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.
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,