Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Scleral Buckle Procedure Medical Transcription Sample Report


PREOPERATIVE DIAGNOSIS:  Retinal detachment, proliferative vitreoretinopathy, right eye.

POSTOPERATIVE DIAGNOSIS:  Retinal detachment, proliferative vitreoretinopathy, right eye.

OPERATION PERFORMED:  Scleral buckle procedure, vitrectomy, membranectomy, laser photocoagulation, silicone oil injection, peripheral iridectomy, right eye.

SURGEON:  John Doe, MD


DESCRIPTION OF OPERATION:  The patient was taken to the operating room and general anesthesia was administered. The face was prepped and draped in the usual sterile ophthalmic fashion and a lid speculum was placed in the right eye. The conjunctiva was opened for 360 degrees and each of the 4 rectus muscles were isolated and tagged in turn using 2-0 black silk sutures. Three mL of 0.25% Marcaine was delivered into the peribulbar space using a blunt tip cannula. Indirect ophthalmoscopy with scleral depression was performed for 360 degrees. The retinal detachment was very thin with atrophic areas and areas of underlying pigmentation, but there were no definite retinal holes or tears visualized. It was decided to perform an encircling buckle and perform peripheral laser photocoagulation for 360 degrees. A 240 band was selected. Nylon 5-0 sutures were placed at a measured distance of 5 mm posterior to the muscle insertion superonasally and superotemporally and 6 mm inferonasally and inferotemporally. The 240 band was placed around the globe, under the muscles and through the sutures, and affixed using a #70 sleeve at the 2 o'clock meridian and pulled up to achieve a moderate height. The 5-0 nylon sutures were tied down. 

At this time, attention was turned to the vitrectomy. Using the 25 gauge system, trocars were placed through the sclera at a measured distance of 3.75 mm posterior to the surgical limbus at the 9:30, 2:30, and infratemporal meridians. The infusion cannula was placed inferotemporally, the tip of the cannula could be seen to be free of tissue, and the infusion cannula was turned on. Using the wide-angle lens system, the light pipe, and the microvitrector handpiece, a core pars plana vitrectomy was carried out. It was discovered that there was no remaining vitreous in the eye and apparently a vitrectomy was performed during one of the previous surgeries.

A small retinotomy was performed in the periphery, in the nasal periphery of the retina. A silicone-tip extrusion cannula was used to remove subretinal fluid, which was quite viscous. An air-fluid exchange was then performed and the retina was reattached at this point. Endolaser photocoagulation was performed along the slope of the buckle for 360 degrees and completely surrounding the retinotomy site using the following laser settings; 200 micron spot size, 0.2 seconds of exposure, 500 milliwatts of power using a total of 900 laser applications. An inferior peripheral iridectomy was performed using a vitrectomy handpiece. Silicone oil, 5000 centistokes, was then injected into the eye. The sclerotomy site where the silicone oil was injected was closed using 7-0 Vicryl sutures. The 25 gauge trocars were removed.

Saline was flushed over the cornea and conjunctiva to remove any residual silicone oil bubbles. Three mL of 0.25% Marcaine was delivered into the peribulbar space using a blunt tip cannula. The 240 band was trimmed as well as the 5-0 nylon sutures. Conjunctiva was closed using 6-0 plain gut sutures. Subconjunctival injections of Ancef and dexamethasone were delivered. Scopolamine 0.25%, Maxitrol, and Alphagan eyedrops were placed in the eye, as well as a patch and shield. The patient was awakened from general anesthesia and taken to the recovery room in the right-side-down position, having tolerated the procedure without complications.