Lagophthalmos Surgery With Gold Weight Consent Form

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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

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