Ophthalmology Medical Transcription Operative Sample Reports For Medical Transcriptionists

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Cataract, traumatic and mature, left eye.

POSTOPERATIVE DIAGNOSIS:  Cataract, traumatic and mature, left eye.

OPERATION PERFORMED:  Phacoemulsification and implantation of intraocular lens, left eye.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  MAC with retrobulbar.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and laid supine on the operating room table.  The patient was sedated and retrobulbar injection of 0.75% Marcaine and 1% lidocaine was made without any complications.  The patient was prepped and draped in a sterile manner for the procedure.  Prior to bringing the patient to the operating room, the patient received three sets of topical dilating, antibiotic drops.  A lid speculum was inserted to part the eyelid.  A paracentesis was made infratemporally.  The anterior chamber was filled with air and then indocyanine green to stain the anterior capsule.  The cataract was noted to be extremely mature.  A small capsulorrhexis was initiated.  Immediately, milky white fluid extruded from the capsulorrhexis opening.  A 27-gauge cannula was then used to aspirate this fluid.  The cystotome was then used to complete the capsulorrhexis.  The nucleus was gently rocked to facilitate mobility.  The phacoemulsification apparatus was introduced into the eye.  The nucleus was phacoemulsified and removed without any complications.  The remaining cortex was removed with irrigation and aspiration.  An SA60 AC 21-diopter lens was placed in the bag and the remaining viscoelastic was removed.  One interrupted 10-0 nylon suture was placed in the cornea.  The patient tolerated the procedure well.  The lid speculum was removed.  One drop of Betadine, one drop of Ciloxan and bacitracin ointment were placed into the eye and patch and shield were applied.  The patient was returned to postanesthesia care in satisfactory condition.  The patient was instructed to take the eye patch off at 6 p.m. and use the topical Vigamox and Pred Forte eye drops every 2 hours until bedtime.
 
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DATE OF OPERATION:  MM/DD/YYYY
 
PREOPERATIVE DIAGNOSIS:  Blind painful eye, right eye, with conjunctival scarring.
 
POSTOPERATIVE DIAGNOSES:
1.  Blind painful eye, right eye, with conjunctival scarring.
2.  Microcornea, right eye.
 
OPERATIONS PERFORMED:
1.  Evisceration with implant, right eye.
2.  Conjunctivoplasty, right eye.
3.  Frost suture for temporary tarsorrhaphy.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  None.
 
ANESTHESIA:  General.
 
ESTIMATED BLOOD LOSS:  Minimal.
 
COMPLICATIONS:  None.
 
DESCRIPTION OF OPERATION:  With the patient in the supine position, in the operating room, after satisfactory anesthesia had been achieved, the patient was prepped and draped for surgery in the usual sterile manner.  One gram first-generation cephalosporin was given during the surgery intravenously.  A lid speculum was placed and peritomy was performed as best as possible given severe perilimbal scarring.  We then initiated the conjunctivoplasty, carefully unrolling and dissecting the conjunctiva back around the muscle insertion to carefully release scar bands and to maximize the length of the conjunctiva, to maximize the sizes of the fornices.
 
After this meticulous procedure had been performed and hemostasis assured, we then entered the posterior limbus with a Supersharp knife and excised the corneoscleral button.  We then carefully eviscerated the intraocular contents and scraped the scleral bag.  Meticulous hemostasis was assured with electrocautery.  Q-tips were used to remove residual retinal and uveal fragments.  A 61-mm sphere was seen to fit in the bag without undue tension.
 
Once hemostasis was assured, we then closed the sclera with interrupted #4-0 Vicryl horizontal mattress sutures overlapping sclera about 3 mm and burying the knots.  We then removed small dog ears medially and laterally, as a relaxing incision of the sclera.  Further relaxing incisions were made in the posterior sclera.  Subsequently, we then reclosed Tenon and conjunctiva in a single layer with a running #6-0 chromic suture.
 
At the end of the procedure, after hemostasis was assured, sterile Polysporin Ophthalmic ointment was applied along with medium-sized conformer, which was seen to fit nicely.  This was followed by Frost suture consisting of #6-0 silk going to the tarsal plates of the upper and lower eyelids to achieve temporary eyelid closure.  This was followed by a pressure patch.  The patient was then returned to the recovery room in good condition.



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