Transscleral FNAB of Choroidal Tumor Procedure Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Probable choroidal melanoma, left eye.
POSTOPERATIVE DIAGNOSIS: Probable choroidal melanoma, left eye.
PROCEDURES PERFORMED:
1. Transscleral fine needle aspiration biopsy, FNAB, of choroidal tumor, left eye.
2. Implantation of radioactive iodine-125, left eye.
SURGEON: John Doe, MD
ANESTHESIA: Local/MAC.
DESCRIPTION OF OPERATION: This patient was brought to the operating room and was positioned on the operating room table. Cardiac and blood pressure monitoring devices were applied. Intravenous sedatives were administered, and a retrobulbar injection was administered to the left eye without complications. The patient was prepped and draped in the usual fashion for a procedure of the left eye. A lid speculum was inserted between the lids to expose the eye. A conjunctival peritomy was created with Westcott scissors and the subconjunctival connective tissues were dissected down the bare sclerae in the four quadrants with a curved Stevens scissors.
Using a Gass muscle hook, separate 4-0 black silk sutures were passed behind the insertions of the superior and inferior rectus muscles to serve as traction sutures during the procedure. The belly of the lateral rectus muscle was secured near its insertion with a double-armed double locking 5-0 Vicryl suture. The muscle was then disinserted from the sclera with Wescott scissors. A 4-0 black silk suture was passed into the stump of the lateral rectus muscle in a baseball stitch fashion to serve as an additional traction suture during the procedure.
Inspection of the sclera immediately posterior to the insertion of the lateral rectus muscle showed no evidence of transcleral tumor extension. Ocular transillumination was performed at this time to cast a shadow of the peripheral choroidal tumor onto the sclera just up and posterior to the insertion of the lateral rectus muscle. The position of the margins of the shadow was marked on the sclera with a sterile marking pen. A dummy 14 mm diameter plaque was positioned overlying the tumor shadow as marked on the sclera. Four 5-0 nylon sutures were placed as plaque fixation sutures relative to four arms of the dummy plaque. The dummy plaque was removed.
At this time, the biopsy was performed in the following manner. A triangular shaped incision with vertical incision parallel to the insertion of the lateral rectus muscle insertion but just posterior to it and a radial incision extending posteriorly from the inferior margin of the initial incision was created on the sclera just posterior to the lateral rectus muscle incision. Using a 57 Beaver blade, a lamellar scleral flap was raised at the triangular site. Fine needle aspiration biopsy of the choroidal tumor was then performed using 25 gauge short hollow lumen needles connected via a sterile connector tubing to an aspirating 10 mL syringe. The surgeon placed the tip of the needle through the sclera and into the substance of the tumor.
Aspiration was then performed by the surgical assistant repeatedly with slight movement of the tip of the needle by the surgeon during this process. The needle was withdrawn from the eye, and the specimen was passed off the table for pathologic processing. The procedure was repeated two times, each with a different needle and each sampling at slightly different area. Once the third biopsy had been completed, the lamellar scleral flap was closed with multiple interrupted sutures of 7-0 Vicryl. The active radioactive plaque was then placed over the tumor shadow as marked on the sclera. The four plaque fixation sutures were passed through the holes in the respective arms with the plaque and tied securely.
The lateral rectus muscle was left in hang-back position over the plaque and was secured with double-armed double locking 6-0 Vicryl suture to the sclera just anterior to the plaque. The conjunctiva was closed with interrupted sutures of 7-0 Vicryl. The traction sutures were cut and removed. The lid speculum was removed. Bacitracin-polymyxin ointment was applied to the surface of the eye. The lids were patched with a double eye pad and lead shield dressing. The patient tolerated the procedure well. The patient was transferred to his inpatient room immediately following the transscleral fine needle aspiration biopsy, FNAB, of choroidal tumor for radiation monitoring and postoperative care.
