Transcript Examples

Examples
BROWN LESION
Dear Dr. Carter:
[patient] was seen in my dermatology clinic on 00/00/0000 for a large brown lesion on her right shoulder. Clinically, this was a
benign dermatofibroma. She was reassured of the benign nature …..Thank you for allowing me to participate in the care of [patient].
If I can answer any specific questions, please do not hesitate to contact me.
Sincerely,
ACNE, MILD
CLINICAL IMPRESSION/DIAGNOSIS
Acne, mild, mostly comedonal.
RECOMMENDATIONS/DISPOSITION:
1. Differin 0.1% gel at bedtime.
2. PanOxyl 5% ……
Thank you for your confidence
•
•
•
•
•
•
COMPLETE SKIN CHECK
•
•
•
•
•
•
HISTORY OF ATOPIC DERMATITIS
•
•
Dear Dr. [name]:
[Patient] was seen in my dermatology clinic on 09/10/2010. He presented with complete skin check. In
particular, he had a lesion on the left arm that was some concern to himself and his wife. On clinical exam,
he had only a benign appearing dermatofibroma on the left upper arm as well as on the right lower
extremity. There were …..
Dear Dr. [name]:
[Patient] was seen in my dermatology clinic on September 10, 2010. She presented to clinic with a long
history of atopic dermatitis and a recent eruption in her left axilla. She also complaints of a recent
outbreak on her lip that has now left her lips darkly pigmented. She denies any new skin care products, or
new lipsticks or chapsticks.
On clinical exam, there was dry, red edematous plaque in the left axilla. Her lips did not show any
eczematous changes, but were hyperpigmented. I do believe she had atopic dermatitis and likely allergic
contact dermatitis on the lips now with post inflammatory hyperpigmentation…….
Examples
• CONGENITAL NEVUS
•
• Dear Dr. [name]:
• [Patient] was seen in my dermatology clinic on
November 31, 2010, with a large brown congenital nevus
on the nasal dorsum. Clinically, the lesion did appear
benign. The patient is…..
• I did discuss this in length with both the patient and her
mother. If they do opt for excision of the lesion, I have
recommended that they see plastic surgery at Children's
Hospital.
• Thank you for allowing me…..
•
• Sincerely,
• Dear Dr. [name]:
• [Patient] was seen in my Dermatology Clinic
on October 21th, 2010. She did have
precancerous lesions on both her left arm, on
her nose, and on her upper cutaneous lips.
These were treated with liquid nitrogen. She
did have some freckling and photoaging on
her face. She was given Tri-Luma to be
used…..
•
•
•
•
•
•
•
SEBORRHEIC KERATOSES
•
•
•
•
•
•
•
CERVICAL SPINE, FLEXION EXTENSION
CLINICAL IMPRESSION/DIAGNOSIS
Benign seborrheic keratoses right temporal and left frontal scalp.
RECOMMENDATIONS/DISPOSITION
The lesions were treated with liquid nitrogen…..
TYPE OF EXAM
Cervical spine, flexion and extension.
FINDINGS
Correlation with cervical spine radiographs of 12/01/08. Lateral flexion and extension views
obtained. Extension appears somewhat limited, with the patient producing relative
straightening of the cervical lordotic curvature. In extension the anterior atlantodental space
measures 3 mm in width, widening to approximately 5 to 6 mm in flexion. In flexion the
posterior spinal laminar line at C1 also appears to project slightly anterior to that of C2 and
more inferiorly. Only a portion of the skull base is included but the tip of the clivus….
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
CHEST X-RAY 3
DATE OF EXAM
12/28/10
TYPE OF EXAM
Chest x-ray.
COMPARISON EXAM
06/23/10.
FINDINGS
PA and lateral views. There is ill-defined infiltrate extending in the left mid-to-lower lung area on PA view,
seen to be located anteriorly extending into the lingular area on lateral view. Lateral view obtained is
somewhat degraded by respiratory motion artifact. There is a suggestion of vague density medially in the
right lower lung area on PA view, particularly when compared with 06/16/08 projection – however, also
somewhat more shallow degree of inspiration currently. At the right mid-upper lung area, overlying the
anterior aspect of the right third rib, there is a 1.2 x 1.0-cm nodule-like density, reflecting change from
previous. The increased density at the right mid lung …..
