Sample Type / Medical Specialty: Ophthalmology
Sample Name: YAG Laser Capsulotomy
Description: Visually significant posterior capsule opacity, right eye. YAG laser posterior capsulotomy, right eye.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Visually significant posterior capsule opacity, right eye.
POSTOPERATIVE DIAGNOSIS: Visually significant posterior capsule opacity, right eye.
OPERATIVE PROCEDURES: YAG laser posterior capsulotomy, right eye.
ANESTHESIA: Topical anesthesia using tetracaine ophthalmic drops.
INDICATIONS FOR SURGERY: This patient was found to have a visually significant posterior capsule opacity in the right eye. The patient has had a mild decrease in visual acuity, which has been a gradual change. The posterior capsule opacity was felt to be related to the decline in vision. The risks, benefits, and alternatives (including observation) were discussed. I feel the patient had a good understanding of the proposed procedure and informed consent was obtained.
DESCRIPTION OF PROCEDURE: The patient was identified and the procedure was verified. Pupil was dilated per protocol. Patient was positioned at the YAG laser. Then, *** of energy were used to perform a circular posterior laser capsulotomy through the visual axis. A total of ** shots were used. Total energy was **. The patient tolerated the procedure well and there were no complications. The lens remained well centered and stable. Postoperative instructions were provided. Alphagan P ophthalmic drops times two were instilled prior to his dismissal.
Post-laser intraocular pressure measured ** mmHg. Postoperative instructions were provided and the patient had no further questions.
Keywords:
ophthalmology, capsule opacity, yag, ophthalmic, yag laser posterior capsulotomy, capsulotomy, opacity, laser, visually, eye, anesthesia,
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