PREOPERATIVE DIAGNOSIS: Epiretinal membrane, cystoid macular edema, right eye.

POSTOPERATIVE DIAGNOSIS: Epiretinal membrane, cystoid macular edema, right eye.

OPERATION PERFORMED: Vitrectomy, membranectomy, right eye.

SURGEON: John Doe, MD

ANESTHESIA: Local monitored.

COMPLICATIONS: None.

ANESTHESIOLOGIST: Jane Doe, MD

INDICATIONS FOR OPERATION: This (XX)-year-old gentleman has progressive loss of central vision in the right eye with a visual acuity of 20/60. He has an epiretinal membrane in the right macula. We discussed with the patient the risks, benefits, and alternatives of surgery to the right eye. He did wish to proceed with the surgery, and he signed the informed consent.

DESCRIPTION OF OPERATION: The patient was taken to the Same Day Surgery Operating Room, and local anesthesia was administered to the right eye using a 50:50 mixture of 2% lidocaine and 0.75% Marcaine delivering 4 mL into the retrobulbar space using 27-gauge Atkinson needle. After good akinesia and anesthesia was achieved, the face was prepped and draped in the usual sterile ophthalmic fashion, and the lid speculum was placed in the right eye.

Using the 25-gauge system, trocars were placed through the conjunctiva and sclera at a measured distance of 3.75 mm posterior to the surgical limbus at the 9:30, 2:30, and infratemporal meridians. The infusion cannula was placed infratemporally, the tip of the cannula could be seen to be free of tissue, and the infusion cannula was turned on.

Using the wide-angle lens system, the light pipe, the microvitrector handpiece, a core pars plana vitrectomy was carried out. The posterior hyaloid was excised, and the vitrectomy was carried out to the periphery for 360 degrees.

Using the macular contact lens and intraocular forceps, the macular epiretinal membrane was carefully peeled off the surface of the retina in one continuous sheet. There were no retinal hemorrhages or tears created. Indirect ophthalmoscopy with scleral depression was performed for 360 degrees. There were no peripheral retinal holes or tears.

All the three trocars were removed and the overlying conjunctiva was massaged using a cotton tip applicator. Subconjunctival injections of Ancef and dexamethasone were delivered. Scopolamine 0.25%, Maxitrol, and Alphagan eye drops were placed in the eye, as well as a patch and shield.

The patient was taken to the recovery room having tolerated the procedure without complications.

POSTOPERATIVE DIAGNOSES:
1.  Right exotropia.
2.  Scar tissue and restricted ocular mobility, right eye.

PROCEDURES PERFORMED:
1.  Resection of right medial rectus, 5.5 mm.
2.  Isolation of previously operated upon right lateral rectus with lysis of scar tissue and adhesions with recession to 17-18 mm posterior to the limbus.
3.  Lysis of adhesions of the inferior oblique in the inferotemporal quadrant.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

COMPLICATIONS:  None.

DESCRIPTION OF PROCEDURE:  Attention was directed to the right eye after it was prepped and draped in the usual sterile ophthalmic fashion. A lid speculum was inserted, and the conjunctiva was marked nasally for reapproximation later. A patch of scleromalacia was visible anterior to the location of the medial rectus insertion, and he had some scarring of the conjunctiva to the sclera anteriorly. As esotropia is more common than exotropia, assume that there had been a medial rectus recession in the past. Thus, we made a radial fornix incision inferonasally and cleaned in the inferonasal quadrant with blunt dissection. The medial rectus muscle was then isolated with a small and then large muscle hook, and L-shape peritomy was then carried superiorly and the conjunctiva was dissected off the sclera. There was surprisingly little scar tissue from surgery, but there was some from early pinguecula and solar conjunctival damage.

The muscle was attached to the globe 6-6.5 mm posterior to the limbus. It was really difficult to tell if there had been, in fact, any previous surgery to the right medial rectus, which we had thought because of the apparent scleromalacia anterior to where the insertion would be. However, it is difficult to tell if there was in fact any surgery there. The muscle was then gathered up and cleaned posteriorly. A second Green hook was inserted at 180 degrees to the first hook. This was used to expose the posterior muscle belly. The muscle was then resected 5.5 mm after suture was passed through the muscle belly and through the upper and lower borders of the muscle just posterior to a point marked at 5.5 mm posterior to the insertion. The muscle was then cross-clamped and transected at the 5.5 mm mark. The muscle stump was disinserted from the globe. The muscle was then advanced just anterior to the 6.5 mm mark, in a more physiologic position about 5.5 mm posterior to the limbus. The muscle was then left unsecured there and the sutures placed to side for exploration of the right lateral rectus.

