Glaucoma Surgery Informed Consent

# Glaucoma Surgery Informed Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Date:** ___________ **Surgeon / Glaucoma Specialist:** ___________ **Surgery Center / Hospital:** ___________ **Patient Name:** ___________ ("Patient") **Date of Birth:** ___________ **Medical Record Number (if applicable):** ___________ **Eye to Be Operated:** ___________ **Procedure(s) Planned:** ___________ --- ## 1. Understanding Glaucoma (a) **Glaucoma** is a group of progressive optic neuropathies characterized by damage to the optic nerve, most often associated with elevated intraocular pressure (IOP). The optic nerve carries visual information from the eye to the brain. Glaucomatous damage is permanent and irreversible; vision lost to glaucoma cannot be restored. (b) The most common form, **primary open-angle glaucoma (POAG)**, is typically asymptomatic in its early and moderate stages, with central vision preserved until late in the disease. This "silent" progression is why many patients are unaware of their disease until significant damage has occurred. (c) **Normal-tension glaucoma** causes optic nerve damage at statistically normal IOP levels. **Angle-closure glaucoma** occurs when the drainage angle between the iris and cornea narrows or closes, causing sudden or progressive IOP elevation. (d) Treatment is directed at lowering IOP, which is currently the only proven method to slow or stop glaucomatous progression. IOP-lowering strategies include eye drop medications, laser procedures (selective laser trabeculoplasty, laser peripheral iridotomy), and incisional surgery. **Type of Glaucoma:** ___________ --- ## 2. Description of the Planned Procedure **Trabeculectomy:** A small opening is created in the sclera (white of the eye) under a hinged scleral flap, creating a new drainage pathway (filtering bleb) that allows aqueous humor to percolate out of the eye under the conjunctiva. Mitomycin C (MMC), an antifibrotic agent, is often applied to the surgery site to reduce scarring and bleb failure. A trabeculectomy with MMC is the most common incisional glaucoma surgery and has the highest IOP-lowering potential. It requires careful post-operative management, including bleb manipulation (laser suture lysis, needling) if healing is suboptimal.