DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Limbal/corneal neoplasia concerning for conjunctival intraepithelial neoplasia versus squamous cell carcinoma of the ocular surface, left eye.
POSTOPERATIVE DIAGNOSIS: Limbal/corneal neoplasia concerning for conjunctival intraepithelial neoplasia versus squamous cell carcinoma of the ocular surface, left eye.
OPERATION PERFORMED: Excision of corneal and conjunctival lesions, left eye, with placement of amniotic membrane graft, left eye.
SURGEON: John Doe, MD
ANESTHESIA: Monitored anesthesia care with topical anesthesia.
ANESTHESIOLOGIST: Jane Doe, MD
SPECIMEN: Limbal/corneal mass from the left eye submitted to pathology.
ESTIMATED BLOOD LOSS: None.
COMPLICATIONS: None.
INDICATIONS: The patient is a (XX)-year-old male who has a mass in the left cornea, which resembles a premalignant neoplasm. The patient is aware of the risks, benefits, and alternatives to the procedure. Informed consent was obtained from the patient.
DESCRIPTION OF OPERATION: The patient was brought to the preoperative holding area, where the operative eye was marked. The patient was then brought to the operating room and placed in the supine position. EKG leads were placed. Intravenous sedation was administered by the anesthesiologist. Topical anesthesia was placed on the ocular surface of the operative eye. A subconjunctival injection of 0.75% bupivacaine and 2% lidocaine was placed in the location of the conjunctival/limbal mass. Using cotton swabs, the limbal/corneal lesion was checked for mobility; it was not mobile. The margins of the tumor were inspected clinically for areas of new involvement. The corneal edge of the lesion was outlined using a Supersharp knife to create a partial depth incision along the anterior edge of the lesion. The posterior edge of the lesion was undermined on the conjunctival side using sharp and blunt dissection, taking care not to disturb any clinically affected areas. Using the angled crescent knife, the posterior edge of the lesion was sharply dissected in the clear cornea to create a superficial keratectomy. This was extended to the previously demarcated anterior edge of the lesion, which was marked using the Supersharp knife. The entire lesion was excised and submitted to pathology. Cautery was applied to achieve hemostasis. The size of the amniotic membrane graft was estimated to be approximately 15 x 15 mm. Tisseel glue was placed on the bed of the incised area. The amniotic membrane was placed into the bed in position. At the conclusion of the procedure, the eye was watertight. The anterior chamber was deep and stable. The intraocular pressure was satisfactory. The amniotic membrane was in good position. The neoplastic tissue was submitted to pathology. The patient tolerated the procedure well and was taken to the recovery room in good condition. Sterile pad and shield were placed on the eye at the end of the procedure. The sponge and needle counts were correct at the end of the case.