Attention was then directed to the right lateral rectus through a radial fornix incision winged inferotemporally. There was obvious conjunctival scarring, and clearly, there had been eye muscle surgery there. The conjunctiva was quite adherent from a combination of both old surgery and from solar conjunctival damage. The incision was carried superiorly, somewhat posterior to the limbus, as it was obvious that the muscle had been recessed. The lateral rectus muscle was quite posterior and small and then large muscle hooks were used to secure the muscle. We could not get a great hold of it and was worried whether the inferior oblique was imbricated into the previously recessed muscle.

Thus, we carried the incision of the conjunctiva and winged it superotemporally as well and hooked the lateral rectus from above successfully, clearly, without imbrication of the inferior oblique. The muscle was then cleaned over its superior aspect as it extended posteriorly. There was a pseudotendon that extended to about 8 mm posterior to the limbus, but this was quite diaphanous, and there was clearly no muscle tissue in it. The muscle itself was in good shape but was located 15 mm posterior to the limbus. There was a copious amount of scar tissue inferotemporally and forced ductions were positive with mild-to-moderate restriction to passive adduction of the eye. The scar tissue was cleaned in the inferotemporal quadrant, and the muscle was then finally freed. Even with this, however, the forced ductions were not completely free. The muscle was then gathered up on double-armed 6-0 Vicryl suture using the real insertion.

The anterior pseudotendon was excised. The muscle was then carefully disinserted from the globe. Forced ductions were not yet free, however, as there was scar tissue underneath the lateral rectus and also between the inferior oblique and the inferotemporal quadrant. The inferior oblique was isolated and cleaned of its scar tissue as was the adhesions of the inferior border of the lateral rectus muscle into the inferotemporal quadrant. After lysis of scar tissue, the forced ductions were freed both with the muscle disinserted and with the muscle reattached. As the muscle had been previously recessed quite a bit, we reattached it between 17 and 18 mm posterior to the limbus in a scleral fixation pattern using the double-armed 6-0 Vicryl suture, which had been previously placed. The conjunctiva was then carefully closed with simple interrupted 8-0 Vicryl sutures temporally.

Attention was then directed to the right medial rectus and the previously resected muscle was then pulled up to its new insertion and tied firmly in place. The conjunctiva was closed with simple interrupted 8-0 Vicryl suture. TobraDex eye ointment was instilled onto the conjunctivae, and the patient was awakened from anesthesia and taken to the recovery room in stable condition. There were no complications.

PREOPERATIVE DIAGNOSIS: Nuclear sclerotic cataract, right eye.

POSTOPERATIVE DIAGNOSIS: Nuclear sclerotic cataract, right eye.

OPERATION PERFORMED: Phacoemulsification with intraocular lens placement, right eye.

SURGEON: John Doe, MD

ANESTHESIA: Local with MAC.

INDICATIONS FOR OPERATION: The patient reported decreased vision in the operative eye that interferes with activities of daily living. After discussing risks, benefits, and alternatives to surgery, the patient decided to proceed with cataract surgery in the operative eye.

The patient was examined preoperatively with complete eye exam, dilated fundus exam, and focused physical examination. The patient’s biometry, which included axial length measurements and corneal keratometry, was reviewed and the appropriate intraocular lens was chosen to give the patient the desired refractive outcome.

DESCRIPTION OF OPERATION: After appropriate consent was obtained, a surgical marking pen was used to mark the operative site. The patient was then taken to the operating room, where the patient was prepped and draped in the usual sterile fashion.

An aspirating Lieberman lid speculum was placed into the eye, and a time-out was performed confirming the patient’s name, operative procedure, operative site, proper lens, pertinent patient history, allergies, among other things. A stab incision blade was used to create a paracentesis through which was injected 1% lidocaine, preservative-free, with 1:1000 epinephrine in a 4:1 ratio.

