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Periocular Repository Corticosteriod Injections

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NOTE:  THIS FORM IS INTENDED AS A SAMPLE FORM.  IT CONTAINS THE INFORMATION OMIC RECOMMENDS YOU AS THE SURGEON PERSONALLY DISCUSS WITH THE PATIENT.  PLEASE REVIEW IT AND MODIFY TO FIT YOUR ACTUAL PRACTICE.  GIVE THE PATIENT A COPY AND SEND THIS FORM TO THE HOSPITAL OR SURGERY CENTER AS VERIFICATION THAT YOU HAVE OBTAINED INFORMED CONSENT.

Version 12/2/2002

POTENTIAL COMPLICATIONS ASSOCIATED WITH PERIOCULAR REPOSITORY CORTICOSTEROID INJECTION(S)

  1. Inadvertent injection into the choroidal or retinal circulation, emboli.
  2. Perforation of the globe with permanent loss of vision/loss of eye.
  3. Cataract.
  4. Glaucoma (increased eye pressure) in injected/other eye that may be transient or permanent and could lead to medical or surgical treatment (i.e., excision of depot or glaucoma filtering operation).
  5. Blepharoptosis.
  6. Proptosis.
  7. Orbital fat atrophy, fibrosis.
  8. Delayed hypersensitivity reactions.
  9. Strabismus.
  10. Conjunctival hemorrhage.
  11. Chemosis.
  12. Infection.
  13. Pain from injection, syncope, adhesions, worsening of condition, Cushing’s Syndrome, pupillary dilatation.

 

                                                                                                                                               

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