DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Macular pucker with macular hole, left eye.
POSTOPERATIVE DIAGNOSIS: Macular pucker with macular hole, left eye.
PROCEDURES PERFORMED: Pars plana vitrectomy, removal of posterior hyaloid face, epiretinal membrane peel, internal limiting membrane peel, air-fluid exchange, and injection of C3F8 gas, left eye.
SURGEON: John Doe, MD
ANESTHESIA: Local with standby.
COMPLICATIONS: None.
INDICATION FOR OPERATION: The patient is a (XX)-year-old female with a history of blurred vision for the last three to four months. On evaluation, the patient was found to have a visual acuity of 20/200 in the left eye. A macular pucker was present with a macular hole. The findings were discussed with the patient and management options were discussed. It was recommended to the patient that she undergo vitrectomy with removal of the pucker and closure of the macular hole. The necessity for postoperative face-down positioning was also discussed. The patient had an opportunity to ask questions regarding the procedure, and these were answered to her satisfaction, and the patient desired to proceed.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position on the eye table. The appropriate monitoring devices were attached. Akinesia and anesthesia were obtained using a 50/50 mixture of 2% lidocaine with 0.75% Marcaine and 1 ampule of Wydase 5 mL given in a retrobulbar fashion followed by a 5 mL lid block with good results. The patient was then prepped and draped in the usual sterile fashion, and a lid speculum was placed in the left eye.
A standard three-port pars plana vitrectomy using the 25 gauge system was prepared measuring 3.5 mm posterior to the limbus. The infusion cannula was visualized prior to commencing infusion. With the aid of the wide-angle viewing system, a pars plana vitrectomy was performed. The vitreous was removed 360 degrees out to the periphery.
The posterior hyaloid face was then elevated off the retinal surface with the vitrectomy handpiece, and this was trimmed out to the periphery. The periphery was examined. No holes or tears were noted. The high magnification contact lens was then placed on the eye, and the intraocular forceps were used to remove the macular pucker off of the surface of the retina. There was significant surface distortion with a macular hole present.
After removal of the pucker, the internal limiting membrane was peeled free of the retinal surface, peeling circumferentially around the macula. There were pinpoint hemorrhages created with removal of the ILM.
The contact lens was then removed, and the wide-angle viewing system was brought back into position, and an air-fluid exchange was performed with the vitrectomy handpiece aspirating over the optic nerve. The eye was allowed to rest for approximately four to five minutes, after which additional fluid was removed off of the optic nerve. No peripheral abnormalities were noted.
Sixty mL of C3F8 gas was exchanged with intraocular air venting via the trocar. The trocars were then removed, and additional gas was inserted to a normal palpation pressure, and the infusion cannula was removed. There was no leak noted at the site of the sclerotomies. The eye was irrigated with Neosporin ophthalmic solution. Subconjunctival injections of 2 mg of dexamethasone, 20 mg of tobramycin, and 100 mg of Kefzol were given. Topical 1% atropine was placed on the eye, and the eye was patched in the usual fashion. The patient tolerated the procedure well and was returned to same-day surgery in the prone position. The patient was instructed to maintain a prone position.