Viscoat was then injected into the anterior chamber. Angled McPherson forceps were used to provide countertraction while a 2.2 mm steel blade was used to enter the anterior chamber. Inamura forceps were used to institute and complete a circumlinear capsulorrhexis.

BSS on a Chang cannula was used to hydrodissect and hydrodelineate the nucleus, which was seen to rotate easily. Phacoemulsification was used to remove the lens using a vertical and horizontal chop technique with a Seibel vertical and horizontal chopper as a second instrument.

Additional Viscoat was injected as needed throughout the procedure to maintain stability of the anterior chamber and protect the corneal endothelium. The epinucleus was removed with phacoemulsification using a Seibel horizontal chopper as a second instrument. I/A was used to remove residual cortical material from the capsular bag, as well as polish the posterior capsular bag using the polymer I/A tip on the capsule polish setting.

Provisc was injected into the capsular bag, and SN60WF 20.0 diopter lens was folded and injected into the capsular bag. Irrigation and aspiration was used to remove residual viscoelastic materials from the capsular bag, as well as the anterior chamber, with special attention made to remove viscoelastic materials from behind the optic. BSS on a cannula was used to hydrate the corneal wounds, as well as reform the anterior chamber. Miostat was then injected into the anterior chamber.

The wounds were then checked for leaks with a Weck-cel and fluorescein strip. There were no leaks. The lid speculum was removed. The eye received drops of prednisolone acetate 1% and Vigamox. The patient was then discharged to the postanesthesia care unit in no acute distress.

PREOPERATIVE DIAGNOSES:
1. Microphthalmos with uveal effusion syndrome, left eye.
2. Dense cataract limiting visualization of the posterior segment, left eye.
3. Possible retinal detachment, left eye.

POSTOPERATIVE DIAGNOSES:
1. Microphthalmos with uveal effusion syndrome, left eye.
2. Dense cataract limiting visualization of the posterior segment, left eye.
3. Retinal detachment with extensive subretinal hemorrhage and advanced proliferative vitreoretinopathy, left eye.

OPERATION PERFORMED:
1.  Pars plana vitrectomy.
2.  Pars plana lensectomy, use of iris hooks.
3.  Membrane peel, use of Perfluoron liquid.
4.  Fluid-air exchange and endolaser and silicone and oil ejection, all done in the left eye.

SURGEON:  John Doe, MD

ANESTHESIA:  Retrobulbar with monitored anesthesia care.

COMPLICATIONS:  None.

INDICATION FOR OPERATION:  The patient is a (XX)-year-old gentleman with a long history of poor visual acuity in both eyes due to microphthalmos. He subsequently, however, developed uveal effusion syndrome with severe decreased visual acuity in his left eye. He underwent a previous scleral dissection with drainage of the corneal detachment in his left eye a few weeks earlier.

Although he showed some slight improvement of the corneal detachment following this procedure, he showed persistent decrease of his visual acuity to bare light perception/no light perception level. A posterior segment evaluation was not possible through his dense cataract. A posterior segment ultrasonography showed some decrease in the height of the corneal detachment but showed some irregular membrane formation posteriorly. This suggested the possibility of retinal detachment.

Surgical intervention with intraocular management, including vitrectomy and lensectomy, was discussed with the patient. After reviewing the risks, benefits, and alternatives of this procedure, the patient agreed to proceed with the surgery. The guarded prognosis for visual recovery considering the severe nature of his condition was explained in detail prior to surgery.

DESCRIPTION OF OPERATION:  The patient was brought back to the ophthalmic operating room where appropriate blood pressure and cardiac monitoring was 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 then inserted in the inferior temporal quadrant approximately 3 mm posterior to the limbus. At this point, the infusion cannula could not be directly visualized due to the dense cataract, and posterior infusion was not initiated.

The MVR blade was then used to make superonasal and superotemporal sclerotomies, again approximately 3 mm posterior to the limbus. Because of his severely constricting pupil, iris hooks were placed in order to allow further dilation of the pupil. Four iris hooks were placed in this process allowing improved visualization through the now dilated pupil.