IMPRESSION
1.
Infiltrate in the left mid-lower lung area (lingula), compatible with pneumonia – however; followup
radiographs to document complete clearing is recommended.
2.
Small nodule in the right mid lung area, reflecting…...
A written preliminary report of these findings and recommendation was provided to Dr. [name]'s office on
12/28/10.
•
•
•
•
•
•
•
•
•
•
•
DATE OF EXAM
12/10/10
•
•
•
IMPRESSION
1.
Cardiomegaly. No evidence of active pulmonary infiltrates or cardiac failure.
2.
Cardiac pacing device…
TYPE OF EXAM
Chest x-ray.
CLINICAL HISTORY
Cough.
FINDINGS
PA and lateral views. Comparison exams - 09/09/00, 09/16/03. The lungs appear clear of active infiltrates. A 1.2cm nodule is present anteriorly in the middle lobe area. This does not appear to have changed significantly from
previous exams in 2000 and 2003, therefore likely benign such as a granuloma. Cardiac pacing device remains in
place, obscuring a portion of the left mid lung on PA view. The cardiac silhouette is enlarged, CTR 19/32.5 with
calcific plaque formation in the thoracic aorta. Previous median sternotomy. Right hemidiaphragm contour
appears somewhat flattened on lateral view. Degenerative changes are present in the shoulders. A surgical clip is
present at the right lower neck area. Mild convexity…..
•
•
•
•
•
•
•
•
•
•
•
•
•
LEFT FOURTH FINGER
DATE OF EXAM
12/10/10
TYPE OF EXAM
Left fourth finger.
CLINICAL HISTORY
Injury, swelling, pain.
FINDINGS
Three views. There is comminuted fracture with mild distraction of fracture
fragments involving the terminal tuft of the distal phalanx in the fourth
finger. Associated soft tissue swelling in the fourth finger . Proximal and
middle phalanges of this finger appear intact. Remainder of the visualized
bony structures appear intact as well. A small opaque density projects
adjacent to the DIP joint of the third finger on AP view, probably faintly
visualized on lateral but obscured on oblique. A small avulsion fracture
fragment of undetermined age could produces such appearance, but the
adjoining bony contours appear intact, suggesting ….
•
•
•
•
•
•
•
•
•
•
•
DATE OF EXAM
12/05/08
•
•
IMPRESSION
1.
On PA view there is a small area of vaguely increased density at the medial aspect of the left lung
base – possibility of mild developing infiltrate in this area cannot be excluded. No corresponding finding
can….
TYPE OF EXAM
Chest x-ray.
CLINICAL HISTORY
Pneumonia.
FINDINGS
PA and lateral views. On PA view there is a small area of vaguely increased density, accentuated markings
medially at the left lung base. No specific corresponding finding is seen on lateral view, however. Remainder
of the lungs appear clear. Particularly the upper lung areas are somewhat overpenetrated on PA view
obtained. Diaphragmatic contours appear….
•
•
•
•
•
•
•
•
•
•
•
•
•
SOB, WHEEZE, CARDIOMYOPATHY
•
•
IMPRESSION
1.
The projections obtained are variably degraded by respiratory motion artifact. The findings are likely
on the basis of congestive heart failure although other developing infiltrate in the right lower lung area
cannot be entirely excluded. Also note associated small right pleural….
DATE OF EXAM
12/22/08
TYPE OF EXAM
Chest x-ray.
CLINICAL HISTORY
SOB, wheeze, cardiomyopathy.
FINDINGS
PA and lateral views. Comparison exams chest x-rays 08/18/99 to 12/17/02. There are varying degrees of
respiratory motion artifact degrading the two PA views and the lateral view obtained. Nonetheless, there
are mildly accentuated markings in the perihilar to lower lung areas. The hilar regions appear mildly
prominent. The configuration is somewhat similar
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
START OF WEEK 4 EXAMPLES
MACULAR HOLE, LEFT EYE
DATE OF OPERATION
01/29/09
DATE OF DICTATION
01/29/09
PREOPERATIVE DIAGNOSES
1. Macular hole, left eye.
2. Epiretinal membrane.
3. Proliferative diabetic retinopathy.
4. Macular edema, left eye.
POSTOPERATIVE DIAGNOSES
1. Macular hole, left eye.
2. Epiretinal membrane.
3. Proliferative diabetic retinopathy
4. Macular edema, left eye.
PROCEDURES
1. Closed pars plana vitrectomy.
2. ICG dye.
3. Membrane peeling and segmentation
4. Internal air/fluid exchange.
5. Injection 5% C3F8 gas, left eye.
•
•
•
•
•
•
•
•
•
•
•
•
SURGEON
[name]
ASSISTANT
None.
