Operative Note Report Sample:

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OPERATIVE NOTE

DATE OF SURGERY: 09/05/10
PREOPERATIVE DIAGNOSIS: Cataract and glaucoma of the left eye.    
POSTOPERATIVE DIAGNOSIS: Cataract and glaucoma of the left eye. 
OPERATIVE PROCEDURE:

Combined phacoemulsification of cataract extraction with primary trabeculectomy without mitomycin of the left eye.
SURGEON: Harry Richard, M.D.
ANESTHESIA:  Retrobulbar block and monitored anesthesia care.
SPECIMEN:   Lens nuclear material.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None. 

INDICATIONS FOR PROCEDURE:  This is a 78-year-old Hispanic female with a diagnosis of cataract and glaucoma affecting her activities of daily living.  All the risks and benefits of the procedure were explained to the patient.  She agreed to sign an informed consent. 

PROCEDURE:  The patient was taken to the Operating Room and was placed in a recumbent position.  A time out was conducted in which the patient’s identity, surgical procedure, intraocular lens power, and name were verified by the surgeon, circulating nurse and scrub nurse.  Attention was given to the right eye and using a lid speculum to open the eye lids.  We used a lid speculum to open the iris of the right eye to initiate the procedure.  Then using a 0.12 forceps and a 15º diamond blade, a paracentesis was performed on the temporal clear cornea.  We injected nonpreserved lidocaine 1 cc through the paracentesis in order to anesthetize the anterior chamber.  The anterior chamber was then refilled through the same incision with viscoelastic.  Then we used a 2.75 diamond blade to perform a shelved temporal clear corneal incision.  We refilled the anterior chamber with additional viscoelastic and then used cystotome and Utrata forceps to complete an anterior capsulotomy.  Then we performed hydrodissection, hydrodelineation, phacoemulsification, irrigation and aspiration of the lens cortical material, and then we implanted an artificial intraocular lens implant power of +21.5 diopters Model SN60WF serial number 10827052017 inside the capsular bag without any complications.   

At the end of the procedure, we used irrigation and aspiration to remove the viscoelastic material, injected 1 cc of Miostat to constrict the pupil, and the seal the corneal wound with balanced salt solution.  We then placed some antibiotic ointment on the eye.  An eye patch and shield were also placed.  We sent the patient to the Recovery Room without any complications where he received postoperative instructions and follow up appointments.