Risk Management



Strabismus Surgery Consent (Addendum to General Consent Form)

[ADDENDUM TO GENERAL CONSENT FORM]

STRABISMUS SURGERY

 

 

 

 

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

  1. Infection
  2. Accidental penetration of the eye
  3. Over- and under-correction
  4. Double vision
  5. Unusual suture reaction
  6. Loss of vision or loss of eye

 

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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