**This is an example of the form your surgeon will fill out with instructions specific to your situation**
Patching of Operative Eye
__ 1st Night Post Surgery __ Day(s) Post Surgery __ Week(s) Post Surgery
Shielding of Operative Eye
__ 1st Night Post Surgery __ Night(s) Post Surgery __ Week(s) Post Surgery
Eye Drops
__ Tobradex 4 X Daily for __ Week(s)
__ Predforte 4 X Daily for __ Week(s)
__ Vigamox 4 X Daily for __ Week(s)
Pain Medication
Plain Tylenol / Tylenol #3 – max 2 pills every 4 hours
Positioning
__ Face Down
__ Right Side Down
__ Left Side Down
__ Head Elevated ____ Degrees
__ Sitting up
__ No Position Required
For __ Day(s) __ Week(s) **Showering- one day after surgery**
Follow up Appointments:
Day 1 Post Surgery: Date & Time: __________________________________
Royal Alex Hospital- Unit 22/Eye Clinic (#111) OR ARC- Suite 400, 10924-107 Ave
2 Weeks Post Surgery: Date & Time: ________________________________
Royal Alex Hospital- Unit 22/Eye Clinic (#111) OR ARC- Suite 400, 10924-107 Ave
Special Instructions:
- Pain after vitrectomy should be mild and treatable with pain Tylenol
- Pain after scleral buckle surgery is moderate and treatable with plain Tylenol or Tylenol #3.
**PLEASE CALL 780-448-1801 if you have increasingly severe eye pain or if you are nauseated and vomiting**