Selective Laser Trabeculoplasty Procedure Note

Procedure: Selective Laser Trabeculoplasty (SLT)

Date: [Procedure date]

Eye: [Right eye (OD) / Left eye (OS)]

Operator: [Operator name, credentials]

(If bilateral same-day SLT is performed, duplicate this entire documentation block for the fellow eye with distinct parameters.)

Pre-Procedure Diagnosis and Indication

Diagnosis: [Primary open-angle glaucoma / Pseudoexfoliation glaucoma / Pigmentary glaucoma / Ocular hypertension / Other glaucoma subtype]

Indication for SLT: [Rationale, e.g., inadequate IOP control versus target, medication intolerance, adherence burden, adjunct to current therapy, or medication reduction despite controlled IOP]

Prior laser/surgery to treated eye: [Prior procedures relevant to aqueous outflow, if any / None]

Angle status: [Open and adequate for SLT]

Informed Consent

Informed consent obtained after discussion of risks, benefits, and alternatives. Risks discussed included [transient IOP elevation, inflammation, discomfort, limited efficacy, need for additional treatment]. Patient questions answered; patient agreed to proceed.

Safety Verification and Time-Out

• Patient identity verified: [Two identifiers confirmed]
• Correct procedure confirmed: SLT
• Correct eye confirmed: [OD / OS]
• Time-out performed: [Yes, immediately prior to laser with operator and staff / No] (If not performed, document reason and mitigation.)
• Site marking: [Not applicable per ophthalmic workflow; verbal verification with patient used / Applied]

Pre-Procedure

• Pre-procedure IOP: [Value] mmHg, [Timing: same day / prior date]
• Pre-treatment medications: [Topical anesthetic and IOP-spike prophylaxis with drug names, eye, timing / Topical anesthetic only]

Procedure Details

[Brief technique narrative: patient positioning, gonioscopy lens used, trabecular meshwork visualized and treated]

Treatment extent: [Degrees or clock hours]

Number of shots: [Total applications]

Energy: [Starting, range, or final titrated value in mJ]

Endpoint: [Titration endpoint, e.g., minimal/fine champagne bubble formation]

(If procedure was aborted or incomplete, document reason, amount completed, and next steps.)

Complications

[None / Complication description including event, severity, timing, and intervention]

Post-Procedure

• Post-procedure IOP: [Value] mmHg at [Timing post-SLT]
• Post-procedure drops given: [Drug names and eye / None]
• Patient status at discharge: [Stable, tolerating well / Other status; note vision changes if any]

(If IOP elevated, document treatment and disposition. If post-IOP not checked, document reason and return precautions given.)

Plan

• Glaucoma medications: [Continue / Hold / Stop / Start] [Medication names, doses, frequencies] (State explicitly if regimen unchanged.)
• Anti-inflammatory drops: [Name, frequency, duration / Not prescribed]
• Follow-up: [Interval and purpose, e.g., IOP check in 1–2 weeks]
• Return precautions: Patient instructed to contact urgently for [severe pain, decreased vision, halos, nausea/vomiting]
• Fellow-eye SLT: [Planned with anticipated timing / Not planned]

Attestation

Electronic signature: [Operator name, credentials, date/time]

(If trainee involved: Include teaching physician attestation documenting presence for the procedure per institutional policy.)