In this PowerPoint presentation, I will be talking about consent taking for retinal procedures. So in order for the patient to give informed consent, there are several essential information that you need to tell the patient. And these include the indication for the procedure, what the procedure is in layman terms so the patient can understand, what the benefits of performing this procedure, and what the risks and complications that may arise from performing this procedure. It’s also important to tell the patient what to expect after performing this procedure, whether there’s going to be any pain, and how long a patient will need to rest after the procedure, and whether there are any alternatives to the procedure that you’re going to perform so that the patient can make an informed choice of whether to perform this procedure or not. If the patient is a minor or has diminished ability to give consent– for example, elderly patients with dementia– then we will need to inform the patient’s guardian or parent or caretaker so that they can give consent on behalf of the patient. So in addition to telling the patient this essential information, you also need to have a witness, a translator present if you are unable to speak the language of the patient. And particularly important is to have family members around as well so that everyone has a clear understanding of why this procedure needs to be performed and [INAUDIBLE] a consensus among everyone that this procedure should proceed. So the common office and OT procedures seen in the retinal department include intravitreal injections, vitreous tap, pneumatic retinopexy, scleral buckle, and vitrectomy. So first we will talk about intravitreal injections. In general, the main indications would be wet AMD, diabetic macular edema, myopic corneal neovascularization, or retinal vein occlusion. So first I will explain to the patient what the procedure entails. And you can see in this photograph that there is an injection. And we have a very fine needle into the eye. OK? And this is what I’ll tell the patient and also at the same time reassure the patient that there will be minimal or no pain involved in this procedure. Next I’ll talk about the types of anti-vascular endothelial growth factor agents that can be given. As far as the cost, number, and frequency of treatments, we shall go into more detail in the next slide. So in terms of benefits, the main indication would be to improve vision and decrease retinal swelling, and also to prevent visual loss. The risks can be divided into ocular risks and systemic risks, so I’ll describe these to the patient separately. In terms of ocular risks, the most common would be a subconjunctival hemorrhage, which is common and also benign. So it is wise to tell the patient about this beforehand so that the patient will not panic when he sees a red eye after the procedure. So more serious complications include endophthalmitis, retinal detachment, raised intraocular pressure, and cataract. Systemic risks are very rare– less than 0.1%– and this includes cardiac problems, stroke, and GI bleed. So post-procedure, I would tell the patient that there may be increased blurring of vision, which may be due to high eye pressure. This occurs rarely, but if it happens, the patient needs to tell me so that I will be able to perform a procedure– a further procedure to release fluid from the front of the eye to decrease the pressure. And also to tell the patient that some redness is normal. Again, it will resolve over the next few days although [INAUDIBLE] as a subconjunctival hemorrhage. But if there is worsening vision, eye pain, or floaters, then this may suggest a more serious complication. And the patient would need to return at once to see the doctor. So I was talking about the types of anti-vascular endothelial growth factors just now. And there are two broad groups. The FDA-approved group will be Lucentis and Eylea. And Avastin is basically open-label use. So you can read up more about the differences between these anti-vascular endothelial growth factors. But the main thing that you need to tell the patient is that there is a difference in the cost. As you can see, Avastin is the cheapest, at $370, and then Lucentis– $980– and Eylea– $1,380– of which only about $300 plus can be deducted from their Medisave. So this is important to tell the patient, also that multiple injections will be needed at frequent intervals, up to monthly. And the patient may expect to be given seven to nine injections in the first year of treatment. It is very important to tell them that multiple injections are needed, because these patients will often come there and say that they have already receive so many injections and are still not getting better. So it’s wise to moderate their expectations at the start of treatment rather than later. So vitreous tap is another common procedure done in the retinal department. And most of the time we do it as a diagnostic procedure– for example, in endopthalmitis. So I’ll tell the patient that I’m going to take a small amount of fluid from the back of the eye using a needle and tell patient why this has to be done– because the fluid is mainly taken so that we can confirm a diagnosis and so they get treatment. And the risks are similar to that of an intravitreal injection, which can include subconjunctival hemorrhage, vitreous hemorrhage, and retinal detachment. Pneumatic retinopexy is performed in patients with superior rhegmatogenous retinal detachment. So this is an office procedure. [INAUDIBLE] Done in the treatment room. Doesn’t require to be performed in the operating theater. And I’ll tell the patient that expansile gas will be injected into the back of the eye, the purpose of which is to reattach the retina and to seal off the retinal break. Importantly, you need to tell the patient that there’s a need for posturing after the procedure for 10 to 14 days, and definitely no air travel in this– when the gas is still in the eye. So benefits are to repair the retinal detachment, avoid visual loss. And risks include subconjunctival hemorrhage, endophthalmitis, cataracts, raised intraocular pressure, as well as failure to reattach the retina or a retinal redetachment. Post-procedure, readied eye pressure may be increased substantially. So this pressure can be relieved by releasing fluid from the front of the eye. We call this an anterior chamber paracentesis. Some redness is normal. Get resolved for the next few days, but of course, you need to tell them that if there’s worsening pain or worsening vision, then please come back immediately. And also get the appropriate posture advice and try to reinforce compliance. Alternative to pneumatic retinopexy would be to perform surgery, which I’ll describe in more detail in the next few slides. So scleral buckle is one of the surgeries that we perform for metogenous retinal detachment. And in layman terms, it will supply a silicon band around the eye. Applying cold lasers to seal the retinal break is cryotherapy, with or without draining the fluid from externally. The procedure can be performed under regional or general anesthesia. And this depends on the patient’s fitness for surgery, for anesthesia, and ability to cooperate during the surgery. In terms of benefits, I’ll tell the patient there’s 80% to 90% chance of reattachment of the retina. 80% of patients will get 6/12 vision or better if the macula is on. And if the macula is off, then about 30% to 40% will achieve 6/12 or better vision after surgery. The risks of scleral buckle include redetachment, refractive changes, raised intraocular pressure, and cataract. Alternatives would be to perform a vitrectomy on pneumatic retinopexy. What to expect post-procedure– because there is a 360-degree conjunctival peritomy, these patients will often feel that– will often have eye weakness, discomfort, as well as chemosis. But these usually resolve over two to four weeks. So vitrectomy is a another surgery that we perform for a rhegmatogenous retinal detachment. But there are other indications as well, which include macular pathologies, such as epiretinal membranes, macular hole, petrous hemorrhage, and endophthalmitis. So first I explain the procedure in layman terms. And it’s this for rhegmatogenous retinal detachment. So essentially we remove the vitreous gel, drain the fluid from underneath the retina, and perform laser to seal off the retinal break. And this followed by injection or gas to see the break and to tamponade the retina. So very important to tell the patient that it’s neat for posturing– face down after the procedure for 10 to 14 days– and that no air travel while the gas bubble is still in the eye. Again, you need to tell the patient that this can be performed under regional or general anesthesia, depending on the factors that we previously discussed. So benefits are similar– 80% reattachment rate; visual prognosis with depend the power macula is on or off. The risks, complications were redetachment, cataract, raise intraocular pressure, macular pucker, and endophthalmitis. So after the procedure, tell them about the eye weakness and discomfort, which is common after surgery but will resolve, and the appropriate posture advice. Thank you.