Sample Name: Vitrectomy
Description: Vitreous hemorrhage, right eye. Vitrectomy, right eye. A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Vitreous hemorrhage, right eye.
POSTOPERATIVE DIAGNOSIS: Vitreous hemorrhage, right eye.
PROCEDURE: Vitrectomy, right eye.
PROCEDURE IN DETAIL: The patient was prepared and draped in the usual manner for a vitrectomy procedure under local anesthesia. Initially, a 5 cc retrobulbar injection was performed with 2% Xylocaine during monitored anesthesia control. A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus. MVR incisions were made 4 mm posterior to the limbus in the *** and *** o'clock meridians following which the infusion apparatus was positioned in the *** o'clock site and secured with a 5-0 Vicryl suture. Then, under indirect ophthalmoscopic control, the vitrector was introduced through the *** o'clock site and a complete vitrectomy was performed. All strands of significance were removed. Tractional detachment foci were apparent posteriorly along the temporal arcades. Next, endolaser coagulation was applied to ischemic sites and to neovascular foci under indirect ophthalmoscopic control. Finally, an air exchange procedure was performed, also under indirect ophthalmoscopic control. The intraocular pressure was within the normal range. The globe was irrigated with a topical antibiotic. The MVR incisions were closed with 7-0 Vicryl. No further manipulations were necessary. The conjunctiva was closed with 6-0 plain catgut. An eye patch was applied and the patient was sent to the recovery area in good condition.
Keywords: ophthalmology, ophthalmoscopic, vitrectomy, endolaser, lancaster lid speculum, vitreous hemorrhage, vitreous, hemorrhage, conjunctiva,