Orbital Decompression Surgery Consent Form
Please click on this link to download the orbital decompression consent form.
INFORMED CONSENT FOR ORBITAL DECOMPRESSION SURGERY
(Removing fat and/or bone from the eye socket)
WHY MIGHT I NEED ORBITAL DECOMPRESSION SURGERY?
Certain conditions such as Graves’s disease can cause the pressure in the orbit (eye socket) to rise to dangerous levels as the muscles that move the eye enlarge. This can put the optic nerve at risk and in some instances can cause blindness. In addition, the increased pressure can cause the eyes to bulge forward giving the patient a “bug-eyed” appearance. By removing fat and/or bone from the eye socket, the soft tissues of the eye socket can relax back into the now enlarged orbit. So, this surgery can help to relieve the pressure in the eye socket and allow the eye tissues to revert to a more normal position.
WHAT ARE THE RISKS OF GRAVES DISEASE AND BULGING EYES TO MY OCULAR HEALTH?
The most serious risks of Graves’s disease to the eye is usually the damage to the optic nerve and loss of vision which can be extensive and permanent. In addition, bulging eyes may not close all the way giving the patient dry eyes and potentially corneal exposure and damage which can cause permanent visual loss. The swollen muscles of Graves’s disease can also result in double vision.
HOW WILL THIS SURGERY AFFECT ME AND MY APPEARANCE?
Orbital decompression surgery is NOT cosmetic surgery. It is being done to save your vision from deteriorating. The cosmetic results of this surgery may be minimal or they may be dramatic. Because of the nature of this disease and the fact that it affects each patient differently, it is impossible to tell prior to surgery if the cosmetic outcome will be pleasing to the patient. Nonetheless, many patients find that they look and feel better after the surgery.
It is important to note that some patients have unrealistic expectations about how orbital decompression 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 ORBITAL DECOMPRESSION SURGERY?
Risks of orbital decompression surgery include but are not limited to: bleeding, infection, scarring, need for more surgery, loss of vision, loss of visual field or even blindness. Some patients may develop double vision after this surgery that may never go away. You may need additional treatment or surgery to treat these or other 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.
WHAT ARE THE ALTERNATIVES TO ORBITAL DECOMPRESSION SURGERY?
You may be willing to live with the symptoms of Graves disease (headache, double vision, visual loss) and decide not to have any surgery at this time. Other options include eyelid surgery, oral steroids or radiation to the orbits. Your doctor is happy to discuss these with you and refer you to the appropriate physicians if you wish.
WHAT TYPE OF ANESTHESIA IS USED? WHAT ARE THE MAJOR RISKS?
Orbital decompression 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 and has encouraged me to ask more questions as they arise. I understand the risks, benefits, and alternatives of orbital decompression 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 orbital decompression surgery on:
Right_____ Left _____ Both sides_________
Patient (or person authorized to sign for patient) DatePlease refer to OMIC's Copyright and Disclaimer regarding the contents on this website