At this point, balanced saline solution was used to hydrate the lens nucleus. An anterior effusion needle was then inserted into the central lens nucleus, and the Fragmatome was used to remove the lens material. Once the central nucleus had been removed, the peripheral cortex was dissected using the vitrectomy instrument. All of the residual capsule material was removed using the vitrectomy instrument in this process. Once the dense cataract had been removed, there was improved visualization posteriorly. The posterior infusion cannula was now visualized, and posterior effusion was initiated as it was in good position.

At this point, the light pipe and vitrector were inserted into the eye, and a core vitrectomy was performed under wide-field visualization using the BIOM lens system. The central core vitreous was densely hemorrhagic. The hemorrhagic core vitreous was now removed in this process. After removing some of the central hemorrhage, the detached retina was now identified. There was extensive preretinal proliferative vitreoretinopathy. There was also a very dense subretinal and suprachoroidal hemorrhage. There was extensive hemorrhage at 360 degrees beneath the retina.

At this point, the vitrectomy instrument was used to carefully dissect all of the vitreous centrally. Vitreous dissection was then carefully extended out into the periphery. Once adequate vitreous dissection was completed, intraocular forceps were used to peel several large bands of surface membranes around the optic nerve and macular region. This allowed some central relaxation of the retina once this maneuver was performed.

At this point, reinspection was performed. It was evident that there was an extensive subretinal and suprachoroidal hemorrhage as a component of his uveal effusion syndrome. A large retinal tear was also identified temporally.

At this point, the retinal tear was enlarged using the vitrectomy instrument. Hemostasis was confirmed along the edge of this retinectomy using the diathermia.
At this point, large clumps of hemorrhage were evacuated from the subretinal space using the vitrectomy instrument through this large retinal tear. An extensive amount of subretinal hemorrhage was removed in this process. There was a significant relaxation of the retina once this was done. Because there was increased mobility of the posterior retina at this point, Perfluoron liquid was injected into the eye to stabilize the posterior pole.

At this time, there still remained a large amount of hemorrhagic material beneath the retina nasally. A drainage retinotomy was then created using the diathermia. This was enlarged using the vitrectomy instrument. Hemostasis along this area was again confirmed using cautery. The vitrectomy instrument was again used to aspirate a significant amount of hemorrhagic material from the subretinal space in this process. This was done through the newly created retinotomy. There was again significant relaxation of the retina once this was done.

At this point, reinspection was performed, and several membranes were identified along with the subretinal space. These membranes were adherent to the underside of the retina. Intraocular forceps were used to grasp and peel these membranes both temporally and nasally through the previously described retinotomies.

At this point, no further membrane peeling was possible. As much of the subretinal hemorrhage was evacuated as possible. A complete air-fluid exchange was then performed. This was done by aspirating the subretinal fluid through the previously described retinotomies. Once the retina was reattached, the Perfluoron liquid was aspirated from the vitreous cavity. The retina remained completely attached at this point. Endolaser photocoagulation was then scattered at 360 degrees in the periphery. Laser was carefully applied along with the large retinotomies both nasally and temporally. The retina remained flat throughout this entire process without significant contraction. After this was done, additional fluid was aspirated from the vitreous cavity ensuring a complete gas fill.

At this point, the iris hooks were removed. The anterior chamber was reinflated and the pupil constricted using Miochol solution. An inferior iridectomy was then created using the vitrectomy instrument. The superonasal sclerotomy was then closed using a 7-0 Vicryl suture. A 7-0 Vicryl suture was then preplaced across the temporal sclerotomy. Then, 1000 centistoke silicone oil was injected into the vitreous cavity. Once there was a complete oil fill, the temporal sclerotomy was closed using a 7-0 Vicryl suture. The infusion cannula was then removed, and the sclerotomy was also closed using a Vicryl suture.

All the wounds were reinspected and confirmed to be well sealed, and the eye had appropriate intraocular pressure. There was no significant prolapse of the oil into the anterior chamber at this point. Indirect ophthalmoscopy was again performed at this point and confirmed the retina to be completely attached with good laser treatment.

At this point, the conjunctiva was then reapposed using a 7-0 Vicryl suture. Subconjunctival injection of antibiotics and Solu-Medrol was then performed. Sub-Tenon’s Kenalog injection was performed for chronic postoperative inflammation control. Antibiotic ointment was then placed in the eye, and the eye was patched in typical fashion for ophthalmic 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. The extremely guarded prognosis for visual recovery considering extensive posterior segment changes was explained in detail to the patient.

