<p> PLACE LABEL HERE EYE LASER RETINAL PHOTOCOAGULATION PRE-OP and POST-OP ORDERS</p><p>The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked. Initial all handwritten order modifications and the bottom of each page when indicated (multipage). </p><p>Diagnosis:  Retinopathy  Retinal Detachment  Retinal Tear  Right eye  Left eye  Both eyes</p><p>PRE-OP ORDERS</p><p>MEDICATIONS TO OPERATIVE EYE (Starting 30 minutes prior to procedure):</p><p>1.  Iopidine (apraclonidine) 1% 1 drop x 1 dose 2.  Mydriacyl (tropicamide) 1% 1 drop q 5 minutes x 2 doses 3.  Neosynephrine (phenylephrine) 2.5% 1 drop q 5 minutes x 2 doses 4.  Cyclogyl (cyclopentolate) 1% 1 drop q 5 minutes x 2 doses</p><p>ADDITIONAL ORDERS: ______</p><p>POST - OP ORDERS</p><p>1. Vital signs per unit routine 2. ❑ Iopidine (apraclonidine) 1% 1 drop x 1 dose to operative eye 3. Mild pain: ❑ Tylenol (acetaminophen) 650 mg po q 4 hrs prn</p><p>ADDITIONAL ORDERS: ______</p><p>______Date Time Physician Signature PID Number </p><p>Copy to pharmacy </p><p>*1-18108* FORM 1-18108 REV. 05/2015 Page 1 of 1</p>