronic dry eye, loss of best corrected visual acuity, loss of best corrected spectacle acuity, contact lens intolerance, strabismus (crossed-eyes), diplopia (double vision), ghosting, total blindness of the eye, loss of the eye (globe) itself, and theoretically death.
41) Understand that complications may require additional procedures to recover vision. These include but are not limited to partial thickness corneal transplantation, cataract extraction, intraocular lens insertion, glaucoma surgery, and full thickness penetrating keratoplasty.
Additional Complications
42) Understand that there may be mild to moderate discomfort during the LASIK procedure. You will be asked to focus on a visual fixation target for best results. Cooperation is required.
43) Understand that there may be increased sensitivity to light, glare, halos, and fluctuations in visual detail. Understand that these conditions usually occur during the normal stabilization period of one to three months, but can last longer. Rarely, these symptoms can be permanent.
44) Understand that an overcorrection or undercorrection can occur and astigmatism can be induced. Furthermore, understand that full correction may not be achieved in the LASIK procedure. This may or may not be amenable to one or more enhancement procedures. This may require the use of glasses and/or contact lenses for reading and/or for distance vision some or all of the time. This need will exist before intervention and possibly thereafter. This may generate additional cost and inconvenience.
45) Understand there may be a “starbursting” or halo effect around lights. You understand that this condition usually diminishes with time, but could be permanent. Understand that your vision may not seem as sharp at night as during the day and that you may need to wear glasses at night. Understand that you should not drive or perform other high visual demand tasks until your acuity is adequate.
46) Understand that there may be a “balance” problem between eyes after LASIK. This phenomenon is called anisometropia. It is the result of different refractive powers for each eye. Another balance problem known as aniseikonia is the result of different image sizes for each eye. Aniseikonia can occur after LASIK. Understand that these conditions may cause eyestrain and disequilibrium. They may make judging distance or depth perception difficult. These conditions can be temporary or permanent.
47) Understand that there is a natural tendency of the eyelids to droop with age and that LASIK as well as other eye surgery may hasten or induce this condition.
48) Understand that there may be pain or a foreign body sensation, particularly during the first 48 hours after surgery. This is particularly true following enhancement procedures.
49) Understand that temporary glasses for distance and/or reading may be necessary while healing occurs and that more than one pair of glasses may be required.
50) Understand that the effects of LASIK beyond ten years presently are unknown and that LASIK has not been in use long enough to assess long-term results. Unforeseen complications or side effects can occur.
51) Understand that visual acuity from LASIK can regress following surgery. If appropriate one or more enhancement procedures may be recommended.
52) Understand that transient or prolonged symptoms of dry eye may develop. These include irritation, itching, burning, tearing, blurred vision, sensitivity to smoky, dry, or noxious environments.
53) Understand that the corneal epithelium (surface) can be mildly or even severely abraded during the LASIK procedure. This will induce significant discomfort for one or more days and will cause blurred vision. Corneal abrasion will also increase the likelihood of epithelial ingrowth, infection, inflammation, undercorrection, overcorrection, regular astigmatism, irregular astigmatism, recurrent corneal erosion (breakdown), and scarring. Rarely, the epithelial defect can be persistent requiring additional interventions or procedures.
54) Understand that the visual correction from LASIK may not be perfect. Understand that it is not realistic to expect that this procedure will result in perfect vision, at all times, under all circumstances, for the rest of one’s life. Understand that glasses or contact lenses may be required to maximize vision for some purposes.
55) Understand that medication will be offered to facilitate the LASIK procedure. This includes anti-anxiety medications and pain-relievers. If you take these medications it is your responsibility to exercise appropriate precautions (avoid driving, operating dangerous equipment, and concomitant drug use etc.). Understand that the use of these medications while pregnant or nursing could seriously jeopardize the fetus (child). A pregnancy test can be facilitated by this office if doubt exists.
56) Understand your responsibility to not drive or operate dangerous equipment until your vision is adequate.
57) Understand that if you currently need reading glasses, you will still need reading glasses after LASIK. It is possible that dependence on reading glasses may increase.
