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«CONTACT LENS WEARING AGREEMENT This will confirm that staff members from Scottsdale Eye Physicians & Surgeons, PC have informed me that I need to ...»

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CONTACT LENS WEARING AGREEMENT

This will confirm that staff members from Scottsdale Eye Physicians &

Surgeons, PC have informed me that I need to remove my contact lenses

prior to measurements and surgery according to the following schedule:

Regular Soft Lenses: Remove 1 week prior to pre-op visit

Soft Toric Lenses: Remove 2 weeks prior to pre-op visit

RGP’S: Remove 3-4 weeks prior to pre-op visit

I do not wear contact lenses currently These recommendations are to ensure that the cornea has had a chance to relax and assume its natural shape prior to surgery.

I agree to these terms and conditions and fully understand and accept any risks involved by not adhering to these precautions.

By execution of this document, I declare that the foregoing is true and correct.

_____________________________________ _____ __________

PATIENT SIGNATURE DATE

5/14/14 2 Dear Patient, Our Surgery Scheduler will be contacting you to you to set up your appointments for Cataract surgery.

Please use the space below to write down your appointment dates and times:

A-Scan/Pre-op Date: _________________ Time: ________ Surgery Date: _________________ Arrive: ________ Surgery Time: _______ 1st Post-op Date: _________________ Time: ________ 2nd Post-op Date: _________________ Time _________

1. Remember to bring this packet with you to your Pre-op Appointment.

2. Please bring all medications, or a list that includes dosages, to your pre-op appointment.

3. All appointments are at our office except the day of surgery.

4. Eye Surgery Center at the Biltmore is located at 2222 E. Highland Ave. Ste. 101. Phoenix AZ.

5. Please contact our Surgery Scheduler@ 480 994-1872 if you have any questions regarding your appointment times.

Directions to Eye Surgery Center at the Biltmore:

Take Indian School Rd. West Turn right at 24th Street Turn left at Highland Ave.

Eye Surgery Center at the Biltmore is located on the NE corner of 22nd Street & Highland Ave.

(602) 279-2434 1/15/15 3 Eye Surgery Center at the Biltmore Medication List Below is a list of medications that are typically used during eye surgery in our center. We have included the usage of these medications and some side effects, if you have questions or concerns please ask your physician, nurse or anesthesia provider. Be sure to alert your nurse and physician to any known allergies that you have.

It is always possible for a person to experience other reactions following the administration of any medication, if you have any questions or concerns following your surgery please consult your physician.

Pre Surgical Eye Drops:

Anesthetic Eye drops, ( Alcaine, Proparacaine, Tetracaine): A topical eye anesthetic used during eye surgery and eye procedures causing numbing of the surface of the eye. Side effects may include: stinging, burning and irritation conjunctival redness may occur; overuse can cause drying of the cornea. Use caution and not to rub the eye until the effects have worn off; which will occur in approximately 30 minutes.

Antibiotic Eye drops are used to prevent eye infections, use as directed by your physician. Note: stopping this medication early may result in the infection returning.

Ocuflox ( Ofloxacin); Vigamox ( Moxifloxacin) : These medications are used to treat bacterial eye infections. Ofloxacin and Moxifloxacin belongs to a class of drugs called quinolone antibiotics. They work by stopping the growth of bacteria. Side effects may include: temporary stinging or burning of the eyes for a minute or two when applied. Temporary blurred vision, eye discomfort, itching, redness, dryness, tearing, feeling as if something is in your eye, or sensitivity to light may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly. Do not use if patient is allergic to Quinolone antibiotics (e.g: Ciprofloxacin, Norfloxacin, Moxifloxacin, Levofloxacin).

Trobramycin: (Tobrex) is an aminoglycoside antibiotic used to treat bacterial infections of the eye. It works by stopping the growth of bacteria.

Side effects may include: tearing, eye redness, eye discomfort, or eyelid itching, or swelling may occur. Use of this medication for prolonged or repeated periods may result in a new fungal eye infection. Do not use it for longer than prescribed. If any of these effects persist or worsen, notify your doctor or pharmacist promptly. Do not use if the patient is allergic to Tobramycin or other Aminoglycosides ( e.g. Gentamicin). Do not wear contact lenses while you are using this medicine.

