Ophthalmology Medical Transcription Operative Sample Reports For Medical Transcriptionists


OPERATIONS PERFORMED:

1.  Ahmed glaucoma valve, right eye.
2.  Scleral graft, right eye.

DESCRIPTION OF OPERATION:  The patient was given a local anesthetic in the holding area as follows.  After intravenous sedation, 6 cc of 2% Xylocaine with epinephrine was injected in the form of a modified Van Lint block followed by peribulbar injection of 3 cc of 4% Xylocaine and Wydase.  A Honan balloon was applied at 30 mmHg pressure and left in place for 15 minutes.  He was taken to the operating suite where the Honan balloon was removed.  He was prepped and draped in the standard fashion for ocular surgery.  During the prep, he was doing a lot of coughing.  I decided that it would be better to put an Ahmed tube and plate in because of the coughing.  The eyelids were parted with a Maumenee-Park lid speculum.  A 4-0 silk superior rectus bridle suture was placed.  The eye was infraducted.  A peritomy was performed 4 mm from the limbus in the superotemporal quadrant.  Conjunctiva and tenons were dissected posteriorly, and the intramuscular septum was penetrated and Ahmed tube and plate were inspected.  The valve was primed with balanced salt solution.  The plate was inserted through the peritomy and teased posteriorly to a point 10 mm posterior to the surgical limbus.  It was sutured into position with two 8-0 nylon sutures.

The tube was extended anteriorly overhanging the limbus.  The tube was cut to length.  A paracentesis was performed infratemporally.  The anterior chamber was then entered with a 23-gauge needle.  The tube was inserted through the opening and it centered in the anterior chamber nicely.  The tube was anchored to the sclera with two 8-0 nylon sutures.

A specimen of sclera was obtained and rehydrated.  A 5-mm graft was cut free and this was sutured over the tube with four 7-0 Vicryl sutures.  Tenons were then closed with 2 interrupted 7-0 Vicryl sutures and conjunctiva was closed with a running horizontal mattress 7-0 Vicryl.  The anterior chamber was soaked with Amvisc, 2 mg of Decadron was injected subconjunctivally.  The eye was dressed with atropine 1% solution, Dexacine ointment, and mild pressure patch and shield.  He tolerated the procedure well.  There were no complications.  He was taken to the discharge area in stable condition.

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OPERATIONS:

1.  Right and left upper lid levator advancement repair.
2.  Right and left upper lid functional blepharoplasty.

DESCRIPTION OF OPERATION:  In the operating room, in the supine position, bilateral upper eyelid crease incisions were marked off 8 mm above the lid margin and carried appropriately medially and laterally.  Mark was then made 11 mm below the brow line.  Using a pinch technique, in the supine position, ascertained that lagophthalmos would not develop.  We then carefully marked off excision between the lid crease and the superior mark, and again using pinch technique, we ascertained that lagophthalmos would not develop.  After mild sedation was achieved, each upper eyelid was infiltrated with 2 mL of local anesthetic with epinephrine and the patient was prepped and draped in the usual sterile ophthalmic fashion.  The incisions were marked on both sides and the skin and muscle were resected keeping the septum intact.  We then widely opened the septum just above insertion into the levator, on the right, and then gently dissected the preaponeurotic fat off the levator aponeurosis.  The fat was teased away from the levator aponeurosis superiorly to expose the aponeurosis.  Hemostasis was assured with electrocautery.  We then exposed the anterior tarsal surface, on the right, using Westcott scissors and placed a #6-0 nylon suture 2 to 3 mm below the superior tarsal border at 90% depth through the tarsus, over the proposed lid peak.  We then brought this up to ever-advancing edges of the levator aponeurosis until, when it was tied off, we had good lid height and lid curve as we wished.  We then performed symmetric procedure on the contralateral side.  After meticulous hemostasis was again assured with electrocautery, we then enclosed each of the incisions with a combination of interrupted and running #6-0 fast-absorbing gut sutures.  Sterile antibiotic ointment and dressing were applied and the patient was then carefully taken from the operating room in satisfactory condition.

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OPERATION:  Bilateral indirect retinal laser photocoagulation.

DESCRIPTION OF OPERATION:  After full explanation of the risks, benefits, and alternatives of surgery that were explained to the parents that included but not limited to cataract, foveal burns, intractable retinal detachment, vitreous hemorrhage, and blindness, informed consent had been obtained via the mother.

