Laser Peripheral Iridotomy Procedure Note

Note Type: Laser Peripheral Iridotomy Procedure Note

Procedure Date: [Procedure date]

Time: [Start time] (Include end time only if captured.)

Location: [Clinic / ASC / OR]

Patient: [Patient name], MRN: [MRN]

Performing Clinician: [Name, credentials]

Eye(s) Treated: [OD (Right) / OS (Left) / Bilateral]

Procedure Summary

Indication: [Indication] (Do not infer; include only if explicitly documented.)

Procedure: Laser Peripheral Iridotomy — [Right / Left / Bilateral]

Anesthesia: [Topical anesthetic drops / other]

Complications: [None / brief summary with reference to details below]

Informed Consent

[Consent statement: risks, benefits, and alternatives discussed; questions answered; patient agreed to proceed. See signed consent form.] (If consent status is unknown or not documented, insert: "[CONSENT: REQUIRED—NOT DOCUMENTED]")

Pre-Procedure Verification

• Correct patient identity confirmed
• Correct procedure confirmed: Laser Peripheral Iridotomy
• Correct laterality confirmed: [Right eye / Left eye / Both eyes]
• Allergies reviewed: [Yes / No / Not documented]
• Anticoagulant/antiplatelet status: [Reviewed / Not documented] [Specifics if available]
• Lens status: [Phakic / Pseudophakic / Aphakic / Unknown]
• Time-out performed: [Single time-out confirming both eyes / Separate time-outs per eye / Alternative verification per site policy] (For bilateral procedures, document laterality confirmation before the second eye.)

Pre-Procedure Clinical Context

• Baseline IOP: [IOP value(s) per eye with method] (If not taken, state "Baseline IOP not documented.")
• Key examination findings: [Gonioscopy details, extent of iridotrabecular contact or PAS, mechanism] (Include only if explicitly documented.)
• Prior angle-closure events: [Relevant history] (Include only if applicable.)
• Current glaucoma medications: [Relevant medications]

Medications Administered

Pre-laser:

• [Drug name, concentration, route, eye]

Post-laser:

• [Drug name, concentration, route, eye]

(Include only medications actually administered for this patient.)

Procedure Details

(Create a separate eye-specific block for each eye treated. Do not combine bilateral procedures as "OU.")

Eye: [Right / Left]

Technique: [Patient positioned at slit lamp laser; topical anesthesia administered; iridotomy lens type with coupling agent applied; laser applied to peripheral iris location at clock hour and quadrant; note if placed under lid margin or at iris crypt; any repositioning, staged approach, or intra-procedure issues] (If procedure was aborted or incomplete, explicitly state reason and next steps.)

Laser Settings — Nd:YAG: [Energy (mJ) per pulse or range], [number of shots], [pulses per burst if used] (Include only if Nd:YAG was used.)

Laser Settings — Argon/532 nm: [Power (mW)], [duration (seconds)], [spot size (µm)], [number of spots] (Include only if Argon/532 nm was used.)

Sequential Argon + Nd:YAG: [Argon pretreatment settings] → [Nd:YAG completion settings] (Include only if sequential technique was used. Provide as separate entries.)

Patency Confirmation: [Patent / Patency uncertain / Not created] — confirmed by [direct visualization of full-thickness opening / egress of aqueous or pigment plume / retroillumination / gonioscopy / other] (If uncertain, state plan for recheck or repeat.)

(Repeat eye-specific block above for second eye if bilateral procedure.)

Post-Procedure Assessment

• Patient tolerance: [Tolerated well / description]
• IOP check: [Time post-procedure] — [IOP value(s) per eye] (If not measured, state "Post-procedure IOP not measured.")
• Slit-lamp findings: [Corneal clarity, anterior chamber reaction, hyphema, lens status] (Include only if relevant.)
• Visual symptoms reported: [Description]
• Interventions: [Details if elevated IOP or other issue requiring treatment]

Complications

[No immediate complications observed / Details: IOP spike, hyphema/bleeding, corneal injury, lens pitting, significant inflammation, vasovagal event, other] (State "No immediate complications observed" only if post-procedure assessment occurred.)

Discharge Medications & Instructions

Medications:

• Topical anti-inflammatory: [Drug, dose, frequency, duration]
• IOP-lowering: [Drug, dose, frequency, duration] (Include only if applicable.)
• Existing glaucoma drops: [Continue unchanged / adjustments]

Instructions:

• Expected symptoms: [Temporary blur, mild discomfort, light sensitivity]
• Red flags requiring return: [Severe pain, decreased vision, persistent redness, flashes/floaters, severe headache/nausea]
• Contact information: [Phone/clinic for urgent concerns]

Follow-Up Plan

• IOP follow-up: [Timing and location]
• Patency and angle status follow-up: [Timing; note if gonioscopy planned]
• Contralateral eye: [Plan if untreated and indicated]
• Contingent instructions: [Return earlier if specific symptoms occur]