DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Intraocular foreign body, left eye.
2. Uveitis, left eye.
3. Vitreitis, left eye.
4. Retinal edema, left eye.
POSTOPERATIVE DIAGNOSES:
1. Intraocular foreign body, left eye.
2. Uveitis, left eye.
3. Vitreitis, left eye.
4. Retinal edema, left eye.
OPERATION PERFORMED:
1. Pars plana vitrectomy with membrane peeling.
2. Removal of intraocular foreign body.
SURGEON: John Doe, MD
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
INDICATION FOR PROCEDURE: This is a (XX)-year-old woman who unfortunately had a traumatic rupture of her eye with an intraocular foreign body that was localized near the area of the ciliary body based on CT scan. After understanding all the risks and benefits, she elected for the procedure as outlined above.
DESCRIPTION OF PROCEDURE: Following informed consent, the patient was taken to the operating room suite where she was prepped and draped in the routine sterile fashion with Betadine instilled into the conjunctival fornix.
A two-port pars plana vitrectomy was established with a self-retaining infusion cannula placed in the inferotemporal quadrant. The cannula was found to move freely within the vitreous cavity prior to the administration of flow. At that time, core vitrectomy was carried out and the fibrin membranes were removed from the retinal surface. Retroillumination was used to the area within the supranasal quadrant to attempt to identify the shadow from the intraocular foreign body. There was a clear entry wound and the intraocular foreign body was within the level of the ciliary body approaching the ciliary processes. Dissection was carried down until visualization of the hemosiderin compounds was available. The rare earth magnet was used on pulse mode to engage the intraocular metallic foreign body and to remove it from the ciliary body. Intraocular tamponade was carried out through this procedure and there was no iatrogenic bleeding at that time.
Following the membrane peeling and removal of the intraocular foreign body, the sclerotomies were closed with 7-0 Vicryl suture. The cutdown wound was also closed with 7-0 Vicryl suture and the conjunctiva reapproximated with 6-0 plain gut. Injections of Ancef and dexamethasone were given. Atropine was instilled. TobraDex was applied. A light pressure patch was put into position. The patient was taken to the postoperative recovery room in stable condition. Pathology received the intraocular metallic foreign body.
The patient will continue to follow up for postoperative retinal care, and ultimately, we will have her continue with Dr. Jane Doe for all of her subsequent comprehensive ophthalmic management. Again, there were no complications during this case.
