David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-7900

 

GENERAL CONSENT FOR MEDICAL AND SURGICAL PROCEDURES

 

 

You have been given information about your condition and the recommended surgical, medical or diagnostic procedure(s) to be used. This consent form is designed to provide a written confirmation of such discussions by recording some of the more significant medical information given to you. It is intended to make you better informed so that you may give or withhold your consent to the proposed procedure(s).

 

 

1.        Condition:  Dr. David S. Pfoff, M.D. has explained to me that the following condition(s) exist in my case:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    

 

2.        Proposed Procedure(s):  I understand that the procedure(s) proposed for evaluating and treating my condition is/are:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             Right eye                 Left eye                 

 

3.        Risks/Benefits of Proposed Procedure(s):

A.       Just as there may be benefits to the procedure(s) proposed, I also understand that medical and surgical procedures involve risks. These risks include allergic reaction, bleeding, blood clots, infections, adverse side effects of drugs, blindness, and even loss of bodily function or life, as well as risks of transfusion reactions and the transmission of infectious disease, including Hepatitis and Acquired Immune Deficiency Syndrome, from the administration of blood and/or blood components.

B.       I also realize that there are particular risks associated with the procedure(s) proposed for me and that these risks include, but are not limited to, those enumerated in the addendum.

 

4.        Complications; Unforeseen Conditions; Results: I am aware that in the practice of medicine, other unexpected risks or complications not discussed may occur. I also understand that during the course of the proposed procedure(s) unforeseen conditions may be revealed requiring the performance of additional procedures, and I authorize such procedures to be performed. I further acknowledge that no guarantees or promises have been made to  me concerning the results of any procedure or treatment.

 

5.        Acknowledgments:  The available alternatives, the potential benefits and risks of the proposed procedure(s), and the likely result without such treatment have been explained to me. I understand what has been discussed with me as well as the contents of this consent form, and have been given the opportunity to ask questions and have received satisfactory answers.

 

6.        Consent to Procedure(s) and Treatment: Having read this form and talked with the physicians, my signature below acknowledges that: I voluntarily give my authorization and consent to the performance of the procedure(s) described above (including the administration of blood and disposal of tissue) by my physician and/or his/her associates assisted by hospital personnel and other trained persons as well as the presence of observers.

 

                                                                                                                                                                                               

Patient (or person authorized to sign for patient)                                           Date

 

                                                                                                                                                                                               

Witness                                                                                                                 Date

David S. Pfoff, M.D., P.C.

INFORMED CONSENT FOR ASTIGMATIC KERATOTOMY (“AK”)

 

Introduction

 

This information, including the benefits, alternatives, and possible complications of surgery, is being provided to you so that you can make an informed decision about having astigmatic keratotomy (“AK”) to treat your astigmatism.  You are encouraged to ask questions about any procedure and have them answered to your satisfaction before agreeing to have the operation.  Take as much time as you need to make your decision.

 

Astigmatic keratotomy is a surgical procedure which consists of making fine microscopic arcuate (curved) incisions, either singly or as a pair at optical zones of either 6 or 7 mm, or relaxing incisions at the limbus, which is the junction of the clear part of the eye (cornea) with the white (sclera) of the eye.  These cuts are made for the purpose of flattening the steepest part of the cornea in an attempt to obtain a more spherical cornea.  AK permanently changes the shape of the cornea.  Although the goal of AK is to improve vision to the point of not wearing glasses, this result is not guaranteed.

 

AK is an elective procedure:  There is no emergency condition or other reason that requires or demands that you have it performed.  You could continue wearing contact lenses or glasses and have adequate visual acuity.  This procedure, like all surgery, presents some risks, many of which are listed below.  You should also understand that there might be other risks not known to your doctor that may become known later.  Despite the best of care, complications and side effects may occur; should this happen in your case, the result might be affected even to the extent of making your vision worse.

 

Alternatives to AK

 

If you decide not to have AK, there are other methods of correcting your astigmatism.  These alternatives include, among others, eyeglasses, contact lenses, and other refractive surgical procedures such as PRK or LASIK.

 

PATIENT CONSENT

 

I give my consent to my ophthalmologist to perform AK, and I declare that I understand the following: I have received no guarantee as to the success of my particular case.  I understand that the following risks are associated with the procedure:

 

Potential Risks and Complications

 

1.         I understand that there is a possibility that my vision may not improve with this surgery or that the desired results of surgery may not be obtained.  It is possible that I may require additional surgery at a later date or that I could still need glasses after surgery.  It is possible that I may not be able to wear contact lenses after having this surgery.

 

2.         As a result of the surgery, it is possible that I could lose vision or lose best-corrected vision.  This could happen as a result of infection that could not be controlled with antibiotics or other means, which could even cause loss of my eye. 

 

3.         Irregular healing of incisions may cause the corneal surface to be distorted.  In that case, it may be necessary for me to wear a contact lens to affect useful vision, and there is a possibility that this may not restore useful vision.

 

4.         I understand that I may experience incapacitating light sensitivity from sunlight or other bright light sources for a varying length of time, or possibly permanently.

 

5.         I understand that I may experience incapacitating glare or halos from oncoming headlights or other bright light sources, particularly in the evening or nighttime, for a varying length of time or possibly permanently.  I am aware that this may interfere with driving for an indefinite period both day and night, and I understand that I am not to drive until I am certain that my vision is adequate both day and night.

 

6.         I understand that fluctuations or variation in vision may occur during the day during the initial stabilization period (up to three months or longer).

 

7.         As occurs in all surgical procedures, scarring is the result of making incisions in living tissue.  This particular surgery is no exception.

 

8.         My eye will be more susceptible to a blow to the eye during the healing phase and possibly somewhat after healing as the microscopic scar tissue may not be as strong as the normal tissue.  Protective eyewear is recommended for all contact and racquet sports where a direct blow to the eye could cause permanent injury to the eye.

 

9.         Additional reported complications include corneal perforation, which could possibly require sutures; incisional inclusions, corneal vascularization, corneal ulcer formation, endothelial cell loss, epithelial healing defects, and very rarely, endophthalmitis (internal infection of the eye, which could lead to permanent loss of vision).

 

10.      I understand that, as with all types of surgery, there is a possibility of complications due to anesthesia, drug reactions or other factors that may involve other parts of my body.  I understand that, since it is impossible to state every complication that may occur as a result of any surgery, the list of complications in this form may not be complete.

 

PATIENT’S STATEMENT OF ACCEPTANCE AND UNDERSTANDING

 

The details of the procedure known as AK have been presented to me in detail in this document and explained to me by my ophthalmologist.  My ophthalmologist has answered all my questions to my satisfaction.  I have read this informed consent form (or it has been read to me), and I fully understand it and the possible risks, complications, and benefits that can result from surgery.  I therefore consent to AK surgery.

 

I wish to have AK performed on my             right               left eye.

 

                                                                                                                                                              

Patient (or person authorized to sign for patient)                                                  Date

 

 

                                                                                                                                                              

Witness                                                                                          Date                                                                     

David S. Pfoff, M.D., P.C.

 

Monovision Addendum and Consent

 

Vision-correcting surgery such as LASIK, PRK and LASEK can precisely and accurately correct fixed focal errors of the eye such as nearsightedness, farsightedness, and astigmatism.  These optical conditions are fundamentally different than presbyopia, the loss of adjustability of focus for near viewing.  Presbyopia is the reason that reading glasses (magnifiers) become necessary, typically in the mid-40's, even for people who have excellent unaided distance vision.  For those that require prescriptive correction to see clearly at distance, bifocals or separate (different prescription) reading glasses become necessary at that age to see clearly at close range.

 

There are several options available to those who are presbyopic, besides wearing bifocals or separate distance and reading glasses.  For example, contact lenses can be worn for distance correction in both eyes, and dime-store reading glasses ("granny glasses") can be put on to read.  For some individuals, wearing a contact lens in one eye for distance vision, and a contact in the other eye for reading, affords a reasonable solution.  This is called monovision (mono for one; one eye for distance, one eye for near vision).

 

If a person enjoys and functions well with monovision in contact lenses, the same option can be created on a more permanent basis with vision-correcting surgery.  If you are contemplating such correction for yourself, it is important to understand the advantages and drawbacks of such care.

 

At this time, there is no perfect treatment or cure for presbyopia.  The typical solutions described above are all to some extent a compromise of one form or another.  For many people, wearing eyeglasses for distance correction is troublesome enough, and wearing bifocals is even less pleasant.  Many people dislike bifocals with a distinct line visible in the lenses, and are willing to sacrifice some degree of sharpness and clarity to eliminate the line (progressive, blended, or Varilux® lenses, for example).  With increasing use of computers in our home and work, additional problems arise because we view computer monitors at a different distance and a different angle (from the horizontal) than typical written material.

 

Reduced depth perception:  For most people, depth perception is best when viewing with both eyes optimally corrected and "balanced" for distance.  Eye care professionals refer to this as binocular vision.   Monovision can impair depth perception to some extent, because the eyes are not focused together at the same distance.  Because monovision can reduce optimum depth perception, it is typically recommended that this option be tried with contact lenses (which are removable) prior to contemplating a surgical correction (which is permanent).

