Sample Name: Rectus Recession
Description: Bilateral rectus recession with the microscopic control, 8 mm, both eyes.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Congenital bilateral esotropia, 42 prism diopters.
PROCEDURE: Bilateral rectus recession with the microscopic control, 8 mm, both eyes.
POSTOPERATIVE DIAGNOSIS: Congenital bilateral esotropia, 42 prism diopters.
PROCEDURE IN DETAIL: The patient was taken to the Surgery Room and placed in the supine position. The general anesthesia was achieved with intubation with no problems. Both eyes were prepped and draped in usual manner. The attention was turned the right eye and a hole was made in the drape and a self-retaining eye speculum was placed ensuring eyelash in the eye drape. The microscope was focused on the palpebral limbus and the eyeball was rotated medially and laterally with no problem. The eyeball rotated medially and upwards by holding the limbus at 7 o'clock position. Inferior fornix conjunctival incision was made and Tenons capsule buttonholed. The lateral rectus muscle was engaged over the muscle hook and the Tenons capsule was retracted with the tip of the muscle hook. The Tenons capsule was buttonholed. The tip of the muscle hook and Tenons capsule was cleaned from the insertion of the muscle. __________ extension of the muscle was excised. The 7-0 Vicryl sutures were placed at the insertion of the muscle and double locked at the upper and lower borders. The muscle was disinserted from original insertion. The suture was passed 8 mm posterior to the insertion of the muscle in double sewed fashion. The suture was pulled, tied, and cut. The muscle was in good position. The conjunctiva was closed with 7-0 Vicryl suture in running fashion. The suture was pulled, tied, and cut. The eye speculum was taken out.
Keywords: ophthalmology, congenital bilateral esotropia, esotropia, tenons capsule, rectus muscle, bilateral rectus recession, rectus recession, eye speculum, muscle hook, eyes, muscle, rectus,