DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Senile immature cataract, right eye.
POSTOPERATIVE DIAGNOSIS: Senile immature cataract, right eye.
OPERATION PERFORMED: Extracapsular cataract extraction of the right eye using phacoemulsification with the insertion of a posterior chamber intraocular lens.
SURGEON: John Doe, MD
ANESTHESIA: Local using a solution of equal parts of 2% Xylocaine and 0.75% Marcaine. The patient was also given general anesthesia standby.
INDICATIONS FOR PROCEDURE: To improve right eye vision.
DESCRIPTION OF OPERATION: After the patient was given a peribulbar local anesthetic injection, he was routinely prepped and draped. Steri-Strips were used to separate the right eyelids. A Superblade was used to enter the eye from the 9 o'clock and 2 o'clock positions. Healon 5 was injected into the anterior chamber. VisionBlue dye was also injected into the anterior capsule of the lens to stain it. The 2.8 mm metal knife blade was used to enter the eye from the superior temporal quadrant. The anterior capsule was broken with a bent-tip 26 gauge needle and a capsulorrhexis was performed with the Utrata forceps. Hydrodissection was carried out with balanced salt solution. The micro tip of the Cavitron unit was then used to emulsify and remove the lens nucleus using a cracking technique. The remaining lens material was removed with an irrigation/aspiration tip. Healon 5 was injected into the capsular bag and into the anterior chamber. A foldable intraocular lens made by Alcon, SN60WF, was injected into the capsular bag using a shooter. The irrigation/aspiration tip was then placed under the intraocular lens and into the capsular bag to remove the Healon 5. The remaining Healon 5 was removed from the anterior chamber. Miostat was injected to constrict the pupil. The corneal wound appeared to be watertight, so no suture was used. The eye was irrigated with 20 mg of kanamycin and 0.5 mL of Celestone. Maxitrol ointment was instilled. The Steri-Strips and drapes were removed. The eye was covered with a dry dressing and a Fox metal shield. The patient tolerated the procedure very well and left the operating room in good condition.
