PLACE LETTERHEAD HERE AND DELETE THE NOTE IN THIS BOX.   
CHANGE FONT SIZE FOR LARGE PRINT

THIS FORM IS INTENDED AS A SAMPLE FORM.  IT CONTAINS THE INFORMATION OMIC RECOMMENDS YOU AS THE SURGEON PERSONALLY DISCUSS WITH THE PATIENT.  PLEASE REVIEW AND MODIFY TO FIT YOUR ACTUAL PRACTICE.  GIVE THE PATIENT A COPY AND RETAIN A COPY IN THE MEDICAL RECORD.

Version 03/5/2021

INFORMED CONSENT FOR YAG LASER CAPSULOTOMY AFTER CATARACT SURGERY

What is Yag laser capsulotomy?
Yag capsulotomy is a laser treatment used to improve vision after cataract surgery, and is usually performed as an outpatient.

A common occurrence after cataract surgery is clouding of the part of the natural lens covering (the capsule) that remains after surgery. This membrane may become cloudy and cause blurred vision, and sometimes patients will see streaks or haloes around lights. This can occur several months or even years after surgery. This problem can worsen with time. 

YAG laser treatment can be done without anesthetic or ocular incision. The laser is applied to the clouded posterior capsule and creates a small opening that allows light to pass though and create clearer vision. After the laser treatment, there is no interruption in physical activities and no patch is needed.

Benefits
Yag capsulotomy is performed to open the clouded part of the membrane and improve vision.

Risks
The most common complication of Yag laser capsulotomy is short-term increased pressure inside the eye, which may require drops to lower the pressure. Additionally, some patients may develop new floaters after this procedure. 

Less common risks include:

•	Detachment of the nerve layer at the back of the eye (retinal detachment)
•	Swelling of the center of the retina (macular edema)
•	Damage to or displacement of the intraocular lens
•	Migration of vitreous gel to position in front of intraocular lens

Alternatives

The alternative is to do nothing. The membrane may continue to thicken over time and cause a worsening of your vision. You may elect to have the Yag capsulotomy at a later date.

Patient Statement:
•	I have read this informed consent form, or someone has read it to me.
•	I understand the information in this informed consent form.
•	I have been informed about the possible benefits, complications, risks, and alternatives to Yag capsulotomy.
•	I have been given the opportunity to ask questions and received satisfactory answers. 
•	I understand that no guarantee of a particular outcome was given.
•	By signing below I am making an informed decision to undergo Yag laser capsulotomy. I received (or have been offered) a copy of this consent. 

I HEREBY GIVE MY INFORMED CONSENT FOR DR. ____________________
TO PERFORM YAG LASER CAPSULOTOMY IN MY _____________ EYE. (state right or left)  

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Signature of patient (or person authorized to sign for patient)		Date

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Printed name