INFORMED CONSENT FOR A BLEPHARORRAPHY

This document contains the information about the reasons, conditions, results, risks and limitations of the proposed medical act.

INFORMED CONSENT FOR AN OPERATION OF BLEPHARORRAPHY

You suffer of an eyelid or eye disease that urges a partial or complete, temporary or permanent closure of the eyelids. As treatment for this condition, your ophthalmologist proposes surgery.

This document contains the information about the reasons, conditions, results, risks and limitations of the proposed medical act.

Why operate?
The lack of protection of the eyeball by the eyelids may lead to anomalies of the ocular surface that may lead to dry eye and corneal lesions that may lead to visual loss.

The operation
It is performed on the patient, while installed on the back, in a sterile environment, under surgical microscope.

* Anaesthesia: it is done by an injection of anaesthetic in the vicinity of the lesion.

* Technique: The operation involves a partial or total, temporary or permanent closure of the eyelids. Chronologically, the steps of the procedure are: Disinfection, anaesthesia by an injection in the area to operate, incision of the eyelid margins, closure with stitches, disinfection and, sometimes, eye pad or eye-cup.

Your ophthalmologist will decide the type of anaesthesia, closure and post-operative treatment depending on the location and size of the lesion.

The time spent in the operating room is 20 to 30 minutes. In the operating theatre, it is of 45 minutes. In short, you leave one hour after your arrival.

Any stitches will be removed 1-4 weeks later.

Usual postoperative course
The postoperative course is simple and last 1 week: slight haematoma, light swelling, mild to moderate pain and redness of the eyelids.

You should be aware that the closure of the eyelids, partial or complete, temporary or permanent is unesthaetic.

Complications of the operation

Although it is perfectly standardized and followed by good results, this type of operation is no exception to the general rule that there is no surgery without risk. It is not possible for your ophthalmologist to ensure formally the success of an intervention.

You should be aware that

* During the anaesthesia and sometimes despite the anaesthesia, during the operation itself, there is a hazard of discomfort and, although very rarely, even pain. This risk depends on the patient?s responsiveness to the anaesthetic
molecule. It is unpredictable.

* In any local anaesthesia and all surgical procedures, there is a hazard of local complications, bleeding and infection and general intolerance that can lead to a severe shock. The risk of these complications is unpredictable. It is so exceptional that it is impossible to quantify.

* After any surgery of the skin, there is a hazard of inadequate or excessive scarring, which can lead to  further unaesthetic scarring, that may necessitate a re intervention. This risk is higher on dark skinned or regularly exposed to sunlight patients. It is not quantifiable.

To what must the patient be careful to, before, during and after the operation?
You agree to follow the precautions, treatments and appointments to be prescribed before, during and after the operation.

THE EVE OF THE OPERATION : Remove make-up; thoroughly wash your hair and face, especially the eyelids and eyelashes, and the whole body with shampoo or soap. Rinse generously and repeat the same thorough washing and rinsing. Dry yourself with a clean towel. Sleep with clean nightclothes and bedding. It is advisable not to take any Aspirin the day before and the day of the operation. You may take it the day after. Discuss already now this matter with your GP.

THE DAY OF THE OPERATION AND DURING THE WEEK FOLLOWING IT: On the morning of that day, upon awakening, re-remove make-up carefully and repeat a thorough double shower as described above. Wear clean underwear and clothes. Take your breakfast and regular medications, except Aspirin. Make sure you have with you all your medications and this document duly signed.

Then go, at the time indicated in your appointment, to your Eue Doctor’s Clinic to register and pay all the medical and surgical costs of that day. These fees will not be reimbursed by the Social Security. They will eventually be reimbursed by your private insurance to which you should check. The Clinic of your Eye Doctor is not involved in these processes.

During the operation, you are requested to keep calm and strictly follow the instructions given by your ophthalmologist.

After the operation, use the eye drops or ointment prescribed on the operated eye at noon, evening and before bed. The application of this treatment is to be continued four times a day (morning, afternoon, evening and before bedtime)
during a whole week.

The presence of an aiding person is advised during the remainder day of the operation.

A little bleeding and swelling (haematoma) of the eyelid should not worry you or keep you from following the treatment.

In case of pain, take one or two, maximum three, Paracetamol tablets per day for up to three days. Avoid Aspirin.

It is always strongly advised not to rub your eyes.

If a protective eye-pad or an eye-cup is placed on the eye, it should be kept throughout sleep, nap or at night, changing the plasters for each application of ointment, all this for 7 days. The plasters stick best on a skin previously washed with soap or a gently rubbed with an alcoholic perfume.

Visual activities, professional and of leisure, are all allowed as long as there is no eye contact with dirt or dust.

Wearing sunglasses is always advisable when exposed to sunlight.

YOU SHOULD CONTACT YOUR OPHTHALMOLOGIST IMMEDIATELY IN CASE OF
* Breathing difficulties
* General malaise
* Fever
* Persistent Bleeding
* Continued strong pain lasting more than 24 hours.

The next appointment
Is held in the Eye Doctor’s Clinic. The fees for this appointment are not included in those of the act here described.

Your eye doctor is willing to answer any questions you would like to ask.

The regulations oblige the physician to prove that he provided the information to the patient. You are asked to sign
this document of which a copy is held by your doctor.

I, undersigned, ......................................., acknowledge that the nature, reasons, conditions, results, limitations and risks of the proposed medical act were explained to me in terms I understood and that it has been satisfactorily answered to all my questions.

I had enough time to think and to make my decision and
     O give my consent
     O do not give my consent
for the realization of the act proposed to me.

Done in ... ... ... ... on the... ... ... ... ... ... ... ... ... ... ... ... ... in two copies of which I keep one.
in 2 copies, one for me and one for the surgeon.
(Sign here and under each page).