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: Phacoemulsification & Lens Implantation - 7

Description: Phacoemulsification with posterior chamber intraocular lens implant in the right eye.
(Medical Transcription Sample Report)

TITLE OF OPERATION: Phacoemulsification with posterior chamber intraocular lens implant in the right eye.

INDICATION FOR SURGERY: The patient is a 27-year-old male who sustained an open globe injury as a child. He subsequently developed a retinal detachment in 2005 and now has silicone oil in the anterior chamber of the right eye as well as a dense cataract. He is undergoing silicone oil removal as well as concurrent cataract extraction with lens implant in the right eye.

PREOP DIAGNOSIS:
1. History of open globe to the right eye.
2. History of retinal detachment status post repair in the right eye.
3. Silicone oil in anterior chamber.
4. Dense silicone oil cataract in the right eye obscuring the view of the posterior pole.

POSTOP DIAGNOSIS:
1. History of open globe to the right eye.
2. History of retinal detachment status post repair in the right eye.
3. Silicone oil in anterior chamber.
4. Dense silicone oil cataract in the right eye obscuring the view of the posterior pole.

ANESTHESIA: General.

PROS DEV IMPLANT: ABC Laboratories posterior chamber intraocular lens, 21.0 diopters, serial number 123456.

NARRATIVE: Informed consent was obtained. All questions were answered. The patient was brought to preoperative holding area where the operative right eye was marked. He was brought to the operating room and placed in the supine position. EKG leads were placed. General anesthesia was induced by the anesthesia service. A time-out was called to confirm the procedure and operative eye. The right operative eye was disinfected and draped in a standard fashion for eye surgery. A lid speculum was placed. The vitreoretinal team placed the infusion cannula after performing a peritomy. At this point in the case, the patient was turned over to the cornea service with Mrs. Jun. A paracentesis was made at the approximately 3 o'clock position. Healon was placed into the anterior chamber. The diamond keratome was used to make a vertical groove incision just inside the limbus at the 108-degree axis. This incision was then shelved anteriorly and used to enter the anterior chamber. The Utrata forceps were used to complete a continuous circular capsulorrhexis after incision of the capsule with the cystotome. Hydrodissection was performed. The lens nucleus was removed using phacoemulsification and irrigation and aspiration. Lens cortex also was removed using irrigation and aspiration. Viscoelastic was placed to inflate the capsular remnant. The diamond knife was used to enlarge the phaco incision. Intraocular lens was selected from preoperative calculations, placed in the injector system, and inserted into the capsule without difficulty. The trailing haptic was placed using the Sheets forceps and the Barraquer sweep to push the IOL optic posteriorly as the trailing haptic was placed. The anterior cornea wound was sutured along with the paracentesis after irrigation and aspiration was performed to remove remaining viscoelastic from the anterior chamber. This was done without difficulty. The anterior chamber was secured and watertight at the end of the procedure. Intraocular pressure was satisfactory. The patient tolerated the procedure well and then was turned over to the retina service in good condition. They will dictate a separate note.

Keywords: ophthalmology, phacoemulsification, intraocular lens implant, posterior chamber, chamber, eye, intraocular, lens,
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Transcribed Medical Transcription Sample Reports and Examples