 

Ocular dominance, and choosing the 'distance' eye correctly:  This is especially important if you are contemplating monovision surgery.  Ocular dominance is analogous to right- or left-handedness.  Typically, eye care professionals believe that for most individuals, one eye is the dominant or preferred eye for viewing.  Several tests can be performed to determine which eye, right or left, is dominant in a particular person.  Conventional wisdom holds that if contemplating monovision, the dominant eye should be corrected for distance, and the non-dominant eye corrected for near.  While this is a good guideline, it should not be construed as an absolute rule.  A very small percentage of persons may be co-dominant (rather analogous to being ambidextrous), and in rare circumstances a person may actually prefer using the dominant eye for near viewing.  The methods for testing and determining ocular dominance are not always 100% accurate; there is some subjective component in the measurement process; and different eye doctors may use slightly different methods of testing.  It is critical to determine through use of contact lenses which combination is best for each person (right eye for distance, left for near; or vice versa) prior to undertaking any surgical intervention.  You can imagine how uncomfortable it might be if monovision were to be rendered "the wrong way around".  It might be compared to a right-handed person suddenly having to write, shave, apply make-up, etc. with the left hand.  Be sure you understand this and have discussed with your surgeon which eye should be corrected for distance, and which for near.  If you have any doubts or uncertainty whatsoever, surgery should be delayed until a very solid comfort level is attained through use of monovision contact lenses.  Under NO circumstances should you consider undertaking monovision surgical correction before you are convinced it will be right for you. 

 

I have read the above and desire MONOVISION surgical correction. 

 

Distance eye: ______                        Near eye:  ______

 

 

David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-790

 

Astigmatism

In order for the eye to work correctly, light coming into the eye must be properly focused on the retina (the back of the eye). When the image is not focused, an irregularity in the eye is to blame. The irregularity comprises either the overall shape of the eye, or the curvature of the cornea (the clear outer covering of the eye), or both. The cornea should be curved equally in all directions. Astigmatism occurs when the cornea is curved more in one direction than another.

Astigmatism is quite common and, in the vast majority of cases, it is due simply to genetic variation. Just as different people have different shaped feet or hands, people also have different shaped corneas. Occasionally, astigmatism is caused by lid swellings such as chalazia, corneal scars, or keratoconus (a rare condition in which the cornea becomes misshapen and pointed rather than smooth and rounded). Astigmatism may cause blurred vision, eyestrain or even headaches. It can also cause images to appear doubled, particularly at night. Small amounts of astigmatism can be ignored. But if any of its symptoms are present, astigmatism can be corrected. 

 

 

 

David S. Pfoff, M.D.

COMPUTERS AND YOUR EYES

Computer-eye interactions put a heavy demand on our visual system, which has developed

over millennia to serve humans in the role of hunter and gatherers. Only in the last century

have  we begun to rely on reading vision for survival. Heavy loads of close reading or

computer work can induce distress on the eye.

Symptoms include eyestrain, headaches, itching and burning, a scratchy sensation, blurring of vision, doubling of vision, and color perception changes. Indirect symptoms can be: neck, shoulder, back and wrist pains, fatigue, and general stress, leading to lower job performance and decreased visual efficiency.

A National Academy of Science report suggests that simply improving the ergonomic condition of the worker could reduce vision complaints by up to 39%. The computer work environment includes many factors that can be controlled, including lighting, user position, computer placement, noise, and air quality.

 YOUR COMPUTER SYSTEM

The computer monitor is unlike a book on your lap. It is straight in front of the user, making it more susceptible to visual interference such as glare, distracting background objects, and variations in ambient light. A mirror effect can occur. The "straight ahead" screen puts different eye muscles to work, leading to visual stress.

Screen contrast is very important. Surprisingly, a dimly lit work environment works best. The eye has less adjusting to do when shifting back and forth from the low light intensity of the computer screen to the varying brightness of the room. Use a desk lamp to provide light for printed text. Avoid getting glare from the lamp on the screen.

Screen colors are also important. Avoid reds and blues. Ideal colors are in the middle of the light spectrum. Use green, yellow, and orange. Choose a color that feels comfortable to look at. Most screens use light print on a dark background, the opposite of a book, which has black text on a white background. Research is inconclusive about what is better. Try it both ways to see which feels better; try varying it throughout the day. Adjust the screen brightness and contrast for maximum comfort. The character size should be 2.5-3.0mm and be in sharp focus. The resolution of the print depends on the dot matrix dimensions of your monitor; 7 x 9 is best, 9 x 11 is better. The Font type should be easy to see at a glance.

Check your monitor every 6 months to see that it is operating at the manufacturer's specifications. Read the manufacturer's guide to find out how to make periodic inspections. Proper maintenance will help maintain text character quality. Screen filters help eliminate glare and static. Filters with polarizing properties trap light reflected from the computer screen, enhancing contrast on the screen. Be sure your filter doesn't make the screen darker and reduce character readability. Static and dust on the screen need to be cleaned daily with an anti-static spray or cloth. Cover the monitor at night. The best covers, of course, are the most expensive. Covers range anywhere from a paltry $20.00 to a whopping $200.00 for certain brands. Most importantly, whether shopping for covers or filters, look for the AOA Seal of Approval. A visor is a slightly more economical way to reduce glare and reflections. Use a detachable keyboard so it can be set in a comfortable position.

 

COMPUTER WORK STATION ERGONOMICS

Recommended Computer Working Distance:

20 inches (50 centimeters)

Recommended line of sight to top of screen:

20 degrees below horizontal*

Recommended line of sight to bottom screen:

0 degrees below horizontal*

* For those who wear bifocals or trifocals, it is recommended that the monitor be plac  located below the level of the desktop.

COMPUTER FURNITURE AND WORKSPACE DESIGN

Avoid chairs that are awkward and uncomfortable when trying to see the screen or use the keyboard; use an adjustable pneumatic chair with lumbar support. A swivel chair with a sturdy base on coasters is good. Your monitor should have a tilt and swivel base. This helps control glare and screen reflections. Get a copy stand to position text at the same distance and height as the screen. If need be,place the copy between the keyboard and the screen. Manage your work space to gain the most comfort, functionality, and privacy. A more comfortable work space results in greater productivity.

While you are at it, eliminate glare from overhead lights and windows. Rotate your monitor away from glare. Use filters, but watch out for loss of screen contrast. Set the room temperature to a comfortable level. Try to get some fresh air into your space. Reduce room illumination; a dimmer switch is useful to regulate light levels. Ambient room light should be 3 times brighter than the monitor's background; use a desk lamp to see your text. Paint the room walls in a flat matte finish or in pastel colors. Position your desk so you can look up and see across the room or out the window. Perhaps most importantly, get up and walk around on your breaks. Focus your eyes on distant objects during your walk. Lastly, keep your work area as quiet as possible.

 TIPS FOR FREQUENT COMPUTER USERS

1.Maintain Eye Moisture. Use artificial tears throughout the day to moisturize your eyes, especially in our dry Colorado air. Blink while waiting for your display to change. We tend to not blink when doing visually demanding tasks.

2.For Contact Lens Wearers: It is crucial that you blink 6-15 times per minute. Drink 6-8 glasses of water per day. Use artificial tears to rewet the eye and contact lenses. Re-clean your lenses after lunch.

3.Wear Computer Eyeglasses. These are prescribed according to how your visual system functions, your age, and the distance of your eyes to the computer screen (measure it). Consider them a part of your work attire, an "occupational tool" just as a welder would regard his safety filter glasses. Are you over forty? Get computer bifocals (top lens for the screen, bottom lens for seeing printed text) or computer trifocals, or PAL's--Progressive Addition Lenses, invisible bifocals.

4.Seek Routine Vision Examinations. As times flies, your eyes change. Get them checked periodically.

5.Maintain Good Posture. Keep your feet on the floor. You may need a foot rest if you are short. Keep the trunk straight, but inclined forward slightly from the hips. Keep the wrists straight while typing. Don't rest the wrists on sharp edges. Keep the thighs horizontal with feet flat. The upper arm should be vertically straight. The forearm should be horizontal or slightly lower while typing. Keep your legs from hitting the bottom of your desk.

6.Take Regular Breaks. Observe the "20/20 Rule": after 20 minutes, look at distant objects for 20 seconds. If performing data entry, break 10 minutes every hour. Get up and walk, or exercise in your chair. The National Institute of Occupational Safety and Health recommends taking a 15 minute alternate task break every hour if you are a full-time computer user.

The above information is general in nature and may not be applicable to each patient and their needs. Routine vision examinations are recommended.

 EYE EXERCISES

1.                        Palming. Close your eyes and cover them with warmed, cupped hands. Rest your cheeks on the heel of your hands. Breathe deeply and slowly. Relax and imagine the beach or mountains or wide open spaces and try to see it with your mind's eye.

2.                        Calendar-Book Rock. Look at your book propped up at about 16 inches. Focus on it. Look at the calendar or clock across the room. Focus on it. Shift back and forth, focusing each time. Repeat. Move the book closer and repeat the cycle.

3.                        Pencil Pushups. Slowly move a pencil in from arm's length towards your nose, keeping it in focus as long as you can. Eventually it will blur and double at about 3-4 inches from your nose. Then move the pencil slowly away from your nose, trying to pull the 2 images together into a single pencil. The images should come into focus as you move it out to arm's length. Repeat several times until your eye muscles seem to do it without a lot of strain.

4.                        Eye Rolls. Look up as high as you can. Then roll your eyes as far to the right as you can. Then look down as far as you can. Then look left. Repeat as many times as necessary. Keep your head still and use only your eye muscles.

5.                        Eye Massage. Gently rub the muscles around your eyes, forehead, temples and cheeks with your fingertips for a moment to massage out the stress.

 STRETCHING EXERCISES

Do some basic stretching exercises at your chair when you get a minute or two and you'll feel better right away. Try to exercise every day. It's a great stress reducer. Eat nutritional food. Get a good night's sleep. All of this impacts your day.

 

David S. Pfoff, M.D.

6881 South Yosemite Street

Centennial, Colorado 80112

303-588-7900

FLOATERS AND FLASHING LIGHTS

In front of the retina lies the vitreous humor. The vitreous is the jelly-like material that fills the large central cavity of the eye. It is composed primarily of water, but it is also made up of proteins and other substances which are more fibrous. Together, the water and fibrous elements give the vitreous the consistency of gelatin.

