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Risk Management
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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
- Failure to accomplish intent of surgery
- Retinal detachment that may require additional surgery or may be inoperable
- Vitreous hemorrhage
- Infection
- Elevated eye pressure (glaucoma)
- Poorly healing or non-healing corneal defects
- Corneal clouding and scarring
- Cataract, which might require eventual or immediate removal of lens
- Double vision
- Eyelid droop
- Loss of circulation to vital tissues in the eye, resulting in decrease or loss of vision
- Permanent blindness, or diminished visual acuity or field
- Loss of eye
CRYOPEXY
In addition to the risks for retina surgery:
- Retinal detachment or macular puckering that may require additional surgery
- Inflammation
- Pigmentary disturbances
Additional comments:
Patient (or person authorized to sign for patient) Date
Witness Date
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