Risk Management



Periocular Repository Corticosteriod Injections

IF YOU ARE ASSESSING WITH A MOBILE DEVICE OR TABLET OR YOU WISH TO SAVE THIS FORM TO YOUR COMPUTER USE THE DOWNLOAD BUTTON. A PREVIEW OF THE FORM IS DISPLAYED BELOW.

PLACE LETTERHEAD HERE AND REMOVE NOTE.  

CHANGE FONT SIZE FOR LARGE PRINT

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.

 

                                                                                                                                               

Patient Signature                                                                                Date

 

Please refer to OMIC's Copyright and Disclaimer regarding the contents on this website

Leave a comment



Six reasons OMIC is the best choice for ophthalmologists in America.

#3. Best at defending claims.

An ophthalmologist pays nearly half a million dollars in premiums over the course of a career. Premium paid is directly related to your carrier’s claims experience. OMIC has a higher win rate taking tough cases to trial, full consent to settle (no hammer) clause, and access to the best experts. OMIC pays 25% less per claim than other carriers. As a result, OMIC’s base rates have consistently averaged approximately 15% lower than multispecialty carriers in the U.S.

61864684