Lucentis
There are two Lucentis consent forms
- Use the Lucentis form for all adult patients receiving Lucentis. This form was revised on 3/13/20 to add intraocular inflammation to the list of complications.
- Ask women of child-bearing age to sign Lucentis.Possible risk for the fetus. This consent form was revised on 11/5/15.
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.
Perform 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.
Avastin risk to fetus
Avastin.Possible risk for the fetus is an addendum to the main Avastin consent form. Use it for women of child-bearing age. This consent form was revised on 11/5/15.
The main Avastin consent form is at www.omic.com/Avastin/.
Avastin
There are two Avastin consent forms
- Use the Avastin form for all adult patients receiving Avastin. This form was revised on 3/13/20.
- Ask women of child-bearing age to sign Avastin.Possible risk for the fetus about the possible risk to the fetus. This form was revised on 11/5/15.
Review our risk management recommendations on the use of anti-VEGF drugs in adults.
Anti-VEGF 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.
ILUVIEN Implant Consent Form
The ILUVIEN implant is approved for the treatment of diabetic macular edema. This form was revised on 3/13/20. Click on the download button in the bar above to save this form.
Corneal Surgery (Addendum to General Consent)
Complications which could occur weeks, months, or even years later:
1. Poor vision, total loss of vision, or loss of eye
2. Bleeding in eye
3. Loss of corneal clarity
4. Chronic inflammation
5. Infection
6. Temporary or permanent blurring of vision because of retinal swelling
7. Detachment of the retina
8. Glaucoma
9. Double vision
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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