Risk Management

Dacryocystorhinostomy (DCR) Consent Form

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PLACE LETTERHEAD HERE AND REMOVE NOTE.   Version 07/20/2009
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NOTE:  THIS FORM IS INTENDED AS A SAMPLE ONLY OF THE INFORMATION YOU AS THE SURGEON SHOULD PERSONALLY DISCUSS WITH THE PATIENT.  PLEASE REVIEW IT AND MODIFY TO FIT YOUR ACTUAL PRACTICE.  GIVE THE PATIENT A COPY.

INFORMED CONSENT FOR DACRYOCYSTORHINOSTOMY (DCR)
(“Tear drain bypass surgery”)

WHAT CAUSES THE NEED FOR DCR SURGERY?
Because of age, injury, or chronic sinus disease, the bony tunnel that drains tears from the eye into the nose can become blocked.  Tears may then back up and run down the cheeks and, in some cases, an infection can develop underneath the skin between the eye and the nose (“dacryocystitis”). Many patients complain also of a gooey discharge and eye irritation.

HOW IS DCR SURGERY PERFORMED?
In a dacryocystorhinostomy (DCR), an incision is made near the inside corner of the eye or within the nose and a new opening is made to allow tears to drain from the eye into the nose.  A flexible stent tube may be left in place for a few weeks (sometimes longer) to keep the new drain open.  This tube can be removed in the office.  The goal of surgery is to eliminate tearing, discharge, and irritation, and reduce the risk of infection.

HOW WILL DCR SURGERY AFFECT MY VISION OR APPEARANCE?
A DCR will not directly affect your vision though many people see better after surgery because they no longer have tearing or discharge from the eye.  If an incision has been made on your skin, a small scar will be created.

WHAT ARE THE MAJOR RISKS OF DCR SURGERY?
Risks of DCR include but are not limited to bleeding, infection, and scarring. In addition, the new drainage channel may not stay open; this happens in less than 10% of all cases, and may require additional surgery to correct. There are additional costs if the surgery needs to be repeated or if revisions are required.

WHAT ARE THE ALTERNATIVES?
You may decide to live with the tearing, discharge, and irritation that a blocked tear duct can cause.  However, if you have had an infection, your surgeon will likely advise surgery to prevent future infections, since these can, in rare circumstances, lead to vision loss.  If your tear duct is completely blocked, there is no other surgery, injection, or medicine available to treat this condition.  If your tear duct is partially blocked, a balloon can be inflated and/or tubes placed to enlarge the duct and keep it open.

WHAT TYPE OF ANESTHESIA IS USED?  WHAT ARE ITS MAJOR RISKS?
DCRs can be performed under sedation with local anesthesia (injections around the nose and eye), or under general anesthesia.  Risks of anesthesia include but are not limited to damage to the eye and surrounding tissues and structures, loss of vision, breathing problems, and, in extremely rare circumstances, stroke or death.

PATIENT’S ACCEPTANCE OF RISKS
I have read the above information and have discussed it with my physician. I understand that it is impossible for the physician to inform me of every possible complication that may occur. My physician has told me that results cannot be guaranteed and that adjustments and more surgery may be necessary, which can result in additional costs. By signing below, I agree that my physician has answered all of my questions and that I understand and accept the risks, benefits, and alternatives of DCR surgery, and understand the costs involved.

I consent to DCR surgery on:

________ Right eye     _________ Left eye    _________ Both eyes

_____________________________________        ____________
Patient (or person authorized to sign for patient)    Date