Risk Management

Retina Surgery Consent (Addendum to General Consent Form)

[ADDENDUM TO GENERAL CONSENT FORM]

RETINA SURGERY

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

1. Failure to accomplish intent of surgery
2. Retinal detachment that may require additional surgery or may be inoperable
3. Vitreous hemorrhage
4. Infection
5. Elevated eye pressure (glaucoma)
6. Poorly healing or non-healing corneal defects
7. Corneal clouding and scarring
8. Cataract, which might require eventual or immediate removal of lens
9. Double vision
10. Eyelid droop
11. Loss of circulation to vital tissues in the eye, resulting in decrease or loss of vision
12. Permanent blindness, or diminished visual acuity or field
13. Loss of eye

CRYOPEXY

In addition to the risks for retina surgery:

1. Retinal detachment or macular puckering that may require additional surgery
2. Inflammation
3. Pigmentary disturbances

Additional comments:

Patient (or person authorized to sign for patient)                                   Date

Witness                                                                                                          Date