Risk Management
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Laser Surgery Consent (Addendum to General Consent)
[ADDENDUM TO GENERAL CONSENT FORM]
LASER SURGERY
Complications which could occur weeks, months, or even years later:
- Failure to achieve intent of surgery
- Loss of central or side vision
- Bleeding in eye
- Early or late increase in pressure in eye (glaucoma)
- Corneal burns
- Damage to lens (cataract)
- Retinal hole
- Collection of fluid in back of eye
- Damage to optic nerve
- Damage to the iris
- Damage to an intraocular lens implant, if present
- Loss of vision or loss of eye
Local complications of anesthesia injections around the eye:
- Perforation of eyeball
- Destruction of optic nerve
- Interference with circulation of retina
- Possible drooping of eyelid
- Respiratory depression
- Hypotension
Additional comments:
Patient (or person authorized to sign for patient) Date
Witness Date
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