Risk Management



Orbital and Plastic Surgery Consent (Addendum to General Consent)

[ADDENDUM TO GENERAL CONSENT FORM]

ORBITAL AND PLASTIC SURGERY

 

 

Complications which could occur weeks, months, or even years later:

  1. Loss of vision
  2. Loss of eye
  3. Double vision
  4. Disfigurement
  5. Hemorrhage or infection
  6. Failure to solve problem, and possible aggravation of problem
  7. Possible necessity for multiple additional procedures, including surgery,  chemotherapy and radiation
  8. Eyelid malposition, possibly requiring secondary procedure
  9. Tearing
  10. Possible penetration of sinuses or intracranial space with attendant complications such as meningitis or spinal fluid leak
  11. Sensory loss on face

 

 

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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