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

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