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

Lagophthalmos Surgery With Gold Weight Consent Form

Please click on this link to download a copy of the lagophthalmos surgery with gold weight consent form.

INFORMED CONSENT FOR LAGOPHTHALMOS SURGERY WITH A GOLD WEIGHT

(“Surgery to help the eye close better”)

 WHAT CAN CAUSE THE NEED FOR EYELID CLOSURE SURGERY?

Certain conditions such as a Bell’s palsy, stroke or trauma to the face can cause problems with closure of the eyelids.  When this happens, the patient’s vision is put at risk from exposure and drying of the cornea.  In severe cases, the eye can get infected and need to be removed.  Surgery to help the eye close better can often improve these conditions and better protect the eye.

WHAT IS EYE CLOSURE SURGERY?

The exact surgery that needs to be performed will vary from patient to patient depending on the patient’s problem, severity, age and goals.  Commonly, more than one procedure is done at a given surgery.  Placement of a gold or platinum weight in the upper eyelid under the skin can help with a more complete closure at night when the patient goes to sleep.  It will NOT help the patient to blink faster or more completely.  A tarsorrhaphy is a procedure that can help to keep some or all of the eye closed permanently or semi-permanently if the palsy is expected to recover.  Your doctor will discuss the various options and help you to choose the procedure that is right for you.

HOW WILL EYELID CLOSURE SURGERY AFFECT MY VISION OR APPEARANCE?

The results of this surgery depend upon each patient’s symptoms, unique anatomy, appearance goals, and ability to adapt to changes. Eyelid closure surgery is NOT cosmetic surgery.  It is being done to save the eye and make the patient more comfortable.  The eye may appear more droopy or look partially closed.   The surgery can often be reversed but his generally requires another surgery and is NOT covered by the fee for the first surgery.

It is important to note that some patients have unrealistic expectations about how eyelid 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?

Risks of eyelid surgery include but are not limited to:  bleeding, infection, an asymmetric or unbalanced appearance, scarring, double vision, tearing or dry eye problems, inability to wear contact lenses, numbness and/or tingling near the eye or on the face, and, in rare cases, loss of vision. 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, changes in appearance may lead to anger, anxiety, depression, or other emotional reactions.

WHAT ARE THE ALTERNATIVES?

You may be willing to live with the symptoms and appearance of poor eyelid closure and decide not to have surgery on your lids at this time.  In some cases the symptoms of poor closure can be improved with aggressive lubrication and taping the eyelids shut.  Some patients are able to keep the eyelids closed with a patch.

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

Most eyelid surgeries are done with “local” anesthesia (lidocaine or novocaine), that is, injections around the eye to numb the area.  You may also receive sedation from a needle placed into a vein in your arm or pills taken before surgery.  Deeper anesthesia can be provided if the patient wishes but most do very well with light sedation.  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 and has encouraged me to ask more questions as they arise. I understand the risks, benefits, and alternatives of eyelid surgery, and the costs associated with this surgery and future treatment.  I feel that I am able to accept the risks involved and will be able to accept changes in my appearance.

I have been offered a copy of this

I consent to eyelid closure surgery on:

Right___________  Left___________ side(s)

Other:  _________________________________________________

______________________________________                    _______________

Patient (or person authorized to sign for patient)                             Date

Facial Bone Repair Consent Form

Please click on this link to download a copy of the facial bone repair consent form.

INFORMED CONSENT FOR FACIAL FRACTURE REPAIR

(“Facial bone repair”)

WHY MIGHT I NEED REPAIR OF THE BROKEN BONES IN MY FACE?

The bones of the face are the framework that all of the skin, muscles and other soft tissue rest on.  If the bones are broken and displaced (moved from their normal position), problems can arise.  Some patients will develop permanent double vision after a fracture that is not repaired.  If the fracture is large enough, some will develop a sunken eye appearance with the broken eye looking smaller.  Many patients will get numbness in the lower lid and cheek after a fracture but this usually gets better even without surgery.  A flattened facial appearance and chewing problems can also result from facial bone fractures

HOW IS THE FACIAL BONE REPAIR DONE?