The infant was brought to the operating room and identified by the attending surgeon.  Following administration of general endotracheal anesthesia by the anesthesia staff, a lid speculum was placed over the right eye, and indirect laser photocoagulation was applied to the avascular peripheral retina for a total of 3000 spots using 150 to 200 milliwatt power at 0.1 second duration.  Maxitrol ointment was placed over the eye, and the lid speculum was transferred to the left eye where the identical procedure was done for a total of 2446 spots.  The lid speculum was removed from the eye, and the eye was then treated with Maxitrol ointment.  The baby was then transported back to the neonatal intensive care unit in satisfactory condition with all vital signs stable in the intubated state.  There were no complications noted, and all instruments were accounted for.  The parents were personally spoken with, with regards to the surgery.  The baby will be reexamined as an inpatient in 1 week.

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OPERATION:  Orbitotomy on the right with biopsy of right lacrimal gland.

DESCRIPTION OF OPERATION:  The patient was brought to major operating room where general ET anesthesia was induced.  Lateral lid crease of the right eye was marked, and I marked the incision to extend lateral to the lateral canthus in case a lateral orbitotomy became necessary, pending the biopsy.  The area of the lateral upper lid, beyond the lateral canthus, was injected with approximately 5 cc of 50:50 mix of 2% Xylocaine with 1:100,000 epinephrine, 0.75% Marcaine with 1:100,000, epinephrine.  He was prepped and draped in the usual manner for sterile oculoplastic surgery. 

Attention was turned to the right upper lid.  A lateral lid crease incision was made with a 15 blade.  Dissection was carried down through the orbicularis to the superior orbital rim using the Colorado needle.  The periosteum of the superior and lateral orbital rim was incised with the Colorado needle.  Freer elevator was then used to reflect the periorbital off the lateral orbital wall and lateral orbital roof.  Prior to proceeding with the orbital dissection, a 4-0 silk suture was placed on the insertion of the lateral rectus muscle for traction to better identify lateral rectus if an orbitotomy became necessary. 

It was obvious, as the periorbital and lacrimal gland was lifted off the superotemporal orbit, that the lacrimal gland was enlarged with an infiltrative mass.  Periosteum was opened near the posterior third of the mass and a modest biopsy was taken.  It was then opened at the anterior edge and a biopsy was taken from this portion.  Clinically, the biopsies looked like a lymphomatous infiltrate.  These were sent for frozen section, and frozen section did reveal lymphomatous infiltrate consistent with non-Hodgkin lymphoma.  Because of the need for special studies, more tissue was excised and pretty much as much of the infiltrative mass that was safely excisable was excised. 

Bleeders were cauterized with the Colorado needle and the use of cottonoids saturated with 1:100,000 epinephrine.  After adequate hemostasis was obtained, the 4-0 silk was removed from the lateral rectus muscle.  The periosteum was closed with 2 interrupted 5-0 Vicryl, and the skin was closed with a running 5-0 fast-absorbing gut.  Polysporin ointment was placed in the right eye and along the wound.  He was awakened and taken to the recovery room in good condition.  Estimated blood loss less than 10 cc.  He tolerated the procedure well without complications.


 
OPERATION PERFORMED:

1.  Pars plana vitrectomy, right eye. 
2.  Membrane peel, right eye.
3.  Endolaser, right eye.
4.  Intravitreal Kenalog injection, right eye.

DESCRIPTION OF PROCEDURE:  The patient was brought back to the ophthalmic operating room where appropriate blood pressure and cardiac monitoring were 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 inserted in the inferotemporal quadrant, approximately 3.5 mm posterior to the limbus.  The infusion cannula was confirmed to be in appropriate position prior to initiating infusion.  The MVR blade was then used to make superior nasal and superior temporal sclerotomies.  The light pipe and the vitrector were inserted into the eye and a core vitrectomy was performed under wide field visualization using the BIOM lens system.  There was no evidence of a pre-existing posterior vitreous detachment.  Therefore, the vitrectomy instrument was used to engage the posterior cortical vitreous around the optic nerve and induce a complete PVD.  Once this was done, the posterior cortical vitreous was dissected using the vitrectomy instrument.  Vitreous dissection was then extended out to the periphery as far as safely possible. 

At this point, the taut posterior hyaloid had been removed, but there was a residual epiretinal membrane.  Membrane peeling was then initiated.  Several drops of Kenalog were then placed on the macular surface.  The loose Kenalog was then aspirated from the eye.  A Tano membrane scraper was then used to elevate a dense epiretinal membrane from the inferior macula.  The membrane was then elevated further across the superior macula using the scraper.   Intraocular forceps were used to peel this large continuous sheet of membrane from the surface of the entire macula.  There was significant relaxation of the retina following removal of the membrane.  A small residual of tough neovascular membrane was then removed from the optic nerve head.  Once this was done, membrane peeling was completed. 

