DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Retinal detachment, right eye, with giant retinal tear.
POSTOPERATIVE DIAGNOSIS: Retinal detachment, right eye, with giant retinal tear.
PROCEDURE PERFORMED: Trans pars plana vitrectomy, Perfluoron endo panretinal photocoagulation, right eye.
SURGEON: John Doe, MD
ANESTHESIA: Retrobulbar, standby.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old Hispanic gentleman with 20/60 acuity in his right eye, retinal detachment, and giant retinal tear. The patient was informed of the diagnosis, risks, benefits of surgery, and alternatives to surgery. After having his questions answered to his satisfaction, the patient gave informed consent to proceed with surgery. The patient stated understanding the fact that a second procedure will be needed to remove the Perfluoron.
DESCRIPTION OF OPERATION: The patient was brought into the operating room and placed supine position on the operating table. Blood pressure and cardiac monitors were placed, and the patient was then administered gentle IV sedation. He was then administered a right side inferior lid approach retrobulbar injection of 5 mL of a solution containing 1:1 mixture of 2% lidocaine without epinephrine and 0.75% Marcaine with 1 mL of hyaluronidase added. There was noted to be good akinesia and anesthesia of the eye after the block.
The patient was prepped and draped in the usual sterile fashion. Trimming the lashes, heavy wire lid speculum was inserted to maintain the right eye in open fashion. A 25 gauge infusion cannula was placed inferotemporal quadrant 4.0 mm posterior to the limbus. The tip of the cannula was directly visualized through the pupil and noted to be free of any overlying tissue. The infusion line was turned to on position. The light pipe and microvitrectomy handpiece was inserted into the eye.
Pars plana vitrectomy was performed. Vitreous and associated dense vitreous and pigmentary debris were removed from the microvitrectomy handpiece. Following clearing of the vitreous and associated debris, the fundus was inspected. Retinal detachment with giant retinal tear was identified.
Perfluoron was administered to the posterior pole with resulting retina attached from 360 degrees. The endolaser probe was inserted. Endo panretinal photocoagulation was applied to retinal periphery x360 degrees. A total of 1060 laser spots were applied with excellent effect. A single 7-0 Vicryl suture was used to close the superior temporal sclerotomy.
All instruments were removed from the eye. The eye was digitally palpated to assess intraocular pressure and found to be within normal limits. Neosporin ophthalmic solution was applied to the ocular surface. Subconjunctival injections of 100 mg of cefazolin, 20 mg of gentamicin, and 2 mg of dexamethasone were administered to the inferior subconjunctival space. Speculum and drapes were removed. A patch was applied to the patient’s eye. He left the operating room in stable condition.