PREOPERATIVE DIAGNOSIS: Pseudophakic bullous keratopathy, right eye.

POSTOPERATIVE DIAGNOSIS: Pseudophakic bullous keratopathy, right eye.

OPERATION PERFORMED: Corneal transplant, endothelial keratoplasty technique, right eye.

SURGEON: John Doe, MD

ANESTHESIA: General.

INDICATIONS FOR OPERATION: Decreased visual acuity and corneal edema.

DESCRIPTION OF OPERATION: The patient was brought to the operating suite and placed in the supine position. After induction of general anesthesia, the patient was prepped and draped in the usual sterile fashion, and the donor cornea was brought into place on a side table, found to be suitable, and was placed on a Moria artificial anterior chamber and the chamber was inflated and the pressure was noted to be about 65 mmHg. The Moria ALTK unit with a 300 micron head was used to remove the anterior portion of the donor cornea. This anterior portion then was placed back on top of the donor cornea, and the entire donor cornea was placed in a well with Optisol solution.

Attention was then turned to the patient’s eye where a 5 mm limbal groove was made at a depth of 350 microns. A scleral tunnel was then performed, and the anterior chamber was entered. Two stab incisions were placed at the 3 and 9 o’clock positions. Healon was instilled in the anterior chamber. A reverse Sinskey hook was used to score the cornea at the 8 mm mark, and the Descemet’s membrane and endothelium were removed.

The donor cornea was then taken out of the Optisol and placed in a Hessburg-Barron punch after the anterior 300 micron portion of cornea was removed. A remodeled button was punched. This button was then taken, folded over taco style in a 60/40 fashion. This was then inserted into the anterior chamber using Utrata forceps. An air bubble was then used to open up the donor cornea and to force it to adhere to the recipient cornea. The Healon had been removed from the anterior chamber prior to placement of the donor cornea.

Three interrupted 10-0 nylon sutures were used to close the 5 mm wound. Most of the air bubble was removed replacing this with BSS; however, a 6 to 7 mm air bubble was left in place, and the patient was instructed to lie on the back for the entire evening. Vigamox drops were applied to the eye. The cornea was precut by the eye bank, and two 10-0 nylon sutures were used to secure the graft in place. The donor size was 7.25 mm. The patient was delivered to the recovery area in stable condition.

PREOPERATIVE DIAGNOSIS: Mohs micrographic surgery induced basal cell carcinoma related defect of left upper eyelid margin.

POSTOPERATIVE DIAGNOSIS: Mohs micrographic surgery induced basal cell carcinoma related defect of left upper eyelid margin.

OPERATION PERFORMED: Reconstruction of left upper eyelid margin utilizing marginal apposition with local myocutaneous flap formation.

SURGEON: John Doe, MD

ANESTHESIA: Topical ocular, total intravenous, local infiltrative with monitored anesthesia care.

ANESTHESIOLOGIST: Jane Doe, MD

SPONGE AND INSTRUMENT COUNT: Correct.

ESTIMATED BLOOD LOSS: 15 mL.

INDICATIONS FOR OPERATION: This (XX)-year-old gentleman was noted to have a defect of the left upper eyelid margin after undergoing Mohs micrographic resection of residual basal cell carcinoma. The defect involved three-quarters of the lid thickness, including all of the anterior lamella.

DESCRIPTION OF OPERATION: After informed consent was obtained, the patient was taken to the operating room and placed supine on the operating room table. Previously, a gentian violet marking pen had been used to mark the fullest clinical extent of the defect after the tight pressure patch was removed and the eyelid skin defatted with an alcohol pad. Also, the lateral palpebral raphe was marked with the same pen should additional laxity be required. The patient received appropriate preoperative sedation and monitoring and instillation of 2% lidocaine with 1:100,000 parts epinephrine, a 25% mixture of 0.75% bupivacaine was instilled subcutaneously along the length and breadth of the left upper eyelid. Additionally, the left lateral canthus was also infiltrated with this same solution. The anesthetic agent was massaged into place. The surgeon performed a surgical scrub.