The vitreous is normally connected to the retina. During aging, the watery portion of the vitreous separates from the fibrous portions. As this occurs, the fibrous elements contract and can pull the vitreous away from the retina. This is called a posterior vitreous detachment. The contraction of the retina is responsible for the characteristic flashers that often accompany a posterior vitreous detachment. Floaters are frequently caused by the fibrous elements changing position during a detachment. They can also be caused by pieces of the retina being dislodged as the vitreous contracts. Besides aging, floaters and flashers are also associated with nearsightedness and injuries to the eye.

Patients should be immediately examined by their eye doctor if they experience an onset of floaters and flashers. Usually nothing unusual is found, and simple reassurance is all that is needed. The flashers eventually go away, and the floaters diminish and become less bothersome with time.

In about 10% of the patients with a posterior vitreous detachment, a tear of the retina is found. If left untreated, these tears may lead to a full retinal detachment. A retinal detachment is a serious, sight-threatening condition requiring a major surgical procedure to repair. It is important to examine the eye within a day of the onset of symptoms. Changes can occur rapidly, and time is of the essence if a retinal detachment

 

 

David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-790

   

IRITIS

 

Now that you have been diagnosed as having iritis, you probably have many questions as to just what iritis is.  Iritis is not an infection, and it is not contagious.  It is an inflammation of the inside of the eye.

 

Most of the time we do not know what causes iritis other than it represents an injury to the eye at sometime in the past.  This injury can occur in many different ways.  Some are obvious and some are not so obvious. 

 

Injury can mean a blow to the eye of physical damage; also it can mean a chemical insult has taken place.  This chemical damage could come from the outside, such as an acid or ammonia burn, or damage from the inside of the eye through the blood.  Some internal chemical injuries are in the form of the body producing allergic type reactions.  These allergic reactions are called “the immune response”.  This involves the body being sensitized to a chemical, usually a protein.  The body’s immune system does not recognize the protein as being a part of its own system, and tries to fight it off by producing antibodies.  Antibodies can lead to inflammation, i.e. “iritis”.  What iritis literally means is an inflammation of the iris (colored part) of the eye.  Since the iris is continuous with the “Uveal Tract”, which is the layer between the retina and the sclera (outside white part), sometimes the inflammation is called UVEITIS.  This generally means that the inflammation is farther back in the eye than just the iris.  What we usually see, in order to make the diagnosis, are little cells floating inside the eye.  Of course, we must use a biomicroscope to do this.  Along with this cellular reaction is a turbidity or haziness of the fluids within the eye.  These cells and haziness allow us to determine progress and severity of the disorder. 

 

Since we do not know what causes iritis most of the time, we must treat it with drugs that reduce inflammation.  These are generally steroid hormones.  There are also medications called non-steroidal anti-inflammatory type drugs.  These drugs, as a general rule, are not as potent as the steroid hormones.

 

Sometimes the iritis is due to another inflammation or infection elsewhere in the body.  Therefore, we try to find the inflammation by laboratory test, and will try to establish a diagnosis as to the cause.  Most of the time we do not find out what is causing the inflammation but we feel obligated to try.  The real “long and short of it” is that we usually end up treating it the same way anyway.  That is, with steroids or non-steroidal anti-inflammatories. 

 

I hope that this short and incomplete explanation will help you understand a little more about iritis and uveitis.

                                                                                    David S. Pfoff, M.D.

 

 

David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-790

 

 

PHOSPHOLINE IODIDE

 

Now that you have been placed on PHOSPHOLINE IODIDE, it is important that you understand some of the systemic or total body effect of this drug.

 

It is important that you alert any anesthesiologist or anesthetist that might put you to sleep for any type of scheduled or emergency surgery.

 

This medication can deplete or reduce the levels of a certain enzyme in your blood, called acetylcholine esterase, which causes you to not be able to breathe after you have had certain types of anesthetic medications, specifically succinylcholine.  This is of sufficient importance that I encourage all of my patients who are using this medication to wear a medic alert bracelet, or something similar.  This is to alert health care professionals, should emergency surgery be needed.

 

It is not anything to worry about, as long as people know about it, but it is important to inform them when you are having an anesthetic.  

 

David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-790

 

INSTRUCTION TO PATIENTS WITH MARGINAL BLEPHARITIS

OR MARGINAL BLEPHAROCONJUNCTIVITIS

 

Soak your loosely closed eyelids with a hot washcloth.  You may rinse out the washcloth underneath the hot water faucet.

 

When the washcloth cools on your eyelids, rewet it under the hot water faucet again and get it steaming hot so that it is just as hot as you can stand it without burning yourself.  Continue this hot soak ten minutes, four times a day.  At the end of the ten minutes, place a drop of Tobradex Eye drops in the sac formed by your lower eyelid and the eyeball, by pulling the eyelid down against the cheekbone.  Then place a drop on your clean finger and lightly apply it to your closed eyelids, especially over the lashes, and let dry.  This may itch or feel sticky but will not show and is transparent.  You may open your eyes after his procedure, and you do not have to keep them closed while the drop is drying. 

 

In the morning and just before bedtime, obtain a cotton-dipped applicator or Q-tip and place a small amount of Ciloxan Ointment, and Tobradex Ophthalmic Ointment on the Q-tip and scrub it into the lashes of both the lower and upper lids just where they go into the skin.  Leave the excess ointment on the eyelids overnight.  It will probably be rubbed off on the pillow.  Change your pillowcases, washcloth and towels once a day.  When you wake up in the morning, wash off all the excess ointment with antibacterial soap with your eyes closed.  When you are finished you can place your finger against your eyelid, making sure it is not sticky and there is no feeling of excess oil or residual ointment on your eyelids. 

 

If you wear eye makeup, discontinue and discard all eye makeup, including brushes, as it is probably contaminated with bacteria and would just reinfect your eyes.  Get a new stock of eye makeup and brushes, and do not use any eye makeup until after the condition has cleared. 

 

Use for ____ week consistently prior to surgery.  Start on ___________. 

 

David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-790

Colo. Lic. 18036 

1.                  ZYMAR 0.3% gtts, 5ml

                 Sig:  Starting the day before surgery upon awakening, use 1 drop in each eye at breakfast, lunch, dinner and bedtime.  

                         Continue on day of surgery.

Refills:  2

 

2.                 Acular LS 5ml  D.A.W.

Sig:  1 drop in operated eye after surgery QID as directed

            Refills:  2

David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-790

 

INFORMED CONSENT FOR LASEK

 

This information must be reviewed so you can make an informed decision regarding    (LASEK) surgery to reduce or eliminate your nearsightedness, farsightedness or astigmatism.  Only you and your doctor can determine if you should have LASEK surgery based upon your own visual needs and medical considerations.  Any questions you have regarding PRK or other alternative therapies for your case should be directed to your doctor. 

 

IN GIVING MY PERMISSION FOR LASEK SURGERY, I DECLARE THAT I UNDERSTAND THE FOLLOWING INFORMATION:

 

The long-term risks and effects of LASEK surgery are unknown.

 

The goal of LASEK with the excimer laser is to reduce or eliminate the dependence upon or need for contact lenses and/or eyeglasses; however, I understand that as with all forms of treatment, the results in my case cannot be guaranteed.  For example:

 

1. I understand that an overcorrection or undercorrection could occur, causing me to become farsighted or nearsighted or increase my astigmatism and that this could be either permanent or treatable. I understand an overcorrection or undercorrection is more likely in people over the age of 40 years and may require the use of glasses for reading or for distance vision some or all of the time.

            2. If I currently need reading glasses, I will likely still need reading glasses after this treatment.  It is possible that dependence on reading glasses may increase or that reading glasses may be required at an earlier age if I have LASEK surgery.

            3. Further treatment may be necessary, including a variety of eyedrops, the wearing of eyeglasses or contact lenses (hard or soft), or additional LASEK or other refractive surgery.

            4. My best vision, even with glasses or contacts, may become worse.

            5. There may be a difference in spectacle correction between eyes, making the wearing of glasses difficult or impossible.  Fitting and wearing contact lenses may be more difficult.

 

ALTERNATIVES TO LASEK SURGERY:

 

The alternatives to LASEK include, among others, eyeglasses, contact lenses, and other refractive surgical procedures.  Each of these alternatives to LASEK has been explained to me.

 

I have been informed, and I understand, that certain complications and side effects have been reported in the post-treatment period by patients who have had LASEK, including the following:

 

            Possible short-term effects of LASEK surgery: The following have been reported in the short- term post-treatment period and are associated with the normal post-treatment healing process: mild discomfort or pain (first 72 to 96 hours), corneal swelling, double vision, feeling something is in the eye, ghost images, light sensitivity, and tearing.

 

 


 

            Possible long-term complications of LASEK surgery:

            1. Haze: Loss of perfect clarity of the cornea, usually not affecting vision, which usually resolves over time.

            2. Glare: Sensation produced by bright lights that is greater than normal and can cause discomfort and annoyance.

            3. Halo: Hazy rings surrounding bright lights may be seen, particularly at night.

            4. Loss of Best Vision: A decrease in my best vision even with glasses or contacts.

            5. IOP Elevation:  An increase in the inner eye pressure due to post-treatment medications, which is usually resolved by drug therapy or discontinuation of post-treatment medications.

6. Mild or severe infection: Mild infection can usually be treated with antibiotics and usually does not lead to permanent visual loss.  Severe infection, even if successfully treated with antibiotics, could lead to permanent scarring and loss of vision that may require corrective laser surgery or, if very severe, corneal transplantation.

           

            The following complications have been reported infrequently by those who have had LASEK surgery: itching, dryness of the eye, or foreign body feeling in the eye; double or ghost images; patient discomfort; inflammation of the cornea or iris; persistent corneal surface defect; persistent corneal scarring severe enough to affect vision; ulceration/infection; irregular astigmatism (warped corneal surface which causes distorted images); cataract; drooping of the eyelid; loss of bandage contact lens with increased pain (usually corrected by replacing with another contact lens); and a slight increase of possible infection due to use of a bandage contact lens in the immediate post-operative period.

