[ADDENDUM TO GENERAL CONSENT FORM]
CORNEAL SURGERY

Complications which could occur weeks, months, or even years later:
1.	Poor vision, total loss of vision, or loss of eye
2.	Bleeding in eye
3.	Loss of corneal clarity
4.	Chronic inflammation
5.	Infection
6.	Temporary or permanent blurring of vision because of retinal swelling
7.	Detachment of the retina
8.	Glaucoma
9.	Double vision

Local complications of anesthesia injections around the eye:
1.	Perforation of eyeball
2.	Destruction of optic nerve
3.	Interference with circulation of retina
4.	Possible drooping of eyelid
5.	Respiratory depression
6.	Hypotension

Additional comments:

												
Patient (or person authorized to sign for patient)			Date

												
Witness								Date