The Ophthalmic Office Procedures Handbook

SECTION 3 Lids, Lashes, and Adnexa

118

RISKS/BENEFITS

Key Risks

■ Bleeding ■ Ulceration ■ Infection ■ Eyelash loss ■ Scarring or distortion of lid anatomy ■ Recurrence of lesion ■ Additional surgery if pathology identifies malignancy

Removal of the lesion is usually the desired benefit. Another benefit might be to get a diag nosis that would dictate whether any further treatment is needed. Risks and complications inherent to a lid biopsy include, but are not limited to, bleeding, infection, lash loss, eye irritation, distortion of the lid anatomy, recurrence, allergic reaction to local anesthetic, ophthalmic ointment or supplies, burn to the skin or lashes, scarring, and in jury to the eye (extremely rare). Temporary decrease in vision due to lid edema or ophthalmic ointment may occur. Permanent vision loss is incredibly rare with this procedure. Additional surgery by a specialist may be indicated if the lesion is a malignancy. If a biopsy is being sent, the patient should be aware that it will take about a week to get a result back from the pathologist. Let the patient know that your office will call the patient and inform them of the results. If it is a skin cancer, you will refer them to an eyelid surgeon for complete removal of the tumor and reconstruction. Reassure the patient that 90% of lid le sions are benign . Of the 10% that are malignant, by far the majority of malignancies are basal cell carcinomas that usually do not spread through the bloodstream and can be completely treated in most cases, especially if diagnosed early. The counseling clinician should not only obtain a signature and witness of the consent form but feel confident that the patient understands. Consent is obtained with communica tion between the clinician and the patient. The form is just a legal document confirming and recording what has already happened in the office between the two parties. The chart should document that the patient has been counseled on the nature of the procedure, the risks, ben efits, and alternatives to the procedure. The expected results have been discussed. PREOPERATIVE CARE It is important to document the specific location of the lesion on the eyelids, either by a pho tograph or a diagram . If a photograph is performed, the CPT code for external photography is 92285 . Documentation of the lesion is important in that if the lesion is malignant, it helps the eyelid specialist know where the biopsy was taken. Usually, the patient waits a period after the biopsy to be seen and the site may have healed, showing little evidence of a procedure.

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