 

I understand there is a remote chance of partial or complete loss of vision in the eye that has had LASEK surgery.

           

I understand that it is not possible to state every complication that may occur as a result of LASEK surgery.  I also understand that complications or a poor outcome may manifest weeks, months, or even years after LASEK surgery.

 

I understand this is an elective procedure and that LASEK surgery is not reversible.

 

FOR WOMEN ONLY: I am not pregnant or nursing.  I understand that pregnancy could adversely affect my treatment result.

 

My personal reasons for choosing to have LASEK surgery are as follows:

 

                                                                           ­­­­­­______________                                       __________  

 

                                                                                                       ________________________             

 

I have spoken with my physician, who has explained LASEK, its risks and alternatives, and answered my questions about LASEK surgery.  I therefore consent to having LASEK surgery.

 

 

                                                                                                                                                             

Patient signature                                    Date                 Witness signature                                  Date

 

                   I have been offered a copy of this consent form (please initial)   ________            

David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-790

 

INFORMED CONSENT FOR YAG POSTERIOR CAPSULOTOMY

 

After modern cataract with lens implant surgery, the back membrane of the cataract is left in place to support the lens implant. This membrane may become cloudy and cause blurred vision, and sometimes patients will see streaks or haloes around lights. These problems worsen with time.

 

In the past, a trip back to the operating room was necessary. A small cut was made and a needle introduced to cut the cloudy membrane. Complications of the surgery included possible infection, retinal swelling, or retinal detachment with possible loss of vision. An anesthetic injection was necessary and complications from the injection included heart or breathing disturbances, damage to the optic nerve, or perforation of the eyeball with the needle.

 

Fortunately, a modern YAG laser treatment can be done without a need for an anesthetic injection or a small cut. Many of the complications noted previously are thereby eliminated. There is no interruption in physical activities and no patch after the laser treatment is needed.

 

Laser surgery is still surgery. Complications can still occur. Some new floaters or spots may be seen. Retinal swelling or detachment can follow this type of surgery as well. The eye pressure may rise temporarily after the YAG laser treatment.

 

THE ALTERNATE TREATMENTS AND THEIR RISKS AND BENEFITS HAVE BEEN EXPLAINED TO MY SATISFACTION. I HEREBY GIVE MY INFORMED CONSENT FOR A POSTERIOR CAPSULOTOMY IN MY RIGHT/LEFT EYE WITH THE YAG LASER.

 

 

 

 

                                                                                                                                               

Patient (or person authorized to sign for patient)                                    Date

 

 

 

                                                                                                                                               

Witness                                                                                                Date

David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-790

EYEWEAR RECOMMENDATIONS:  BLUE BLOCKING SUNGLASSES

We are frequently asked for a recommendation regarding sunglasses. Research has strongly suggested that the wavelengths to filter out are in the ultraviolet and blue portion of the sun's spectrum.

The leading cause of blindness in the population over the age of seventy is Age Related Macular Degeneration. It is felt that cumulative exposure to these wavelengths is a strong contributor to this malady. Evidence is based on the description of blue light hazard by Dr. Ham several years ago. For the same amounts of photon-energy, blue and ultraviolet wavelengths have a much larger potential to do damage to the retina than the green and red portions of the spectrum.

The final common denominator is the production of highly reactive oxygen, hydroxyl, and peroxy free radicals. This happens with exposure to UV wavelengths and in other processes such as injury or inflammation. The end result is to deconjugate, or break down, the double bonds in membrane lipid molecules. The number of retinal photoreceptors (rods and cones) is high in these molecules.

From a nutritional point of view, this is the basis for our recommendation to take supplemental amounts of the anti-oxidant vitamins as well as green, leafy vegetables such as Brussels sprouts, spinach, kale, and broccoli.

There is also a large volume of evidence to show that cataract (a clouding of the crystalline lens of the eye) is due, in great extent, to the ultra-violet wavelengths, specifically ultraviolet A. One would expect that areas of the world that have greater exposures to ultraviolet light might have a higher incidence of cataracts. This has been shown to be true: as one gets closer to the equator the incidence goes up. In Tibet, where the average elevation is 15,000 feet, the incidence is very high. Incidence is higher in Tucson, AZ, where the photon count is higher, than in Rochester, NY.

As a result of these studies, we recommend blue-blocking and ultraviolet filtering sunglasses. A pure blue blocker is an amber or orange color. This tends to distort colors, as one would expect--mainly greens and reds. To counter this effect, some sunglasses are made with acceptable compromises. Some brands are: Serengeti, Bolle, and Oakley.

Do not wear blue colored lenses as a method of blocking the sun; this is exactly opposite to what is protective

David S. Pfoff, M.D.

950 E. Harvard Ave.  #350

Denver, CO  80210

303-588-7900

 

CONJUNCTIVITIS

The conjunctiva is the clear membrane that comprises the tough, leathery outer coat of the eye; the white of the eye lies behind the conjunctiva. The conjunctiva has thousands of small blood vessels and serves to lubricate and protect the eye while the eye moves in its socket.

Inflammation of the conjunctiva is called conjunctivitis. Conjunctivitis can have a variety of causes, such as bacteria (in pink eye, for example), viruses, chemicals, allergies, and a handful of others. In many cases it is difficult to determine the primary cause for the inflammation. One of the most common is bacterial infection.

Bacterial conjunctivitis is indicated by swelling of the lid and a yellowish discharge.  Sometimes it causes the eye to itch and the eyelids to become clogged with pus-like waste matter, particularly upon waking.  The conjunctiva appears red and sometimes thickened.  Often, both eyes are involved. 

The bacteria most commonly at fault are staphylococcus, streptococcus, and h. influenza.  Conjunctivitis is readily contagious, easily transmitted by rubbing the eye after contact with infected household items such as towels or handkerchiefs.  It is common for entire families to become infected simultaneously. 

Conjunctivitis can be directly cured with treatment.  Usually antibiotic drops and compresses ease the discomfort and clear up the infection in a few days.  In a handful of cases, the inflammation does not respond well to the initial treatment with eye drops.  In these situations, which are rare, a second visit to the office should be made and additional measures undertaken. 

In cases of severe infection, oral antibiotics are necessary.  Covering the eye is not recommended because a cover provides protection for the germs causing the infection.  If left untreated, conjunctivitis can create serious complications, such as infections in the cornea, lids and tear ducts. 

Certain precautions can be taken to avoid the disease and to stop its spread.  Careful washing of the hands, the use of clean handkerchiefs, and avoidance of contagious individuals are recommended.  Small children frequently get conjunctivitis due to poor hygiene. 

 

David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-790

 

FOODS TO AVOID

FOR MIGRAINE DISEASE PATIENTS

 

·       Chocolate

·       Aged cheeses

·       Nuts

·       Herring

·       Coffee

·       Tea

·       Anything containing Nitrites

·       Any alcoholic beverages

o      Red Wine

o      Gin

o      Bourbon

o      Beer

·       Sausages

o      Wieners

o      Lunch meats

·       MSG (Monosodium Glutamate)

    Female Hormones

    Birth Control Pills

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-790

 

NOTICE OF PRIVACY PRACTICES

Uses and Disclosures

 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU

HOW YOU CAN GET ACCESS TO THIS INFORMATION

 

PLEASE REVIEW IT CAREFULLY

 

Treatment

Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment.  For example, results of laboratory tests and procedures will be available in your medical records to all health professionals who may provide treatment or who may be consulted by staff members.

 

Payment

Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services.  For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.

 

Healthcare Operations

Your health information may be used as necessary to support the day-to-day activities and management of David S. Pfoff, M.D.  For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.

 

Law Enforcement

Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law enforcement investigations, and to comply with government mandated reporting.

 

Public Health Reporting

Your health information may be disclosed to public health agencies as required by law.  For example, we are required to report certain communicable diseases to the state’s public health department.

 

Other use and disclosures require your authorization

Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization.  If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization.  However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.

 

Additional Uses of Information

Appointment reminders.  Your health information will be used by our staff to send you appointment reminders.  We may also leave appointment reminder information on your answering machine, voice mail, or with a responsible adult at the number you have indicated to us.  Lab results, X-ray, test results and other pertinent information, including medical instruction and advice are left on work or home voice mail, answering machine or with a responsible adult at the number you have indicated to us. 

 

Information about your Treatments

Your health information may be used to send you information on the treatment and management of your mediation condition that you may find to be of interest.

 

 

 

Individual Rights

You have certain rights under the federal privacy standards.  These include:

 

Clinic’s Duties

We are required by law to maintain the privacy of your protected health information, and to provide you with this notice of privacy practices.  We are also required to abide by the privacy policies and practices that are outlined in this notice.

 

Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy policies and practices.  These changes in our policies and practices may be required by changes in federal and state laws and regulations.  Whatever reason for these revisions, we will provide you with a revised notice on your next office visit.  The revised policies and practices will be applied to all protected health information that we maintain. 

 

Requests to Inspect Protected Health Information

As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing.  You may obtain a form to request access to your records by contacting Cathy De Mahy at the Business Office.

 

Complaints

If you would like to submit a comment or complaint about our privacy practices, you may do so by sending a letter outlining your concerns to:

 

            David S. Pfoff, M.D., P.C.                                   Office of Civil Rights

            6881 S. Yosemite St.                 OR                   1960 Stout Street, Room 1185

           Centennial, CO  80112                                         Denver, CO  80294

 

If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concerns to the same address.  You will not be penalized or otherwise retaliated against for filing a complaint.

 

Contact Person

For further information concerning our privacy practices please contact the Business Manager or Dr. Pfoff at:

 

                                                6881 S. Yosemite Street

                                                Centennial,  CO  80112

                                                303-588-7900

 

Effective Date

This notice is effective on 4/6/2006.

