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Laser Surgery Consent (Addendum to General Consent)

[ADDENDUM TO GENERAL CONSENT FORM]

LASER SURGERY

 

 

 

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

  1. Failure to achieve intent of surgery
  2. Loss of central or side vision
  3. Bleeding in eye
  4. Early or late increase in pressure in eye (glaucoma)
  5. Corneal burns
  6. Damage to lens (cataract)
  7. Retinal hole
  8. Collection of fluid in back of eye
  9. Damage to optic nerve
  10. Damage to the iris
  11. Damage to an intraocular lens implant, if present
  12. 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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