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.
- Inadvertent injection into the choroidal or retinal circulation, emboli
- Perforation of the globe with permanent loss of vision/loss of eye
- Glaucoma (increased eye pressure) in injected/other eye that may be transient or permanent and could lead to medical or surgical treatment (i.e., excision of depot or glaucoma filtering operation)
- Orbital fat atrophy, fibrosis
- Delayed hypersensitivity reactions
- Conjunctival hemorrhage
- Pain from injection, syncope, adhesions, worsening of condition, Cushing’s Syndrome, pupillary dilatation