 

 

David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-790

 

HOME CARE FOLLOWING CATARACT SURGERY

You have just had one of the most delicate operations in modern surgery, and with the advanced microscopic technique used in your operation you have been spared the ordeal that cataract patients formerly had to endure: long periods of immobility, long hospitalization, having the eyes patched for days, and strict limitation of activity.

As your vision gradually clears, you should feel only minor discomfort. You will be restricted to moderate activity for only three days after surgery, and three weeks for strenuous activity.

Keep in mind that complications are much easier to avoid than to correct. It is important for you to carefully follow Dr. Pfoff's directions regarding medications and activities so that your eye will have every chance to heal properly and achieve maximum vision. Vision will be clearer some days than others. Some days your vision may seem blurred. This is normal.

INSTRUCTIONS

It is important to avoid strain and pressure on the eye. Anything that increases blood pressure in the small vessels of the eye should be avoided, including constipation and heavy lifting. Constipation may result from certain medications, including aspirin. It is wise to take whatever precautions necessary to prevent constipation.

It will not damage your eye to read, but if it becomes uncomfortable or you feel tired, you should stop. Watching television is also acceptable, as well as any use of the eye that is comfortable.

PROTECTION 

For the first three days after surgery, your eye must be protected at all times. Do not rub your eye under any circumstances. It is crucial to wear physical protection over the eye at all times. During the day, glasses are adequate. However, the protective shield provided after the surgery should be worn any time you sleep. This will protect you from inadvertently rubbing the eye during sleep. It is best not to sleep face down to prevent pressure on the operated eye. You may sleep on your non-operated side or on your back. You will be given a pair of Solar Shields sunglasses to protect your eyes from the ultraviolet rays of the sun. Please wear these every time you go outside following surgery until Dr. Pfoff prescribes new glasses for you, approximately four weeks after your surgery.

 CLEANING

Once your bandage is removed you must clean your eye for the next week. Using Sterile Eye Solution, cleanse the eye gently and without pressure, until dried mucus and crusts on your lashes are washed away. Sterile eye solution can also be used as eyewash, or as eye drops to relieve discomfort of itching and tearing. Upon cleaning the eye you may occasionally get a drop or two of blood from the eye. This is from the vessels on top of the eye where the incision was made to remove the cataract. It is nothing to be alarmed about.

  EYE DROPS

After your eye patch is removed, you will begin using the medication, which is crucial to the healing of the eye. Please follow the instructions as instructed by Dr. Pfoff. The drops should be used 4 TIMES A DAY. Please use the drops 5 minutes apart.     

Some itching and discomfort is normal after surgery and eye drops. You may also experience occasional shooting pain. Tylenol is usually sufficient and stronger medication is seldom necessary. The medication routine is vital. You must use the medication faithfully and exactly as directed. We have found that patients who follow the instructions exactly do better than patients who do not, and we would like to add you to the list of patients who do well.

A 'scratchy' feeling is the most common complaint after cataract surgery and is normal. You may also notice a small white area on the surface of the eye below the iris. This is normal and is due to the medication injected at the time of the surgery. It will subside in 2-3 weeks. Redness, a lazy lid and increased tearing are also common. You may note a few floaters and shimmering lights. Avoid rubbing or squeezing your eye although it itches.

GROOMING

You may gently brush or comb your hair the day after surgery. It is permissible to shower or shampoo the day after surgery as long as you take the following precautions:

1.                  When shampooing, keep your head back to avoid getting soap or shampoo in your eye, and

2.                  Do not vigorously scrub your head. You may brush your teeth as soon as you like after surgery and men may shave when desired.

ACTIVITY 

You may gradually resume normal activity. It is all right to look down or bend over, as long as you do so slightly with your head no lower than your heart. You may do anything that you feel comfortable with, but avoid straining at all costs. Do not do anything that creates physical stress for at least three days, such as turning mattresses, lifting garbage cans or heavy suitcases, or other physical heroics.

Eliminate any vigorous activities with jerky, jolting motions such as scuba diving, weight lifting, jogging, golf and skiing for three days. You may take walks with good cushioned shoes and ride an indoor stationery bike. In general, if you don't behave either as an invalid or an athlete you should have no difficulty.

Remember that no postoperative course is perfectly smooth. At times there are temporary setbacks and periods of depression. This is normal, but if you are worried or concerned about anything, or have any questions, please do not hesitate to call. We want your postoperative course to be as worry free as possible and we don't mind your calling us at any time we can be of help to you. Our office phone is 303-588-7900. This line is answered during business hours, and forwarded to Dr. Pfoff after hours. 

David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-790

 

Addendum: Consent for Bilateral Simultaneous LASEK

 

While many patients choose to have both eyes treated at the same surgical setting, there may be risks associated with simultaneous treatment that are not present when the eyes are treated on different days.  If you elect to have LASEK surgery performed on both eyes at the same time, you should understand both the possible advantages and disadvantages of your decision.

 

Safety:  The risk of infection and other healing complications is applicable to both eyes simultaneously.  Therefore, if an infection occurs in one eye, it may also occur in the other eye.  Although rare, a serious infection in both eyes can cause significant loss of vision and even legal blindness.  By choosing to have LASEK performed on separate days, you will avoid the risk of having one or more of these complications in both eyes at the same time.

 

Accuracy:  If there is an over-correction or under-correction in one eye, chances are it may happen in both eyes.  If a retreatment is required in one eye, it is quite possible that your fellow eye may also require a retreatment.  By having surgery on separate days, the doctor can monitor the healing process and visual recovery in the first eye and may be able to make appropriate modifications to the treatment plan for the second eye if necessary.  In some patients, this may improve the accuracy of the result in the second eye. By correcting both eyes simultaneously, there is no opportunity to learn from the healing patterns of the first eye before treating the second eye.

 

Visual Recovery: Some patients may experience symptoms such as blurred vision, night glare or ghost images that may delay recovery of normal vision. Blurred vision may continue for several weeks, which could make driving difficult or dangerous and could interfere with your ability to work if it occurs in both eyes.  There is no way of predicting how long your eyes will take to heal.  If the eyes are operated separately, you can generally function with your fellow eye while the first eye is healing. However, there may be a period of imbalance in vision between your two eyes, producing a form of double vision.  If you are able to wear a contact lens in your unoperated eye, the corrective lens could minimize this imbalance. The balance in vision between your two eyes may be restored more rapidly if they are operated on the same day.

 

Satisfaction:  Both eyes tend to experience similar side effects.  If you experience undesirable side effects such as glare, ghost images, increased light sensitivity, or corneal haze in one eye, you will likely experience them in both eyes.  These side effects may cause a decrease in vision or other negative effects, and some patients have elected to not have their second eye treated.

By having each eye treated on separate dates, you will have the opportunity to determine whether the LASEK procedure has produced satisfactory visual results without loss of vision or other undesirable side effects.  If you are over age 40, you will also have an opportunity to experience the change in your close vision that results from the correction of your nearsightedness or farsightedness.  This could influence your decision on whether or not to fully correct your other eye to maintain some degree of close vision without the need for glasses (monovision).

 

Convenience:  It may be inconvenient for you to have each eye treated at separate visits because it would necessitate two periods of recovery from the laser surgery and might require additional time away from work.

 

Cost:  Professional and facility fees are the same if the eyes are operated on different days.  Keep in mind that the additional time off work can be costly.                                                                                                                                                                           

 

Consent Statement:

 

“I have read and understand the above risks and benefits of bilateral simultaneous LASEK, and I understand that this summary does not include every possible risk, benefit and complication that can result from bilateral simultaneous LASEK.  My doctor has answered all of my questions about the LASEK procedure.  I wish to have both of my eyes treated during the same treatment session if my doctor determines that the treatment in the first eye appeared to be technically satisfactory. 

 

The reason(s) I wish to have both eyes treated at the same time are:

 

 Greater convenience

 Possible faster recovery

 Less time away from work

 Contact lens intolerance and/or difficulty wearing contacts                  

 Elimination of possible vision imbalance between treated and untreated eyes

 Other:                                                                                              

 

                                                                                                                                               

Patient signature                                                                                                Date

David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-790

 

 

INFORMED CONSENT FOR CATARACT OPERATION

AND/OR IMPLANTATION OF INTRAOCULAR LENS

Introduction

This information is given to you so that you can make an informed decision about having eye surgery. Take as much time as you wish to make your decision about signing this informed consent.  You have the right to ask questions about any procedure before agreeing to have it.

Except for unusual situations, a cataract operation is indicated only when you cannot function satisfactorily due to poor sight produced by the cataract.  You must remember that the natural lens within your own eye, even with a slight cataract, has some distinct advantages over any man-made lens.

After your doctor has told you that you have a cataract, you and your doctor are the only ones who can determine if or when you should have a cataract operation based on your own visual needs and medical considerations.

 

Alternative Treatments

You may decide not to have a cataract operation at this time.  However, should you decide to have an operation, you need to know that there are three methods of restoring useful vision after the operation:

1.      Intraocular Lens: In the United States, an intraocular lens is by far the most common form of restoring vision after cataract surgery.  This is a small artificial lens, usually made of plastic, silicone or acrylic material, surgically and permanently placed inside the eye.  Objects are seen at their normal size. Conventional eyeglasses (not cataract spectacles) may be required in addition to an intraocular lens for best vision.

2.      Spectacles (glasses): Cataract spectacles required to correct your vision are usually thicker and heavier than conventional eyeglasses.  Cataract spectacles increase the size of objects by about 25%.  Clear vision is obtained through the central part of cataract spectacles, which means you must learn to turn your head to see clearly on either side.  Cataract spectacles usually cannot be used if a cataract is only in one eye (and the other is normal) because they may cause double vision.

3.      Contact Lens: A hard or soft contact lens, placed on the outside of your cornea each day, increases the apparent size of objects only about 8%.  Handling of a contact lens is difficult for some individuals. Most lenses must be inserted and removed daily and not everyone can tolerate them.  For near tasks, reading glasses may be required in addition to the contact lenses.