Endolaser photocoagulation was then applied, 360 degrees, in the retinal periphery.  This was applied to complete a typical panretinal laser photocoagulation pattern. 

After adequate laser application was completed, plugs were placed in each of the sclerotomies and indirect ophthalmoscopy was performed.  There was no evidence of peripheral retinal tear or retinal detachment.  At this point, the superior nasal and superior temporal sclerotomies were closed using a 7-0 Vicryl suture.  The infusion cannula was then removed and this sclerotomy was also closed using the Vicryl suture. 

Intraocular injection of 4 mg of Kenalog was then performed using a needle inserted through the pars plana.  After this was done, all the wounds were reinspected, confirmed to be well sealed and the eye had an appropriate intraocular pressure.  At this point, the conjunctiva was re-apposed using the 7-0 Vicryl suture.  A subconjunctival injection of antibiotics and Solu-Medrol was then performed.  Antibiotic ointment was then placed in the eye.  Then, the eye was patched in typical fashion for ophthalmologic 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.

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OPERATION:  Right inferior oblique recession, 4 mm posterior and 2 mm lateral to the temporal border of the right inferior rectus insertion.

DESCRIPTION OF THE PROCEDURE:  After informed consent was obtained from the patient, the patient was identified by the surgeon and brought to the operating room.  IV lines were started.  General anesthesia was induced.  The patient was prepped and draped in the usual fashion.  A lid speculum was placed in the right eye.  Forced ductions were performed.  No significant restrictions were found.  An incision was made in the inferotemporal quadrant down to bare sclera using Westcott scissors.  The lateral rectus muscle was isolated with a large Jameson muscle hook.  A #4-0 silk traction suture was placed around the lateral rectus muscle, and this was affixed to the drape superiorly.  The inferior rectus muscle was isolated with a large Jameson muscle hook.  A Desmarres retractor was placed to retract conjunctiva.  The inferior oblique muscle was directly visualized.  The inferior oblique muscle was isolated with multiple passes of a small and large muscle hook.  Care was taken to ensure complete isolation of all the muscle fibers.  A straight hemostat was clamped across the inferior oblique muscle close to its insertion, and the muscle was disinserted from the globe.  The inferior oblique muscle was then secured with a double-armed #6-0 Vicryl suture with a locking knot centrally and locking knots at both poles of the muscle.  The previously placed Vicryl suture was then passed through partial-thickness sclera at a position 4 mm posterior and 2 mm lateral to the temporal border of the right inferior rectus muscle.  The Vicryl suture was tied down in this position.  The amount of the recession was verified with calipers.  The overlying conjunctiva was closed with interrupted #8-0 Vicryl suture.  The patient tolerated the procedure well and was transferred to the recovery area in stable condition.
 
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DATE OF OPERATION:  MM/DD/YYYY
 
PREOPERATIVE DIAGNOSIS:  Visually significant pterygium, left eye.
 
POSTOPERATIVE DIAGNOSIS:  Visually significant pterygium, left eye.
 
OPERATION PERFORMED:  Pterygium excision with graft, left eye, with mitomycin.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  None.
 
ANESTHESIA:  Topical lidocaine gel with monitored anesthesia care.
 
DETAILS OF OPERATION:  After explaining the risks and benefits of this procedure and appropriate consent forms having been signed, the patient was wheeled from the holding area to the operating room where the patient was prepped and draped in the usual sterile manner. A lid speculum was placed. The pterygium was excised over the conjunctiva with Westcott scissors and undermined to sclera. The corneal portion of the pterygium was sharply dissected off the cornea in a laminar fashion with a Bard-Parker blade. After this was done, the cornea was scraped to remove any residual pterygium and also the adjacent sclera was also scraped with a Bard-Parker blade. Then, throughout the portion, hemostasis was maintained with cautery. Once this was adequately controlled, approximately 0.2 strength mitomycin, 0.2 per mL, on a Weck-Cel was placed over the previous pterygium site over the sclera. This was held in place for approximately one minute. Then, the area was copiously irrigated with BSS. Once this was done, a flap of conjunctiva was freed inferiorly and superiorly and brought over to cover the previously noted scleral defect. This was closed with interrupted 7-0 Vicryl. Once this was done, the lid speculum and drapes were removed. TobraDex ointment was placed in the eye. The eye was patched and the patient was instructed to follow up the following day.
 