58) Understand that if you currently do not require reading glasses and are over 40, you will probably require reading glasses immediately or soon after LASIK (even if you can currently take your glasses off and read). If you are younger it is possible that dependence on reading glasses will occur at an earlier age.
59) Even 90% clarity of vision is still slightly blurry. Enhancement surgeries can be performed when vision is stable unless it is unwise or unsafe. In order to perform an enhancement surgery adequate corneal tissue must remain. If it is inadequate or marginal an alternative method of visual rehabilitation will be recommended.
60) Understand that, as with all types of surgery, there is a possibility of complications due to anesthesia, drug reactions, or other factors that may involve other parts of the body. Understand that this list of complications is incomplete.
61) Understand that LASIK is not reversible.
62) Understand that underlying medical problems and physical conditions may increase the risk of complication following LASIK. Furthermore, some of these conditions may go undiagnosed resulting in uninformed risk. These include but are not limited to keratoconus (a corneal disease), immune deficiency syndrome (HIV), auto-immune disease, demyelination syndromes (MS), optic nerve disease, glaucoma, ophthalmic vascular insufficiency, collagen-vascular disease (Rheumatoid Arthritis, Lupus), Herpes (Simplex, Zoster), anterior basement membrane dystrophy, amblyopia (lazy eye), monofixation syndrome, compensated tropias and phorias, diabetes, and pregnancy.
63) Understand that in some circumstances the anatomy of the eye and the orbit make it difficult or impossible to achieve adequate exposure and/or suction for successful flap creation. In these cases surgery must be postponed for a few weeks. Sometimes, the surgery can not be performed on one or both eyes and alternatives to LASIK must be sought. Sometimes LASEK will be recommended as a safer intervention.
64) Understand that LASIK does not prevent you from developing eye problems and disease states. This list includes, but is not limited to ptosis, dry eye, recurrent erosion syndrome, infectious keratitis, glaucoma, cataracts, uveitis, retinal degeneration, retinal detachment, diabetic retinopathy, presbyopia, and progressive myopia. LASIK as does any ocular surgical intervention increases your need for periodic ocular health evaluation and management.
65) Understand the cost of the LASIK procedure does not include the price of all medications, interventions, procedures, and therapies.
66) Understand the risks of not having LASIK are limited to those associated with your current visual condition and method of correction. These include but are not limited to the dangers that may be associated with losing glasses or contact lenses, the risks of corneal scarring, astigmatism, neovascularization, and infection from wearing contact lenses, and the risks of trauma to the eye caused by breakage of spectacles or contact lenses while worn.
67) Understand that despite what appears to be a perfect operation with excellent measured Snellen visual acuity one may not be satisfied with the results. This may be the result of decreased contrast sensitivity, problems associated with adjusting to presbyopia, dry eye, recurrent erosion syndrome, glare, starbursts, unreasonable surgical expectations, or other non-measured visual characteristics, functionality, or phenomena
Simultaneous vs Non-Simultaneous LASIK
68) All patients will be offered the choice of either bilateral or unilateral surgery. There will be no additional total surgical cost.
69) Both within and outside the United States, LASIK has become a common procedure for many refractive surgery patients. The second eye may be treated sooner than three months after the first eye, or even at the same time; however, there may be risks associated with simultaneous treatment that are not present when the eyes are treated on different days. If you elect to have surgery performed on both eyes at the same surgical encounter, you should understand both the possible advantages and disadvantages of your decision.
The advantages of having LASIK performed on each eye during a separate surgical encounter are:
70) Safety: You will not experience the risk of developing an infection in both eyes at the same time, which although very rare, could lead to significant loss of vision in both eyes. Since the pressure in the eye is increased significantly for a short time during the LASIK procedure, there is a very remote possibility of internal bleeding or damage to the retina or optic nerve, which could lead to significant loss of vision or even blindness. Should this happen to both eyes, the consequences could of course be devastating.