ANESTHESIA
Local 2% Xylocaine mixed with 0.75% Marcaine.
DESCRIPTION OF OPERATION: With adequate sedation, the patient was brought to the main eye surgery operating
suite, where he received a retrobulbar injection of the above local anesthetic. After adequate anesthesia and akinesia
were obtained, the left eye was prepped and draped in the usual manner for eye surgery. A lid speculum was placed.
Three sclerotomies were performed 3 mm behind the limbus. Through the inferotemporal sclerotomy site was
introduced the irrigating cannula, which was secured with a 6-0 Vicryl mattress suture. Through the 2 superior
sclerotomy sites were introduced the fiberoptic light pipe and Accurus vitrectomy machine. With the contact lens
system sutured into place and the operating microscope in position, the pars plana vitrectomy was begun. The
vitreous gel was filled with floaters and debris. It was truncated, cut, and aspirated without difficulty. The posterior
hyaloid was artificially detached with the vitrector. It was peeled free, cut and aspirated without difficulty. Once the
vitreous cavity was totally cleared and the posterior hyaloid removed, an aliquot of ICG dye mixed in Provisc was
layered on the posterior pole and allowed to remain for three minutes. The excess was then aspirated with the
tapered extrusion cannula. Then, utilizing the diamond dusted Tano pick, an epiretinal membrane was identified,
elevated and carefully peeled free. It was a tenacious membrane stuck very tightly to the retina, but eventually it was
completely removed. At this point, an internal air/fluid exchange was carried out followed by the filling of the vitreous
cavity with a 5% mixture of C3F8 gas. All three sclerotomy sites were then closed with 6-0 Vicryl. The conjunctiva and
tenon capsules were closed with 8-0 Vicryl. A subconjunctival injection of tobramycin and dexamethasone was made
in the inferior cul-de-sac. Maxitrol ointment was instilled. The eye was patched and a Fox shield placed. The patient
was then returned to the recovery area in good condition. During the procedure, the patient received Cleocin 600 mg
IV. The intraocular pressure was left less than 5 mm Hg. The patient will be discharged home and admonished to
remain in the face-down position. He is discharged home on Diamox 250 mg a day and Tylenol for pain. He will be
seen in our [place] office by me tomorrow morning at 8:00 a.m.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
RHEGMATOGENOUS RETINAL DETACHMENT
OPERATIVE NOTE
DATE OF OPERATION
01/29/09
DATE OF DICTATION
01/29/09
PREOPERATIVE DIAGNOSES
1. Rhegmatogenous retinal detachment, left eye
2. High myopia, left eye.
3. Status post argon laser x2, left eye.
POSTOPERATIVE DIAGNOSES
1. Rhegmatogenous retinal detachment, left eye
2. High myopia, left eye.
3. Status post argon laser x2, left eye.
PROCEDURES
1. Closed pars plana vitrectomy.
2. Internal air/fluid exchange.
3. Cryopexy.
4. Injection 5% C3F8 gas, left eye……
•
•
•
•
•
ANESTHESIA
Local 2% Xylocaine mixed with 0.75% Marcaine.
DESCRIPTION OF OPERATION
With adequate pre-op sedation, the patient was brought to the main eye surgery operating suite, where he received a
retrobulbar injection of the above local anesthetic. After adequate anesthesia and akinesia were obtained, the left eye was
prepped and draped in the usual manner for eye surgery. A lid speculum was placed. Three sclerotomies were performed 3
mm behind the limbus. Through the inferotemporal sclerotomy site………..There was 1 large jagged tear localized at the 2
o’clock meridian and multiple smaller tears, probably 10 in all. An internal air/fluid exchange was then carried out through the
large retinal tear superotemporally. Eventually, the retina was totally flattened and no additional retinotomy was required.