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DATE OF OPERATION:  MM/DD/YYYY
 
PREOPERATIVE DIAGNOSIS:  Chronic endophthalmitis, right eye
 
POSTOPERATIVE DIAGNOSIS:  Chronic endophthalmitis, right eye.
 
OPERATION PERFORMED:  Pars plana vitrectomy with injection of intravitreal antibiotics, right eye.
 
SURGEON:  John Doe, MD
 
ANESTHESIA:  MAC.
 
COMPLICATIONS:  None.
 
DESCRIPTION OF OPERATION:  After informed consent was obtained, the patient was brought  to the operating room and placed under brief anesthesia.  Then, 10 mL of 50:50 mixtures of 0.75% Marcaine and 2% lidocaine were placed.  The patient was then prepared and draped in the usual sterile fashion. 
A wire lid speculum was placed in the patient's right eye.  A 270-degree conjunctival peritomy was then performed using 0.12 forceps and Westcott scissors.  Excellent hemostasis was obtained with bipolar cautery.  Scleral marks were then made in the lateral temporal, supratemporal and supranasal quadrants, 3 mm posterior to the corneoscleral limbus.  A 6-0 Vicryl mattress suture was placed around the lower temporal mark.  A 20-gauge MVR blade was used to penetrate the vitreous cavity through the site.  A 4 mm infusion cannula was then temporarily set in place, was well visualized to be in the vitreous cavity through the pupils.
 
Two superior sclerotomy sites were then each made with 20-gauge MVR blade.  Core vitrectomy was then performed.  There was already a posterior vitreous attachment, but the vitrectomy was carried out as far as possible in the vitreous space.  Careful indirect ophthalmoscopy with scleral depression was then performed and no peripheral abrasion noted.  The two superior sclerotomy sites were then each closed with an interrupted 6-0 Vicryl suture in X fashion. 
Intravitreal antibiotics were then placed through the pars plana with a 30-gauge needle.  Both 0.1 mL of vancomycin solution of 10 mg/mL and 0.1 mL of amikacin solution of 4 mg/mL were each placed. 
 
The infusion cannula was then removed and a mattress suture was tied apparently.  The conjunctiva was reapposed using two interrupted 7-0 Vicryl sutures.  Subconjunctival injections of dexamethasone, Ancef and Kenalog were placed.  An atropine drop, Maxitrol ointment, patch and shield were then applied. 
The patient tolerated the procedure well.  There were no complications. 

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DATE OF OPERATION:  MM/DD/YYYY
 
PREOPERATIVE DIAGNOSIS:  Central retinal vein occlusion with neovascular glaucoma, right eye.
 
POSTOPERATIVE DIAGNOSIS:  Central retinal vein occlusion with neovascular glaucoma, right eye.
 
OPERATIONS PERFORMED:
1.  Pars plana vitrectomy.
2.  Membrane peeling.
3.  Ahmed shunt placement.
4.  Scleral patch graft on right eye.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  None.
 
ANESTHESIA:  MAC.
 
COMPLICATIONS:  None.
 
DETAILS OF OPERATION:  After informed consent was obtained, the patient was brought to the operating room, placed on brief anesthesia and prepped well.  Ten mL of 50:50 mixtures of 0.75% Marcaine and 2% lidocaine were placed in a modified Van Lint lid block as well as retrobulbar injection.  The patient was then prepared and draped in the usual sterile fashion.  A wire lid speculum was placed in the patient's right eye.  A 270-degree conjunctival peritomy was then performed using 0.12 forceps and Westcott scissors.  Excellent hemostasis was obtained with bipolar cautery.
Curved Steven scissors were then used to penetrate Tenon's capsule in superior quadrants.  A #2-0 silk tie was used to grasp the superior rectus and lateral rectus.  Scleral marks were then made 3 mm posterior to the corneoscleral limbus, lower temporal, supratemporal and supranasal quadrants.  The #6-0 Vicryl mattress sutures were placed around the temporal mark.  A 20-guage MVR blade was then used to penetrate the vitreous cavity through the site.  A 4 mm infusion cannula was then temporally sewn in place.  It was well visualized in the vitreous cavity through the pupil.  Two superior sclerotomy sites were then each made with a 20-guage MVR blade.
 
