DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Epiretinal membrane, cystoid macular edema, right eye.
POSTOPERATIVE DIAGNOSIS: Epiretinal membrane, cystoid macular edema, right eye.
OPERATION PERFORMED: Vitrectomy, membranectomy, right eye.
SURGEON: John Doe, MD
ANESTHESIA: Local monitored.
COMPLICATIONS: None.
ANESTHESIOLOGIST: Jane Doe, MD
INDICATIONS FOR OPERATION: This (XX)-year-old gentleman has progressive loss of central vision in the right eye with a visual acuity of 20/60. He has an epiretinal membrane in the right macula. We discussed with the patient the risks, benefits, and alternatives of surgery to the right eye. He did wish to proceed with the surgery, and he signed the informed consent.
DESCRIPTION OF OPERATION: The patient was taken to the Same Day Surgery Operating Room, and local anesthesia was administered to the right eye using a 50:50 mixture of 2% lidocaine and 0.75% Marcaine delivering 4 mL into the retrobulbar space using 27-gauge Atkinson needle. After good akinesia and anesthesia was achieved, the face was prepped and draped in the usual sterile ophthalmic fashion, and the lid speculum was placed in the right eye.
Using the 25-gauge system, trocars were placed through the conjunctiva and sclera at a measured distance of 3.75 mm posterior to the surgical limbus at the 9:30, 2:30, and infratemporal meridians. The infusion cannula was placed infratemporally, the tip of the cannula could be seen to be free of tissue, and the infusion cannula was turned on.
Using the wide-angle lens system, the light pipe, the microvitrector handpiece, a core pars plana vitrectomy was carried out. The posterior hyaloid was excised, and the vitrectomy was carried out to the periphery for 360 degrees.
Using the macular contact lens and intraocular forceps, the macular epiretinal membrane was carefully peeled off the surface of the retina in one continuous sheet. There were no retinal hemorrhages or tears created. Indirect ophthalmoscopy with scleral depression was performed for 360 degrees. There were no peripheral retinal holes or tears.
All the three trocars were removed and the overlying conjunctiva was massaged using a cotton tip applicator. Subconjunctival injections of Ancef and dexamethasone were delivered. Scopolamine 0.25%, Maxitrol, and Alphagan eye drops were placed in the eye, as well as a patch and shield.
The patient was taken to the recovery room having tolerated the procedure without complications.
