Please read this consent form carefully as you are considering LipiFlow treatment. After you have read each section and feel comfortable with your understanding, please sign to indicate informed consent for treatment.
Dry eye is an extremely common condition. It is a major cause of eye discomfort and decreased vision. Dry eye can limit your activities and impact your quality of life. While there is no cure for dry eye syndrome, there are a variety of treatment options that can help with the frustrating symptoms that accompany dry eyes.
One of the most common causes of dry eye symptoms results from a condition called Meibomian Gland Dysfunction (MGD). In a healthy eye lid, there are many small meibomian glands which secrete fatty oils to help create a stable and quality tear film. These oils help prevent the watery component of your tears from evaporating too quickly. If your meibomian glands are clogged, the important oily component cannot be released onto the surface of the eye, allowing the tears to evaporate or dry up, causing dry eye symptoms. This is called Evaporative Dry Eye.
LipiFlow Thermal Pulsation Treatment is completed using an FDA approved medical device. Treatment is delivered by a doctor or other practitioner to apply warmth and massage to the eyelids. This allows the oils from the blocked glands to flow into the tear film. In conjunction with an eye examination, your doctor conducts testing to determine if the LipiFlow system is a good treatment option for you.
You will be seated during your LipiFlow treatment and a mild anesthetic drop will be placed into your eyes. Your doctor will gently position the LipiFlow device between your eyelids and the eye itself. You will be asked to keep your eyelids closed during the procedure. The system directs controlled warmth to the eyelid while protecting and insulating the eye. During treatment, you will feel warmth and a mild to moderate pulsing sensation on your eyelids. The temperature of this warmth is slightly above body temperature. The LipiFlow system also applies massage to the outer eyelid surface to further release oils from the blocked meibomian glands into the tear film. The treatment will take 12 minutes for each eye. You will be monitored by a trained ophthalmic technician during the entire course of your treatment. You may experience minor irritation or redness from the procedure. Home care instructions will be explained.
You will be advised to complete an in-office procedure prior to treatment called Foreign Body Lid Margin Debridement in an effort to remove buildup and crust, including epithelial gland caps of lid tissue accumulating along the edges of the eyelids. Your eyes will be numbed with a mild anesthetic drop and while seated at the slit lamp, your doctor will debride the eyelid of accumulated buildup with a medical instrument. This minor procedure is included in your LipiFlow treatment.