4 Phenylephrine ophthalmic drops ( Neo-synephrine, Mydfrin) : 2.5 % and 10% solutions, are used to dilate (enlarge) the pupil before eye surgery. Side effects may include: burning, tearing, light sensitivity, and blurred vision. Do not use if the patient is allergic to phenylephrine. Use caution in patients with narrow angle glaucoma and hypertension.

Mydriacyl (Tropicamide) : This medication is in a class of drugs known as anticholinergics and is used to dilate the pupil of the eye by relaxing certain eye muscles. It is used in preparation for eye surgery and some eye examinations.





Side effects may include: Burning, stinging, redness, temporary blurred vision, dry mouth, or sensitivity to light may occur.

Cyclogyl ( Cyclopentolate): This medication is in a class of drugs known as anticholinergics. It works by temporarily dilating the pupil of the eye and relaxing the muscles of the eye. It is used in preparation for eye surgery and some eye examinations. Side effects may include: Burning, stinging, redness of the eye, eye irritation, or temporary blurred vision may occur. Do not use in patients that are allergic to Cyclopentolate or Belladonna Alkaloids (e.g., Atropine).

Non-steroidal anti-inflammatory - NSAIDS (Ketorolac, Acular): NSAIDS work by blocking the production of prostaglandin, a substance that causes pain. It also works to reduce swelling and inflammation following eye surgery. Side effects may include: headache, temporary stinging, burning of the eye. Do not use in patients that are allergic to Ketorolac, Acular, Toradol or other non-steriodal antiinflammatory drugs ( e.g. Ibuprofen, Naproxen, Celecoxib) or ASA.

Pilocarpine (Pilocar): This medication is in a class of drugs known as cholinergics. Pilocarpine is used to constrict the pupil when a smaller pupil is required for eye surgery. It may be used during surgery to decrease the pupil size. Pilocarpine is also used to treat glaucoma symptoms by decreasing the pupil size and decreasing the fluid inside the eye. Side effects may include: temporary irritation, burning, stinging of the eye, temporary blurred vision, poor vision in dim light (do not drive, especially at night after using this medication), headache, or brow ache may occur. Do not use if the patient has an allergy to Pilocarpine. Caution in use in patients with asthma, heart disease, or recent heart attacks.

Betadine drops: A diluted betadine solution is used to disinfect the eye tissues and help prevent eye infections both prior to and following eye surgery. Side effects may include: stinging, burning and/ or eye irritation. Do not use if the patient is allergic to topical Betadine.

–  –  –

Anti- anxiety/ Sedatives:

Versed (Midazolam): Versed is a benzodiazepine drug that causes relaxation, sleepiness and can cause a partial or complete loss of memory during the use of the drug. It is frequently used prior to surgery to calm and relax the patient. Side effects may include: pain, tenderness and redness at the injection site, nausea, and drowsiness.

Diprivan (Propofol): Diprivan is a short –acting hypnotic, amnestic sedative used for relaxation prior to surgical procedures. Diprivan is administered intravenously. Side effects may include: slight burning or stinging around the injection site, numbness or tingly feeling, nausea, cough, confusion, agitation, and anxiety.

Non-steriodal anti-inflammatory (NSAIDS); ( Toradol, Ketorolac) : May be given for short term pain relief usually given before or after surgery, also to decrease swelling. It works by blocking the body's production of certain natural substances that cause inflammation. Side effects may include: upset stomach, nausea, vomiting, constipation, diarrhea, gas, dizziness, or drowsiness may occur.

NSAIDS can also cause bleeding if taken over long periods of time ( take only for the prescribed number of days). Do not use in patients that are allergic to Ketorolac, Toradol, other non-steriodal anti-inflammatory drugs (e.g. Ibuprofen, Naproxen, Celecoxib) or Asprin.

Fentanyl ( Sublimaze) : Fentanyl is a narcotic (opioid) analgesic. It works in the brain and nervous system to cause anesthesia and decrease pain. Fentanyl is given intravenously and used for producing anesthesia for surgery and treating pain before, during and after surgery. Side effects may include: drowsiness, lightheadedness, weakness, fatigue, feelings of euphoria.

