Risk Management

Lid Laceration Repair Consent Form and Addendum

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LID LACERATION REPAIR CONSENT 5 12 2019

INFORMED CONSENT FOR EYELID LACERATION REPAIR

(“Repair of cut to the eyelid”)

WHY MIGHT I NEED REPAIR OF THE CUTS ON MY EYELIDS?

The eyelid is a multilayered structure that covers and protects the eye. It contains muscles that open and close the eye. The eyelids function to protect the eye and keep out foreign material as well as to regularly spread tears on the surface of the eye to keep it moist and then drain away the tears. The tears are produced by the lacrimal (tear) gland located in the eye socket in the upper outer corner on both sides.  The tears are secreted onto the eyeball and drain through small holes in the inner corner of the eyelids into the nose and throat through the tear drain system.  If the tear drain system has been damaged by the laceration, it may scar shut (become blocked) so that tears cannot drain into the nose.  The tears will then run down your face (as if you were crying).

A laceration is a cut that can go partly or fully through the eyelid. Lacerations to the eyelid can severely affect the ability of the eyelids to maintain their function. The goal of eyelid laceration repair is to improve the appearance and function of the eyelid, protect the eyeball, reduce discomfort and irritation, reduce tearing and discharge, and reduce the risk of infection.

HOW IS EYELID LACERATION REPAIR DONE?

Repair of cuts to the eyelids is often done in an operating room with the patient under anesthesia, but might be done in the emergency department of the hospital or even the doctor’s office if the cuts are not severe. You and your doctor will decide which location is best for you. The doctor will often use sutures (stitches) or sometimes glue to close the wound. Again, you and your doctor will decide what materials are needed to give you the best result.

The ophthalmologist (eye surgeon) may test the tear drain to find out if and where it has been cut.  If the tear drain has been cut, a flexible tube may be inserted into the tear drain during the repair and left in place for a few months (sometimes longer) to keep the drain open. Later, this tube can be removed in the office.

HOW WILL EYELID LACERATION REPAIR SURGERY AFFECT MY VISION OR APPEARANCE?

The results of eyelid laceration repair surgery depend on the severity and location of damage (which parts of the eyelid are cut), symptoms, individual anatomy, and appearance goals. Eyelid laceration surgery is not considered cosmetic surgery, but most patients feel that they look better after the surgery than they did with the cuts. Eyelid laceration surgery does not improve blurred vision caused by problems inside the eye, or by vision loss caused by injuries to the eye ball, muscles that move the eye, or nerve damage behind the eye and does not repair paralyzed/injured nerves. Eyelid surgery cannot repair all problems associated with trauma to the face and/or eye.

It is important to understand that some patients have unrealistic expectations about how eyelid laceration 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 eyelid laceration surgery include but are not limited to: bleeding, infection, scarring, an unbalanced appearance between the eyes, difficulty closing the eyes (which may cause damage to the cornea-the clear covering of the eyeball), drooping of the eyelid(s), double vision, numbness and/or tingling near the eye or on the face, tearing, dry eye, scarring, pain, loss of lashes, poor cosmetic result and, in rare cases, loss of vision. If the tear drain has been cut, even after repair it may not stay open and may require additional surgery to correct. 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 cuts to your eyelid and decide not to have surgery on your eyelid lacerations at this time (although this is not usually recommended). Cosmetic work may be needed to help the eyelid function or improve your appearance at a later date.

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

Most eyelid surgeries are done with some type of anesthesia and/or sedation but this depends on the patient and type of injury. If the cut is small and not severe, you may do well with just local numbing shots. If the cuts are severe, you may be more comfortable completely asleep. Risks of anesthesia include but are not limited to damage to the eye and surrounding tissue and structures (from the numbing shots), loss of vision, infection, damage to mouth and/or breathing structures, breathing problems, and, in extremely rare circumstances, stroke or death. The anesthesiologist will review the specific risks of the type of anesthesia you will have with surgery. If you have surgery in the operating room, the risks will be covered in the anesthesia consent and any questions should be reviewed with the anesthesiologist prior to surgery.

PATIENT’S ACCEPTANCE OF RISKS

I have read the above information and have discussed it with my doctor. I understand that it is impossible for my doctor to inform me of every possible complication that may occur with eyelid laceration 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 Dr. _______________________ 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 laceration repair, and the costs associated with this surgery and future treatment, and I feel I am able to accept the risks involved.

I consent to eyelid repair surgery on:

Right side____ Left side ____ Both sides______

Other:            ________________________________________________________________________

X _____________________________________________               ________________________

Patient (or person authorized to sign for patient)                          Date

Physician Declaration:  The contents of this document have been explained to the patient and all questions and concerns have been answered.  To the best of my knowledge, I feel that the patient has been adequately informed and has consented.

X______________________________________________              ________________________

Physician                                                                                             Date