Upon his return, the patient was prepped and draped in the usual sterile fashion for ophthalmic surgery. A hard corneoscleral shield was placed before the cornea on the left side after a series of 0.5% tetracaine drops had been applied. The defect was then examined, and additional full-thickness resection was required to allow for wound apposition. This converted the defect into one in which an H flap could be fashioned for closure of the myocutaneous section. The sharp Westcott scissor was then used to resect the tissue. The area of the lateral and medial section was globalized to allow for flap formation and apposition. A series of preplaced sutures were then used to anastomose at the area just anterior to the mucocutaneous junction. The eyelash line and the remnant of lateral and medial tarsal plate were then anastomosed with preplaced sutures as well. The lid margin was then anastomosed first at the area just anterior to the mucocutaneous junction. The eyelash line and then the gray line were anastomosed with a 6-0 Vicryl suture as well. The deep 5-0 Vicryl sutures were then anastomosed as these had been preplaced. We developed myocutaneous tissue laterally, which was then anastomosed with a series of deep buried 6-0 Vicryl sutures. The eyelid level and contour was noted to be appropriately reformed. A horizontal relaxing incision was then repaired with a series of deep buried 6-0 Vicryl sutures.

The cutaneous layer was then closed with a series of interrupted and continuous locking 6-0 fast-absorbing plain suture. The eyelid level and contour remained appropriate. The hard corneoscleral shield was removed and then replaced with a ProShield soaked in balanced salt solution. The wounds were dressed with TobraDex ointment. A cool moistened eye pad was placed. An ice pack was placed. The patient tolerated the procedure well and was turned over to Anesthesia and then removed to the recovery room in stable condition.

PREOPERATIVE DIAGNOSIS: Macular hole, right eye.

POSTOPERATIVE DIAGNOSIS: Macular hole, right eye.

OPERATION PERFORMED: Pars plana vitrectomy with membrane peeling and gas fluid exchange, 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 with propofol. Ten mL of 50/50 mixture of 0.75% Marcaine and 2% lidocaine was placed in a modified Van Lint lid block as well as a 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. Scleral marks were then made 3 mm posterior to the corneoscleral limbus, in the lower temporal, supratemporal, and supranasal quadrants. The 6-0 Vicryl mattress suture was placed around the lower temporal mark. A 20 gauge MVR blade was then used to penetrate the vitreous cavity through this site. A 4 mm infusion cannula was then temporarily set in place. It was well visualized to be in the vitreous cavity through the pupil. Two superior sclerotomy sites were then each made with a 20 gauge MVR blade. Core vitrectomy was then performed. There was no posterior vitreous detachment. One was created using high suction vitreous cutter over the disk. Vitrectomy was then carried out as far as possible to the vitreous base.

Attention was then turned to the posterior pole where a rent was created in the internal limiting membrane, and it was grasped with intraocular forceps and carefully peeled off the surface of the macula. Careful indirect ophthalmoscopy scleral depression was then performed, and no peripheral retinal breaks were noted. The two superior sclerotomy sites were then each closed with interrupted 6-0 Vicryl suture in X fashion. The infusion cannula was removed and the mattress sutures tied up permanently. Conjunctiva was reapposed using two interrupted 7-0 Vicryl sutures. Subconjunctival injections of dexamethasone and Ancef were placed. An Atropine drop, Maxitrol ointment, and a patch and shield were then applied. The patient tolerated the procedure well. There were no complications.

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Probable choroidal melanoma, left eye.

POSTOPERATIVE DIAGNOSIS: Probable choroidal melanoma, left eye.

PROCEDURES PERFORMED:
1.  Transscleral fine needle aspiration biopsy, FNAB, of choroidal tumor, left eye.
2.  Implantation of radioactive iodine-125, left eye.

SURGEON:  John Doe, MD

ANESTHESIA:  Local/MAC.

DESCRIPTION OF OPERATION:  This patient was brought to the operating room and was positioned on the operating room table. Cardiac and blood pressure monitoring devices were applied. Intravenous sedatives were administered, and a retrobulbar injection was administered to the left eye without complications. The patient was prepped and draped in the usual fashion for a procedure of the left eye. A lid speculum was inserted between the lids to expose the eye. A conjunctival peritomy was created with Westcott scissors and the subconjunctival connective tissues were dissected down the bare sclerae in the four quadrants with a curved Stevens scissors.

