Punctal Plug Consent Form

Was evaluated by the doctor and have been previously informed that I have Ocular Surface Disease due to Dry Eye Syndrome. As a result I chose to be tested with collagen plugs to see if canalicular occlusion would relieve my dry eye and related symptoms. My symptoms improved during the testing and because I experienced no complications (irritation or infection) from the collagen plugs, the doctor has recommended canalicular occlusion with non-dissolvable canalicular plugs.

Risks and Complications:
Non-dissolvable canalicular plugs may cause tearing or watery eyes and while uncommon, irritation, infection, or allergic reaction may occur. If any of these complications arise, the plug may be removed by flushing saline solution into the punctal opening and through the lacrimal system.

Possibility of Success:
Having responded favorably to testing with collagen implants, I realize that I probably will benefit from placement of non-dissolvable canalicular plugs. However, I realize that neither my response to the test, the doctor, nor the staff can guarantee the success of this treatment. It is not recommended to rub the eyes or lids after the plugs have been inserted.

Alternatives:
I may choose to use eye drops and decongestants to temporarily relieve the symptoms I am experiencing. However, these methods fail to treat the cause of the problem and require repeated use. I may choose to do nothing for my condition. If left untreated, I understand that my symptoms probably will continue and might even get worse (tear production is reduced with age). Mild Dry Eye Syndrome may result in irritation of the eye. Severe Dry Eye syndrome can result in the loss of vision or the entire eye.

Argon laser and electrocautery are surgical procedures that may cause damage to tissue. These may be difficult to reverse should complications arise (irritation, infection, or watery or tearing eyes).

Informed Consent:
I have discussed and been encouraged to discuss my condition with the doctor. I have had all my questions answered. I understand my condition and the benefits and drawbacks of punctal occlusion using non-dissolvable canalicular plugs. I hereby request non-dissolvable plugs be placed in my tear drainage ducts to treat my dry eye condition. I will document my response to this treatment and, upon any eventual change in my condition, notify my doctor for evaluation and corrective action.
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