Anterior chamber paracentesis
This is a sample form for Anterior Chamber Paracentesis.Click on the name of the form or the download button to access it.
We would like to thank Dr. Ansari and his team at Ophthalmic Consultants of Boston for developing and sharing his practice’s glaucoma forms with us. We made some content and formatting changes.
Corneal transplant consent form for PK, DSEK, DMEK
This form compares three types of corneal transplant surgery: Corneal transplant consent comparing PK, DSEK, DMEK
Texas Consent Requirements Effective 2020
The Texas Medical Disclosure Panel (TMDP) revised the Disclosure and Consent for Medical Care and Surgical Procedures Rules and Regulations: Texas HHS Rules and Regulations.
Effective January 1, 2020, Texas physicians should use the new informed consent form for patients undergoing 9 ophthalmic procedures (see List A below).
The Texas specific consent form should be used in combination with the OMIC procedure specific consent form.
The new Texas consent forms can be downloaded from the Texas HHS website (link above).
List A: 9 eye treatments and procedures that require specific risks listed on Texas specific consent form listed below or go to the following link: Direct Link to List A
(f) Eye treatments
(1) Eye muscle surgery.
(A) Additional treatment and/or surgery.
(B) Double vision.
(C) Partial or total blindness.
(2) Surgery for cataract with or without implantation of intraocular lens.
(A) Complications requiring additional treatment and/or surgery.
(B) Need for glasses or contact lenses.
(C) Complications requiring the removal of implanted lens.
(D) Partial or total blindness.
(3) Retinal or vitreous surgery.
(A) Complications requiring additional treatment and/or surgery.
(B) Recurrence or spread of disease.
(C) Partial or total blindness.
(4) Reconstructive and/or plastic surgical procedures of the eye and eye region, such as blepharoplasty, tumor, fracture, lacrimal surgery, foreign body, abscess, or trauma.
(A) Blindness.
(B) Nerve damage with loss of use and/or feeling to eye or other areas of face.
(C) Painful or unattractive scarring.
(D) Worsening or unsatisfactory appearance.
(E) Dry eye.
(5) Photocoagulation and/or cryotherapy.
(A) Complications requiring additional treatment and/or surgery.
(B) Pain.
(C) Partial or total blindness.
(6) Corneal surgery, such as corneal transplant, refractive surgery and pterygium.
(A) Complications requiring additional treatment and/or surgery.
(B) Pain.
(C) Need for glasses or contact lenses.
(D) Partial or total blindness.
(7) Glaucoma surgery by any method.
(A) Complications requiring additional treatment and/or surgery.
(B) Worsening of the glaucoma.
(C) Pain.
(D) Partial or total blindness.
(8) Removal of the eye or its contents (enucleation or evisceration).
(A) Complications requiring additional treatment and/or surgery.
(B) Worsening or unsatisfactory appearance.
(C) Recurrence or spread of disease.
(9) Surgery for penetrating ocular injury, including intraocular foreign body.
(A) Complications requiring additional treatment and/or surgery.
(B) Possible removal of eye.
(C) Pain.
(D) Partial or total blindness.
List B: 3 eye treatments and procedures that do not require a Texas specific consent form listed below or go to the following link: Direct Link to List B
(f) Eye procedures that do not require a TX specific consent form
(1) Administration of topical, parenteral (such as IV), or oral drugs or pharmaceuticals, including, but not limited to, fluorescein angiography, orbital injection or periocular injections.
(2) Removal of extraocular foreign bodies.
(3) Chalazion excision.
BEOVU potential risk to the fetus
There are two BEOVU forms:
Use BEOVU for all adult patients receiving Beovu.
Ask women of child-bearing age to also sign BEOVU.Possible risk for the fetus.
The BEOVU prescribing label states that there is a possible risk to the fetus from this and other anti-VEGF drugs.
It should only be used in women of childbearing age if the possible benefit for the woman is greater than the potential risk to the fetus.
BEOVU
There are two BEOVU forms
Use BEOVU for all adult patients receiving BEOVU. This form was updated on 3/13/20 to add retinal arterial occlusion to the list of complications.
Ask women of child-bearing age to sign Beovu.Possible risk for the fetus about the possible risk to the fetus. The BEOVU prescribing label states that there is a possible risk to the fetus from this and other anti-VEGF drugs. It should only be used in women of childbearing age if the possible benefit for the woman is greater than the potential risk to the fetus.
Review our risk management recommendations on the use of anti-VEGF drugs in adults.
AntiVEFG drugs for adults addresses on- and off-label use, preventing endophthalmitis, informed consent issues, and documentation. It incorporates key guidelines on intravitreal injection published by a panel of experts. It also addresses the FDA warning about Avastin in more detail.
Conduct a time out before each intravitreal injection.
OMIC has received reports of “wrong” events associated with intravitreal injections. These include wrong patient, wrong eye, wrong condition, wrong drug, and wrong dose.
To ensure that the correct drug and dose are injected into the correct eye every time, the ophthalmologist needs to lead a time out. Time-out before intravitreal injections/ provides the opportunity to confirm that the patient, medical record, and ophthalmologist are in agreement.