Under direct visualization through the operating microscope, transconjunctival cryotherapy was applied clockwise from the 11
o’clock to the 3 o’clock meridian, completely covering the large tear superotemporally as well as multiple smaller tears in the
area of extensive lattice degeneration. At the conclusion, the retina was flat and good cryo marks were visible. The vitreous
cavity was then filled with a 5% mixture of C3F8 gas. All three sclerotomy sites were…. ………
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
TRAUMATIC DISLOCATED CATARACT
OPERATIVE REPORT
DATE OF OPERATION
1/30/2009
PREOPERATIVE DIAGNOSIS
Traumatic dislocated cataract and iris sphincter rupture, right eye.
POSTOPERATIVE DIAGNOSIS
Traumatic dislocated cataract and iris sphincter rupture, right eye.
OPERATION PERFORMED
Intracapsular cataract extraction with sutured posterior chamber intraocular lens implant, iridoplasty suture, and anterior
vitrectomy, right eye.
ANESTHESIA
Local MAC.
ATTENDING SURGEON
[name]
ANESTHESIOLOGIST
[name]
SURGICAL TECHNIQUE
Retrobulbar anesthesia was administered by the anesthesiologist in the holding area. A Honan balloon was placed over the right
orbit at a pressure of 30 mmHg for approximately 20 minutes. The balloon was removed and the patient was taken to the operating
room and placed supine on the table. The right eye was prepped and draped in sterile fashion, and a Lieberman lid speculum
placed in the interpalpebral fissure. A bridle suture of 4-0 silk on a tapered needle was passed under the insertion of the superior
rectus muscle to aid in positioning the eye. A superotemporal conjunctival recession was performed with Westcott scissors which
were used to clear sclera of tenon capsule…..
A Thornton ring was used as a reference for the marks. Two smaller conjunctival recessions were performed
adjacent to these marks. Hemostasis was obtained with wet field cautery. The superotemporal sclera was
marked with Castro-Viejo calipers for a chord length of 7 mm. A scleral groove incision was created
between these marks with a diamond paracentesis blade which was also used to create a paracentesis at
the inferior corneal limbus…………
The anterior chamber was entered through this incision with a 3-mm keratome followed by a 5.5-mm
keratome. The wound was opened to the full 7 mm chord length and then extended on either side for a
total of approximately 10 mm. The Viscoat cannula was passed behind the dislocated cataractous
crystalline lens, and it was elevated to the iris plane. A lens vectis was then passed behind the lens and
was used to deliver it from the eye with little difficulty. Sponge and scissor vitrectomy…..
The IOL from Alcon mode CZ70BD of 19.5 diopters was brought to the field and irrigated with BSS. A doublearmed 9-0 Prolene suture with CTC6L needles was passed through 1 eyelet on one of the haptics and was
arranged so that the lens would not be torqued when the suture was tied. One of the needles was passed
through the primary incision and posterior to iris and out through sclera adjacent to the inferotemporal
corneal mark. The second needle was passed in similar fashion
The wound was again tested and found to be free of vitreous. Miochol solution was infused into the anterior
chamber and the pupil began to constrict everywhere except inferiorly, where the sphincter rupture was.
A steel MVR blade was used to create 2 more paracentesis incisions on either side of the inferior
paracentesis. A 10-0 Prolene suture on a CTC6L needle was …..
The automated vitrector was used to remove viscoelastic from the anterior chamber. The primary incision was
further closed with interrupted sutures of 10-0 nylon. The knots were trimmed and buried in sclera. The
wound was dried and tested and found to be watertight. The Lewicky cannula was removed and a single
radial suture of 10-0 Vicryl was placed in the paracentesis incision. The wound….
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
UNCONTROLLED NEOVASCULAR GLAUCOMA
OPERATIVE REPORT
DATE OF OPERATION
01/30/09
PREOPERATIVE DIAGNOSIS
Uncontrolled neovascular glaucoma due to diabetic retinopathy, right eye.
POSTOPERATIVE DIAGNOSIS
Uncontrolled neovascular glaucoma due to diabetic retinopathy, right eye.
