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English neweyes informed consent

NEWEYES LASER IRIDOPLASTY
INFORMED CONSENT
I, Mr, Mrss, ____________________________________________________ as the patient or legal representative, with Identification card or Passport number _____________________, recognize that Doctor ________________________ has informed me about the fol owing topics, related to treatment I wil undergo.
A) NEWEYES LASER IRIDOPLASTY:
Laser iridoplasty is a procedure that involves applying laser impacts on anterior
surface of iris stroma. Thus iris pigmented layer is eliminated, remaining unchanged the deeper layers, with less pigmentation. Iris posterior pigmented layer, the Goal of treatment is to reduce superficial pigmented layers of iris to get a clearer appearance, greenish or bluish, with different degrees of intensity, depending on
B) RISKS AND COMPLICATIONS:
Laser iridoplasty can produce complications you should know and accept.
• Procedure is performed in the office under topical anesthesia.
• Complications that can occur after treatment are fol owing:
- Iris hemorrhage. - Iris inflammation, which is usual y transient and needs topical and general - Elevation of intraocular pressure. - Iris peripheral adherences to cornea, or central ones to lens. - Iris irreversible atrophy with a non reactive pupil to light (Urrets-Zavalía Syndrome), due to acute and reflex nerve or vascular damage. WARNING: Used laser and technique are accredited long time ago, but
NEWEYES application is new for both. These treatments were started up in
January 2012, thus don’t have sufficient experience.
IMPORTANT: Neweyes laser treatment is not indicated in patients suffering
glaucoma, anterior or posterior uveítis (ocular inflammation) and self-inmune
collagen diseases, or metabolic disorders as diabetes. Also is not indicated in
anticoagulated patients (SINTROM) or having antiplatelet drugs (PLAVIX, AAS,

Relevant to the health implications:

This procedure doesn’t affect any visual essential structure.

- Laser iridoplasty is useful to get clearer eyes, from brown color to green or blue, but this change is usual y irreversible. - It is not possible to warrant a 100% of effectiveness. Sometimes final color can be irregular by dots, or the clearing process can continue on time. - Otherwise, NEWEYES laser effect could be limited. Then will be necessary more laser sessions to improve final outcome, if there are not contraindications. C) PARTICULAR PATIENT RISKS:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
• The pacient may revoke this document before treatment at any time.
• This written report is complementary to DOCTOR verbal information.
Thus I DECLARE:
That I have been assisted by Dr _______________________, who, after listen to
me and visiting me, has informed that:
My diagnostic is .
My indicated treatment is .

• I have been informed with sufficient advance to laser treatment, in order to
understand, assess and think about al related aspects.
• I have had enough time to ask for the doctor any doubt or question.
• I’m fully aware that I wil undergo laser treatment, and as such, there’s no total
guarantee of success.
• I assume the potential risk of complications about this technique, that I have
informed previously.
• I told the doctor the whole truth about my general and eye diseases, al ergies and
drugs I usual y take, in order to prevent unnecessary risks.
I GIVE MY CONSENT:

1. To undergo NEWEYES LASER, and any other complementary procedure to 2. To take to me didactic photos or videos, with total respect of my anonymity. 3. To the presence of authorized personnel during laser procedures. Doctor’s signature Patient’s signature Witness’s signature Nº Col. ID card Nº DNI Nº

Source: http://www.eyecos.eu/img/docs/docs_en/ENGLISH_NEWEYES_INFORMED_CONSENT.pdf

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