• 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

    My ophthalmologist has diagnosed me with dry eye syndrome. Typical symptoms of this condition include burning and (paradoxically) watering and a sensation like something is in the eye. In many cases dry eyes are caused by the body’s failure to produce enough tears. Blocking the tear drainage system with punctal or intracanalicular (tear duct) plugs may improve symptoms by keeping more tears in the eye. Severe cases of dry eye may lead to infection and in rare cases, blindness or loss of the eye.

    ALTERNATIVES

    1. Artificial tears or ointment – Lubrication increases moisture on the surface of the eye. Depending on severity, these over-the-counter drops and ointments may be applied several times daily for maximal comfort
    2. Restasis – Used twice daily, this prescription eye drop increases production of the body’s own tears. 
    3. Surgical tear drainage closure – The punctum and canaliculus may be surgically occluded by thermal cautery (heat) or ligation (suture closure). These methods should be considered permanent.
    4. No Treatment – I may choose to do nothing and tolerate the symptoms of my dry eye condition.

    RISKS

    1. Infection - The punctal plug is a foreign material and may be associated with infection around the plug. Infections can be treated with antibiotics and removal of the plug.
    2. Excessive Tearing – In some cases, plugs may cause an overflow of tears. Your doctor may decide to remove the plugs in this situation.
    3. Irritation – The exposed end of the punctal plug may cause irritation and need to be replaced with a different size plug or removed.
    4. Loss of the Plug – The punctal plug may fall out or need to be replaced.
    5. Retention of plug in or permanent scarring of the tear duct – Although rare, plugs may become lodged in the tear drainage pathway (canaliculus) or cause scarring. Surgery may be necessary to re-establish tear drainage

    CONSENT FOR TREATMENT

    By signing below, I acknowledge that I have read and understand the above and have had the opportunity to discuss this information with my doctor to my satisfaction. I consent to the insertion of punctal plugs in the (PLEASE CIRCLE):


    RIGHT lower upper       LEFT lower upper 

    Patient signature
    Date