Repair of broken bones in the face is usually done in an operating room with the patient under general anesthesia (completely asleep).  Your doctor will NOT remove the eyeball or peel your face off!!   Small incisions are used to get to the fractures – often inside the mouth or inside the eyelid.  Delicate instruments are used to move the eye and soft tissues to one side and allow your doctor to see and repair the fracture.  Usually, thin flat implants are placed over the fracture and screwed into position to repair the break.  These may be permanent or they may be dissolvable.  Some implants have titanium in them, some are plastic and some are made of other material.  Your doctor will choose the type that he feels is best for your type of fracture.

HOW WILL FACIAL FRACTURE SURGERY AFFECT MY VISION OR APPEARANCE?

The results of facial fracture repair surgery depend upon each patient’s severity and location of trauma (which bones are broken), symptoms, unique anatomy and appearance goals. Facial fracture surgery is not considered cosmetic surgery but most patients feel that they look better after they have healed.  Facial fracture surgery does not improve blurred vision caused by problems inside the eye, or by visual loss caused by neurological trauma behind the eye and does not repair paralyzed nerves.  This surgery cannot repair all problems associated with trauma to the face.

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

WHAT ARE THE MAJOR RISKS?

Risks of facial fracture surgery include but are not limited to:  bleeding, infection, an asymmetric or unbalanced appearance, scarring, difficulty closing the eyes (which may cause damage to the underlying corneal surface), double vision, numbness and/or tingling near the eye or on the face, and, in rare cases, loss of vision. 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, changes in appearance may lead to anger, anxiety, depression, or other emotional reactions.

WHAT ARE THE ALTERNATIVES?

You may be willing to live with the symptoms and appearance of flattened face, double vision or sunken eye and decide not to have surgery on your facial fractures at this time.  In some cases the double vision may be improved with glasses or eye muscle surgery.  Cosmetic work with implants and fillers may help the appearance at a later date.

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

Most facial fracture surgeries are done with 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 with facial fracture repair.
• 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 facial fracture repair, and the costs associated with this surgery and future treatment, and that I feel I will be able to accept the risks involved.

I have been offered a copy of this document.

I consent to facial fracture repair surgery on:

Right ___________Left___________ side(s)

Other:  _________________________________________________

_______________________________________                    _______________

Patient (or person authorized to sign for patient)                             Date

Evisceration/Enucleation Consent Form

Please click on this link to download a copy of the evisceration/enucleation consent form.

INFORMED CONSENT FOR EVISCERATION/ENUCLEATION

(Removal of part or the entire eye)

WHAT CAUSES THE NEED FOR EYE REMOVAL?

Because of trauma or disease such as diabetes or malignant tumor that leads to blindness and pain (phthisis), it is sometimes necessary to remove part (evisceration) or all (enucleation) of the eye.  Most blind eyes do NOT need to be removed if they are not painful or if they have no malignant tumor.  If a malignant tumor such as a retinoblastoma or melanoma is found in the eye, enucleation may be required.  If an eye has become very painful with no useful vision from trauma or multiple intraocular surgeries, part of the eye may need to be removed by evisceration to stop the pain.

HOW IS THE SURGERY PERFORMED?

During an enucleation, the patient is typically placed under general anesthesia (completely asleep) and the entire eyeball (the globe) is removed.  Usually, an implant is placed in the socket under the soft tissues and attached to the eye muscles to fill up the space left from the removed eye.  With an evisceration, the white part of the eye (sclera) with its attached muscles is left alone.  Only the inside degenerated part is removed.  The implant is then placed inside the sclera and closed up under the soft tissue.  The goal of surgery is to eliminate the tumor or pain and leave the patient with a good cosmetic outcome.

HOW WILL THIS SURGERY AFFECT MY ACTIVITIES AND MY APPEARANCE?

In most cases, the removal of a damaged and scarred eye will improve the cosmetic appearance but these judgments are always subjective (beauty is in the eye of the beholder).  Because most patients having this surgery are already blind in the eye to be removed, their daily activities change little if at all.