Xylocaine ( Lidocaine ): Xylocaine Is a local anesthetic agent that is injected around the eye for numbing the eye or can be used in a jelly form that is used directly on the surface of the eye for local anesthesia. In the injection form, lidocaine is usually mixed with hyaluronidase to help with absorption and distribution of the injection. Side effects may include: stinging and burning, redness, temporary blurred vision. Following an injection of the medication it can take several hours to completely wear off, if your eye has been patched closed follow the instructions for removing the patch; corneal abrasions may occur if the patch is removed to soon.

–  –  –

gasping, feeling unusually hot; slow heart rate, weak pulse; feeling restless or anxious, ringing in the ears, metallic taste, speech problems, numbness or tingling around your mouth, tremors, feeling light-headed, or fainting; or problems with urination and allergic reactions. Following an injection of the medication it can take several hours to completely wear off, if your eye has been patched closed follow the instructions for removing the patch; corneal abrasions may occur if the patch is removed too soon.

Antihypertensive Agents (Blood Pressure lowering medications) medication may be given to reduce the blood pressure, if the pressure is higher than optimal.

Lowering high blood pressure helps prevent strokes, heart attacks, and kidney problems.

Labetalol (Trandate): This medication is both an alpha blocker and beta blocker. It works by blocking the action of certain natural chemicals in your body such as epinephrine on the heart and blood vessels. This effect lowers the heart rate, blood pressure, and strain on the heart. Side effects may include: tiredness, diarrhea, lightheadedness, hypotension (low blood pressure,or dizziness especially on standing.

Hydralazine (Apresoline): Hydralazine is a vasodilator. It is used to lower high blood pressure, and works by relaxing blood vessels so blood can flow through the body more easily. Side effects may include: pounding/fast heartbeat, loss of appetite, nausea, vomiting, diarrhea, lightheadedness, hypotension (low blood pressure) or dizziness especially on standing.

Dextrose: Intravenous glucose medication that is used to raise the body’s blood sugar. It is given intravenously if blood sugar level is too low. Side effects may include: Increased blood sugar.

Antiemetic: Given to prevent or treat nausea and or vomiting.

Zofran (Ondansetron): Is used to prevent and treat nausea and vomiting after surgery. It works by blocking one of the body's natural substances (serotonin) that causes vomiting. Side effects may include:http://www.webmd.com/migraines-headaches/default.htm headaches, lightheadedness, dizziness, drowsiness, tiredness. Tell your physician if you are allergic to serotonin blockers.

–  –  –

Intra-operative Medications:

Antibiotic eye drop ( Vigamox, Ocuflox, Tobramycin):See pre-operative antibiotic eye drops.

Antibiotic injections ( Vigamox, Cefuroxime): Injections in the eye post surgery to reduce the risk of post operative infections. Side effects may include: stinging, burning or redness around the injection site.

Steroid eye drops ( Predforte, Prednisolone) : Reduces inflammation in the eye following eye surgery. Can cause the pressure in the eye to increase.

Trimoxi (Triamcinolone and Moxifloxacin) injection: Trimoxi is a single injection of the steroid Triamcinolone and the antibiotic Moxifloxacin that some surgeons choose to use on their patients. The Trimoxi is injected into the eye following cataract surgery. In most cases there is no need for antibiotic eye drops before surgery and no need for antibiotic or steroid eye drops following cataract surgery if this injection is used. Side effects may include: floaters for a few days post injection, blurred vision in the immediate post operative period, and an increase in eye pressure in patients with glaucoma.

Pilocarpine, Miochol and Miostat are medications used to constrict the pupil during or following some eye surgeries, these medications may cause brow aching or headaches temporarily.

Balanced salt solution- used to moisten the surface of the eye and keep the eye chamber inflated during cataract removal.

Shugarcaine ( Phenylephrine, Lidocaine and Balanced Salt Solution mixture):

Shugarcaine is sometimes injected into the anterior chamber of the eye during cataract surgery to increase and/ or maintain the pupil dilation, or to reduce floppy iris syndrome during cataract surgery in patients that have used Flomax.

Pressure Lowering Eye drops: The eye drops are sometimes used to lower the pressure in the eye following eye surgery or eye procedures such as laser procedures.

–  –  –



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