Highline Vision Center
Highline Center For Vision Performance

Amniotic Membrane Insertion | Consent Form

Informed Consent for Amniotic Membrane Insertion

Amniotic membranes are donated human tissue that can be used as a dressing to facilitate ocular surface reconstruction and to promote healing. Amniotic membranes are indicated for acute chemical/thermal burns, recurrent corneal erosion, persistent corneal epithelial defects, filamentary keratitis, vernal keratoconjunctivitis, dry eye, microbial keratitis, nodular degeneration, Stevens Johnson Syndrome, post-infectious corneal inflammation, corneal ulcers, pterygium, band keratopathy, bullous keratopathy, and PRK among other conditions. While an absolute guarantee of tissue safety is not possible, donor tissue is procured and processed according to standards established by the American Association of Tissue Banks and the FDA. All tissues are screened thoroughly for disease and are recovered under fully informed consent.

Maintaining a healthy ocular surface is critical to a normally functioning eye. In those cases, listed above, sutureless amniotic membranes have been shown to provide a valuable tool to control inflammation, reduce scarring, and promote epithelialization.

While alternate treatments for the above conditions do exist, your doctor has determined that an amniotic membrane will likely allow for the most successful resolution of your condition. Patients generally tolerate amniotic membranes well, though blurred vision and mild irritation are among the most common side effects noticed.

I have been educated on what an amniotic membrane is and how it will be used to treat my condition. I understand that while not a guarantee of successful outcome, an amniotic membrane will likely allow my eye to heal properly and recover to its best ability. I authorize my eye doctor to utilize this medical technology. My signature below affirms this information has been reviewed with me and my questions about the procedure answered:
By typing your name above you are providing your signature on this consent form.
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