TEXAS OPHTHALMIC PLASTIC, RECONSTRUCTIVE



TEXAS OPHTHALMIC PLASTIC, RECONSTRUCTIVE

& ORBITAL SURGERY ASSOCIATES

NAME______________________________________________________ DATE ______________

PHONE ___________________________AGE ______OCCUPATION ___________________________

1. Do you have any allergies (particularly to medicines)? Please list _____________________________________________________________________________

2. Are you now taking any medications (list name, dose and frequency)?

DRUG NAME |DOSE |FREQUENCY |DRUG NAME |DOSE |FREQUENCY | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |Have you ever had any surgery (list ALL procedures!) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. Do you have any medical problems (list ALL diagnosis, problems)? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Has any member of your family had a condition similar to the one for which you are being treated?

________________________________________________________________________________

PLEASE DESCRIBE YOUR PROPOSED SURGERY IN YOUR OWN WORDS - PLEASE INCLUDE A SPECIFIC DESCRIPTION OF WHICH SIDE, WHICH EYELID ETC. IS TO BE OPERATED – (i.e. right upper eyelid, both upper eyelids) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PLEASE INITIAL EACH LINE THAT APPLIES

_______ 1. I understand that my insurance company may require that the copay and deductible be estimated and paid prior to any procedure. It can be difficult to get this information from your insurance company. We will let you know your “ESTIMATED” balance prior to surgery as soon as we find out from your insurance company.

_______ 2. DROOPY EYELID SURGERY. I understand there is a 15% chance that droopy eyelid surgery (ptosis) may need to be repeated. We make every effort to ensure symmetry in surgery but eyelids are quite variable in how they heal. If your lids are not symmetrical you may require another operation at your expense. If the amount of asymmetry is not bad enough to qualify for insurance “medical necessity” you will be required to pay for the revision procedure.

_______ 3. EYELID SURGERY. The eyelid skin is the thinnest skin in the body. It takes 2 weeks for 80 % of eyelid swelling to subside and 3-6 months for all swelling to go away. There is great variability from person to person in this. Patience is important.

_______ 4. TEAR DUCT SURGERY. I understand that I may have a stent placed in my tear duct. This can be temporary or permanent. Your eye will still water while the temporary stent is in place (it doesn’t drain tears but keeps the drain from scarring shut). Tear duct surgery has a success rate between 75% - 94% and depends on the patient and underlying condition. When your stent is removed there will be a charge for this procedure.

_______ 5. ORBITAL SURGERY. For tumors, trauma and fractures of the orbit you may have postoperative swelling that causes double vision. This should resolve in days to months. On occasion it doesn’t resolve and it will need to be addressed. Orbital surgery is quite delicate and there is a risk to your vision with any procedure in the confines of the orbit.

_______ 6. COSMETIC SURGERY. We will make every effort to ensure that you have an excellent result. However, patients heal at different rates and in different ways. No guarantee is made as to final outcome. Eyelid symmetry is difficult to achieve and in general 1 mm of asymmetry is considered an excellent result (everyone’s face has underlying asymmetries). Occasionally, patients will require additional surgery after the swelling has resolved. This may be at your expense.

_______ 7. MEDICARE PATIENTS. We make every effort to conform to Medicare’s ever changing and difficult guidelines. Medicare will NOT pre-certify procedures prior to them being performed. They may indeed audit your procedure after the fact. We have patient sign an Advanced Beneficiary Notification so that if Medicare denies your claim after the fact you will be responsible for the fee’s incurred.

SURGICAL INSTRUCTIONS

1-2 WEEKS BEFORE AND 1-2 WEEKS AFTER SURGERY

1. Avoid all products that interfere with blood clotting. (i.e. aspirin, ibuprofen, non-steroidal anti-inflammatory drugs, vitamin E, garlic extract and alcohol). Usually stop Over the Counter medications 7-10 days preoperatively and you can resume them 3-5 days postoperatively. Discuss this with your primary care doctor.

2. Avoid all smoking and nicotine products.

3. Avoid all medications unless cleared through our office. You must notify us of any medications you are taking. This includes over-the-counter nonprescription drugs.

4. Acetaminophen (Tylenol) is allowed pre- and postoperatively for pain.

NIGHT PRIOR TO SURGERY

1. Do not eat or drink anything after midnight except as directed by our staff.

DAY OF SURGERY

1. Take preoperative medications as instructed.

2. Remove contact lenses.

3. Leave valuables at home or with family members.

4. Remove all your jewelry prior to coming to surgery.

5. Wear loose, comfortable clothing. Bring sunglasses to wear home.

6. Do not wear any makeup.

7. You will need transportation to and from the surgery center. You will NOT be allowed to drive the day of surgery.

8. Do NOT drive after surgery until cleared by your surgeon.

9. Do not sign any papers or make important decisions for 24 hours after surgery. Medications may alter your judgment.

CALL IMMEDIATELY FOR THESE PROBLEMS

1. Severe pain

2. Dimming or loss of vision that does not clear with blinking and not caused by ointment

3. Continuous bleeding that is not controlled by cold application

AFTER SURGERY

1. DO NOT RUB YOUR EYES – BE VERY CAREFUL ABOUT NOT PULLING WOUNDS APART. SLEEP WITH METAL/PLASTIC EYE SHIELDS IF YOU ARE CONCERNED YOU WILL RUB YOUR EYES IN YOUR SLEEP!!!!

