DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Microphthalmos with uveal effusion syndrome, left eye.
2. Dense cataract limiting visualization of the posterior segment, left eye.
3. Possible retinal detachment, left eye.
POSTOPERATIVE DIAGNOSES:
1. Microphthalmos with uveal effusion syndrome, left eye.
2. Dense cataract limiting visualization of the posterior segment, left eye.
3. Retinal detachment with extensive subretinal hemorrhage and advanced proliferative vitreoretinopathy, left eye.
OPERATION PERFORMED:
1. Pars plana vitrectomy.
2. Pars plana lensectomy, use of iris hooks.
3. Membrane peel, use of Perfluoron liquid.
4. Fluid-air exchange and endolaser and silicone and oil ejection, all done in the left eye.
SURGEON: John Doe, MD
ANESTHESIA: Retrobulbar with monitored anesthesia care.
COMPLICATIONS: None.
INDICATION FOR OPERATION: The patient is a (XX)-year-old gentleman with a long history of poor visual acuity in both eyes due to microphthalmos. He subsequently, however, developed uveal effusion syndrome with severe decreased visual acuity in his left eye. He underwent a previous scleral dissection with drainage of the corneal detachment in his left eye a few weeks earlier.
Although he showed some slight improvement of the corneal detachment following this procedure, he showed persistent decrease of his visual acuity to bare light perception/no light perception level. A posterior segment evaluation was not possible through his dense cataract. A posterior segment ultrasonography showed some decrease in the height of the corneal detachment but showed some irregular membrane formation posteriorly. This suggested the possibility of retinal detachment.
Surgical intervention with intraocular management, including vitrectomy and lensectomy, was discussed with the patient. After reviewing the risks, benefits, and alternatives of this procedure, the patient agreed to proceed with the surgery. The guarded prognosis for visual recovery considering the severe nature of his condition was explained in detail prior to surgery.
DESCRIPTION OF OPERATION: The patient was brought back to the ophthalmic operating room where appropriate blood pressure and cardiac monitoring was established. The patient underwent retrobulbar injection of 4% lidocaine and 0.75% Marcaine in a 1:1 mix under mild IV sedation. The patient was then prepped and draped in typical sterile fashion for ophthalmic surgery.
Superior nasal and temporal conjunctival peritomies were then created. Hemostasis was then obtained using cautery. An infusion cannula was then inserted in the inferior temporal quadrant approximately 3 mm posterior to the limbus. At this point, the infusion cannula could not be directly visualized due to the dense cataract, and posterior infusion was not initiated.
The MVR blade was then used to make superonasal and superotemporal sclerotomies, again approximately 3 mm posterior to the limbus. Because of his severely constricting pupil, iris hooks were placed in order to allow further dilation of the pupil. Four iris hooks were placed in this process allowing improved visualization through the now dilated pupil.
At this point, balanced saline solution was used to hydrate the lens nucleus. An anterior effusion needle was then inserted into the central lens nucleus, and the Fragmatome was used to remove the lens material. Once the central nucleus had been removed, the peripheral cortex was dissected using the vitrectomy instrument. All of the residual capsule material was removed using the vitrectomy instrument in this process. Once the dense cataract had been removed, there was improved visualization posteriorly. The posterior infusion cannula was now visualized, and posterior effusion was initiated as it was in good position.
At this point, the light pipe and vitrector were inserted into the eye, and a core vitrectomy was performed under wide-field visualization using the BIOM lens system. The central core vitreous was densely hemorrhagic. The hemorrhagic core vitreous was now removed in this process. After removing some of the central hemorrhage, the detached retina was now identified. There was extensive preretinal proliferative vitreoretinopathy. There was also a very dense subretinal and suprachoroidal hemorrhage. There was extensive hemorrhage at 360 degrees beneath the retina.
At this point, the vitrectomy instrument was used to carefully dissect all of the vitreous centrally. Vitreous dissection was then carefully extended out into the periphery. Once adequate vitreous dissection was completed, intraocular forceps were used to peel several large bands of surface membranes around the optic nerve and macular region. This allowed some central relaxation of the retina once this maneuver was performed.
At this point, reinspection was performed. It was evident that there was an extensive subretinal and suprachoroidal hemorrhage as a component of his uveal effusion syndrome. A large retinal tear was also identified temporally.
At this point, the retinal tear was enlarged using the vitrectomy instrument. Hemostasis was confirmed along the edge of this retinectomy using the diathermia.
At this point, large clumps of hemorrhage were evacuated from the subretinal space using the vitrectomy instrument through this large retinal tear. An extensive amount of subretinal hemorrhage was removed in this process. There was a significant relaxation of the retina once this was done. Because there was increased mobility of the posterior retina at this point, Perfluoron liquid was injected into the eye to stabilize the posterior pole.
At this time, there still remained a large amount of hemorrhagic material beneath the retina nasally. A drainage retinotomy was then created using the diathermia. This was enlarged using the vitrectomy instrument. Hemostasis along this area was again confirmed using cautery. The vitrectomy instrument was again used to aspirate a significant amount of hemorrhagic material from the subretinal space in this process. This was done through the newly created retinotomy. There was again significant relaxation of the retina once this was done.
At this point, reinspection was performed, and several membranes were identified along with the subretinal space. These membranes were adherent to the underside of the retina. Intraocular forceps were used to grasp and peel these membranes both temporally and nasally through the previously described retinotomies.
At this point, no further membrane peeling was possible. As much of the subretinal hemorrhage was evacuated as possible. A complete air-fluid exchange was then performed. This was done by aspirating the subretinal fluid through the previously described retinotomies. Once the retina was reattached, the Perfluoron liquid was aspirated from the vitreous cavity. The retina remained completely attached at this point. Endolaser photocoagulation was then scattered at 360 degrees in the periphery. Laser was carefully applied along with the large retinotomies both nasally and temporally. The retina remained flat throughout this entire process without significant contraction. After this was done, additional fluid was aspirated from the vitreous cavity ensuring a complete gas fill.
At this point, the iris hooks were removed. The anterior chamber was reinflated and the pupil constricted using Miochol solution. An inferior iridectomy was then created using the vitrectomy instrument. The superonasal sclerotomy was then closed using a 7-0 Vicryl suture. A 7-0 Vicryl suture was then preplaced across the temporal sclerotomy. Then, 1000 centistoke silicone oil was injected into the vitreous cavity. Once there was a complete oil fill, the temporal sclerotomy was closed using a 7-0 Vicryl suture. The infusion cannula was then removed, and the sclerotomy was also closed using a Vicryl suture.
All the wounds were reinspected and confirmed to be well sealed, and the eye had appropriate intraocular pressure. There was no significant prolapse of the oil into the anterior chamber at this point. Indirect ophthalmoscopy was again performed at this point and confirmed the retina to be completely attached with good laser treatment.
At this point, the conjunctiva was then reapposed using a 7-0 Vicryl suture. Subconjunctival injection of antibiotics and Solu-Medrol was then performed. Sub-Tenon’s Kenalog injection was performed for chronic postoperative inflammation control. Antibiotic ointment was then placed in the eye, and the eye was patched in typical fashion for ophthalmic surgery.
The patient tolerated the procedure well and was transferred to the recovery room in good condition. Proper postoperative management was reviewed with the patient prior to discharge. The extremely guarded prognosis for visual recovery considering extensive posterior segment changes was explained in detail to the patient.
