Risk Management

Optic Nerve Sheath Fenestration Consent Form

Please click on this link to download the optic nerve sheath fenestration consent form.

INFORMED CONSENT FOR OPTIC NERVE SHEATH FENESTRATION

(Making a window in the covering of the optic nerve)

 WHY MIGHT I NEED OPTIC NERVE SHEATH FENESTRATION SURGERY?

Pseudotumor cerebri (SOO-doh-too-mur SER-uh-bry) occurs when the pressure inside the skull (intracranial pressure) increases for no obvious reason. The patient’s symptoms are similar to those of a brain tumor, but no tumor is present. This condition is typically seen in overweight or obese women of child-bearing years but can also be seen in males and females of all ages.  The cause is poorly understood.  When this condition happens, the high pressure can be diagnosed with a lumbar puncture (LP or spinal tap).  Pseudotumor cerebri can cause visual problems including blindness if left untreated. Medications often can reduce this pressure, but in some cases, surgery is necessary to preserve your vision.

WHAT ARE THE RISKS OF PSUEDOTUMOR CEREBRI TO MY HEALTH?

Symptoms of pseudotumor cerebri include symptoms that closely mimic large brain tumors: headache, nausea, vomiting, pulsating sounds within the head and vision loss.  The most serious of these is usually the damage to the optic nerve and loss if vision which can be extensive and permanent.

HOW WILL THIS SURGERY AFFECT ME AND MY APPEARANCE?

The cosmetic results of this surgery are typically minimal.  Several different techniques can be used to do this surgery and your surgeon will choose the technique that seems best for you.  With one technique, a small (roughly ½ inch incision) is made in the upper eyelid in the inside corner.  This is usually imperceptible when healed.

It is important to note that some patients have unrealistic expectations about how optic nerve sheath surgery will impact their lives. Carefully evaluate your goals and your ability to deal with the outcome before agreeing to this surgery.  Understand the risks and ask questions of your doctor.

WHAT ARE THE MAJOR RISKS of OPTIC NERVE SHEATH FENESTRATION SURGERY?

Risks of optic nerve sheath surgery include but are not limited to:  bleeding, infection, scarring, need for more surgery, loss of vision, loss of visual field or even blindness. You may need additional treatment or surgery to treat these complications; the cost of the additional treatment or surgery is NOT included in the fee for this surgery. Due to individual differences in anatomy, response to surgery, and wound healing, no guarantees can be made as to your final result.  For some patients headache symptoms and /or vision loss may continue or never go away.

WHAT ARE THE ALTERNATIVES TO OPTIC NERVE SHEATH FENESTRATION SURGERY?

You may be willing to live with the symptoms of pseudotumor cerebri (headache, double vision, etc.) and decide not to have any surgery at this time.  Other options include neurosurgery such as a lumboperitoneal (LP) shunt or ventriculoperitoneal (VP) shunt.  Your doctor will refer you to a neurosurgeon if you wish to have a consult to discuss the risks and benefits of these procedures.

WHAT TYPE OF ANESTHESIA IS USED? WHAT ARE THE MAJOR RISKS?

Optic nerve sheath surgery is done under general anesthesia with the patient completely asleep.  Risks of anesthesia include but are not limited to damage to the eye and surrounding tissue and structures, loss of vision, breathing problems, and, in extremely rare circumstances, stroke or death.

PATIENT’S ACCEPTANCE OF RISKS

• I understand that it is impossible for my doctor to inform me of every possible complication that may occur.
• My doctor has told me that results cannot be guaranteed, that adjustments and more surgery may be necessary (and that there may be additional costs associated with more treatment).
• By signing below, I agree that my doctor has answered all of my questions I understand the risks, benefits, and alternatives of optic nerve sheath surgery, and the costs associated with this surgery and future treatment.  I feel that I am able to accept the risks involved.

I have been offered a copy of this document.

I consent to optic nerve sheath surgery on:

Right        Left      side: _________

Other:  _________________________________________________

_______________________________________                    _______________

Patient (or person authorized to sign for patient)                             Date