WHAT ARE THE MAJOR RISKS OF THIS SURGERY?

Risks of eye removal include (but are not limited to) bleeding, infection, scarring and the complete and total loss of the eye contents forever. In addition, there can be problems with the implant that may require additional surgery to correct but this is uncommon. There may be additional costs if the surgery needs to be repeated or if revisions are required.

WHAT ARE THE ALTERNATIVES?

You may simply decide to live with the pain and associated problems that a blind and painful eye can cause.  However, if you have a tumor in the eye, you may require other procedures such as chemotherapy or radiation to deal with the malignancy.

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

Eye removal can be performed under sedation with local anesthesia (injections around the eye), but is usually done under general anesthesia.  Risks of anesthesia include but are not limited to damage to the surrounding tissues and structures, 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.
• I have been informed 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, that I understand and accept the risks, benefits, and alternatives of eye removal 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           EVISCERATION       ENUCLEATION     surgery on the:

Right        Left      side: _________

Other:  _________________________________________________

_______________________________________                    _______________

Patient (or person authorized to sign for patient)                             Date

Entropion Consent Form

Please click on this link to download a copy of the entropion consent form.

INFORMED CONSENT FOR ENTROPION SURGERY (“Lower eyelid repair”)

WHAT CAN CAUSE THE NEED FOR LOWER EYELID SURGERY?

With age, the skin, muscles and tendons of the lower eyelid can sag and droop.  In addition, the fat that surrounds and cushions the eyeball can bulge forward through the skin of the lower lids.  As the tendons of the lower lid sag, the lower lid can invert and turn inward with the lashes rubbing the eyeball. This can lead to tearing, mucous discharge (mattering), crusting of the eyelashes and scratching of the cornea.

 HOW WILL EYELID SURGERY AFFECT MY VISION OR APPEARANCE?

The results of entropion repair depend upon each patient’s symptoms, unique anatomy, appearance goals, and ability to adapt to changes. Entropion repair only corrects the droopiness and sagginess but is not considered a cosmetic procedure.  By correcting this droopiness of the lower lid, the surgery typically improves tearing and mucous discharge as well as the foreign body sensation that is caused by lashes rubbing the eye.  Entropion repair does not improve blurred vision caused by problems inside the eye, or by visual loss caused by neurological disease behind the eye.

Because saggy in-turned eyelids are typically consequences of aging, most patients feel that entropion repair improves their appearance and makes them look better with eyes that are not red all the time. Some patients, however, have unrealistic expectations about how changes in appearance will impact their lives. Carefully evaluate your goals before agreeing to this surgery.

WHAT ARE THE MAJOR RISKS?

Risks of entropion repair include but are not limited to:  bleeding, infection, an asymmetric or unbalanced appearance, scarring, difficulty closing the eyes (which may cause damage to the underlying corneal surface), double vision, tearing or dry eye problems, inability to wear contact lenses, numbness and/or tingling near the eye or on the face, and, in rare cases, loss of vision. 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, changes in appearance may lead to anger, anxiety, depression, or other emotional reactions.

WHAT ARE THE ALTERNATIVES?

You may be willing to live with the symptoms and appearance of droopy saggy lower lids with tearing, red eyes and mucous discharge and decide not to have surgery on your lids at this time.

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

Most lid surgeries are done with “local” anesthesia (lidocaine or novocaine), that is, injections around the eye to numb the area.  You may also receive sedation from a needle placed into a vein in your arm or pills taken before surgery.  Deeper anesthesia can be provided if the patient wishes but most do very well with light sedation.  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.
• I have been informed 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, that I understand and accept the risks, benefits, and alternatives of entropion repair, and the costs associated with this surgery and future treatment, and that I feel I will be able to accept changes in my appearance.

I have been offered a copy of this document.

I consent to entropion repair surgery on:

Both lower lids: ____________

Right     or      left      lower lids: _________

Other:  _________________________________________________

_____________________________________                    _______________

Patient (or person authorized to sign for patient)                             Date