Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Ophthalmology
Sample Name: Clear Corneal Temporal Incision

Description: Clear corneal temporal incision (no stitches). A lid speculum was placed in the fissure of the right eye.
(Medical Transcription Sample Report)

CLEAR CORNEAL TEMPORAL INCISION (NO STITCHES)

DESCRIPTION OF OPERATION: Under satisfactory local anesthesia, the patient was appropriately prepped and draped. A lid speculum was placed in the fissure of the right eye.

The secondary incision was then made through clear cornea using 1-mm diamond keratome at surgeon's 7:30 position and the anterior chamber re-formed using viscoelastic. The primary incision was then made using a 3-mm diamond keratome at the surgeon's 5 o'clock position and additional viscoelastic injected into the anterior chamber as needed. The capsulorrhexis was then performed in a standard circular tear fashion. The nucleus was then separated from its cortical attachments by hydrodissection and emulsified in the capsular bag. The residual cortex was then aspirated from the bag and the bag re-expanded using viscoelastic. The posterior chamber intraocular lens was then inspected, irrigated, coated with Healon and folded, and then placed into the capsular bag under direct visualization. The lens was noted to center well. The residual viscoelastic was then removed from the eye and the eye re-formed using balanced salt solution. The eye was then checked and found to be watertight; therefore, no suture was used. The lid speculum and the drapes were then removed and the eye treated with Maxitrol ointment.

A shield was applied and the patient returned to the recovery room in good condition.

Keywords: ophthalmology, clear corneal temporal incision, intraocular lens, corneal temporal incision, lid speculum, incision, temporal, chamber, corneal, viscoelastic, eye,
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Transcribed Medical Transcription Sample Reports and Examples