INFORMED CONSENT FOR PERIPHERAL

IRIDOTOMY

Laser peripheral iridotomy (LPI) is the preferred procedure for treating angle-closure
glaucoma caused 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 chamber
Conditions causing synechial closure of the anterior chamber angle
include the following:

Neovascular glaucoma
Iridocorneal endothelial (ICE) syndrome
Patients 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: _______________

INFORMED CONSENT FOR PERIPHERAL

IRIDOTOMY

Doctors Name: ______________________ Signature_______________________ Time:

___________