Sample Type / Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification
Description: Phacoemulsification with posterior chamber intraocular lens - Sample/Template.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Senile cataract OX
POSTOPERATIVE DIAGNOSIS: Senile cataract OX
PROCEDURE: Phacoemulsification with posterior chamber intraocular lens OX, model SN60AT (for Acrysof natural lens), XXX diopters.
INDICATIONS: This is a XX-year-old (wo)man with decreased vision OX.
PROCEDURE: The risks and benefits of cataract surgery were discussed at length with the patient, including bleeding, infection, retinal detachment, re-operation, diplopia, ptosis, loss of vision, and loss of the eye. Informed consent was obtained. On the day of surgery, (s)he received several sets of drops in the XXX eye including 2.5% phenylephrine, 1% Mydriacyl, 1% Cyclogyl, Ocuflox and Acular. (S)he was taken to the operating room and sedated via IV sedation. 2% lidocaine jelly was placed in the XXX eye (or, retrobulbar anesthesia was performed using a 50/50 mixture of 2% lidocaine and 0.75% marcaine). The XXX eye was prepped using a 10% Betadine solution. (S)he was covered in sterile drapes leaving only the XXX eye exposed. A Lieberman lid speculum was placed to provide exposure. The Thornton fixation ring and a Superblade were used to create a paracentesis at approximately 2 (or 11 depending upon side and handedness, and assuming superior incision) o'clock. Then 1% lidocaine was injected through the paracentesis. After the nonpreserved lidocaine was injected, Viscoat was injected through the paracentesis to fill the anterior chamber. The Thornton fixation ring and a 2.75 mm keratome blade were used to create a two-step full-thickness clear corneal incision superiorly. The cystitome and Utrata forceps were used to create a continuous capsulorrhexis in the anterior lens capsule. BSS on a hydrodissection cannula was used to perform gentle hydrodissection. Phacoemulsification was then performed to remove the nucleus. I & A was performed to remove the remaining cortical material. Provisc was injected to fill the capsular bag and anterior chamber. A XXX diopter SN60AT (for Acrysof natural lens) intraocular lens was injected into the capsular bag. The Kuglen hook was used to rotate it into proper position in the capsular bag. I & A was performed to remove the remaining Viscoelastic material from the eye. BSS on the 30-gauge cannula was used to hydrate the wound. The wounds were checked and found to be watertight. The lid speculum and drapes were carefully removed. Several drops of Ocuflox were placed in the XXX eye. The eye was covered with an eye shield. The patient was taken to the recovery area in a good condition. There were no complications.
Keywords: ophthalmology, phacoemulsification, acrysof, acrysof natural lens, acular, kuglen hook, ocuflox, provisc, sn60at, senile cataract, thornton fixation ring, bleeding, capsular bag, decreased vision, diopters, diplopia, infection, loss of the eye, loss of vision, ptosis, retinal detachment, lid speculum, thornton fixation, anterior chamber, intraocular lens, intraocular, chamber, lidocaine,