Risk Management

Ptosis Surgery Consent Form

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PLACE LETTERHEAD HERE AND REMOVE NOTE.   Version 07/20/2009
CHANGE FONT FOR LARGE PRINT
NOTE:  THIS FORM IS INTENDED AS A SAMPLE ONLY OF THE INFORMATION YOU AS THE SURGEON SHOULD PERSONALLY DISCUSS WITH THE PATIENT.  PLEASE REVIEW IT AND MODIFY TO FIT YOUR ACTUAL PRACTICE.
IT IS IMPORTANT TO DOCUMENT AND EXPLAIN THE ETIOLOGY OF THE CONDITION CAUSING THE DROOPY EYELID AND HOW THAT CONDITION MIGHT AFFECT THE RESULTS OF SURGERY.
GIVE THE PATIENT A COPY.

Informed Consent for Ptosis Surgery
(Droopy eyelid surgery)

WHAT IS PTOSIS AND HOW IS IT CORRECTED?

Ptosis is a condition that occurs when one or both upper eyelids droop and the edge of the upper eyelid falls towards or over the pupil . Ptosis is usually caused by stretching or thinning of the tendon between the muscle that raises the eyelid and the eyelid itself. With stretching or thinning, the muscle that normally raises the eyelid has to work harder to lift it. This leads to symptoms of eyelid and forehead muscle fatigue, and eyelid heaviness. Other, less common causes of ptosis are nerve or muscle damage from any cause, various types of eyelid surgery, infection, muscle weakness, and systemic diseases such as stroke and tumors behind the eye, myasthenia, hypertension, thyroid disorders and diabetes. Children can be born with congenital ptosis; the muscle is abnormally stiff and does not function well. This condition usually lasts until it is surgically corrected. Ptosis surgery is not the procedure of choice for removing excess fat and skin in the upper eyelid. Under certain circumstances it can be combined with the operation known as blepharoplasty when fat and skin removal is an added goal of surgery.

To correct ptosis, the surgeon needs to make an incision or cut the skin of the upper eyelid in order to reach the muscles and tendons. The surgeon chooses where to make the incision based upon what treatment the eyelid needs. With the front or anterior approach, the surgeon makes an incision in the skin in the upper eyelid crease or fold in order to reach the muscle and tendon; if there is no eyelid fold, one can be created when the incision is made. The anterior approach allows the surgeon to trim excess skin and fatty tissue from the upper eyelid if needed during the surgery. If no skin or fat needs to be removed, the surgeon can raise the eyelid through an inside approach by placing the incision on the inside or moist part of the upper eyelid; with this approach, there is no cosmetic scarring. If the muscle is not strong enough to lift the eyelid, the surgeon must create a “sling” by connecting the moving eyelid to the frontalis muscle in the forehead.

HOW WILL PTOSIS SURGERY AFFECT MY VISION AND APPEARANCE
The droopy eyelid is like a curtain that blocks the view. Patients with ptosis frequently notice that they have less peripheral or side vision, particularly when looking up. The more ptosis, the greater the peripheral vision loss. When the eyelid is raised, either manually by hand, or surgically through one of the approaches described above, the blockage is removed and the eye can see. Ptosis surgery only corrects vision loss due to droopy eyelids. It does not improve blurred vision caused by problems inside the eye, or by visual loss caused by neurological disease behind the eye. To prevent amblyopia or poor visual development in children born with congenital ptosis, the surgery needs to be done early in life.

Patients with ptosis report that droopy eyelids make them look and feel “tired.” When the eyelid is raised in ptosis surgery, patients usually prefer the new eyelid position, and feel it improves their appearance as well as their peripheral vision. When only one eyelid is raised, it may affect how the eyelid on the other side looks. If this happens, ptosis surgery on the other side may be needed. If the position and shape of the eyelids do not match, additional surgery may be needed.

WHAT ARE THE MAJOR RISKS OF PTOSIS SURGERY?

Risks of ptosis surgery, like most eyelid surgical procedures 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), a “wide-eyed” or “open” appearance, difficulty with or inability to wear contact lenses, double vision, tearing, or dry eye problems, numbness and/or tingling in the operated eyelid, near the eye, or on the face, and in rare cases, loss of vision. While ptosis correction is usually permanent, the condition can recur. If it does, you may need to have repeat surgery.

The result of ptosis surgery cannot be guaranteed. Ptosis correction involves surgery on the tendon and/or muscle inside the eyelid, which can make the results unpredictable. At times, the surgeon may need to adjust the position and shape of the eyelid after ptosis surgery. The adjustments can be done early (within the first ten days) after surgery, or later on if asymmetry of the eyelid position or shape occur. The final result depends upon your anatomy, your body’s wound healing response, and the underlying cause of the ptosis. Some patients have difficulty adjusting to changes to their appearance. Some patients have unrealistic expectations about how changes in appearance will impact their lives. Carefully evaluate your goals, expectations and your ability to deal with changes to your appearance and the possible need for repeat surgery before agreeing to this surgery.

WHAT ARE THE ALTERNATIVES TO PTOSIS SURGERY?

Patients can live with ptosis and blocked or reduced peripheral vision; however, there is no reliable method to correct ptosis on a permanent basis without surgery. Patients who are too sick to have surgery may find relief by lifting their eyelid with their fingers or tape in order to see. Obviously, the eyelid droops again as soon as this temporary lifting is stopped.

WHAT TYPE OF ANESTHESIA IS USED AND WHAT ARE ITS RISKS
In children, general anesthesia is necessary. In teenagers and adults, ptosis surgery is usually performed on an outpatient basis under local anesthesia. The patient must be able to cooperate to some degree. Ptosis surgery with minimal (oral) sedation is desired in most cases. Some cases require sedation from a needle placed into a vein in your arm before surgery. Fortunately, even with no sedation, most patients do not find the operation to be very painful, and it only takes a short period of time. Risks of anesthesia, when administered, include but are not limited to damage to the eye and surrounding tissues and structures, loss of vision, breathing problems, and, in extremely rare circumstances, stroke or death.

Patient’s acceptance of risks

I have read the above information and have discussed it with my physician. I understand that it is impossible for the physician to inform me of every possible complication that may occur. My physician has told me that results cannot be guaranteed and that adjustments and more surgery may be necessary. By signing below, I agree that my physician has answered all of my questions and that I understand and accept the risks, benefits, and alternatives of ptosis correction.

I consent to ptosis surgery on:

________ Right eye     _________ Left eye    _________ Both eyes

_________________________________________         _____________
Patient (or person authorized to sign for patient)            Date