• Ophthalmic Mutual Insurance Company (OMIC)

    Note: This form is intended as a sample form of the information that you as the surgeon should personally discuss with the patient. Please review and modify to fit your actual practice. Give the patient a copy and send this form to the hospital or surgery center as verification that you have obtained informed consent.


    CONDITION AND PROPOSED TREATMENT

    Your ophthalmologist has evaluated you and diagnosed you with a chalazion, which is a localized inflammatory response involving sebaceous glands of the eyelid that occurs when the gland duct is obstructed. A chalazion may resolve spontaneously or with warm compresses, lid scrubs, and lid massage. When there is no improvement, the chalazion may be incised and drained. After local anesthesia, a chalazion instrument is put in place and an incision is made in the inner aspect of the eyelid. The contents of the chalazion are then carefully drained with a curette followed by gentle pressure or heat to control any bleeding.

    ALTERNATIVES TO SURGERY

    1. Lid Hygiene – Warm compresses, lid massage and scrubs; may not improve chalazion if deep.
    2. Steroid Injection – May require more than one injection. Can result in depigmentation of the eyelid, steroid deposits at the injection site, or in rare instances occlusion of retinal and choroidal blood vessels with possible loss of vision
    3. No Treatment – I may choose no treatment and tolerate the chalazion.

    RISKS AND COPMLICATIONS

    No procedure is entirely risk free. Adverse effects from incision and drainage of chalazion may include:

    1. Infection – Infections can be treated with topical or oral antibiotics
    2. Bleeding – Normally controlled with gentle pressure or heat cautery at the incision site.
    3. Pain – Minimal and resolves with healing of incision.
    4. Recurrence – Chalazion may recur if incomplete excision.
    5. Loss of lashes in the involved area
    6. Eyelid notching in the area of the inflammation
    7. Damage to the globe from the scalpel, needle used to inject the anesthetic, or cautery instrument.
    8. Vision loss, including blindness.

    CONSENT FOR TREATMENT

    By signing below I acknowledge that I have read and understand the above, and have had my questions answered by the surgeon to my satisfaction.

    I consent to the incision and drainage of the chalazion on my _____ Right eye _____ Left eye

    Patient signature
    Date