Sample Name: Cataract Extraction - 2
Description: Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Cataract, left eye.
POSTOPERATIVE DIAGNOSIS: Cataract, left eye.
PROCEDURE PERFORMED: Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.
A 3.2-mm incision was made in clear cornea at the limbus with a diamond keratome at the 3 o'clock position, and 0.1 cc of 1% Xylocaine without preservative was instilled into the anterior chamber. It was then filled with viscoelastic. A stab incision was made into the anterior chamber at the limbus at 5 o'clock position with a microblade.
A cystitome was used to make a capsulotomy, and the capsulorrhexis forceps were used to complete a circular capsulorrhexis. The nucleus was hydrodelineated and hydrodissected with balanced salt solution on a 26-gauge cannula, and the phacoemulsifier was used to phacoemulsify the nucleus using a bimanual technique with the nucleus rotator inserted through the keratotomy incision. The irrigation-aspiration handpiece was used to systematically aspirate cortex 360 degrees. The posterior capsule was vacuumed; it was clear and intact.
The capsular bag and the anterior chamber were filled with viscoelastic. A model MA30AC lens, power 21.5 diopters, serial number 864414.095, was folded, grasped with the lens insertion forceps and inserted into the capsular bag. The trailing loop was placed inside the bag. The viscoelastic was removed with the irrigation-aspiration handpiece. The lens centered well. A single 10-0 nylon suture was placed to close the wound. It was checked and ascertained to be watertight. Decadron 0.25 cc, 0.25 cc of antibiotic and 0.25 cc of Xylocaine were injected subconjunctivally. Dexacidin ointment was placed in the eye, and the procedure was terminated.
The procedure was well tolerated by the patient who was returned to the recovery room in good condition.
Keywords: ophthalmology, anterior chamber, keratome, limbus, intraocular lens, cataract extraction, extracapsular, phacoemulsification, capsular, cataract, chamber, intraocular,