Lucentis treatment plan Patient label

GoodHopeHospital Date…………………………

Rapid Access Lucentis Clinic

Personal and medical details

Telephone home
other / Allergies etc
Aware of reason for admission Y / N / Has own transport Y / N
Medical history / Medications
Warfarin Y / N / Smokes Y / N number………..
alcohol …………………..units/day / Low fat diet Y / N
portions vegetables/fruit day …. (7-9 ideal) / Exercise...... minutes/day
Ocular history
Blepharitis Y / N……….mild glaucoma…Y / N
Previous cataract surgery Y / N……… other conditions ……………………….…………
Severe glaucoma… Y / N…………………………………………………………
BP / Cholesterol if known……… mmols/l
P……… / BM………mmols/l

Vision with distance correction

RIGHT / LEFT / Snellen / Logmar
O / N / V / S / R / O / N / V / S / R / 200 (6/60) / +1.0
K / D / N / R / O / K / D / N / R / O / 160 / +0.9
Z / K / C / S / V / Z / K / C / S / V / 125 / +0.8
D / V / O / H / C / D / V / O / H / C / 100 / +0.7
O / H / V / C / K / O / H / V / C / K / 80 / +0.6
H / C / X / K / O / H / C / X / K / O / 63 / +0.5
N / C / K / H / D / N / C / K / H / D / 53 / +0.4
Z / H / C / S / R / Z / H / C / S / R / 40 (6/12) / +0.3
S / Z / R / D / N / S / Z / R / D / N / 32 / +0.2
H / C / D / R / O / H / C / D / R / O / 25 / +0.1
R / D / O / S / N / R / D / O / S / N / 20 (6/6 ) / 0.0

Score right………left …………

Poor vision right………left …………

Ocular examination (Rapid Access Lucentis Clinic)

Blepharitis present Yes/no

APD APD

tonopen

G. Benoxinate 0.4% R&L

G. Tropicamide 1% R&L

G. Phenylephrine 2.5% R&L Time Signature

Anterior segment

Cataract 0-5 (5 mature cataract)

Disc cupping

retina

OCT Y / N .....comments......

FFA Y / N...... comments......

Diagnosis

RIGHT / LEFT
Classic subfoveal CNV
Occult, no PED
Occult, PED
dry..geographic
Dry..hard drusen
Mixed dry
Soft drusen / Classic subfoveal CNV
Occult, no PED
Occult, PED
dry..geographic
Dry..hard drusen
Mixed dry
Soft drusen

Other diagnoses /comments

......

...... Signature……………….

Action (Rapid Access Lucentis Clinic) ring options (can select more that one option)

  1. proceed with lucentis 3 injection starting program RIGHT / LEFT / BOTH
  2. discharge
  3. Low vision appointment
  4. partial sight registration blind registration
  5. no Lucentis but follow up…Y / N .how many months……………
  6. GP to help with blood pressure
  7. GP to advise regarding cholesterol
  8. practice nurse to advise regarding healthy diet
  9. Macular Degeneration Society booklet telephone number…..
  10. continue with more Lucentis:

RIGHT / LEFT
next injection will be number …………..
book 1…..2……3 booster injections / next injection will be number …………..
book 1…..2……3 booster injections

Dates of Lucentis injections

  1. ………………… RIGHT / LEFT
  2. ………………… RIGHT / LEFT
  3. ………………… RIGHT / LEFT
  4. ………………… RIGHT / LEFT
  5. ………………… RIGHT / LEFT
  6. ………………… RIGHT / LEFT

Operating theatre preparation room Lucentis

RIGHT / LEFT

G Benoxinate0.4%Right / Left

G Tropicamide 1%Right / Left

G Phenylephrine 2.5% Right / Left TimeSign………….

G Benoxinate 0.4%5……10…..15…..20 minutes to treated eye Right / LeftSign………….

Eye cleaned with 50 / 50 Betadine / WaterTimeSign………….

(start in prep-room at least 10 minutes before injection)

Pre op check list

Prep room

/ Theatre
Blepharitis / YN
Identity band applied / YN / YN
Consent signed / YN / YN
Site marked / YN / YN
Allergies checked / YN/K / YN/K
Make up removed / YN/A
Contact lenses removed / YN/A
Hearing aid removed / YN N/A / YN N/A
Injection number
(eye to be injected) / 1……2……3…..4…..5….6…..7…..8….9…..10…..
Sign

Operation recordLucentis

RIGHT / LEFT

surgeon
Intravitreal Lucentis 0.05mls 0.5mg
Injection number / 1……2……3…..4…..5….6…..7…..8….9…..10…..
eye / Right / Left
Benoxinate
Polvidone iodine/water 50/50 / prep-room / Immediately pre-op
Sterile trolley/gown/drape
Lid speculum
Injection site mm behind limbus / 3.5 pseudophakic / 4.00mm
site / Superior temporal / Inferior temporal
30 gauge needle
Balanced salt washout of conjunctiva at end of procedure
G Chloramphenicol minims very end
Pain level / Not felt / Twinge / intermediate / severe

Comments

……………………………………………………………………………………………………………….

Post operative care, back in prep room

Site comfortable / Y / N
Remove mark / Y / N
Give Levofloxacin / Y / N / Sign
Post op advice given / Y / N
Date next appt

Comments…………………………………………………………………………………………………….

Post operative advice sheet, Lucentis

Patients must contact the Lucentis team nurse
(outside working hours the Birmingham and Eye Centre Emergency department) immediately if any of the following signs of infection or other complications develop (within 2 hours of the problem developing). Severe infection may develop in the 5 days after the injection (usually day1 or 2), but very rarely indeed after this 5 day period.

  • pain
  • blurry or decreased vision,
  • sensitivity to light
  • redness of the eye (The eye may be slightly red after the injection and the next day.Mild discomfort is normal.)
  • discharge from the eye.

Basic advice

  1. you must NOT rub the eyes
  2. swim for three days after each injection.
  3. use the Levofloxacin drops 4 times a day for 4 days after the injection

Telephone numbers

Good Hope ………….…………………

HeartlandsHospital………….…………………

Solihull………….…………………

Birmingham and Eye Centre Emergency department……………………………..

Consent notes Lucentis

1 in 1000 risk of severe eye infection which may lead to loss of eye

1 in 100 risk of other complications less serious, which include retinal tear, retinal detachment, cataract, high eye pressure.

Some patients notice an improvement in vision. Others will lose a little sight but will keep much better vision hat without Lucentis. One person in 10 will lose a lot of central vision before the condition stabilises.

(add this paragraph to the regular consent)

SIGN