DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Nuclear sclerotic cataract, right eye.
POSTOPERATIVE DIAGNOSIS: Nuclear sclerotic cataract, right eye.
OPERATION PERFORMED: Phacoemulsification with intraocular lens placement, right eye.
SURGEON: John Doe, MD
ANESTHESIA: Local with MAC.
INDICATIONS FOR OPERATION: The patient reported decreased vision in the operative eye that interferes with activities of daily living. After discussing risks, benefits, and alternatives to surgery, the patient decided to proceed with cataract surgery in the operative eye.
The patient was examined preoperatively with complete eye exam, dilated fundus exam, and focused physical examination. The patient’s biometry, which included axial length measurements and corneal keratometry, was reviewed and the appropriate intraocular lens was chosen to give the patient the desired refractive outcome.
DESCRIPTION OF OPERATION: After appropriate consent was obtained, a surgical marking pen was used to mark the operative site. The patient was then taken to the operating room, where the patient was prepped and draped in the usual sterile fashion.
An aspirating Lieberman lid speculum was placed into the eye, and a time-out was performed confirming the patient’s name, operative procedure, operative site, proper lens, pertinent patient history, allergies, among other things. A stab incision blade was used to create a paracentesis through which was injected 1% lidocaine, preservative-free, with 1:1000 epinephrine in a 4:1 ratio.
Viscoat was then injected into the anterior chamber. Angled McPherson forceps were used to provide countertraction while a 2.2 mm steel blade was used to enter the anterior chamber. Inamura forceps were used to institute and complete a circumlinear capsulorrhexis.
BSS on a Chang cannula was used to hydrodissect and hydrodelineate the nucleus, which was seen to rotate easily. Phacoemulsification was used to remove the lens using a vertical and horizontal chop technique with a Seibel vertical and horizontal chopper as a second instrument.
Additional Viscoat was injected as needed throughout the procedure to maintain stability of the anterior chamber and protect the corneal endothelium. The epinucleus was removed with phacoemulsification using a Seibel horizontal chopper as a second instrument. I/A was used to remove residual cortical material from the capsular bag, as well as polish the posterior capsular bag using the polymer I/A tip on the capsule polish setting.
Provisc was injected into the capsular bag, and SN60WF 20.0 diopter lens was folded and injected into the capsular bag. Irrigation and aspiration was used to remove residual viscoelastic materials from the capsular bag, as well as the anterior chamber, with special attention made to remove viscoelastic materials from behind the optic. BSS on a cannula was used to hydrate the corneal wounds, as well as reform the anterior chamber. Miostat was then injected into the anterior chamber.
The wounds were then checked for leaks with a Weck-cel and fluorescein strip. There were no leaks. The lid speculum was removed. The eye received drops of prednisolone acetate 1% and Vigamox. The patient was then discharged to the postanesthesia care unit in no acute distress.
