OPERATIVE REPORT

 

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:  Dr. XXX

 

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 partial superior peritomy was constructed. 

A temporal paracentesis was then created.  The eye was then filled with

viscoelastic.   Next, a scleral tunnel incision was made and the anterior

chamber entered.  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 1.1 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 central 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.