Vitrectomy Surgery Consent Form

PROCEDURE

Vitrectomy Surgery.

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DESCRIPTION OF PROCEDURE

A vitrectomy is a surgical procedure to remove some or all of the vitreous gel from the inside of the eye. The vitreous is a clear, jelly-like substance that fills the inside of the eye. This procedure may be performed to treat various eye conditions.

The procedure typically involves the following steps:

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1. Local anesthesia with sedation.

2. Making small incisions in the eye.

3. Inserting small instruments into the eye.

4. Removing some or all of the vitreous gel.

5. Performing other necessary procedures, such as:

   • Repairing retinal detachments.

   • Removing scar tissue.

   • Treating macular holes.

   • Removing foreign objects.​

6. Injecting a temporary replacement for the vitreous, such as saline, gas, or silicone oil.

7. Closing the incisions.

 

BENEFITS

The goal of this procedure is to:

• Treat the underlying eye condition.

• Improve or stabilize vision.

• Relieve symptoms such as blurred vision, distortion, or floaters.

 

ALTERNATIVES

Alternatives to vitrectomy surgery depend on the specific eye condition being treated. They may include:

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• Observation: If the condition is not severe or progressing slowly.

• Laser treatment: To seal retinal tears or blood vessels.

• Injections of medication: To treat certain retinal conditions.

• Scleral buckling: A procedure to repair retinal detachments.

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The risks and benefits of these alternatives have been explained to me.

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RISKS AND COMPLICATIONS

I understand that, as with any surgical procedure, there are risks and potential complications associated with vitrectomy surgery. These include, but are not limited to:

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• Common Side Effects

  • Temporary discomfort, pain, or itching.

  • Temporary blurred vision.

  • Temporary eye redness and swelling.

  • Dry eye symptoms.

  • Sensitivity to light.

  • Need for eye drops.

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• Potential Complications

  • Infection inside the eye (endophthalmitis).

  • Bleeding inside the eye (vitreous hemorrhage).

  • Retinal detachment or tears.

  • Increased eye pressure (glaucoma).

  • Cataract formation or progression.

  • Swelling of the retina (macular edema).

  • Scotomas or spots in vision.

  • Damage to the retina or other eye structures.

  • Double vision.

  • Droopy eyelid (ptosis).

  • Need for further surgery.

  • Loss of vision (rare).

  • Complications related to the use of gas or silicone oil, if used, such as increased eye pressure or the need for additional procedures for removal.

 

I have been informed about the material risks that are specific to my circumstances, including the potential need for additional procedures or treatments.

 

ACKNOWLEDGEMENT OF UNKNOWN RISKS

I understand that it is not possible or reasonable to predict or explain every possible risk or complication that may occur.

 

POST-PROCEDURE CARE

I understand that I will need to follow my physician's instructions carefully after the procedure. This may include:

• Using prescribed eye drops.

• Wearing an eye patch or shield.

• Maintaining a specific head position (if instructed).

• Avoiding strenuous activity.

• Avoiding rubbing or putting pressure on my eye.

• Attending all scheduled follow-up appointments.

• Reporting any signs of infection or complications promptly.

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AUTHORIZATION OF ADDITIONAL PROCEDURES IN UNFORESEEN CIRCUMSTANCES

I understand that during the procedure, unforeseen or unknown conditions may be discovered that require additional or different procedures than those initially planned. I authorize the above-named healthcare provider, or their designate, to perform such additional procedures that, in their professional judgment, are immediately necessary and desirable to address these conditions, and where delaying such procedures would not be in my best interest.

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ANESTHESIA/SEDATION

In addition to topical freezing drops, I understand that I may receive sedation for my vitrectomy surgery. The goal is to reduce pain and anxiety and help me remain comfortable and calm. I have been informed that sedation for eye surgeries is generally very safe, and that my vital signs will be monitored throughout the procedure. Complications related to anesthesia, though rare, including cardiac or respiratory problems.

I understand that the following sedation options have been discussed:

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• Oral Sedation (Ativan): I understand that I may receive oral sedation with Ativan. Potential side effects of oral sedation may include drowsiness, dizziness, confusion, and nausea.

• IV Sedation: In some cases, IV sedation may be used. I understand that IV sedation involves administering medication through a vein. I have been informed that IV sedation is generally very safe, and that my vital signs will be monitored throughout the procedure. I understand that I will not be put to sleep. Some rare side effects of IV sedation include, but are not limited to, decreased breathing rate, nausea, vomiting, and dizziness.

• No Sedation: I understand that I have the option to undergo the surgery with only topical freezing drops and no additional sedation.

 

I acknowledge that the anesthesiologist or my surgeon will assess me provide their recommendation regarding the most appropriate form of anesthesia/sedation for my individual needs. I understand that the final decision regarding the type of sedation will be made in my best interest and safety.

 

I understand that if my medical history is complicated, the anesthesiologist will arrange to see me before my surgery. I also understand that I may request to see my anesthesiologist prior to my surgery for any clarification or information regarding the anesthesia/sedation.

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CONSENT TO ANESTHESIA AND MEDICATIONS

I consent to the administration of appropriate anesthesia and all other medications deemed necessary to facilitate the treatment.

 

REGULATORY CONSIDERATIONS

I understand that Vitrectomy Surgery may be considered off label in certain circumstances by regulatory agencies, such as Health Canada.

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CONFIRMATION OF UNDERSTANDING

I acknowledge that I have read and understood the above information presented to me and I have been offered a copy of this consent form.  I have had the opportunity to ask questions about the procedure, its alternatives, risks, and benefits. I agree I have received all of the information to make an informed decision. I voluntarily consent to the Vitrectomy Surgery described above.

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RIGHT TO WITHDRAW CONSENT

I understand that I have the right to withdraw my consent at any time before the procedure begins.

 

ACKNOWLEDGEMENT

I acknowledge that no guarantees have been made to me as to the result of the procedure(s).