Ophthalmologic Operative Transcription Sample Reports for Medical Transcriptionists:
OPERATION PERFORMED: Phacoemulsification with intraocular lens, left eye, and examination under anesthesia.
OPERATION IN DETAIL: The patient was brought into the operating room and placed in the supine position on the operating table. Blood pressure and cardiac monitors were placed. The patient was then administered gentle IV sedation and was then administered a left-sided inferior lid approach retrobulbar injection of 5 mL of a solution containing 1:1 mixture of 2% lidocaine without epinephrine and 0.75% Marcaine with 1 mL of hyaluronidase added. There was noted to be good akinesia and anesthesia of the eye after block. The patient was prepped and draped in the usual sterile fashion with trimming of lashes. A heavy wire lid speculum was inserted to maintain the left eye in open fashion. A 3 mm keratome was used to make a clear corneal incision at the 11 o'clock meridian. This was then shelved into the anterior chamber. A cystitome was used to perform a continuous tear capsulorhexis. The capsular fragment was removed with Utrata forceps. The BSS cannula was used to hydrodissect the lens. Nucleus and lens were noted to be freely mobile in the capsular bag. The lens was then removed in a divide-and-conquer technique with phacoemulsification handpiece. Following this, remaining cortical material was removed with mechanical irrigation-aspiration handpiece. The lens capsular bag and anterior chamber deepened with Healon. The posterior chamber lens was inserted with a lens inserter. The haptics were rotated to 3 and 9 o'clock positions. The optic was noted to be well centered. Remaining Healon was irrigated from the anterior chamber with BSS. The wound was closed with single 10-0 nylon suture. The wound was checked for its integrity and found to be watertight. An examination under anesthesia was performed with 20-diopter lens and direct ophthalmoscope. There was clear vitreous and the retina was attached 360 degrees with excellent laserpexy. Subconjunctival injections of 100 mg of cefazolin, 20 mg of gentamicin, and 2 mg of dexamethasone were administered to the inferior subconjunctival space. Speculum and drapes were removed, and patch applied to the patient's eye. The patient left the operating room in stable condition.
PROCEDURE PERFORMED: Repair of corneoscleral laceration, left eye.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was brought to the operating room, where blood pressure and cardiac monitoring devices were applied. The patient was prepped with Betadine 5% solution, being careful to avoid excess pressure on the left eye. The patient was draped for a procedure on the left eye. A Lieberman lid speculum was inserted. A Weck-Cel sponge vitrectomy was performed along the links of the corneoscleral laceration, which extended limbus to limbus and 2-3 mm on either side of the limbus onto the sclera. As the patient had already had a previous vitrectomy, there was not much vitreous present. The capsular bag was protruding through the corneal laceration, and this was grasped with 0.12 forceps and amputated. Balanced salt solution on a 30-gauge cannula was injected into the eye through the corneal laceration to inflate the globe. Multiple 10-0 nylon interrupted sutures were placed to close the corneal laceration. Healon was used at various times throughout the procedure to help feel the wound and to reposition part of the iris, which protruded through the wound. The conjunctiva was resected at the limbus on either side, exposing the scleral lacerations. Multiple 10-0 nylon interrupted sutures were used to close the scleral wounds. As the scleral sutures were tightened to prevent wound leakage, some of the corneal sutures needed to be replaced and made tighter. Once all sutures were in place, balanced salt solution was injected through the corneal wound until the globe was sufficiently pressurized. The wound was checked with a fluorescein strip and found to be tight and secure. Vancomycin was injected through the corneal wound into the eye. The patient had also received IV vancomycin during the procedure. He was also given a 20 mg dose of Decadron IV at the end of the procedure. The eyelid speculum was removed from the eye and the eye was rinsed with balanced salt solution. The drapes were removed and the periocular skin was cleaned with wet and dry sponges. Polysporin ophthalmic ointment was instilled in the eye and a piece of Transpore tape was used to tape the eye closed. Next, a light eye patch was placed on the eye and a metal shield was placed over the eye patch. The patient was reversed from anesthesia and extubated without complications. He was taken to the postanesthesia care unit in stable condition.