OPERATION PERFORMED
1. Glaucoma drainage implant placement, right eye.
2. Pericardium patch graft placement, right eye.
SURGEON
[name]
ANESTHESIA
Monitored anesthesia care with IV sedation and retrobulbar block, right side.
ANESTHESIOLOGIST
[name]
GLAUCOMA DRAINAGE IMPLANT
Baerveldt, model BG101-350, serial [number], expiration date 2010/11.
PERICARDIUM TISSUE
TranZgraft, serial [number].
DESCRIPTION OF PROCEDURE
After identification of the patient in the preoperative holding area, she was taken to an anesthesia suite where the anesthesiologist placed
cardio-respiratory surveillance monitors and an IV. IV sedation was given at this time. Retrobulbar block anesthesia was given to the right
side using a 1:1 mixture of 2% lidocaine and 0.75% Marcaine with addition of Amphadase. The patient ….
This suture was used to place the eye into down gaze. A conjunctival peritomy was created between the 9 o’clock
and 2 o’clock position. All subconjunctival and subtenon adhesions were cautiously freed by both blunt and
sharp dissection. Hemostasis was obtained using wet field cautery. The superior and lateral rectus muscles were
identified with a muscle hook. The Baerveldt glaucoma drainage implant was flushed by injection of balanced
salt solution and free flow was noted. Four stab incisions were placed into the proximal portion of the drainage
tube. Then, a 3-0 nylon suture was placed intraluminally to control fluid flow initially. The drainage implant was
then introduced into the superotemporal quadrant and each wing of the implant plate was placed underneath
the superior and lateral rectus muscle, respectively. The drainage implant plate was then anchored 9 mm
posterior to the corneal limbus using two single interrupted 6-0 silk sutures. The drainage tube was then cut to
size. A peripheral clear corneal paracentesis incision was placed temporally. The anterior chamber was
deepened and stabilized by injection of Viscoat viscoelastic substance. A 23-gauge needle tract was placed
superotemporally posterior to….
At the end of the surgery, the drainage implant was covered with healthy appearing conjunctiva which was secure at
the corneal limbus. The anterior chamber remained deep with an appropriately placed anterior chamber
drainage tube. The intraluminal……
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
BLEPHAROCHALASIS
DATE OF OPERATION
02/04/09
DATE OF DICTATION
02/04/09
PREOPERATIVE DIAGNOSIS
1. Blepharochalasis, all 4 eyelids.
2. Graves ophthalmopathy, both orbits.
POSTOPERATIVE DIAGNOSIS
1. Blepharochalasis, all 4 eyelids.
2. Graves ophthalmopathy, both orbits.
PROCEDURES
1. Blepharoplasty with excision of skin, muscle, and fat, right upper eyelid.
2. Blepharoplasty with excision of skin, muscle, and fat, left upper eyelid.
3. Blepharoplasty with excision of skin, muscle, and fat, right lower eyelid.
4. Blepharoplasty with excision of skin, muscle, and fat, left lower eyelid.
SURGEON
[NAME]
ANESTHESIA
MAC
ESTIMATED BLOOD LOSS
5 mL.
COMPLICATIONS
None.
INDICATIONS
[patient] is a 78-year-old woman with Graves disease. This has caused swelling and proptosis of both her eyes and the orbital fat periocularly. She
presents at this time for removal of the fat to decompress her orbit anteriorly. She ….
•
•
PROCEDURE
Once sufficient sedation was obtained, Tetracaine drops were instilled in both eyes and both upper eyelids were
infiltrated utilizing 2% lidocaine with epinephrine and 0.5% Marcaine with epinephrine. A total of 10 mL was
used. The eyelid …
•
Surgery commenced with incision of the skin and orbicularis muscle in the areas identified in the upper eyelids.
Monopolar cutting cautery was used for this. Once the skin and muscle had been removed the orbital septum
was opened and a large amount of anterior orbital fat billowed forth. This was removed….
•
Attention then turned to the lower lids. With closure of the upper eyelids, the lower lids were also infiltrated
utilizing the same anesthetic. An oblique incision was made in a skin fold temporally and a subciliary incision
created across the full width of the lower lid. The skin muscle flap anteriorly was raised down to the level of the
arcus marginalis utilizing monopolar cutting cautery. Very dense orbital septum inferiorly was found bilaterally.
