Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Extracapsular Cataract Extraction Medical Transcription Sample


Mature traumatic cataract, right eye.

Mature traumatic cataract, right eye.

Planned extracapsular cataract extraction with posterior chamber intraocular lens implant, right eye.

John Doe, MD




The patient arrived in the operating room after adequate preoperative sedation, intravenous line and cardiac monitor initiated. The patient was prepped and draped in the usual sterile fashion after smooth induction of general endotracheal anesthesia. Attention was directed to the right eye, where a chalk-white cataract was noted.

A Lieberman wire lid speculum was placed between the lids of the right eye. A fornix-based conjunctival flap to the superior 3 o'clock was fashioned with Westcott scissors using blunt and sharp dissection. Hemostasis was obtained with wet-field cautery. Initially, this procedure was approached as a phacoemulsification case. A 3 mm limbal wound was fashioned with a 69 Beaver blade in partial thickness fashion. A crescent knife was used to dissect a scleral tunnel anteriorly into clear cornea.

A superotemporal paracentesis stab was performed with a 75 Beaver blade. The anterior chamber was deepened with Viscoat. The scleral tunnel was then completed with a 2.8 mm keratome into the anterior chamber. A bent 25 gauge needle cystotome and a Viscoat syringe introduced into the anterior chamber and an attempt was made to perform a continuous tear capsulorrhexis. In the light of the mature white lens, as well as flocculent material, visualization of the anterior capsule was extremely difficult and a continuous tear capsulorrhexis could not be performed. 

It was elected at this point to convert to a can-opener capsulotomy through 360 degrees and convert to an extracapsular cataract extraction. The 3 mm limbal wound was extended 1 o'clock on either side with corneoscleral scissors, first passing nasally then temporally. A traction suture was placed into the 12 o'clock cornea, and with gentle pressure from above and below the lens, nucleus was expressed from the eye uneventfully. The limbal wound was secured with 3 interrupted 8-0 Vicryl sutures.

Irrigation/aspiration handpiece was introduced into the anterior chamber. Cortical cleanup was performed uneventfully. A good red reflex was noted. The posterior capsule remained intact. The limbal wound was secured nasally and temporally with interrupted 10-0 nylon sutures whose knots were buried to 12 o'clock. Vicryl suture was removed. The capsular bag was filled with Provisc.

A 21.5 diopter posterior chamber intraocular lens implant was inspected under the operating microscope and found to be free of defect. The lens implant was placed in the eye with the inferior J-loop being reposited behind the iris leaflet and within the capsular bag. Using a one-handed maneuver, the superior J-loop was placed behind the iris leaflet within the capsular bag. The lens was rotated such that its major axis was from the 3 to 9 o'clock positions. The lens was noted to be well centered and stable.

The limbal wound was secured with an additional 6 interrupted 10-0 nylon sutures whose knots were buried. Viscoelastic was removed from the anterior chamber. The chamber was deepened with balanced salt solution and the wound was tested and found to be watertight. Subconjunctival gentamicin and Solu-Medrol were administered. Maxitrol ointment was instilled. The lid speculum was removed. The eye was patched. The patient was extubated uneventfully.

Ophthalmology Operative Samples # 1             Ophthalmology Operative Sample Reports #2