71) It is also possible to develop a delayed cloudiness in the cornea or even corneal scarring which is not visible immediately after the procedure. Although this is uncommon and generally clears with time, it can result in significant loss of vision for a prolonged period of time. Should this occur in both eyes at the same time, carrying out normal activities could be difficult.
The advantages of having LASIK performed on each eye during a separate surgical encounter are:
72) Safety: You will not experience the risk of developing an infection in both eyes at the same time, which although very rare, could lead to significant loss of vision in both eyes. Since the pressure in the eye is increased significantly for a short time during the LASIK procedure, there is a very remote possibility of internal bleeding or damage to the retina or optic nerve which could lead to significant loss of vision or even blindness. Should this happen to both eyes, the consequences could of course be devastating.
73) It is also possible to develop a delayed cloudiness in the cornea or even corneal scarring which is not visible immediately after the procedure. Although this is uncommon and generally clears with time, it can result in significant loss of vision for a prolonged period of time. Should this occur in both eyes at the same time, carrying out normal activities could be difficult.
74) Accuracy: The doctor can monitor the healing process and visual recovery in the first eye and may be able to make appropriate modifications to the treatment plan for the second eye. By delaying surgery, it may be possible in some patients to improve the accuracy of the result in the second eye.
75) Visual Recovery: Although most LASIK patients experience a rapid recovery in their vision, the recovery can at times be delayed. If the eyes are operated separately, you can function with the fellow eye while the first eye fully recovers. This is especially true if you are able to wear a contact lens in the unoperated eye.
76) Satisfaction: You will be given the opportunity to determine whether the LASIK procedure has produced satisfactory visual results without loss of vision or other uncommon undesirable side effects such as glare, halos, starbursting, ghost images, or increased light sensitivity. If you are over age 40, you will have an opportunity to experience the change in your close vision which results from the correction of your refractive disorder. This could influence your decision on whether or not to fully correct your other eye to maintain some degree of close vision without the need for glasses (monovision).
The disadvantages of having LASIK performed on each eye during a separate surgical encounter are:
77) Convenience: It may be inconvenient for you to have each eye treated at separate visits. This will necessitate two periods of recovery from the laser surgery and may require additional time away from work.
78) Visual Recovery: There will be a potential period of imbalance in vision between your two eyes. This is especially important if you are unable to wear a contact lens in your unoperated eye. It is not usually possible to use the operated eye without a corrective lens along with a strong corrective lens in the unoperated eye because it produces a strong sense of imbalance, dizziness, and a form of double vision (anisometropia).
79) Cost: The additional time off work must be considered.
The advantages of having LASIK performed on each eye during the same surgical encounter are:
80) Convenience: It may be more convenient to have both eyes treated during the same encounter.
81) Visual Recovery: The balance in vision between your two eyes will usually be restored more rapidly.
82) Cost: You will be missing less work by allowing both eyes to recover at the same time.
The disadvantages of having LASIK performed on each eye during the same surgical encounter are:
83) Safety: The risks of infection, delayed clouding of the cornea, corneal scarring and internal bleeding or retinal or optic nerve damage are very rare but potentially devastating. If these serious but rare complications occur in one eye, they may also occur in the other. Should any of these complications happen, you could experience significant loss of vision or even temporary or permanent legal blindness.
84) Accuracy: By correcting both eyes simultaneously, there is no opportunity to learn from the healing patterns of the first eye before treating the second eye. Therefore, if there is an over-correction or under-correction in one eye, it may happen in both eyes. If a retreatment is required in one eye, it is possible that your fellow eye may also require a retreatment.
85) Visual Recovery: LASIK patients generally experience rapid visual recovery. Some patients, however, can experience delayed visual recovery and experience symptoms such as blurred vision, night glare, halos, starbursting, or ghost images. There is no way of predicting how long your eyes will take to heal, and some of these complications can result in prolonged recovery of normal vision. Blurred vision may rarely continue for several weeks in both eyes, which could make driving difficult or dangerous and could interfere with your ability to work. The healing corneal flap is most susceptible to trauma during the first several weeks after surgery. Should both flaps become accidentally displaced, significant temporary and rarely permanent visual loss in both eyes may result.
