Barnet Dulaney Perkins Eye Center
Eye Drop Schedule for AFTER Lens Replacement SurgeryPatient’s Name:Physician’s Name:Date of Surgery:Eye:Right LeftALWAYS WASH YOUR HANDS BEFORE INSTILLING YOUR EYE DROPSShake your eye drops before using.Sit or lie down and look up. Gently pull down the lower eyelid and put the drop into the “pocket” created. Do not touch anything to the tip of the bottle.Separate all drops by at least 5 minutes.1st Week Days:Dates:DiclofenacGRAY CAP3 times a day? ??? ??? ??? ??? ??? ??? ??Pred AcetatePINK/WHITE CAP 3 times a day? ??? ??? ??? ??? ??? ??? ??2nd WeekDates:DiclofenacGRAY CAP3 times a day? ??? ??? ??? ??? ??? ??? ??Pred AcetatePINK/WHITE CAP3 times a day? ??? ??? ??? ??? ??? ??? ??Please call your pharmacy if you run out of any dropsPatient Signature:Date: ................
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