DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Ruptured globe, left eye.
POSTOPERATIVE DIAGNOSIS: Ruptured globe, left eye.
PROCEDURE PERFORMED: Exploration and attempted repair of eye globe rupture, left eye.
SURGEON: John Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 5 mL.
DISPOSITION: To the recovery room in good condition.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old Hispanic male who was assaulted earlier this morning with possibly light perception vision in his left eye and obvious globe rupture with iris prolapsing through the inferior half of the cornea with a laceration extending from the center of the cornea horizontally into the sclera visibly approximately 2.5 mm.
DESCRIPTION OF OPERATION: After informed consent had been obtained, the patient was taken back to the operating room where cardiac and blood pressure monitoring devices were applied. The patient was gently prepped by the physician with Betadine paint for procedure of the left eye. Special care was taken not to put pressure on the globe. A lid speculum was gently inserted, and on examination, it was apparent that the laceration extended across the entire inferior one-third of the cornea from limbus to limbus and nasally into the sclera.
A 360-degree peritomy was performed taking care not to put pressure on the globe. It was evident that the laceration extended behind the lateral rectus muscle. Attempts were made to close the anterior portion of the wound by repositing the iris back into the anterior chamber and closing with interrupted sutures with 10-0 nylon, starting temporally and advancing nasally. Eleven sutures were placed to close the cornea.
Next, attention was turned toward the scleral laceration. The medial rectus was isolated using muscle hook and was imbricated with 6-0 Vicryl suture. The lateral rectus was disinserted from the globe to allow for further exploration of the wound. The wound continued posteriorly with prolapsed uvea several millimeters back to just before the optic nerve. This wound was deemed irreparable. The medial rectus was then sutured back to the globe through its original insertion, and the conjunctiva was closed with Tenon’s in a single layer fashion with 7-0 Vicryl suture.
The conjunctiva was well apposed at the end of the case and injections of 100 mg cefazolin and 4 mg dexamethasone were given into the subconjunctival space. Polysporin ointment was placed in the eye, and the eye was pressure patched. The patient was extubated and taken back to the recovery room in good condition.
