Ectropion Consent Form
Please click on this link to download a copy of the ectropion consent form.
INFORMED CONSENT FOR ECTROPION (“Lower lid 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 evert and turn inside out. This can lead to tearing, mucous discharge, crusting of the eyelashes and skin irritation. Excess skin and fat also create what many feel is an unattractive, aged appearance in the lower lids (“bags under the eyes”).
WHAT IS A LOWER LID ECTROPION REPAIR?
Repair of a lower lid ectropion is typically done as an outpatient procedure. The patient usually gets a “local” injection of lidocaine (novocaine) and sedation although deeper anesthesia can be given if needed. The tendons of the eyelid in the corners of the eye are usually tightened with sutures through small incisions. The specifics are tailored to each patient’s needs. Also, some patients may chose to have cosmetic “add-on” procedures performed at the same time as functional (insurance) surgery. For example, they may chose to have their lower lid fat bags removed knowing that this is NOT covered by insurance.
HOW WILL EYELID SURGERY AFFECT MY VISION OR APPEARANCE?
The results of ectropion repair depend upon each patient’s symptoms, unique anatomy, appearance goals, and ability to adapt to changes. Ectropion 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. Ectropion 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 inside-out eyelids are typically consequences of aging, most patients feel that ectropion repair improves their appearance and makes them look better. 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 ectropion 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 ectropion repair surgery on:
Both lower lids: ____________
Right or left lower lids: _________
Other: _________________________________________________
_______________________________________ _______________
Patient (or person authorized to sign for patient) Date
Anterior Orbiotomy Consent Form
Please click on this link to download a copy of the anterior orbiotomy consent form.
INFORMED CONSENT FOR ORBITAL SURGERY
(“Eye socket surgery”)
WHY MIGHT I NEED SURGERY OF MY EYE SOCKET?
The eye socket is a relatively small space with many important structures in it. Surgery of the orbit (eye socket) may be necessary to remove foreign bodies (wood, metal, etc.) or tumors. In some cases, if the foreign body or tumor is not pressing on the eye structures, it may be safely left alone. In other cases, it is important to the safety of the eye to remove it. This is best done by a specialist in eye socket surgery.
HOW IS THE EYE SOCKET SURGERY DONE?
Surgery of the eye socket is usually done in an operating room with the patient under general anesthesia (completely asleep). Your doctor will NOT remove the eyeball!! Small incisions are used to get to the tumor or foreign body and delicate instruments are used to move the eye to one side and allow your doctor to see the mass. Your doctor may need to patch the eye after surgery but often does not.
HOW WILL EYE SOCKET SURGERY AFFECT MY VISION OR APPEARANCE?
The results of orbital (eye socket) surgery depend upon each patient’s severity and location of the mass, symptoms, unique anatomy and appearance goals. Eye socket surgery is not considered cosmetic surgery but most patients feel that they look better after they have healed. Orbital surgery does not improve blurred vision caused by problems inside the eyeball, or by visual loss caused by neurological trauma behind the eye. 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 orbital 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 orbital 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 associated with the foreign body or tumor (pain, visual loss, double vision, etc.) and decide not to have surgery on your eye socket at this time. In some cases, double vision may be improved with glasses or eye muscle surgery.
WHAT TYPE OF ANESTHESIA IS USED? WHAT ARE THE MAJOR RISKS?
Most orbital 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.
- 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 orbital surgery, 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 orbital surgery on:
Right_____ Left_____ Both sides: _________
Other: _________________________________________________
_______________________________________ _______________
Patient (or person authorized to sign for patient) Date
“My Doctor Never Told Me That Would Happen” – A Patient Centered Approach to Informed Consent – Part Three
Course Description
Informed consent is a collaborative process where ophthalmologists and patients (family members) communicate and exchange information prior to making important eye healthcare decisions. In the video “My Doctor Never Told Me That Would Happen” – A Patient Centered Approach to Informed Consent, past OMIC Board Member, Tamara R. Fountain, MD, guides viewers through the many issues surrounding the informed consent process.
In Part Three of this video, Dr. Fountain reviews some “real world applications” of the informed consent process such as:
- Patients insisting that the physician, “Do whatever you think best”
- Parents refusing to consent to their child having necessary surgery
- In a teaching setting, patients who refuse to allow residents/fellows perform surgery
- The importance of understanding a patient’s social/cultural background and economic status as it relates to surgery/treatment
