Risk Management
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Orbital and Plastic Surgery Consent (Addendum to General Consent)
[ADDENDUM TO GENERAL CONSENT FORM]
ORBITAL AND PLASTIC SURGERY
Complications which could occur weeks, months, or even years later:
- Loss of vision
- Loss of eye
- Double vision
- Disfigurement
- Hemorrhage or infection
- Failure to solve problem, and possible aggravation of problem
- Possible necessity for multiple additional procedures, including surgery, chemotherapy and radiation
- Eyelid malposition, possibly requiring secondary procedure
- Tearing
- Possible penetration of sinuses or intracranial space with attendant complications such as meningitis or spinal fluid leak
- Sensory loss on face
Local complications of anesthesia injections around the eye:
- Perforation of eyeball
- Destruction of optic nerve
- Interference with circulation of retina
- Possible drooping of eyelid
- Respiratory depression
- Hypotension
Additional comments:
Patient (or person authorized to sign for patient) Date
Witness Date
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