OPERATION PERFORMED: Cataract extraction with lens implantation of the left eye.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position on the operating room table. A mixture of Xylocaine and Marcaine 3 mL were injected. Following this, a retrobulbar injection was administered using the same mixture; total of 3 mL. A Schiotz tonometer reading with a 5.5 g weight was 5. A lid speculum was inserted into the left eye. A fornix-based flap was made superiorly extending from the 11 o'clock position to the 1:30 position. Hemostasis was obtained using bipolar cautery at the time of surgery. A 6 mm cord length incision was made at the 11 o'clock position 2 mm posterior to the surgical limbus. Using a #64 Beaver blade, a horizontal incision was made from the 12 o'clock position and 10 o'clock position. The incision was dissected anteriorly. A super-sharp blade was used to enter the anterior chamber at the 2 o'clock position. Trypan blue dye was injected to the anterior chamber and one minute later irrigated out of the anterior chamber. Using a 3.2 mm keratome, the anterior chamber was entered at the 11:30 position. Viscoat was injected into the anterior chamber. A cystotome on a Healon syringe was inserted into the anterior chamber and an anterior capsulotomy was performed. Using a straight cannula, hydrodissection was performed. Phacoemulsifier was then inserted into the anterior chamber and the nucleus removed using a two-handed technique. The I/A instrument was inserted into the anterior chamber and cortex was removed. Healon was injected into the anterior chamber. A posterior chamber J-loop intraocular lens was inserted. Miochol was injected into the anterior chamber. The wound was closed using 10-0 nylon suture. Healon was removed from the anterior chamber. The conjunctiva was closed using a bipolar cautery. The patient was given one drop of Pred Forte, TobraDex, pilocarpine, and Timoptic ophthalmic drops were placed in the left eye. Two eye patches and a Fox metal shield were placed over the left eye. The patient tolerated the procedure well and was transferred to same day surgery in satisfactory condition.
OPERATION PERFORMED: Pars plana vitrectomy, air-fluid exchange, cryoretinopexy, left eye.
DESCRIPTION OF OPERATION: The patient was identified and brought to the operating room, where he was placed in the supine position on the operating table. The appropriate monitoring devices were attached. Akinesia and anesthesia were obtained using a 50/50 mixture of 2% lidocaine with 0.75% Marcaine and one ampule of Wydase, 5 mL given in retrobulbar fashion followed by a 5 mL lid block with good results. The patient was then prepped and draped in the usual sterile fashion and a lid speculum was placed in the left eye. A standard 3-port pars plana vitrectomy was prepared measuring 4 mm posterior to the limbus. The infusion cannula was visualized prior to commencing infusion. With the aid of the wide-angle viewing system, a pars plana vitrectomy was performed. The vitreous was removed 360 degrees out to the periphery. The peripheral vitreous was adherent to the posterior and anterior vitreous base and this was trimmed overlying the detached retina and over the retinal break superotemporally. After removing as much of the anterior-posterior vitreous traction as possible, the retinal break was marked with endodiathermy. Scleral depression was then performed of the periphery looking for any other obvious abnormal holes or tears. There were multiple areas of atrophic thin retina inferiorly with no frank tear. However, the vitreous was trimmed with depression overlying this area. An air-fluid exchange was then performed with the flute needle evacuating via the retinal break with complete flattening of the retina. Cryo was then placed around the retinal break, as well as in the inferior quadrant from approximately the 4 o'clock to the 7 o'clock position at the periphery with good uptake. Additional fluid was then removed off of the optic nerve and the instruments were removed. The sclerotomies were closed with X-shaped 7-0 Vicryl sutures. The eye was irrigated with Neosporin ophthalmic solution. Additional local was given via a blunt cannula in the retrobulbar space, after which the conjunctiva was reapproximated and closed with 8-0 Vicryl suture. Subconjunctival injections of 2 mg of dexamethasone and 20 mg of tobramycin were given. Topical 1% atropine was placed in the eye and the eye was patched in the usual fashion. The patient tolerated the procedure well and was returned to same day surgery in satisfactory condition.
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