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Baerveldt Tube Implant Medical Transcription Sample Report

DATE OF OPERATION:
MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Juvenile glaucoma, right eye.

POSTOPERATIVE DIAGNOSIS:
Juvenile glaucoma, right eye.

OPERATION PERFORMED:
1.  Baerveldt tube implant, right eye.
2.  Pericardial patch graft, right eye.

SURGEON:
John Doe, MD 

ASSISTANT:
None.

ANESTHESIA:  General.

ANESTHESIOLOGIST:
Jane Doe, MD 

INDICATIONS FOR SURGERY:
Uncontrolled glaucoma.

DESCRIPTION OF OPERATION:
The patient was taken to the operative suite where general anesthetic was induced.  The patient was prepped and draped in the standard fashion for ocular surgery.  The eyelids were parted with a Maumenee-Park lid speculum.  A 4-0 silk superior rectus bridle suture was placed.  The eye was infraducted.

A peritomy was performed 4 mm from the limbus in the superotemporal quadrant.  Conjunctiva and Tenon's were dissected posteriorly and the intermuscular septum was penetrated.  A Baerveldt, 250 square millimeter tube and plate were inspected.  Patency of the tube was confirmed with irrigation.  The tube was ligated just anterior to the plate with a 7-0 Vicryl suture and a fenestration opening was placed anterior to the ligature.

The plate was inserted through the peritomy, advanced posteriorly to a point 10 mm posterior to the surgical limbus.  It was sutured into that location with two 8-0 nylon sutures.  The tube was extended anteriorly overhanging the limbus.  The tube was cut to length.

A paracentesis was performed temporally.  A full-thickness sclerostomy was created with a 23-gauge needle.  The tube was inserted through the sclerostomy and centered in the anterior chamber nicely.  The tube was anchored to the sclera with two 8-0 nylon sutures.

A specimen of pericardium was obtained and rehydrated.  A 5 mm graft was cut free and this was sutured to the tube with four 7-0 Vicryl sutures.  Conjunctiva was then closed with a running horizontal mattress 7-0 Vicryl suture.  Decadron 2 mg was injected subconjunctivally in the inferotemporal quadrant.

The eye was dressed with atropine 1% solution, Maxitrol ointment, and mild pressure patch and shield.  The patient was awakened by Anesthesia and taken to the recovery room in stable condition.

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