DICTATED BY

 

ID#

 

SERVICE

 

DATE OF DICTATION

 

PATIENT NAME

 

MEDICAL RECORD NUMBER

 

PATIENT'S DATE OF BIRTH

 

SERVICE:  Ophthalmology.

 

DATE OF SURGERY

 

PREOPERATIVE DIAGNOSIS:  Presenile nuclear cataract, left eye.

 

POSTOPERATIVE DIAGNOSIS:  Presenile nuclear cataract, left eye.

 

PROCEDURE:  Phacoemulsification with posterior chamber intraocular lens

implantation (CeeOn, 23.0 diopters, serial number 680903349), left eye.

 

ATTENDING PHYSICIAN:  Dr. XXX, who was present and scrubbed

for the entire case.

 

RESIDENT PHYSICIAN:

 

ANESTHESIA:  Local with monitored anesthesia care.

 

COMPLICATIONS:  None.

 

INDICATIONS:  This gentleman complained of poor vision in his left eye

and was noted to have a cataract.  After discussing the risks, benefits

and alternatives, the patient elected to proceed with cataract

extraction of the left eye.

 

TECHNIQUE:  The patient was brought to the Operating Room and placed in

the supine position after informed written consent was found to be complete

on the chart.  Retrobulbar anesthesia was administered using a

50/50 mixture of lidocaine 2% and bupivacaine 0.75%. The patient was then

prepped and draped in the usual sterile fashion.  A lid speculum was

placed in the left eye.  A superotemporal paracentesis was then created. The

eye was then filled with viscoelastic. A superonasal, clear cornea,

multiplanar incision was constructed.    A continuous curvilinear

capsulorrhexis was then made.  BSS hydrodissection was then completed.  Phacoemulsification was then performed using a divide-and-conquer technique.

Total phacoemulsification time was 3.2 minutes at 27%.  Automated

irrigation/aspiration was used for cortical clean-up.  The eye was filled

with viscoelastic, and a CeeOn 23.0-diopter lens was placed into the

capsular bag.  Automated irrigation/aspiration was then used to clean any

 remaining viscoelastic.  The wounds were then checked and found to be

 watertight, and the eye was left at physiologic pressure.  At the end of

the case, the intraocular lens was found to be centered, the pupil round,

and the cornea clear.  A subconjunctival injection of gentamicin and

dexamethasone was then administered.  TobraDex ointment was then placed in

 the left eye, which was then patched and shielded.

 

The patient was transferred to the Recovery Room in stable condition. 

 

The attending physician, Dr. XXX was present and scrubbed for

the entire case.