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									                        EYE MUSCLE SURGERY CONSENT FORM

You will need a clearance note from your child’s pediatrician or family doctor before admission
to the hospital. Please make sure to bring it the day of the surgery.
Laboratory work may be needed. If necessary you must have it done the week prior to surgery.
The day prior to surgery, in the afternoon you will be contacted by the hospital. They will give
you clear instructions of the time the last feeding prior to surgery should be. This will depend on
the age of the patient and the time of the surgery. The importance of an empty stomach prior to
anesthesia will be emphasized. All food and fluid will need to be held after a certain hour. Make
sure you follow these instructions.

This information is given to you so you can make an informed consent decision about proceeding
with eye muscle surgery on you or your child. You have the right to ask questions about any
procedure before agreeing to have the operation.
Eye muscle surgery is designed to put the eyes in a more satisfactory alignment. Eye muscles are
attached outside the eye. Each muscle has partner-muscles and opponent-muscles. The eyes move
when one set of muscles pull and the opposing set relaxes. “Strengthening” operations make an
individual muscle pull more effectively by shortening or tucking the muscle to reduce its effective
length. “Weakening” operations make individual muscle pull less effectively by moving the two
ends of the muscle closer together.
We decide before surgery which muscle we think will be operated. However, this may be
modified at the time of surgery depending on the manner in which the eyes may be moved
passively under anesthesia. Then, the final decision as to the most desirable approach to the eye
muscle problem is made. The operative permission therefore will always involve permission to
test and operate both eyes if necessary.

The eye muscles lie beneath the filmy membrane (conjunctiva) covering the white of the eyes.
Incisions are made in this filmy membrane to expose the attachment of a muscle or its tendon to
the white part of the eye. These tendons are then moved in a way to make the muscle effectively
longer or shorter. The muscles are reattached to the white part of the eye (sclera) by stitches.
These stitches are usually absorbable material not requiring removal. Following surgery the area
of the incision in the filmy membrane and the point where the sutures are placed, may exhibit
some redness or swelling. The eyelids are usually not manipulated, but occasionally following
surgery the eyelids maybe are temporarily discolored or swollen. Tears are usually tinged with
blood the first day; tears and secretion tend to dry and collect on the eyelids.

Eye muscle surgery is not an exact science. It is based upon average responses to “shortening” or
“lengthening” a given muscle a set number of millimeters. The average response to shortening or
lengthening an eye muscle is predictable. However, there may be an over-response or under-
response to any given surgery.


In most instances we plan to achieve with one procedure a satisfactory correction of the eye
muscle problem. Because of varying responses, or because of the magnitude or complicated
nature of any given muscle problem, more than one operation may be necessary. It is important
not to evaluate the outcome of the surgery during the first several weeks following surgery.
The operated muscles do not function with full power immediately. Until full function is
regained, the eye position may change frequently. It may take up to six to twelve weeks to regain
full function.

Following muscle surgery the patient is taken to the recovery room where special nurses and
equipment are available. Here the recovery from anesthesia is supervised. When a satisfactory
state of consciousness returns, the patient is sent to a separate room. The family can rejoin the
patient at this time.

Eating: until the patient is well awake nothing by mouth should be encouraged. Once awake, the
patient may have ice chips or small sips of a beverage. Nausea may occur after the administration
of anesthesia. Large quantities of food should be avoided in the immediate post-operative period
as they can irritate the stomach. Usually the patient is able to resume a regular diet the day
following surgery.
Bandages: the eyes are not covered. There may be a small amount of discharge. The discharge
may be tinged with blood. Secretions can be gently wiped away with a moist tissue.
Tearing: tearing may occur the first few days after surgery. If it is bothersome, they can be
gently wiped away with a tissue or other soft material like a towel.
Pain: generally there is little or no pain except on extreme movements of the eyes. The patient
learns this and tends to move the head rather than move the eyes.
Activity: the patient is able to use the yes the day of surgery. All patients are allowed up with
supervision the same day. Infants and small children may be held in the parent’s arms. Swimming
is not permitted for one week. Keep soap and water out of eyes while bathing.
Glasses: the eyes may be light sensitive following surgery. In this case, older patients will
appreciate sunglasses or wide-brimmed hats. Younger patients may choose to close their eyes to
avoid the light. If glasses are worn before surgery, they will probably be continued immediately
after surgery. They may be modified at some time during the post-operative period.
Medications: any regular medication that the patient is taking should be continued upon leaving
the hospital. Occasionally, special medicines will be prescribed for you to take home. We instill
an ointment into the eyes after surgery. You will be given some of this ointment to take home. A
small amount of this is to be placed inside the lower eyelids nightly for the first week. On the day
of discharge from the hospital this is not necessary.
Office visits: generally the first checkup after surgery is within the first week. Regular visits will
then be scheduled at certain intervals. If there is any problem between scheduled visits please
report that and additional visits will be arranged.



This information is given to you so you can make an informed consent decision about proceeding
with strabismus surgery in you/your child. Take as much time as you wish to make the decision
about signing this informed consent. You have the right to ask questions about any procedure
before agreeing to have the operation.
Strabismus surgery is undertaken to correct the misalignment between the eyes and improve one
or more of the following: binocularity, stereo vision and fusion; diplopia or double vision;
significant compensatory head position; to decrease amblyopia or improve its management;
improve visual fields and to decrease nystagmus. Based on the age of the patient and the type of
ocular deviation the impact on each of these abnormalities will defer and determine the relative
urgency for the timing of surgery compared to other more conservative alternative methods.
You understand that you/your child do/does not have to undergo strabismus surgery but the
reason this has been recommended is because we have reached maximum results with alternative
treatment. The surgery will improve ocular alignment but with this type of surgery there always is
a probability of under or over corrections, some of which may require further surgery. In general,
the reoperation rate varies between 10% and 25% depending on the basic characteristics of the
original condition. Sometimes we may have to continue the use of glasses and/or prisms for the
treatment of the deviation. If there is amblyopia we may have to continue patching and/or drops.
Direct complications of surgery are unlikely but they may include hemorrhage (bleeding),
infection, slip or detachment of an extraocular muscle, double vision and even total loss of vision.
As with any surgery, there is a possibility of other complications due to anesthesia or drug
reaction. It is impossible to state every complication that may occur as a result of surgery.
Therefore, this list is incomplete.
You may have told and agree with your doctor’s recommendations that the benefits outweigh the
risks of these complications and therefore have decided to proceed with the operation listed



“I have read and understand the above risks and benefits for eye muscle surgery, and
understand that this summary does not include every possible risk, benefit and
complication that can result from eye muscle surgery. My doctor has answered all of my
questions about eye muscle surgery”.

I/We agree that the surgery should be done

_____________________________________________ _______________________
Print name of Patient or Patient’s Representative Date
if Patient is a minor

_____________________________________________             ________________________
Signature of Patient or Patient’s Representative           Relationship to Patient
if Patient is a minor

Your understanding of surgery is as follows:
Please briefly describe in your own words the surgery that you think will be done______




I have discussed the proposed surgery with the patient/family. In my opinion the patient/family
understands the reasons, the risks, the alternatives and the expected course of the proposed
surgery. I plan and have discussed the following operation (exact procedure):




____________________________________________              _________________________
Surgeon’s Signature                                         Date

_____________________________________________ _________________________
Print name of Witness                           Witness Signature



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