Upon opening, again a large amount of fat billowed forth. This was excised utilizing monopolar cutting cautery
flush with the adjacent tissues. Care was taken not to remove an excessive amount so as to avoid creating a
deeper depressed orbit. Once a sufficient amount of orbital fat was removed from the….
•
At the end of the procedure, a sling was placed on the lower lid utilizing Steri-Strips and Mastisol skin adhesive.
A small amount of Bacitracin…..
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
SUSPECT GIANT CELL ARTERITIS
OPERATIVE NOTE
DATE OF OPERATION
02/03/09
PREOPERATIVE DIAGNOSIS
Suspect giant cell arteritis.
POSTOPERATIVE DIAGNOSIS
Suspect giant cell arteritis.
PROCEDURE
Bilateral temporal artery biopsy.
SURGEON
[name]
COMPLICATIONS
None.
ANESTHESIA
MAC
DESCRIPTION OF THE OPERATION
After informed consent and a physical examination, the patient was escorted to the operating room and placed in the
supine position. Cardiac monitor was placed. IV sedation was started. The temporal regions were palpated. A branch
of the temporal artery was outlined on each side with a marking pen. These areas were then infiltrated with 1%
lidocaine with 0.375% bupivacaine with epinephrine. The patient was then prepped and draped in the usual sterile
fashion. Attention was directed to the right side first. A 15 blade was used to …..
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
VITREOUS HEMORRHAGE 2
OPERATIVE REPORT
DATE OF OPERATION
02/02/09
DATE OF DICTATION
02/02/09
PROCEDURE
Pars plana vitrectomy with membrane peeling and endolaser, left eye.
PREOPERATIVE DIAGNOSIS
Vitreous hemorrhage secondary to proliferative diabetic retinopathy, left eye……
DETAILS OF PROCEDURE
After being informed of the risks, benefits and alternatives of the procedure, the patient gave informed
written consent. Preoperatively, dilating eye drops were placed in the left eye. The patient was given a
retrobulbar injection by Dr. [name] the anesthesiologist and taken to the operating room. The left eye was
prepped and draped in the usual sterile fashion. A lid speculum was placed in the eye. Conjunctival
peritomies were created with Westcott scissors. Hemostasis was achieved with wet field cautery. An MVR
blade was used to create a sclerotomy 3.5 mm posterior to the limbus….
•
CORNEAL EDEMA
•
•
•
•
•
•
•
•
•
•
•
DATE OF OPERATION
01/29/09
•
•
DESCRIPTION OF PROCEDURE
The patient was identified in the holding area and escorted to the pre-op anesthesia area. Cardiovascular
monitoring was established. The anesthesiologist performed a retrobulbar block on the left eye followed by Honan
balloon decompression. Adequate akinesia and anesthesia was achieved. The patient was escorted to the
operating theater and was prepped and draped in the usual fashion for eye surgery. Attention was turned to the
graft tissue which was brought to the sterile surgical side table and mounted on the artificial anterior chamber. This
was secured and then the artificial anterior chamber was pressurized. The corneal graft epithelium was removed
with a paten spatula. Pachymetry of the graft measured 518 microns. After ensuring….
•
(continued next slide)
PREOPERATIVE DIAGNOSIS
Corneal edema, left eye.
POSTOPERATIVE DIAGNOSIS
Corneal edema, left eye.
OPERATION PERFORMED
Descemet stripping automated endothelial keratoplasty (DSAEK), left eye……
Attention was turned to the patient. A lid speculum was placed in the left eye. Superior and inferior 4-0 silk bridle
sutures were placed and a temporal conjunctival peritomy was performed. Hemostasis was obtained with wet
field cautery. A 5 mm scleral incision was made with a fixed depth diamond blade. A feather blade was then
used to fashion a scleral tunnel. The cornea was measured at 12 mm white to white. An 8.5 mm DSAEK
marker was used to mark the planned graft area. Two paracenteses were made into the eye with the inner
aspect of the paracenteses within the planned graft coverage area. An infusion cannula was inserted into the
left-handed paracentesis. A Price hook was inserted through the other paracentesis and used to score
Descemet membrane. The edges of Descemet….
