DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Right eye corneoscleral laceration.
2. Uveal prolapse, right eye.
3. Vitreous prolapse, anterior chamber, right eye.
4. Traumatic cataract, right eye.
POSTOPERATIVE DIAGNOSES:
1. Right eye corneoscleral laceration.
2. Uveal prolapse, right eye.
3. Vitreous prolapse, anterior chamber, right eye.
4. Traumatic cataract, right eye.
OPERATIONS PERFORMED:
1. Repair of complex corneoscleral laceration, right eye.
2. Resection of prolapsed uveal tissue, right eye.
3. Anterior vitrectomy for vitreous prolapse, right eye.
4. Injection of intracameral antibiotics, right eye.
5. Partial aspiration of traumatic cataract, right eye.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia.
ANESTHESIOLOGIST: Jane Doe, MD
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: None.
COUNTS: Needle and sponge counts were correct at the end of the case.
DISPOSITION: The patient will be admitted for observation and postoperative care.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old female who presented with a complex corneoscleral laceration to the right eye. The patient’s preoperative vision measured at count fingers at 1 foot in the right eye. The patient’s preoperative examination disclosed flat anterior chamber with vitreous prolapse and a traumatic cataract. The patient elected to undergo operative repair of the right eye penetrating ocular injury.
DESCRIPTION OF OPERATION: The patient was brought to the main operative room, where the operative eye was marked. The patient was brought to the operating room and placed in the supine position. EKG leads were placed. Intravenous sedation was administered. General anesthesia was induced without complication. The ocular surface and periorbital skin of the operative eye were disinfected and draped in the standard fashion for eye surgery. A lid speculum was placed. A time-out was called. Additional topical anesthesia was placed on the ocular surface of the operative eye.
Viscoelastic was injected into the anterior chamber with complex corneoscleral laceration. The 9-0 nylon was used to approximate the limbus. Interrupted 10-0 nylon sutures were used to repair the complex corneal laceration.
Next, Westcott scissors were used to create an inferior peritomy. Full extent of the scleral laceration was visualized. Interrupted 9-0 nylon sutures were used to close the scleral aspect of the laceration. Uveal prolapse was seen through the inferior scleral laceration. Uvea was repositioned and uvea that could not be repositioned was resected.
Next, two paracenteses were made at the 9 o’clock and 3 o’clock positions. An anterior vitrectomy was performed for vitreous prolapse. A traumatic cataract was visualized in the anterior chamber, and the traumatic cataract was partially aspirated with a 27-gauge cannula.
Next, intracameral clindamycin, vancomycin, and ceftriaxone antibiotic were administered. The chamber was filled with balanced salt solution. A physiologic pressure was achieved. The paracenteses were sutured with 10-0 nylon suture. All suture knots were buried.
The wounds were checked and were felt to be watertight. The anterior chamber was deep. The intraocular pressure was satisfactory. The lid speculum was removed. Gentamicin ointment was placed on the operative eye followed by sterile patch and shield.
The patient tolerated the procedure well and was taken to the recovery area in good condition. The surgeon performed the entire procedure.