Using a Gass muscle hook, separate 4-0 black silk sutures were passed behind the insertions of the superior and inferior rectus muscles to serve as traction sutures during the procedure. The belly of the lateral rectus muscle was secured near its insertion with a double-armed double locking 5-0 Vicryl suture. The muscle was then disinserted from the sclera with Wescott scissors. A 4-0 black silk suture was passed into the stump of the lateral rectus muscle in a baseball stitch fashion to serve as an additional traction suture during the procedure.

Inspection of the sclera immediately posterior to the insertion of the lateral rectus muscle showed no evidence of transcleral tumor extension. Ocular transillumination was performed at this time to cast a shadow of the peripheral choroidal tumor onto the sclera just up and posterior to the insertion of the lateral rectus muscle. The position of the margins of the shadow was marked on the sclera with a sterile marking pen. A dummy 14 mm diameter plaque was positioned overlying the tumor shadow as marked on the sclera. Four 5-0 nylon sutures were placed as plaque fixation sutures relative to four arms of the dummy plaque. The dummy plaque was removed.

At this time, the biopsy was performed in the following manner. A triangular shaped incision with vertical incision parallel to the insertion of the lateral rectus muscle insertion but just posterior to it and a radial incision extending posteriorly from the inferior margin of the initial incision was created on the sclera just posterior to the lateral rectus muscle incision. Using a 57 Beaver blade, a lamellar scleral flap was raised at the triangular site. Fine needle aspiration biopsy of the choroidal tumor was then performed using 25 gauge short hollow lumen needles connected via a sterile connector tubing to an aspirating 10 mL syringe. The surgeon placed the tip of the needle through the sclera and into the substance of the tumor.

Aspiration was then performed by the surgical assistant repeatedly with slight movement of the tip of the needle by the surgeon during this process. The needle was withdrawn from the eye, and the specimen was passed off the table for pathologic processing. The procedure was repeated two times, each with a different needle and each sampling at slightly different area. Once the third biopsy had been completed, the lamellar scleral flap was closed with multiple interrupted sutures of 7-0 Vicryl. The active radioactive plaque was then placed over the tumor shadow as marked on the sclera. The four plaque fixation sutures were passed through the holes in the respective arms with the plaque and tied securely.

The lateral rectus muscle was left in hang-back position over the plaque and was secured with double-armed double locking 6-0 Vicryl suture to the sclera just anterior to the plaque. The conjunctiva was closed with interrupted sutures of 7-0 Vicryl. The traction sutures were cut and removed. The lid speculum was removed. Bacitracin-polymyxin ointment was applied to the surface of the eye. The lids were patched with a double eye pad and lead shield dressing. The patient tolerated the procedure well. The patient was transferred to his inpatient room immediately following the transscleral fine needle aspiration biopsy, FNAB, of choroidal tumor for radiation monitoring and postoperative care.

PREOPERATIVE DIAGNOSES:
1.  Nuclear cataract, right eye.
2.  Astigmatism, right eye.

POSTOPERATIVE DIAGNOSES:
1.  Nuclear cataract, right eye.
2.  Astigmatism, right eye.

OPERATIONS PERFORMED:
1.  Phacoemulsification with posterior chamber intraocular lens implant, right eye.
2.  Limbal relaxing incision, right eye.

SURGEON:  John Doe, MD

ANESTHESIA:  Topical with monitored anesthetic care.

ANESTHESIOLOGIST:  Jane Doe, MD

INDICATIONS FOR OPERATION:  This is a (XX)-year-old female who presents with decreased vision. The patient stated that she is having difficulty reading as well as driving and was found with a nuclear cataract and astigmatism of the right eye. Informed consent was obtained from the patient.

DESCRIPTION OF OPERATION:  The patient was pretreated with topical dilating agents, antibiotic, nonsteroidal drops, and anesthetic gel to the right eye. After adequate anesthesia and dilation, the patient was brought to the operating room where the right eye was sterilely prepped and draped in the usual fashion for intraocular surgery, including 5% Betadine into the cul-de-sac for one minute and draping of the lid margins and lashes well away from the operative field. A lid speculum was placed between the eyelids and the microscope positioned over the eye and used for guidance throughout the procedure.

The predetermined limbal relaxing incisions were then marked on the cornea with the surgical marker, then incised perpendicular to the cornea at the surgical limbus with the Nichamin using the Thornton ring for fixation.

