DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
Ruptured globe, left eye; status post ocular penetrating
trauma, left eye; mild cataract, left eye; vitreous hemorrhage, left eye; possible
retinal detachment, left eye.
POSTOPERATIVE DIAGNOSES:
Ruptured globe, left eye; status post ocular penetrating
trauma, left eye; cataract, left eye; vitreous hemorrhage, left eye; retinal
detachment, left eye; perforating scleral injury, left eye; intraocular foreign
body, left eye.
OPERATION PERFORMED:
A 20-gauge vitrectomy, left eye; removal of intraocular
foreign body, left eye; repair of scleral laceration, left eye; removal of
vitreous hemorrhage, left eye; repair of retinal detachment, left eye; air-fluid
exchange, left eye; silicone oil vitreous substitute air exchange, left eye; indirect
laser placement, left eye.
SURGEON: John Doe , MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION:
The patient was identified in the holding area and dilating drops were
placed in his left eye. He was brought back to the operating room and placed
supine on the operating room table. General anesthesia was initiated, and a
retrobulbar block using only a few mL of 2% lidocaine and 0.75% Marcaine was
given to his left eye. No digital pressure was applied following the
retrobulbar block in case that there was an additional scleral laceration. The
left eye was then prepped and draped in the usual sterile fashion. The
operating microscope was brought into position, as well as the 20-23-gauge
vitrectomy system. A 360-degree conjunctival peritomy was performed. Each of
the 4 quadrants were spread using the Stevens scissors. The rectus muscles were
isolated with 2-0 black silk suture ties. The globe was explored and a large
scleral laceration under the lateral rectus muscle was identified. The lateral
rectus muscle was removed at its insertion and the scleral laceration repaired
using 8-0 nylon interrupted sutures. There was vitreous presentation at the
laceration site. This was removed gently using the Weck-cel technique. The
intraocular foreign body was found at the distal end of the wound. The metallic
foreign body was sent to pathology. The lateral rectus muscle was then
resutured to the sclera. The indirect ophthalmoscope was used to inspect the
retina and vitreous. View was obscured by the vitreous hemorrhage. Since it was
felt that there was retinal incarceration within the wound and likely retinal
detachment, the decision was made to perform the vitrectomy. The 23-gauge
cannulas were placed. The infusion trocar was verified and the infusion
pressure turned on to 20 mmHg. Two additional trocars were placed at the 10 and
2 o'clock positions. No light pipe or Microvit were used to enter the eye. With
the assistance of intravitreal Kenalog for visualization, the central vitreous
and vitreous hemorrhages were removed. There was retinal detachment found,
which did involve the macula. Fortunately, the scleral laceration only extended
to the temporal edge of the macula and did not involve the fovea. There was
loss of overlying choroid and RPE in the area of the scleral laceration site.
Using intraocular diathermy and the Microvit, the retina was removed from the
sites of incarceration. Perfluoron was then used to flatten the retina and
laser placed along the edges of the previously incarcerated retina using the
indirect ophthalmoscope attachment. A Perfluoron air exchange was performed
followed by a silicone oil vitreous substitute air exchange. I noted that the
optic nerve appeared healthy. The sclerotomies were closed and the eye left
watertight at a pressure of approximately 20 mmHg. Then, 0.2 mL of intravitreal
Kenalog was placed to hopefully prevent formation of proliferative
vitreoretinopathy postoperatively. Subconjunctival injections of vancomycin and
dexamethasone were given as well. The corneal epithelium was decompensating
towards the end of the case, but fortunately no corneal scraping was required.
The conjunctiva was closed using 8-0 Vicryl suture. A patch and shield and
TobraDex ointment were placed over the patient's left eye. The patient will be
admitted for postoperative positioning and will be seen in one day for followup.
Rectus Recession Operative Sample Report Entropion Repair Operative Sample ReportOphthalmology Operative Samples # 1 Ophthalmology Operative Sample Reports #2
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