Informed Consent for Pterygium Excision Surgery

Procedure Name

Form Sections

Section 1info grid

Surgical Facility Name

Attending Ophthalmic Surgeon

Patient Full Legal Name

Date of Birth

Medical Record Number (MRN)

Operative Eye

Planned Reconstruction Method

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Section 3list block

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Section 12signature block

Patient / Authorized Representative Signature

Witness Signature (If Required)

Attending Surgeon Signature

Informed Consent for Pterygium Excision Surgery

Patient and Surgical Information

Surgical Facility Name

Attending Ophthalmic Surgeon

Patient Full Legal Name

Date of Birth

Medical Record Number (MRN)

Operative Eye

Planned Reconstruction Method

Nature and Purpose of the Procedure

Pterygium excision is a surgical procedure performed to remove a non-cancerous, fleshy growth of the conjunctiva (pterygium) that has invaded the cornea of the eye, causing irritation, redness, astigmatism, or visual obstruction. Under local anesthesia (drops or injection) with optional mild sedation, the surgeon dissects the pterygium tissue away from the cornea and sclera. To minimize the risk of recurrence, the bare area of the sclera is reconstructed using a small piece of healthy tissue harvested from under the upper eyelid (conjunctival autograft) or a donor tissue (amniotic membrane graft). The graft is secured in place using microscopic sutures or special tissue adhesive. The procedure typically takes 30 to 45 minutes.

Material Risks and Potential Complications

Recurrence: the most common complication, where the pterygium grows back, sometimes larger or more aggressive than the original, occurring in approximately 5 to 15 percent of cases with autografts.

Infection or inflammation of the cornea or sclera, which can cause pain and require antibiotic drops.

Graft displacement, loss, or necrosis, requiring secondary surgical intervention or re-grafting.

Persistent dry eye, redness, irritation, or foreign body sensation in the operative eye.

Corneal scarring, thinning, or astigmatism, which may cause permanent visual blurriness or require corrective lenses.

Double vision (diplopia) due to scarring or restriction of the extraocular muscles controlling eye movement.

Expected Benefits

Expected benefits include the removal of the physical growth, relief from chronic eye irritation and redness, restoration of a smoother corneal surface, improvement in visual clarity, and reduction of astigmatism.

Reasonable Alternatives

Conservative management: lubricating eye drops, anti-inflammatory drops, or wearing UV-blocking sunglasses to reduce growth triggers.

Watchful waiting and monitoring the size of the growth during regular eye exams.

Declining surgery and accepting the potential progression of the growth across the cornea.

Consent for Anesthesia Services

I understand that anesthesia services are needed for this procedure. The anesthesia provider will separately explain the risks, benefits, and alternatives of the specific anesthesia plan (e.g., general, regional, or local sedation) and obtain separate consent.

Consent for Blood Transfusion

I understand that during this procedure, significant blood loss may occur. If my physician determines it is medically necessary to preserve my life or health, I consent to the administration of blood or blood products.

Tissue Disposal and Pathology

I authorize the medical facility to retain, preserve, use for educational purposes, or dispose of any tissue, fluid, or body parts removed during the procedure in accordance with standard medical practices and legal requirements.

Photography and Observer Consent

I consent to the photographing or video recording of the procedure for medical, scientific, or educational purposes, provided my identity is not revealed. I also consent to the presence of medical students, residents, or device manufacturer representatives as approved by my surgeon.

No Guarantees

I acknowledge that the practice of medicine and surgery is not an exact science. I understand that no guarantees or assurances have been made to me regarding the outcomes or results of this procedure.

Patient Acknowledgment and Consent

I certify that I have read and fully understand this consent form. My physician has explained the procedure, its risks, benefits, and alternatives. I have had all my questions answered to my satisfaction, and I voluntarily consent to the proposed treatment.

Signatures and Verification

Patient / Authorized Representative Signature

Witness Signature (If Required)

Attending Surgeon Signature

Document ID: CC-PENDING

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