Risk Management



Glaucoma Surgery Consent (Addendum to General Consent)  (Download in Spanish)

[ADDENDUM TO GENERAL CONSENT FORM]
GLAUCOMA SURGERY

Complications which could occur days, weeks, months, or years later:
1. Loss of eye
2. As a result of the surgery, vision could be made worse or, in rare cases, totally lost
3. Abnormal collection of fluid in eye, necessitating a second operation
4. Bleeding in the eye
5. Chronic inflammation
6. Infection, early or much later
7. Early or late increase of pressure in eye (glaucoma)
8. Development or worsening of cataract
9. Irritation or discomfort in the eye that may persist
10. Failure to achieve intent of surgery, necessitating a reoperation
11. In spite of surgery, vision could become worse from continuing degenerative changes in the eye

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

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