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Trabeculectomy of Eye Operative MT Sample Report

DATE OF OPERATION:
MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Open angle glaucoma, right eye.

POSTOPERATIVE DIAGNOSIS:
Open angle glaucoma, right eye.

OPERATION PERFORMED:
Trabeculectomy, right eye.

SURGEON:
John Doe, MD

ASSISTANT:
None.

ANESTHESIA:
General.

ANESTHESIOLOGIST:
Jane Doe, MD

INDICATIONS FOR OPERATION:
Uncontrolled glaucoma.

DESCRIPTION OF OPERATION:  The patient was taken to the operating suite where general anesthetic was induced.  The patient was prepped and draped in 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 and the eye was then retracted.

A peritomy was performed 8 mm from the limbus directly superiorly.  Conjunctiva was dissected anteriorly.  Tenon's capsule was removed.  Hemostasis was obtained with mild electrocautery.  A 3.5 mm rectangular scleral flap of half scleral thicknesses was dissected out into clear cornea.  A paracentesis was performed inferotemporally.  The anterior chamber was deepened with an air bubble.  A pledget was soaked with mitomycin-C.  The pledget was placed over the scleral flap, beneath conjunctiva, and left in place for 2 minutes, after which time the pledget was removed and the area was irrigated with copious balanced salt solution.  A 1 x 3 mm resection of trabecular meshwork was excised.

A peripheral iridectomy was performed.  The scleral flap was then closed with five 10-0 nylon sutures.  The knots were buried.  Tenon's capsule was closed with two 8-0 Vicryl sutures and conjunctiva was closed with a running horizontal mattress 10-0 nylon suture.  The anterior chamber was deepened with balanced salt solution.  A nice, diffuse bleb resulted and tested watertight.

Decadron 2 mg was injected subconjunctivally in the inferotemporal quadrant.  The eye was then dressed with atropine 1% solution, Maxitrol ointment, a torpedo dressing, mild pressure patch and shield.  The patient tolerated the procedure well, was awakened by Anesthesia and taken to the recovery room in stable condition.

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