A paracentesis was then created with a 1 mm diamond blade, and 0.5 mL of 1% unpreserved lidocaine was injected into the anterior chamber. Viscoat was then used to deepen the anterior chamber and to enlarge the pupil.

The 2.8 mm diamond keratome was then used to create a temporal wound, carrying it 2 mm within the corneal stroma before entering the anterior chamber. Continuous curvilinear capsulorrhexis was then created. The lens nucleus was then hydrodelineated and hydrodissected. The lens nucleus was rotated. The lens nucleus was then divided in the middle, and the nucleus removed in standard stop-and-chop fashion. The epinucleus was then removed with phacoemulsification. The cortex was then removed with irrigation and aspiration. The injectable lens was then placed into the posterior capsule under viscoelastic. The viscoelastic was then removed, and the wound hydrated and found to be watertight. Vigamox and Acular LS drops were then instilled into the eye, and the lid speculum was removed. A clear eye shield was then taped over the eye. The patient was transferred to the recovery room in good condition.

PREOPERATIVE DIAGNOSIS:  Macular pucker with macular hole, left eye.

POSTOPERATIVE DIAGNOSIS:  Macular pucker with macular hole, left eye.

PROCEDURES PERFORMED:  Pars plana vitrectomy, removal of posterior hyaloid face, epiretinal membrane peel, internal limiting membrane peel, air-fluid exchange, and injection of C3F8 gas, left eye.

SURGEON:  John Doe, MD

ANESTHESIA:  Local with standby.

COMPLICATIONS:  None.

INDICATION FOR OPERATION:  The patient is a (XX)-year-old female with a history of blurred vision for the last three to four months. On evaluation, the patient was found to have a visual acuity of 20/200 in the left eye. A macular pucker was present with a macular hole. The findings were discussed with the patient and management options were discussed. It was recommended to the patient that she undergo vitrectomy with removal of the pucker and closure of the macular hole. The necessity for postoperative face-down positioning was also discussed. The patient had an opportunity to ask questions regarding the procedure, and these were answered to her satisfaction, and the patient desired to proceed.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed in the supine position on the eye table. The appropriate monitoring devices were attached. Akinesia and anesthesia were obtained using a 50/50 mixture of 2% lidocaine with 0.75% Marcaine and 1 ampule of Wydase 5 mL given in a retrobulbar fashion followed by a 5 mL lid block with good results. The patient was then prepped and draped in the usual sterile fashion, and a lid speculum was placed in the left eye.

A standard three-port pars plana vitrectomy using the 25 gauge system was prepared measuring 3.5 mm posterior to the limbus. The infusion cannula was visualized prior to commencing infusion. With the aid of the wide-angle viewing system, a pars plana vitrectomy was performed. The vitreous was removed 360 degrees out to the periphery.

The posterior hyaloid face was then elevated off the retinal surface with the vitrectomy handpiece, and this was trimmed out to the periphery. The periphery was examined. No holes or tears were noted. The high magnification contact lens was then placed on the eye, and the intraocular forceps were used to remove the macular pucker off of the surface of the retina. There was significant surface distortion with a macular hole present.

After removal of the pucker, the internal limiting membrane was peeled free of the retinal surface, peeling circumferentially around the macula. There were pinpoint hemorrhages created with removal of the ILM.

The contact lens was then removed, and the wide-angle viewing system was brought back into position, and an air-fluid exchange was performed with the vitrectomy handpiece aspirating over the optic nerve. The eye was allowed to rest for approximately four to five minutes, after which additional fluid was removed off of the optic nerve. No peripheral abnormalities were noted.

Sixty mL of C3F8 gas was exchanged with intraocular air venting via the trocar. The trocars were then removed, and additional gas was inserted to a normal palpation pressure, and the infusion cannula was removed. There was no leak noted at the site of the sclerotomies. The eye was irrigated with Neosporin ophthalmic solution. Subconjunctival injections of 2 mg of dexamethasone, 20 mg of tobramycin, and 100 mg of Kefzol were given. Topical 1% atropine was placed on the eye, and the eye was patched in the usual fashion. The patient tolerated the procedure well and was returned to same-day surgery in the prone position. The patient was instructed to maintain a prone position.