INFORMED CONSENT FOR PERIPHERAL IRIDOTOMY

Laser peripheral iridotomy (LPI) is the preferred procedure for treatingangle-closure glaucomacaused by relative or absolute pupillary block. LPI eliminates pupillary block by allowing the aqueous to pass directly from the posterior chamber into the anterior chamber, bypassing the pupil. LPI can be performed with an argon laser, with a neodymium:yttrium-aluminum-garnet (Nd:YAG) laser, or, in certain circumstances, with both.Indications:Indications for LPI include the following: Acute angle-closure glaucoma Chronic angle-closure glaucoma Fellow eye of acute angle-closure glaucoma Narrow/occludable angle Miscellaneous conditions, including phacomorphic glaucoma, aqueous misdirection, nanophthalmos, pigmentary dispersion syndrome, and plateau iris syndrome

Contraindications:Contraindications for LPI include conditions that cause poor visualization of the iris, angle closure due to synechial closure of the anterior chamber angle, and a patient who is unable to cooperate.Conditions causing poor visualization of the iris include the following: Corneal edema Corneal opacity Flat anterior chamberConditions causing synechial closure of the anterior chamber angle include the following: Neovascular glaucoma Iridocorneal endothelial (ICE) syndromePatients who are unable to cooperate include the following: Patients who cannot sit comfortably at the laser table Patients who cannot keep the head still

THE ALTERNATE TREATMENTS AND THEIR RISKS & BENEFITS HAS BEEN EXPLAINED TO MY SATIFACTION. I HEREBY GIVE MY INFORMED CONSENT FOR A PERIPHERAL IRIDOTOMY IN MY RIGHT/LEFT EYE WITH THE YAG LASER.Patient (or person authorized to sign for patient) Name: __________________ Signature: _____________________ Date: __________________ Time: _______________Doctors Name: ______________________ Signature_______________________ Time: ___________