• 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.


    Vitrectomy is the surgical removal of the vitreous gel from the middle of the eye.
    This procedure may be done for several reasons. To remove scar tissue membranes from the retinal surface, to repair macular holes, to repair retinal detachments, to remove vitreous hemorrhage, as well as other less frequent indications.
    Patients with diabetes are particularly prone to retina problems for which a vitrectomy may be recommended (to remove blood in the vitreous gel caused by abnormal vessel growth and vessel hemorrhage).

    During a vitrectomy, the surgeon inserts small instruments into the eye, cuts the vitreous gel, and removes it by suction. After removing the vitreous gel, the surgeon may treat the retina with a laser (photocoagulation), cut or remove fibrous or scar tissue from the retina, flatten areas where the retina has become detached, or repair tears or holes in the retina or macula.
    At the end of the surgery, saline, air or a gas (perfluropropane or sulfur hexafluoride), or silicone oil may be injected into the eye to replace the vitreous gel to restore normal pressure in the eye.


    The available alternatives, some of which include pneumatic retinopexy or a scleral buckling procedure for those patients who have a retinal detachment. The potential benefits and risks of the proposed procedure, and the likely result without such treatment have been explained to me.

    Additional Comments: 


    Vitrectomy has been shown to improve visual acuity in many people who have severe vitreous hemorrhage that has not cleared on its own. A vitrectomy can decrease the risk of severe bleeding complications in people who have begun to have bleeding into the vitreous gel. It can also reduce the risk of severe bleeding into the eye in people with growth of abnormal blood vessels in the iris. If the surgery is being done for a retinal detachment the visual result will depend on the extent of the detachment and absence of a secondary detachment later. If performed for epiretinal memebrane or macular hole, there is a high likelihood of vision improvement, but there can be no guarantee.


    A Vitrectomy is performed under local (injection) or anesthesia, with sedation. General anesthesia may be used instead in some cases. It is typically performed as an outpatient procedure. In some cases a hospital stay overnight may be required.

    There are some risks associated with anesthesia, whether general or local. Complications of anesthesia injections around the eye may include: perforation of the eyeball, injury to the optic nerve resulting in loss of vision, hemorrhage, retinal detachment, interference with retinal circulation resulting in possible vision loss, drooping of the upper eyelid, hypotension or lowering of the blood pressure, and respiratory depression. General anesthesia can result in heart and breathing problems, and in a very unusual and rare instances, death or diminished brain function can occur.


    There is no guarantee that the surgery will improve your condition. Sometimes it doesn’t work. In addition, surgery is risky. Sometimes it can make the problem worse, cause an injury, or create a new problem; if it does, this is called a complication. Complications can happen right away or not until days, months, or years later. You may need more treatment or surgery to treat the complications.

    This document lists the major risks of vitrectomy surgery to help you decide whether you are ready to accept the risks. After vitrectomy surgery, you may have vision loss, blindness, loss of the eye, as well as bleeding, infection, and injury to the eye or nearby body parts.
    Other major risks can include:

    • Retinal detachments that may require additional surgery or may be inoperable
    • Elevated eye pressure (glaucoma)
    • Poorly healing or non-healing corneal defects
    • Corneal clouding and scarring
    • Cataract, which might require eventual or immediate removal of the lens
    • Double Vision
    • Eye lid droop
    • Loss of circulation to vital tissues in the eye, resulting in decrease or loss of vision
    • Phthisis (disfigurement and shrinkage of eyeball)

    Additional comments: 


    I have read the above information (or it was read to me) and have discussed it with my physician. I understand that it is impossible for the physician to inform me of every possible complication that may occur. My physician has told me that results cannot be guaranteed and that more treatment or surgery may be necessary. By signing below, I agree that my physician has answered all of my questions and that I understand and accept the risks, benefits, and alternatives of vitrectomy surgery. I have been offered a copy of this document.

    I wish to have a ____________________ operation on my _____ Right eye _____ Left eye

    Patient signature