 

Consent for Operation

In giving my permission for a cataract extraction and/or for the possible implantation of an intraocular lens in my eye, I declare I understand the following:

 

  1. Cataract surgery, by itself, means the removal of the natural lens of the eye by a surgical technique.  In order for an intraocular lens to be implanted in my eye, I understand I must have cataract surgery per- formed either at the time of the lens implantation or before lens implantation.

Page 1 of 3. Please initial after reading  ____________

 

  1. Complications of surgery to remove the cataract: As a result of the surgery and local anesthesia injections around the eye, it is possible that my vision could be made worse.  In some cases, complications may occur weeks, months or even years later. Complications may include hemorrhage (bleeding), perforation of the eye, loss of corneal clarity, retained pieces of cataract in the eye, infection, detachment of the retina, uncomfortable or painful eye, droopy eyelid, glaucoma and/or double vision.  These and other complications may occur whether or not a lens is implanted and may result in poor vision, total loss of vision or even loss of the eye in rare situations.

 

  1. Specific complications of lens implantation: Insertion of an intraocular lens may induce complications which otherwise might not occur.  In some cases, complications may develop during surgery from implanting the lens or days, weeks, months, or even years later.  Complications may include loss of corneal clarity, infection, uveitis, iris atrophy, glaucoma, bleeding in the eye, inability to dilate the pupil, increased night glare and/or halo, double or ghost images, dislocation of the lens and retinal detachment.  In rare instances, lens power measurements may significantly vary resulting in the need for corrective lenses or surgical replacement of the intraocular lens.

 

  1. If an intraocular lens is implanted, it is done by surgical method.  It is intended that the small plastic, silicone or acrylic lens will be left in my eye permanently.

 

  1. At the time of surgery, my doctor may decide not to implant an intraocular lens in my eye even though I may have given prior permission to do so.

 

  1. The results of surgery in my case cannot be guaranteed.  Additional treatment and/or surgery may be necessary.  I may need laser surgery to correct clouding of vision. At some future time, the lens implanted in my eye may have to be repositioned, removed surgically, or exchanged for another lens implant. 

 

  1. I understand that cataract surgery and the calculations for intraocular implants are not "an exact science."  I accept that I might need to wear glasses or contact lenses subsequent to surgery to obtain my best vision.  There is also the possibility of the need for subsequent surgeries such as, lens exchange, placement of an additional lens, or refractive laser surgery if I am not satisfied with my vision after cataract removal.

 

The basic procedures of cataract surgery, and the advantages and disadvantages, risks and possible complications of alternative treatments have been explained to me by the doctor.  Although it is impossible for the doctor to inform me of every possible complication that may occur, the doctor has answered all my questions to my satisfaction.  In signing this informed consent for cataract operation, and/or implantation of intraocular lens, I am stating I have read this informed consent (or it has been read to me) and I fully under- stand it and the possible risks, complications and benefits that can result from the surgery.

 

 

Page 2 of 3. Please initial after reading  ____________


 

If I decide to have an operation, I agree to have the type of operation listed below which I have indicated by my signature:

 

1)      I wish to have a cataract operation WITH an intraocular lens implant.

 

 

                                                                                                                                         

Patient (or person authorized to sign for patient)                                   Date

 

 

2)      Since my cataract was previously removed and I have been informed that my eye is medically acceptable for lens implantation, I wish to have an intraocular lens implant.

 

 

                                                                                                                                         

Patient (or person authorized to sign for patient)                                   Date

 

 

 

 

 

 

 

                                                                                                                                               

Patient’s Name (print)                                                                         Age                        Date

 

 

 

 

                                                                                                                                               

Witness’ Signature                                                                                              Date

 

 

 

 

                                                                                                                                               

Doctor’s Signature                                                                                              Date

 

David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-790

 

 

INFORMED CONSENT FOR LASER IN-SITU KERATOMILEUSIS (LASIK)

 

INTRODUCTION

This information is being provided to you so that you can make an informed decision about the use of a device known as a microkeratome, combined with the use of a device known as an excimer laser, to perform LASIK.  LASIK is one of a number of alternatives for correcting nearsightedness, farsightedness and astigmatism.  In LASIK, the microkeratome is used to shave the cornea to create a flap.  The flap then is opened like the page of a book to expose tissue just below the cornea’s surface.  Next, the excimer laser is used to remove ultra-thin layers from the cornea to reshape it to reduce nearsightedness.  Finally, the flap is returned to its original position, without sutures.

 

LASIK is an elective procedure: There is no emergency condition or other reason that requires or demands that you have it performed.  You could continue wearing contact lenses or glasses and have adequate visual acuity. This procedure, like all surgery, presents some risks, many of which are listed below.  You should also understand that there may be other risks not known to your doctor, which may become known later.  Despite the best of care, complications and side effects may occur; should this happen in your case, the result might be affected even to the extent of making your vision worse.

 

ALTERNATIVES TO LASIK

If you decide not to have LASIK, there are other methods of correcting your nearsightedness, farsightedness or astigmatism.  These alternatives include, among others, eyeglasses, contact lenses and other refractive surgical procedures.

 

PATIENT CONSENT

 

In giving my permission for LASIK, I understand the following: The long-term risks and effects of LASIK are unknown.  I have received no guarantee as to the success of my particular case. I understand that the following risks are associated with the procedure:

 

VISION THREATENING COMPLICATIONS

 

1.                   I understand that the microkeratome or the excimer laser could malfunction, requiring the procedure to be stopped before completion.  Depending on the type of malfunction, this may or may not be accompanied by visual loss.

 

2.                   I understand that, in using the microkeratome, instead of making a flap, an entire portion of the central cornea could be cut off, and very rarely could be lost.  If preserved, I understand that my doctor would put this tissue back on the eye after the laser treatment, using sutures, according to the ALK procedure method.  It is also possible that the flap incision could result in an incomplete flap, or a flap that is too thin.  If this happens, it is likely that the laser part of the procedure will have to be postponed until the cornea has a chance to heal sufficiently to try to create the flap again.

 

3.                   I understand that irregular healing of the flap could result in a distorted cornea.  This would mean that glasses or contact lenses may not correct my vision to the level possible before undergoing LASIK.  If this distortion in vision is severe, a partial or complete corneal transplant might be necessary to repair the cornea.

 

4.                   I understand that it is possible a perforation of the cornea could occur, causing devastating complications, including loss of some or all of my vision.  This could also be caused by an internal or external eye infection that could not be controlled with antibiotics or other means.

 

5.         I understand that mild or severe infection is possible.  Mild infection can usually be treated with antibiotics and usually does not lead to permanent visual loss.  Severe infection, even if successfully treated with antibiotics, could lead to permanent scarring and loss of vision that may require corrective laser surgery or, if very severe, corneal transplantation or even loss of the eye. 

 

I understand that other very rare complications threatening vision include, but are not limited to, corneal swelling, corneal thinning (ectasia), appearance of “floaters” and retinal detachment, hemorrhage, venous and arterial blockage, cataract formation, total blindness, and even loss of my eye.

 

NON-VISION THREATENING SIDE EFFECTS

 

1.                   I understand that there may be increased sensitivity to light, glare, and fluctuations in the sharpness of vision.  I understand these conditions usually occur during the normal stabilization period of from one to three months, but they may also be permanent.

 

 

 

2.                   I understand that there is an increased risk of eye irritation related to drying of the corneal surface following the LASIK procedure.  These symptoms may be temporary or, on rare occasions, permanent, and may require frequent application of artificial tears and/or closure of the tear duct openings in the eyelid. 

Patient Initials  ____

 

 

3.                   I understand that an overcorrection or under correction could occur, causing me to become farsighted or nearsighted or increase my astigmatism and that this could be either permanent or treatable.  I understand an overcorrection or under correction is more likely in people over the age of 40 years and may require the use of glasses for reading or for distance vision some or all of the time.

 

4.                   I understand that at night there may be a “starbursting” or halo effect around lights.  I understand that this condition usually diminishes with time, but could be permanent.  I understand that my vision may not seem as sharp at night as during the day and that I may need to wear glasses at night.  I understand that I should not drive until my vision is adequate both during the day and at night. 

Patient Initials____

 

 

5.                   I understand that I may not get a full correction from my LASIK procedure and this may require future enhancement procedures, such as more laser treatment or the use of glasses or contact lenses.

 

6.                   I understand that there may be a “balance” problem between my two eyes after LASIK has been performed on one eye, but not the other.  This phenomenon is called anisometropia.  I understand this would cause eyestrain and make judging distance or depth perception more difficult.  I understand that my first eye may take longer to heal than is usual; prolonging the time I could experience anisometropia.

 

7.                   I understand that, after LASIK, the eye may be more fragile to trauma from impact.  Evidence has shown that, as with any scar, the corneal incision will not be as strong as the cornea originally was at that site.  I understand that the treated eye, therefore, is somewhat more vulnerable to all varieties of injuries, at least for the first year following LASIK.  I understand it would be advisable for me to wear protective eyewear when engaging in sports or other activities in which the possibility of a ball, projectile, elbow, fist, or other traumatizing object contacting the eye may be high.

 

8.                   I understand that there is a natural tendency of the eyelids to droop with age and that eye surgery may hasten this process.

 

9.                   I understand that there may be pain or a foreign body sensation, particularly during the first 48 hours after surgery.

 

10.               I understand that temporary glasses either for distance or reading may be necessary while healing occurs and that more than one pair of glasses may be needed.

 

11.               I understand that the long-term effects of LASIK are unknown and that unforeseen complications or side effects could possibly occur.

 

12.               I understand that visual acuity I initially gain from LASIK could regress, and that my vision may go partially back to a level that may require glasses or contact lens use to see clearly.

