Sample Name: Phacoemulsification & Lens Implantation - 5
Description: Phacoemulsification with IOL, right eye. Cataract, right eye. A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Cataract, right eye.
POSTOPERATIVE DIAGNOSIS: Cataract, right eye.
OPERATION PERFORMED: Phacoemulsification with IOL, right eye.
ANESTHESIA: Topical with MAC.
PROCEDURE IN DETAIL: After appropriate consent was obtained, the patient was brought to the operating room and then prepared and draped in the usual sterile fashion per Ophthalmology. A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat. A 2.75-mm keratome then made a stab incision at the 2 o'clock position through which an anterior capsulorrhexis was performed using cystotome and Utrata. BSS on blunt cannula, hydrodissector, and spun the nucleus after which phacoemulsification divided the nucleus in 3 quadrants each was subsequently cracked and removed through phacoemulsification I&A. Healon was injected into the posterior capsule and a XXX lens was then placed with a shooter into the posterior capsule and rotated into position with I&A, which then removed all remaining cortex as well as viscoelastic material. BSS on blunt cannula hydrated all wounds, which were noted to be free of leak and lid speculum was removed. Under microscope, the anterior chamber being soft and well formed. Pred Forte, Vigamox, and Iopidine were placed in the eye. A shield was placed over the eye. The patient was followed to recovery where he was noted to be in good condition.
Keywords: ophthalmology, lid speculum, lens, iol, viscoat, posterior, capsule, cataract, speculum, incision, phacoemulsification,