Attention was turned to the graft tissue, which was centered on the cutting block with low vacuum applied. An
8.25-mm trephination was performed. Provisc was placed on the endothelial side and a two-thirds fold-over
was performed. The stromal side was marked. The tissue was grasped with the Ogawa DSAEK insertion
forceps, brought to the patient, and inserted through the temporal incision into the anterior chamber where it
was noted to unfold spontaneously. A 30-gauge needle …..
The conjunctival peritomy was closed with interrupted 10-0 Vicryl sutures. At the end of 10 minutes, a slight
amount of fluid was released from the temporal incision to soften the eye somewhat. A full air bubble was left
in the eye. The patient has an incomplete iris diaphragm and a tube shunt in place. The silk sutures….
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
FAILED PENETRATING KERATOPLASTY
•
•
SURGICAL TECHNIQUE
Retrobulbar anesthesia was administered by the anesthesiologist in the holding area. A Honan balloon was placed
over the left eye at a pressure of 30 mm Hg for approximately 20 minutes. The balloon was removed and the
patient was taken to the operating room and placed supine on the table. The left eye was prepped and draped in
sterile fashion. The donor table was set up with irrigation attached to the artificial anterior chamber. The donor
was brought to the field and placed endothelium side down on the base of the anterior chamber with irrigation
running to remove air underneath the donor. The locking ring was put in position and the base was tightened
against the retaining ring. Hemostats were placed on the infusion line at approximately four inches and three
inches from the artificial anterior chamber. Epithelium was removed with Weck-cel sponges. Central pachymetry
was performed and the Moria microkeratome….
(continued next page)
•
DATE OF SURGERY
02/04/09
DATE OF DICTATION
02/04/09
PREOPERATIVE DIAGNOSIS
Failed penetrating keratoplasty graft, left eye.
POSTOPERATIVE DIAGNOSIS
Failed penetrating keratoplasty graft, left eye.
OPERATION PERFORMED
Descemet stripping automated endothelial……
Attention was turned to the host cornea. The assistant had opened the eye and placed an Ogawa self-retaining lid
speculum. Bridle sutures of 4-0 silk on tapered needles were passed under the insertions of the inferior and
superior rectus muscles. These were draped around the lid speculum and weighted with mosquito hemostats
to position the eye. The preexisting corneal graft was measured with Castroviejo calipers and a Hanna
trephine of 8.75 mm was chosen. A temporal conjunctival recession was performed with Westcott scissors,
which were used to clear tenon from sclera. Hemostasis was obtained with wet field cautery. The corneal
epithelium was tested and was found to be thick and loose. Therefore superficial keratectomy was performed.
The temporal sclera was marked with the Castroviejo calipers at 5 mm . A scleral partial thickness frown…..
Attention was returned to the donor cornea. Excess Optisol was removed with a Weck-cel sponge and vacuum was
applied. The trephine guide was put in position and the trephine holder was placed and used to punch the
donor button. The guide was removed. The corneoscleral rim was removed and vacuum was terminated.
Provisc was placed on the left-hand two-thirds of the endothelium. The graft was folded in a 70/30 taco fold
and was grasped with Ogawa DSAEK forceps on the stromal sides. The surgical assistant returned to the
microscope to the operative field. The graft was brought to the field and passed through the temporal incision
and released in the anterior chamber without difficulty. An Ogawa cortex aspirating cannula….
•
•
•
The temporal incision was closed with a single radial suture of 10-0 Vicryl. The knot was trimmed and buried
in sclera. The conjunctival recession was closed with two horizontal mattress sutures of 10-0 Vicryl. The
needle was passed so that the knots would be buried when tied. At the end of 10 minutes, another
paracentesis incision was created at the nasal limbus and an air/fluid exchange was performed with BSS
leaving an approximately 20% air bubble in the anterior chamber….
•
•
•
•
•
•
•
•
•
•
FUCHS CORNEAL DYSTROPHY
•
The microkeratome head was inspected for tightness and blade movement and was engaged on the pivot post
on the microkeratome base. The turbine motor was started and horizontal translation was accomplished
manually. The resulting corneal cap…..
