Dr. Bream & Associates

CONTACT LENS CONSENT FORM

Welcome to our clinic. We are pleased to offer this service to our patients in order to reduce the waiting times and the exposure in a public setting.

The information provided is strictly confidential.

Please fill out this application completely to the best of your ability.

A copy will be sent to your email address given in this form.

 

Thank you
EYETELLIGENCE Team

 

• ACKNOWLEDGEMENT

RISKS

1. Potential Adverse Health Effects - The most common eye problems encountered by contact lens users are excess tearing, itching, burning, sensitivity to light, dryness, and occasional blurred or distorted vision. These conditions may be worsened by improper care or cleaning of contact lenses and increase the risk of developing an eye infection. Clinical studies suggest that the extended use of contact lenses, particularly overnight, increases the risk of    developing corneal ulcers. This condition is called ulcerative keratitis. An ulcer can perforate or scar the cornea in a day or two, leading to permanent scarring of the cornea or even blindness.

2. Risk of Ulcerative Keratitis - Contact lens wearers are at risk of sight threatening adverse events such as corneal ulceration, which may lead to scarring and visual loss. The risk of corneal ulceration is approximately 1 in 3000, 1 in 2000, and 1 in 500 patients per year for hard, soft daily wear, and soft continuous wear lenses, respectively.

3. Lifestyle Considerations -Anything that causes dry eyes, including antihistamines, birth control pills, alcohol and air travel, can make contact lenses uncomfortable, and can increase the risk of an eye infection. In addition, environmental contaminants, such as dust, smoke, sprays and pollen, can irritate the eyes when you wear contacts.

4. Smoking – Smokers are eight times more likely to develop corneal ulcers than non-smokers, no matter which type of contact lenses they wear.

5. Swimming – Swimming with contact lenses is NOT recommended. Bacteria and other organisms can travel from the water into the eye and contact lens. Because of reduced tear exchange with contact lenses your natural ability to “blink away” these contaminants are significantly reduced, allowing for susceptibility and increased risk of infection.

* The above risks may be reduced, but are still possible, with the use of RGP or hard lenses.

MINIMIZING YOUR RISK

The most important step you can take is to have your contact lenses prescribed and fitted by a qualified eye care professional. You should also participate fully in the follow-up care that is recommended, and:

• Read all of the patient information pamphlets that come with your contact lenses.

• Clean and care for your contacts as recommended by your eye care professional.

• Wash your hands thoroughly before handling your contacts & Do not use tap water or saliva to clean contacts.

• Preservatives used in contact lens solutions may become irritating. If this happens, consult your eye care professional. Also consult your eye care professional before switching brands of contact lens solutions as it can lead to toxic reactions or irritation.

• Do not wear your lenses past the time period that is recommended by your eye care professional.

• Bear in mind that overnight wear of contact lenses, including extended-wear contacts, is associated with an increased risk of serious eye infection.

• Never share your contact lenses with anyone else.
Avoid using temporary lenses that are included with costumes and are not approved by a doctor.

• Carry "artificial tears," a wetting solution, or glasses with you when you are likely to get dry, irritated eyes.

• Remember that contact lenses do not offer any eye protection. Use appropriate protective eye-wear when playing sports, especially hockey or squash.

In summary, if you experience blurred or hazy vision, or develop a pain in your eye while wearing contact lenses, remove them immediately. If the pain or blurred vision does not go away within a few hours, or if it gets worse, contact your eye care professional or go to the nearest emergency department.

ALTERNATIVES

1. Laser Eye Surgery – Laser eye surgery can reduce or eliminate the need for glasses or contact lenses. Not everyone is an ideal candidate for the procedure. Ask your eye doctor for more information regarding laser refractive surgery.

2. Spectacles – Glasses, although may not be to your aesthetic appeal, are generally considered a safer alternative to contact lenses with respect to infections and inflammation.

3. No Correction – If you have chosen contact lenses for aesthetic purposes (ex. Colored contacts) or if your prescription if very mild you may have the option not to wear contact lenses.

CONSENT FOR TREATMENT

By signing below, I acknowledge that I have read and understand the above and have had the opportunity to discuss this information with my doctor to my satisfaction. I hereby consent to the use of contact lenses while fully understanding the risks associated with contact lens use.