DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Nuclear cataract, right eye.
2. Astigmatism, right eye.
POSTOPERATIVE DIAGNOSES:
1. Nuclear cataract, right eye.
2. Astigmatism, right eye.
OPERATIONS PERFORMED:
1. Phacoemulsification with posterior chamber intraocular lens implant, right eye.
2. Limbal relaxing incision, right eye.
SURGEON: John Doe, MD
ANESTHESIA: Topical with monitored anesthetic care.
ANESTHESIOLOGIST: Jane Doe, MD
INDICATIONS FOR OPERATION: This is a (XX)-year-old female who presents with decreased vision. The patient stated that she is having difficulty reading as well as driving and was found with a nuclear cataract and astigmatism of the right eye. Informed consent was obtained from the patient.
DESCRIPTION OF OPERATION: The patient was pretreated with topical dilating agents, antibiotic, nonsteroidal drops, and anesthetic gel to the right eye. After adequate anesthesia and dilation, the patient was brought to the operating room where the right eye was sterilely prepped and draped in the usual fashion for intraocular surgery, including 5% Betadine into the cul-de-sac for one minute and draping of the lid margins and lashes well away from the operative field. A lid speculum was placed between the eyelids and the microscope positioned over the eye and used for guidance throughout the procedure.
The predetermined limbal relaxing incisions were then marked on the cornea with the surgical marker, then incised perpendicular to the cornea at the surgical limbus with the Nichamin using the Thornton ring for fixation.
A paracentesis was then created with a 1 mm diamond blade, and 0.5 mL of 1% unpreserved lidocaine was injected into the anterior chamber. Viscoat was then used to deepen the anterior chamber and to enlarge the pupil.
The 2.8 mm diamond keratome was then used to create a temporal wound, carrying it 2 mm within the corneal stroma before entering the anterior chamber. Continuous curvilinear capsulorrhexis was then created. The lens nucleus was then hydrodelineated and hydrodissected. The lens nucleus was rotated. The lens nucleus was then divided in the middle, and the nucleus removed in standard stop-and-chop fashion. The epinucleus was then removed with phacoemulsification. The cortex was then removed with irrigation and aspiration. The injectable lens was then placed into the posterior capsule under viscoelastic. The viscoelastic was then removed, and the wound hydrated and found to be watertight. Vigamox and Acular LS drops were then instilled into the eye, and the lid speculum was removed. A clear eye shield was then taped over the eye. The patient was transferred to the recovery room in good condition.