2. Leave dressing on wound for 24 hours and then remove unless instructed by

your doctor (if there is a dressing).

3. Place ice bags (frozen peas work quite well) on your wounds 4-6 times daily for 10 minutes for the first 3 –5 days postoperatively unless otherwise instructed.

4. Clean wounds 1-2 times daily with a cotton tip applicator (Q-tip) dipped in

Sterile saline solution (wring out the q-tip). Be sure to wring the applicator out so you do not completely soak the wound while cleaning. Do this for 7 –10 days as needed.

5. Apply antibiotic ointment to the wounds after cleaning as in step three. You should do this 2 times daily as directed by your doctor.

6. Apply the same antibiotic ointment to your affected eye(lid) at bedtime for the first 7 days to prevent drying of your eye at night.

7. Do not get your eye wet for the first 7 days or directed otherwise by your doctor.

8. Do not rub your eye or the wound for the first 2 –3 weeks unless directed otherwise by your doctor.

9. For pain control take extra-strength Tylenol unless directed otherwise by your doctor.

10. Take oral antibiotics as directed.

11. Do not blow your nose (or pick your nose) for the first 2 –3 weeks (tear duct surgery).

12.Call your doctor if you experience persistent bleeding, significant pain, loss of vision, infection.

13.You need to see your doctor approximately one week following your surgery unless instructed otherwise. Please call the doctor’s office to make this appointment.

COMMON POSTOPERATIVE QUESTIONS

FIRST WEEK

Limit your activity sharply over the first week after surgery. You are encouraged to walk around the house, but avoid bending over at the waist, picking up heavy objects, or straining of any kind. If you exert yourself, bleeding may result. We ask that you not drive for one day after surgery or if you are still taking narcotics. When you rest or sleep, keep your head elevated on two or three pillows and avoid turning on your side or face. Drink plenty of fluids and avoid salty foods and those that require much chewing, such as steak. You will need to discontinue contact lenses after surgery. You may resume contact lens usage when cleared by your doctor (this may be 1-6 weeks after surgery).

SMOKING, ALCOHOL, MEDICATIONS TO AVOID THE FIRST 2 WEEKS

Smoking should be strictly avoided because it interferes with the blood supply to the healing tissues and hinders healing. Alcohol consumption should also be eliminated because this may act as an anticoagulant and result in bleeding. Aspirin, Advil (ibuprofen), and similar medications may also cause bleeding. Check with us before taking any medication. If you feel nauseated or vomit, avoid food and drink. Take only 2 to 3 ounces of clear liquids at hourly intervals. Discontinue pain medication until nausea passes. If these symptoms persist, call for anti-nausea medication because subsequent vomiting may be harmful and lead to complications.

Washing your hair with baby shampoo is encouraged on the first night before your first postoperative visit. You may keep your eyes from getting wet by placing a dry washcloth over your eyes and incisions while carefully washing your hair. Avoid irritating any of the suture lines. You may slowly resume your activities after the first week. Let your body tell you how much to do. Moderately strenuous exercise may be resumed in 1-3 weeks (unless otherwise instructed by your doctor). Build up to this level slowly. You may begin by walking or other similar light exercise. In any event, do not strain, grimace, or do anything of sufficient exertion to cause your pulse rate to increase sharply. Avoid excess sunlight. Even a mild sunburn may cause prolonged swelling or irritation of the healing incisions. Do not compare your progress with that of other patients. Remember, everyone heals in his or her own unique way. Also, if you have any questions or concerns, call us. Your family and friends may mean well, but we can probably give you better information.

You should not have anything more than mild pain and some discomfort. Anything beyond this should be reported to us.

PAIN, SWELLING, BRUISING, INFECTION

It is unusual to have significant pain after eyelid or orbital surgery. If the prescribed medication does not control the pain, please report this to us promptly. There is discomfort, of course, but remember that this will pass quickly. Some swelling and bruising is to be expected. This is maximal at 48 hours after surgery and gradually subsides over the following 10-14 days. The last 20% of swelling may last 3-6 months. Swelling of the eyeball itself is common and frequently is described as "a bag of jelly" on the eye. This is treated with antibiotic cream and topical lubrication. Infection is unusual. Fever, localized swelling, redness, and tenderness may signify a developing infection and should be reported. Appropriate treatment will be initiated.

MEDICATIONS

Avoid medications that contain aspirin or ibuprofen for 2 to 3 weeks. Both pain and sleep medications are prescribed. Take them as needed, but, after the first 24 hours, Extra Strength Tylenol (acetaminophen) may be sufficient. Remember that the pain and sleep medication may impair your reactions, so avoid driving or other hazardous activities while taking them. If the prescribed medications do not control your symptoms, please call us. Nausea may occasionally be related to these medications. Small amounts of clear fluids at regular intervals may help. If this is not effective, call us.

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