•
A temporal conjunctival recession was performed with Westcott scissors, which were also used to clear sclera
of tenon capsule. Hemostasis was obtained with wet field cautery. The temporal sclera was marked with
Castroviejo calipers set at 5 mm . A diamond step blade was used to create a scleral groove incision in a frown
configuration between and beyond these marks. A scleral tunnel incision was created with a feather blade.
Paracentesis incisions were created in the superotemporal…..
(continued next page)
•
DATE OF SURGERY
02/04/09
PREOPERATIVE DIAGNOSIS
Fuchs corneal dystrophy with corneal edema, left eye…….
SURGICAL TECHNIQUE
Retrobulbar anesthesia was administered by the anesthesiologist in the holding area. A Honan balloon was
placed over the left orbit at a pressure of 30 mmHg for approximately 20 minutes. The balloon was removed
and the patient was taken to the operating room and placed supine on the table. The left eye was prepped
and draped in sterile fashion. The donor table was prepared with irrigation connected to the artificial anterior
chamber. The donor cornea was placed on the anterior chamber base with irrigation running to remove air
from under the donor. Irrigation was discontinued and the retaining ring was locked in position and the base
was tightened against the retaining ring. Hemostats…..
•
•
The incision was now gaped with an Ogawa cortex aspirating cannula to remove the blue dye from the anterior chamber, and
the aspirating cannula was then used to strip Descemet's within the score marks. The exposed stroma was slightly roughened
peripherally with the Price DSAEK hook, and the temporal wound was expanded to 5.2 mm with disposable keratome.
Attention was returned to the donor cornea. The metal cover was removed. Excess Optisol was removed from the cornea with
Weck-cel sponges. Proper centration ….
•
The assistant moved the microscope back to the operative field. The wound was grasped with Colibri forceps and the graft was
inserted with the Ogawa forceps. After insertion, it became apparent that a temporal iridodialysis was created. The wound was
…..
•
The eye was left at an appropriate pressure as the needle was withdrawn. Pressure was applied to the needle tract with a
Weck-cel sponge as the needle was withdrawn. Corneal drainage incisions were placed in 4 quadrants using a Price DSAEK
blade. The incisions were approximately 1.5 mm central to the corneal mark. The incisions were gaped with a Sinskey hook
until no more fluid was expressed and timing was begun for 10 minutes. Further fluid was expressed with the LASIK flap roller.
The temporal incision was …..
•
The lid speculum and drapes were removed. Atropine 1% solution and Vigamox were placed on the eye, and the eye was
patched and shielded. The patient …..
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
BILATERAL UPPER LID BLEPHAROPLASTY
•
The upper lids were then infiltrated with 1% lidocaine with 0.375% bupivacaine with epinephrine. The patient was then
prepped and draped in the usual sterile fashion. Attention was directed to the right side first. Using the needle-tip cautery, an
incision was made through the skin and orbicularis muscle along the previously-noted ….
•
A dissection plane was then carried out between the levator aponeurosis and the underlying Muller muscle. A double-armed 50 nylon ….
•
Attention was then directed to the left side where the levator advancement and the upper lid blepharoplasty were performed in
the exact ….
(continued next page)
•
PREOPERATIVE DIAGNOSES
Bilateral upper lid ptosis, bilateral upper lid dermatochalasis, bilateral brow ptosis.
POSTOPERATIVE DIAGNOSES
Bilateral upper lid ptosis, bilateral upper lid dermatochalasis, bilateral brow ptosis…….
ANESTHESIA
MAC.
COMPLICATIONS
None.
DESCRIPTION OF OPERATION
After informed consent and a physical examination, the patient was escorted to the operating room and placed in the supine
position. A cardiac monitor was placed. IV sedation was started. The upper lids were inspected and the upper lid creases were
marked on each side with a marking pen. A conservative blepharoplasty was also….
Attention was then directed to the right side, where a dissection plane was carried out between the orbicularis muscle
and the underlying orbital septum to the superior orbital rim. The superior orbital rim was then identified and
incised with a 15 blade. Periosteum….
Attention was then directed to the pretrichial markings. A 15 blade was used to make an incision along the previously
noted pretrichial markings. A flap of skin and subcutaneous fat was removed. A 15 blade was then used to make an
incision through the periosteum medial to the conjoined tendons on either side. A Freer periosteal….