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Vitrectomy Scleral Laceration Repair Air-Fluid Exchange Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
Ruptured globe, left eye; status post ocular penetrating trauma, left eye; mild cataract, left eye; vitreous hemorrhage, left eye; possible retinal detachment, left eye.

POSTOPERATIVE DIAGNOSES:
Ruptured globe, left eye; status post ocular penetrating trauma, left eye; cataract, left eye; vitreous hemorrhage, left eye; retinal detachment, left eye; perforating scleral injury, left eye; intraocular foreign body, left eye.

OPERATION PERFORMED:
A 20-gauge vitrectomy, left eye; removal of intraocular foreign body, left eye; repair of scleral laceration, left eye; removal of vitreous hemorrhage, left eye; repair of retinal detachment, left eye; air-fluid exchange, left eye; silicone oil vitreous substitute air exchange, left eye; indirect laser placement, left eye.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

DESCRIPTION OF OPERATION:  The patient was identified in the holding area and dilating drops were placed in his left eye. He was brought back to the operating room and placed supine on the operating room table. General anesthesia was initiated, and a retrobulbar block using only a few mL of 2% lidocaine and 0.75% Marcaine was given to his left eye. No digital pressure was applied following the retrobulbar block in case that there was an additional scleral laceration. The left eye was then prepped and draped in the usual sterile fashion. The operating microscope was brought into position, as well as the 20-23-gauge vitrectomy system. A 360-degree conjunctival peritomy was performed. Each of the 4 quadrants were spread using the Stevens scissors. The rectus muscles were isolated with 2-0 black silk suture ties. The globe was explored and a large scleral laceration under the lateral rectus muscle was identified. The lateral rectus muscle was removed at its insertion and the scleral laceration repaired using 8-0 nylon interrupted sutures. There was vitreous presentation at the laceration site. This was removed gently using the Weck-cel technique. The intraocular foreign body was found at the distal end of the wound. The metallic foreign body was sent to pathology. The lateral rectus muscle was then resutured to the sclera. The indirect ophthalmoscope was used to inspect the retina and vitreous. View was obscured by the vitreous hemorrhage. Since it was felt that there was retinal incarceration within the wound and likely retinal detachment, the decision was made to perform the vitrectomy. The 23-gauge cannulas were placed. The infusion trocar was verified and the infusion pressure turned on to 20 mmHg. Two additional trocars were placed at the 10 and 2 o'clock positions. No light pipe or Microvit were used to enter the eye. With the assistance of intravitreal Kenalog for visualization, the central vitreous and vitreous hemorrhages were removed. There was retinal detachment found, which did involve the macula. Fortunately, the scleral laceration only extended to the temporal edge of the macula and did not involve the fovea. There was loss of overlying choroid and RPE in the area of the scleral laceration site. Using intraocular diathermy and the Microvit, the retina was removed from the sites of incarceration. Perfluoron was then used to flatten the retina and laser placed along the edges of the previously incarcerated retina using the indirect ophthalmoscope attachment. A Perfluoron air exchange was performed followed by a silicone oil vitreous substitute air exchange. I noted that the optic nerve appeared healthy. The sclerotomies were closed and the eye left watertight at a pressure of approximately 20 mmHg. Then, 0.2 mL of intravitreal Kenalog was placed to hopefully prevent formation of proliferative vitreoretinopathy postoperatively. Subconjunctival injections of vancomycin and dexamethasone were given as well. The corneal epithelium was decompensating towards the end of the case, but fortunately no corneal scraping was required. The conjunctiva was closed using 8-0 Vicryl suture. A patch and shield and TobraDex ointment were placed over the patient's left eye. The patient will be admitted for postoperative positioning and will be seen in one day for followup.
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