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Laser Iridotomy Procedure Transcription Example / Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Narrow-angle glaucoma, left eye.

POSTOPERATIVE DIAGNOSIS:  Narrow-angle glaucoma, left eye.

OPERATION PERFORMED:  Laser iridotomy, left eye.

SURGEON:  John Doe, MD

ANESTHESIA:  Topical proparacaine.

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old male with a history of narrow-angle glaucoma, at high risk for blindness or angle-closure glaucoma, diagnosed on physical examination by gonioscopy. Risks, benefits and alternatives of laser iridotomy were discussed with the patient preoperatively. The patient agreed and signed appropriate consent preoperatively.

DESCRIPTION OF PROCEDURE:  On the day of the procedure, the left eye was identified as the operative eye. The patient received 3 sets q. 5 minutes of the following drops; proparacaine, pilocarpine and Iopidine. Appropriate constriction and anesthesia were achieved. The patient was then brought back to the laser suite, where first the argon laser was used to pretreat the iris superiorly in an area that was covered by the lid with the following settings:  800 milliwatts, 0.06 seconds duration and 50 micron spot size, and then the YAG laser was used to complete the iridotomy with the following settings; 5 millijoules, 2 pulses and a total of 2 pulses applied. Good flow of aqueous was noted from the posterior chamber to the anterior chamber and a patent iridotomy was obtained. The patient was given the following postoperative instructions:  No bending, coughing, lifting, straining or sneezing.  Return to the clinic for further followup care, and the patient is to use prednisolone acetate 1 drop, left eye, 4 times a day for 1 week.