 

13.               I understand that the correction that I can expect to gain from LASIK may not be perfect.  I understand that it is not realistic to expect that this procedure will result in perfect vision, at all times, under all circumstances, for the rest of my life.  I understand I may need glasses to refine my vision for some purposes requiring fine detailed vision after some point in my life, and that this might occur soon after surgery or years later.

 

14.               I understand that I may be given medication in conjunction with the procedure and that my eye may be patched afterward.  I therefore, understand that I must not drive the day of surgery and not until I am certain that my vision is adequate for driving.

 

15.               I understand that if I currently need reading glasses, I will still likely need reading glasses after this treatment.  It is possible that dependence on reading glasses may increase or that reading glasses may be required at an earlier age if I have this surgery.

 

16.               Even 90% clarity of vision is still slightly blurry.  Enhancement surgeries can be performed when vision is stable UNLESS it is unwise or unsafe. If the enhancement is performed within the first six months following surgery, there generally is no need to make another cut with the microkeratome.  The original flap can usually be lifted with specialized techniques.  After 6 months of healing, a new LASIK incision may be required, incurring greater risk.  In order to perform an enhancement surgery, there must be adequate tissue remaining.  If there is inadequate tissue, it may not be possible to perform an enhancement.  An assessment and consultation will be held with the surgeon at which time the benefits and risks of an enhancement surgery will be discussed.

 

17.               I understand that, as with all types of surgery, there is a possibility of complications due to anesthesia, drug reactions, or other factors that may involve other parts of my body.  I understand that, since it is impossible to state every complication that may occur as a result of any surgery, the list of complications in this form may not be complete.

 

FOR PRESBYOPIC PATIENTS (those requiring a separate prescription for reading):  The option of monovision has been discussed with my ophthalmologist.  

 

PATIENT’S STATEMENT OF ACCEPTANCE AND UNDERSTANDING

The details of the procedure known as LASIK have been presented to me in detail in this document and explained to me by my ophthalmologist.  My ophthalmologist has answered all my questions to my satisfaction.  I therefore consent to LASIK surgery.

 

I give permission for my ophthalmologist to record on video or photographic equipment my procedure, for purposes of education, research, or training of other health care professionals.  I also give my permission for my ophthalmologist to use data about my procedure and subsequent treatment to further understand LASIK.  I understand that my name will remain confidential, unless I give subsequent written permission for it to be disclosed outside my ophthalmologist’s office or the center where my LASIK procedure will be performed.

 

 

Patient Name                                        Date                      Witness Name                     Date

 

I have been offered a copy of this consent form (please initial) _____

 

 

 

 

 

 

David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-790

 

What Patients Want to Know about
CustomVue™ Individualized Laser Vision Correction

Frequently Asked Questions

 

 

Understanding the Procedure

What is laser vision correction?

Laser vision correction is a procedure that improves vision by permanently changing the shape of the cornea (the clear covering of the front of the eye) with a laser. Often referred to as LASIK and LASEK, they are the most commonly performed type of laser procedures and effective treatments for a wide range of vision problems.

 

What is a laser?

A laser is a technology that utilizes ultraviolet light to precisely reshape the inner layers

of the cornea. This reshaping is capable of correcting nearsighted and astigmatism

conditions using the CustomVue procedure.

 

How does the laser know what to correct in my eyes?

Laser vision correction is based on precise measurements of the imperfections in your vision. These measurements are taken with a powerful measurement tool known as the WaveScan®. The WaveScan information is transferred to the laser to guide the treatment.

 

What is a WaveScan® and a WavePrint® Map?

WaveScan technology provides a measurement and a visual representation of your vision based on the behavior of light waves. It compares light passing through your eye to the same light pattern from an eye that needs no vision correction. The WavePrint Map is the output of the WaveScan, it captures the unique imperfections of a person’s visual path.

 

How accurate is WaveScan technology?

WaveScan technology identifies and measures imperfections in an individual’s vision 25 times more precisely than standard methods used for glasses and contact lenses.

 

Does the WaveScan® hurt?

No, the WaveScan is a measurement device that you simply gaze into while it measures the vision imperfections in your eye.

 

What is CustomVue™ laser vision correction?

VISX CustomVue™ is an individualized laser vision correction treatment that is WaveScan-guided. This enables a doctor to measure and correct unique imperfections in each individual’s vision that could never be measured before with standard methods used for glasses and contact lenses. With the CustomVue procedure, nearsighted and astigmatic individuals have the potential to achieve a new level of vision that we call Personal Best Vision.

 

What do you mean by Personal Best Vision?

Personal Best Vision refers to the new level of laser vision correction that can be achieved with the CustomVue procedure. Since WaveScan technology can measure and correct imperfections that are unique to each individual’s vision with 25 times more precision than standard measurements for glasses and contact lenses, individuals can potentially achieve the best possible vision for their eyes.

 

How does the CustomVue procedure work?

First, the WaveScan technology measures the imperfections in the eyes and produces a WavePrint® Map. Much like a fingerprint, no two WavePrint maps are alike. Then, the treatment information is transferred to the VISX STAR S4™ laser. The doctor then uses that information to fine-tune the procedure thereby providing a new level of precision and accuracy.

 

What can the CustomVue procedure do for me?

As shown in the clinical study, CustomVue has the potential to produce better vision than is possible with glasses and contact lenses. It tailors a distinct correction for each individual–in fact each treatment is “designed” by the unique characteristics of your individual eye.

 

Results

Is the CustomVue procedure FDA approved?

Based on the clinical study, the U.S. FDA has approved the CustomVue procedure as safe and effective for treating nearsightedness and astigmatism.

 

What are some of the results of CustomVue™ to date?

In the FDA study, one year after the VISX CustomVue™ procedure:     

100% of participants could pass a driving test without glasses or contact lenses

98% of participants could see 20/20 or better without glasses or contact lenses

70% of participants could see better than 20/20 without glasses or contact lenses

In addition, many participants reported that they had clearer, better vision both during the day and at night, compared to their vision with glasses or contact lenses before the procedure.

 

What does better than 20/20 mean?

20/20 is the current standard for excellence in vision. But, as shown in a clinical study, individuals with the CustomVue procedure have the potential to see even better than 20/20. In fact, one year after the CustomVue procedure nearly 70 percent of clinical study participants saw 20/16 or better.

 

Can the CustomVue procedure improve my night vision?

Yes, potentially. In the clinical study, four times as many people were very satisfied with their vision
at night after the procedure as compared to their night vision before the procedure with glasses and contact lenses.

 

 

 

David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-790

                                   

CHALAZION

 

Now that you have been diagnosed as having a CHALAZION, pronounced

K-LAZ-E-ON or CH-LAZ-E-ON (with a long “A”), you probably have a number of questions regarding this problem.

 

First, let me discuss a little anatomy and physiology of the eyelid.  Amongst other things, the lid is responsible for secreting part of the tear film.  The tear film is comprised of three layers:  1. The mucinous layer, which is closest to the surface of the cornea; 2. The aqueous layer, which is responsible for keeping the cornea moist; and 3. The fatty layer, which keeps the aqueous layer from drying out. 

 

The glands that secrete the fatty layer of the tear film are the problem in the formation of a CHALAZION.  These glands are called the meibomian glands.  They number 60 to 70 and run vertically in the lids for about ¼”, and parallel to one another, and are located in a cartilaginous plate the keeps the lid somewhat stiff, called the tarsal plate.  These glands are in both the upper and lower lids. 

 

Sometimes these glands become stopped up, and cause a backup of the fatty secretions to form.  This creates a cystic cavity in which a large amount of pressure is built up in an enclosed space and causes, not infrequently, a great deal of pain, as well as localized swelling.  A bump frequently is felt in this location.  The cause of this stoppage is not well known, but usually does not result from an infection, but from a dysfunction of the fatty glands themselves. 

 

The treatment of this situation is usually not antibiotics or medications, but the use of hot moist soaks to enlarge the blood vessels and get more blood supply to the swollen tissue.  With time, one of two things usually happens:  1. The blood takes away the swelling, or 2. The cystic cavity breaks to the inside of the lid and drains into the tear film and out of the eyelids externally.  The hot soaks may be applied as often as desired, but at least 10 minutes at a time, four times a day.  The more often the hot soaks are used, the faster the resolution of the problem.  The intensity of the heat should not be enough to burn the skin, but as hot as you can stand without burning. 

 

This treatment is carried out for at least two weeks.  Most of the time, this is all that is necessary to resolve the problem.  On occasion, however, surgery is required to open the cystic space to the inside of the eyelid and roughen the cells lining the space to destroy them.  Rarely, however, they do recur and have to be re-operated. 

 

Another method of treatment is to inject the cystic cavity of the inflammation with a steroid hormone.  This method has a relatively high rate of resolution, in the order of 70-80%.  Whereas the surgery method approaches 100%.

 

On occasion, the condition is associated with a blepharitis or infection in the eyelids, lashes, or meibomian glands, and must then be treated with antibiotics.  It is the tendency of people, when treated with this method, to want to eliminate the hot soaks, as they take the most time to administer, and cause the greatest inconvenience.  This is just the opposite of what should be done, as the hot soaks are the most important.  If you want to eliminate some part of the treatment, and I do not recommend that you do, eliminate the medication.

 

I hope this information will be of benefit to you in understanding this condition and its treatment.

 

                                                                                     

David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-7900

Dry Eyes and Reflex Tearing

 

Now that you have been diagnosed as having dry eyes and reflex tearing, you might have some questions regarding this paradoxical problem.

 

Many patients question, if they have too few tears, why should they have all the tearing that they do.  It is a rather interesting explanation.  First, we must discuss a little neuroanatomy.  The surface of the eye is supplied with nerves, which run to the brain.  These nerves sense when the eye is becoming dry.  They send a message to the brain, which registers this information.  The brain then sends a message back down to the eye and especially the lachrymal (tear) gland, which is located under the upper-outer portion of the eyelid, to secrete a sudden gush of tears.  This gland is responsible for the production of the aqueous portion of the tears.

