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CONSENT FORM FOR INCISION AND DRAINAGE OF CHALAZION
Your ophthalmologist has evaluated you and diagnosed you with a chalazion, which is a localized inflammatory response involving sebaceous glands of the eyelid that occurs when the gland duct is obstructed.
A chalazion may resolve spontaneously or with warm compresses, lid scrubs and lid massage. When there is no improvement, the chalazion may be incised and drained.
After local anesthesia, a chalazion instrument is put in place and an incision is made in the inner aspect of the eyelid. The contents of the chalazion are then carefully drained with a curette followed by gentle pressure or heat to control any bleeding.
- Lid Hygiene – Warm compresses, lid massage and lid scrubs. These may not improve a deep chalazion.
- Steroid Injection – May require more than one injection. Possible complications include depigmentation of the eyelid, steroid deposits at the injection site, and in rare cases occlusion of retinal and choroidal blood vessels with possible loss of vision.
- No Treatment – I may choose no treatment and tolerate the chalazion.
No procedure is entirely risk free. Adverse effects from incision and drainage of chalazion may include:
- Infection – Usually treated with topical or oral antibiotics.
- Bleeding – Normally controlled with gentle pressure or cautery at the incision site.
- Pain – Usually minimal and resolves with healing.
- Recurrence – Chalazion may recur if incompletely excised.
- Loss of eyelashes in the involved area.
- Eyelid notching in the area of inflammation.
- Damage to the eyeball (globe) from the scalpel, needle used for anesthesia, or cautery instrument.
- Vision loss, including blindness.
By signing below, I acknowledge that I have read and understood the information above and have had all my questions answered by the surgeon to my satisfaction.
I consent to the incision and drainage of the chalazion on my: