Risk Management

Orbital and Plastic Surgery Consent (Addendum to General Consent)





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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