 

The tears are secreted from several ducts into the space between the eyelids.  They wash across the surface of the eyeball toward the nose.  On the upper and lower eyelid are located two small holes (puncta) which are connected to ducts (canniliculus) which then drain into the nose.  This is why people can sometimes taste the drops that are put in their eyes. 

 

To treat this problem, the use of artificial lubricating drops of varying frequency is necessary. Most of the time, the minimum use of the artificial tears is at least four times per day. 

For more severe conditions, they may be necessary every half hour.  Occasionally, lubricating ointment is necessary, but tends to blur vision a great deal. 

 

There are many tear supplements on the market, and all are “over-the-counter”, which means they can be purchased without a prescription.  The list of these medications is long, and includes such medications as:

 

 

 

        REFRESH

        TEARS NATURAL

        LYTEERS       

        LIQUIFILM TEARS

        TEARS NATURALE

        AND MANY MORE . . .

 

A relatively new prescription medication doubles the output of tears. Restasis is available by Rx.

 

This list is, by no means, exhaustive, but just names a few.  I have tended to use non-preserved solutions because some people develop sensitivity to the preservatives with prolonged use.  In our contact lens wearers, some studies have shown that as many as 20% develop sensitivity to the preservatives in their drops.

 

New procedures for help in severe cases are being developed.  Some of these are closing the drainage holes (puncta) through which the tears are carried into the nose.  This can be done with a laser or by burning the hole closed with a cautery.  Usually a trial occlusion with a punctual-plug is done first to see if a difference is noticed.  The procedure can sometimes be reversed, but should be considered to be permanent for the purpose of deciding to have surgery. 

 

I hope this short discussion will better help you understand your situation.

 

                                                                       

David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-790

 

WHAT YOU SHOULD KNOW ABOUT . . .

VITAMINS

 

There is a significant and growing amount of information accumulating on the use of the antioxidant vitamins and their effects on the formation of cataracts and age-related macular degeneration.  We are recommending the use of these vitamins as well as certain trace elements as a potential deterrent to the development of these conditions.  There are several brands on the market, however, the preferred brand is:

 

I-CAPS MV – Take four (4) tablets per day, with breakfast

OR

You may purchase each vitamin separately and take enough of each to equal:

1,000 mg Vitamin C; 5,000 I.U. Vitamin A (as Beta Carotene); 800 I.U. Vitamin E; 100 mg Zinc (sulfate, picolinate, or gluconate); 1mg Copper (elemental); 20 mg Manganese; and 20 mg Lutein.

 

 

DIETARY RECOMMENDATIONS

 

One serving of Lutein-zeaxanthin rich vegetables per day:  (listed in micrograms/100G)

Kale-21,900; Collard greens-16,300; Spinach (cooked and drained)-12,600; Spinach (raw)-10,200; Celery-3,600; Scallions (raw)-2,100; Leeks (raw)-1,900; Broccoli (raw)-1,900 (cooked)-1,800; Leaf lettuce-1,800; Green peas-1,700; Brussels sprouts-1,300

USE OLIVE OIL ON THE VEGETABLES TO AID IN THE ABSORPTION OF THE LUTEIN. 

 

BLUE BLOCKING SUNGLASSES

 

There is significant scientific evidence to recommend the use of sunglasses that block out the blue and ultraviolet portions of the light from the sun.  Sunlight, as we all know, has all the colors of the rainbow in it.  It is thought, and can be shown experimentally, that the blue portions are toxic to the retina of the eye.  Scientific literature also provides sufficient evidence to recommend the use of ultraviolet filtering sunglasses in the prevention of cataracts and age-related macular degeneration.

 

The sunglasses we recommend block out both of these toxic rays and should be worn by everyone from the “cradle to the grave”.  They will be an amber brown color lens and are often referred to as “540’s”, “Blue Blockers”, or “Ambervision” sunglasses.  Your optometrist can help you in obtaining the correct protection in prescription or non-prescription eyewear. 

David S. Pfoff, M.D., P.C.

6881 S. Yosemite

Centennial, CO  80112

303-588-790

 

 

PATIENT MEDICAL HISTORY

 

Name ______________________________________ Date________________________

Date of Birth_____________________                 Date of last eye exam_____________________

 

List any prescription and over the counter medications you take:__________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

 

Do you have any allergies to medications?  _________  If yes, please list:__________________

_____________________________________________________________________________

 

List all major illnesses:___________________________________________________________

_____________________________________________________________________________

List any surgeries you have had:___________________________________________________

_____________________________________________________________________________

 

Do you currently have any problems in the following areas?  If YES, please provide information.

EYE PROBLEMS

YES

NO

EXPLANATION OF PROBLEM

Loss of Vision

YES

NO

 

Blurred vision, fluctuating vision

YES

NO

 

Drooping eyelid

YES

NO

 

Distorted vision (halos)

YES

NO

 

Loss of side vision

YES

NO

 

Double vision

YES

NO

 

Dryness

YES

NO

 

Mucous discharge

YES

NO

 

Redness

YES

NO

 

Sandy or gritty feeling

YES

NO

 

Itching, burning

YES

NO

 

Crossed eyes, lazy eye

YES

NO

 

Foreign body sensation

YES

NO

 

Excess tearing/watering

YES

NO

 

Glare/light sensitivity

YES

NO

 

Eye pain or soreness

YES

NO

 

Infection of eye or lid

YES

NO

 

Tired eyes

YES

NO

 

GENERAL

YES

NO

 

Fever

YES

NO

 

Weight loss

YES

NO

 

Other

YES

NO

 

EAR, NOSE, THROAT (sinus,ear infection,

chronic cough,dry mouth,etc)

YES

NO

 

CARDIOVASCULAR (heart, vessels, etc)

YES

NO

 

RESPIRATORY

YES

NO

 

GASTROINTESTINAL (stomach,ulcers,intestinal)

YES

NO

 

GENITAL, KIDNEY, BLADDER

YES

NO

 

MUSCLES, BONES, JOINTS

YES

NO

 

SKIN

YES

NO

 

NEUROLOGICAL

YES

NO

 

PSYCHIATRIC

YES

NO

 

ENDOCRINE (diabetes,thyroid,etc.)

YES

NO

 

 

 

 

 

FAMILY HISTORY         M=MOTHER      F=FATHER       S=SIBLING       GP=GRANDPARENT

 

DISEASE

YES

NO

RELATIONSHIP TO PATIENT

Blindness

YES

NO

 

Glaucoma

YES

NO

 

Arthritis

YES

NO

 

Cancer

YES

NO

 

Diabetes

YES

NO

 

Heart disease or high blood pressure

YES

NO

 

Kidney disease

YES

NO

 

Lupus

YES

NO

 

Stroke

YES

NO

                                                                    

Thyroid disease

YES

NO

 

Other

YES

NO

 

 

SOCIAL HISTORY

Current occupation:_________________________________________________

Education level:____________________________________________________

Marital status: _____________________________________________________

 

Do you drive?

Yes

No

 

Do you have visual difficulty when driving?

Yes

No

 

Do you have problems with night vision?

Yes

No

 

Have you ever tried to wear contact lenses?

Yes

No

 

Do you currently wear contact lenses?

Yes

No

If yes, how long?             

Do you currently wear glasses?

Yes

No

If yes, how old is your prescription?____

Do you drink alcohol?

Yes

No

If yes, how often?

Do you smoke?

Yes

No

If yes, how much?

Have you ever had a blood transfusion?

Yes

No

If yes, when?

 

 

 

 

 

 

 

 

Reviewing physician’s signature   __________________________________________________ 

                       

David S. Pfoff, M.D.

950 E. Harvard Ave.  #350

Denver, CO  80210

303-588-7900

 

HOME CARE FOLLOWING LASER SURGERY

·               Try to rest quietly or sleep as much as possible until your follow-up appointment, keeping your head slightly elevated.

·               Leave the plastic shields in place for the remainder of the day following the procedure, and throughout the night. You may remove them the next morning, unless otherwise instructed by your doctor.  Please continue to use the plastic shields while sleeping for 1 week.

·               Do not rub or bump the eyes.

·               Your eyes may tear and possess a gritty or "foreign body" sensation, and may be sensitive to light.

·               One of the most important things you can do to reduce discomfort is to keep both eyes closed as much as possible.

·               Take precautions to avoid getting your eyes wet when you shower or bathe.

·               Take your medications exactly as prescribed by your doctor.

The next few days following your LASIK or LASEK procedure:

Your vision may fluctuate for the first few days. This will usually stabilize after the first week or so. Your eyes may continue to tear, have a foreign body sensation and be sensitive to light. Taking all of your medications as directed will help relieve any discomfort.

Though an eye infection is very rare: during the first week, be careful not to get anything in your eyes (including soap and water) and do not use eye make-up or mascara.

Normal activities may resume after the first week, except for swimming (your doctor will advise you when it is safe to resume swimming). It will still be normal to experience eye discomfort, sensitivity to light and glare, and tearing as the eyes continues to heal.

Protect your eyes from sun radiation with a good pair of sunglasses that provide UV protection. Heavy UV exposure can burn your eyes and cause regression problems any time for the following year.

During the first week, Dr. Pfoff will instruct you to wear the shields whenever you are sleeping. As the tape that holds your shield in place becomes unusable, you may use scotch tape or Band Aids to keep your shield in place. If your skin is unusually sensitive you may wish to purchase medical paper tape at a drug store.

It is very important that you strictly observe your follow-up appointments, which will occur at:

o                                      1 day

o                                      1 week

o                                      1 month

o                                      3 months

o                                      6 months

o                                      1 year (dilated exam)

Contact the office, 303-588-7900, if you experience any change of symptoms or notice a decrease in vision.