86) Satisfaction: Both eyes tend to experience similar side effects. If you experience undesirable side effects such as glare, halos, ghost images, increased light sensitivity, or corneal haze in one eye, you will likely experience them in both eyes. These side effects may cause a decrease in vision or other negative effects, and some patients have elected to not have their second eye treated.
Patient’s Request Form
Mark one and only one:
__ I request LASIK on both eyes* during the same surgical encounter.
__ I request LASIK on the RIGHT eye during this surgical encounter.
__ I request LASIK on the LEFT eye during this surgical encounter.
__ Other _____________________________________
* in some cases the surgeon will opt to perform LASIK on only one eye during this surgical encounter based on clinical considerations. This may or may not be determined preoperatively.
Patient’s Statement of Acceptance and Understanding
I certify that the LASIK procedure has been presented to me in sufficient detail (and in terms I understand) to render informed consent.
I acknowledge viewing multimedia presentations and reading related materials which further explain the LASIK procedure.
I have had an opportunity to discuss my questions and concerns with my doctor and staff and am satisfied with the answers provided.
I fully understand the risks, benefits, complications, and alternatives to LASIK as they have been presented and have made this decision without duress of any kind.
Mark one and only one:
__ I want emmetropia (operated eye(s) see distance with minimal or
no spectacle dependence).
__ I want monovision -R (right eye sees near and the left sees distance
with minimal or no spectacle dependence).
__ I want monovision -L (left eye sees near and the right sees distance
with minimal or no spectacle dependence).
__ Other _____________________________________
Video and Photographic Release
A record of your surgery will become part of the medical record. This includes only a view of your eye as it appears through the surgical microscope. Your face and body will not be shown; your privacy will not be violated.
You may have a VHS copy if you wish.
Your medical record may be used for education, research, and training of other health care professionals.
You may restrict the presentation of your LASIK surgical video to health care professionals. This will prevent the general public (friends, relatives, and prospective patients) from viewing your procedure.
Mark one and only one*:
__ Allow friends, relatives, and prospective patients to view my LASIK surgical video.
__ Restrict my LASIK surgical video to education, research, and training of health-care professionals.
__ Other _____________________________________
* In all cases your name, appearance, and identity will remain confidential. Your face and body will not be shown.
Webcast Release
Our Elkins Park facility has very high speed internet connectivity. We can webcast your LASIK surgery and will provide you with a CDROM of your procedure in Quicktime format. This can be stored on the web.
In addition, there is a controllable robotic pan-tilt-zoom camera with access to our operating suite. Your family or friends can log onto www.lasiktv.com to view both the surgery and the operating suite during your procedure.
Naturally, this is entirely optional and without cost. Unauthorized access to your webcast is not possible.
We consider your privacy and your entire medical record to be sacrosanct. We will always respect your preference.
Please Circle TRUE or FALSE:
TRUE – FALSE
There are no risks associated with LASIK.
TRUE – FALSE
Night driving problems, glare, halos, and dry eye can occur for some time after surgery.
TRUE – FALSE
You’ll never have to wear reading glasses.
TRUE – FALSE
100% can drive and use a computer the next day.
TRUE – FALSE
There is a guarantee of 20/20 vision with LASIK.
TRUE – FALSE
Absolutely everyone returns to work in 24 hours.
TRUE – FALSE
You must have follow-up and regular eye exams after this surgery.
TRUE – FALSE
Visual fluctuation and regression can occur.
TRUE – FALSE
Reading and driving are perfect right after LASIK.
TRUE – FALSE
Undercorrections and overcorrections never happen.
TRUE – FALSE
Glasses may be required for some tasks.
TRUE – FALSE
You will never develop unrelated eye problems.
TRUE – FALSE
You have not worn contacts for the required time interval.
Regarded as a foremost Philadelphia and Bucks County LASIK surgeon, Dr. Lewis is proud to offer his patients a variety of advanced refractive treatments. In addition to performing LASIK and Epi-LASIK, he specializes in helping Visian ICL Philadelphia patients achieve clear vision though implantation of these sophisticated contact lenses.