A core vitrectomy was then performed.  There was an epiretinal membrane present, which was carefully dissected, which was partially attached to the vitreous.  This was carefully peeled off the surface of the macular area.  Vitrectomy was carried out as far as possible in the vitreous space and 765 spots of endolaser were used to place additional panretinal photocoagulation.  Ahmed shunt type PS2 was then placed into the supratemporal pocket between the conjunctiva and sclera.  This was sewn into place 10 mm posterior to the corneoscleral limbus with two interrupted #5-0 Mersilene sutures.  The clip was then inserted through the supratemporal sclerotomy site.  This was also sewn down with two interrupted #5-0 Mersilene sutures.
 
Careful and direct ophthalmoscopy scleral corrections were then performed.  No peripheral retinal breaks were noted.  The tube was placed after it was primed and trimmed to an appropriate length.  The supranasal sclerotomy site was then closed with interrupted #6-0 Vicryl suture in an X fashion.  A piece of donor scleral patch graft was placed over the pars plana clip as well as the tube.  Several interrupted #6-0 Vicryl sutures were placed to secure this.  The infusion cannula was removed and the mattress suture was tied up permanently.  Conjunctiva was reapposed using two interrupted #7-0 Vicryl sutures.
Subconjunctival injections of dexamethasone and Ancef were placed.  Atropine drops, Maxitrol ointment, patch and shield were then applied.  The patient tolerated the procedure well.  There were no complications.

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DATE OF OPERATION:  MM/DD/YYYY
 
PREOPERATIVE DIAGNOSES:
1.  Proliferative diabetic retinopathy, right eye.
2.  Epiretinal membrane with taut posterior hyaloid and secondary macular edema, right eye.
 
POSTOPERATIVE DIAGNOSES:
1.  Proliferative diabetic retinopathy, right eye.
2.  Epiretinal membrane with taut posterior hyaloid and secondary macular edema, right eye.
 
OPERATIONS PERFORMED:
1.  Pars plana vitrectomy, right eye. 
2.  Membrane peel, right eye.
3.  Endolaser, right eye.
4.  Intravitreal Kenalog injection, right eye.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  None.
 
ANESTHESIA:  Retrobulbar with monitored anesthesia care.
 
DESCRIPTION OF OPERATION:  The patient was brought back to the ophthalmic operating room where appropriate blood pressure and cardiac monitoring were 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 inserted in the inferotemporal quadrant, approximately 3.5 mm posterior to the limbus.  The infusion cannula was confirmed to be in appropriate position prior to initiating infusion.  The MVR blade was then used to make superior nasal and superior temporal sclerotomies.  The light pipe and the vitrector were inserted into the eye and a core vitrectomy was performed under wide-field visualization using the BIOM lens system.  There was no evidence of a pre-existing posterior vitreous detachment.  Therefore, the vitrectomy instrument was used to engage the posterior cortical vitreous around the optic nerve and induce a complete PVD.  Once this was done, the posterior cortical vitreous was dissected using the vitrectomy instrument.  Vitreous dissection was then extended out to the periphery as far as safely possible. 
 
At this point, the taut posterior hyaloid had been removed, but there was a residual epiretinal membrane.  Membrane peeling was then initiated.  Several drops of Kenalog were then placed on the macular surface.  The loose Kenalog was then aspirated from the eye.  A Tano membrane scraper was then used to elevate a dense epiretinal membrane from the inferior macula.  The membrane was then elevated further across the superior macula using the scraper.   Intraocular forceps were used to peel this large continuous sheet of membrane from the surface of the entire macula.  There was significant relaxation of the retina following removal of the membrane.  A small residual of tough neovascular membrane was then removed from the optic nerve head.  Once this was done, membrane peeling was completed. 
 
Endolaser photocoagulation was then applied, 360 degrees, in the retinal periphery.  This was applied to complete a typical panretinal laser photocoagulation pattern. 
 
After adequate laser application was completed, plugs were placed in each of the sclerotomies and indirect ophthalmoscopy was performed.  There was no evidence of peripheral retinal tear or retinal detachment.  At this point, the superior nasal and superior temporal sclerotomies were closed using 7-0 Vicryl suture.  The infusion cannula was then removed and this sclerotomy was also closed using the Vicryl suture. 
Intraocular injection of 4 mg of Kenalog was then performed using a needle inserted through the pars plana.  After this was done, all the wounds were re-inspected, confirmed to be well sealed and the eye had an appropriate intraocular pressure.  At this point, the conjunctiva was reapposed using the 7-0 Vicryl suture.  A subconjunctival injection of antibiotics and Solu-Medrol was then performed.  Antibiotic ointment was then placed in the eye.  Then, the eye was patched in typical fashion for ophthalmologic 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. 





 
 
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