Operative Report Sample:

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OPERATIVE REPORT

DATE OF OPERATION:   03/10/10
PREOPERATIVE DIAGNOSIS: Cataract left eye.    
POSTOPERATIVE DIAGNOSIS: Cataract left eye. 
OPERATIVE PROCEDURE:
Phacoemulsification with anterior chamber intraocular lens placement. 
SURGEON: Harry Richard, M.D.
ANESTHESIA: Monitored anesthesia care.   
COMPLICATIONS: Rupture of the posterior capsule.


INDICATIONS FOR PROCEDURE:
  
The patient has noticed visual loss and impairment of visual acuity in the left eye over the last phase after diagnosis and discussion of surgery, risk and benefits, the patient opted for cataract surgery in the left eye. 

PROCEDURE IN DETAIL:    The patient was identified prior to operative area and holding area the correct eye was identified with a YES.  A peribulbar block was given in the reoperative area under normal conditions.  The patient was brought into the operative suite were leads and monitors were placed.  It was confirmed that the left eye was the operative eye.  A lid spectrum was spectrum was fashioned in the operative eye and the area was approached from the temporal area.  A small groove was made at the two o’clock position using a corneal scleral blade.  An incision was made at the six o’clock position with a 1 mm keratome.  The anterior chamber was filled with Tryphan blue to stain the capsule.  Viscoelastic was then inserted into the eye.  The two o’clock position was then entered with a 2.7 mm keratome and using the cystotome and Utrata complete capsulorrhexis was performed.  At this point it was noted that the patient’s pupil dilated very poorly.  Hydrodissection was made with BSS and a cannula.  The nucleus was spin and noted free of attachments.  The phacoemulsification unit was then used to do the chopping technique to remove the nucleus.  This was done without any problems.  Residual cortex was removed using the I & A hand piece.  At this point, it was noted there was a small rent in the posterior capsule and it was elected to put an anterior chamber intraocular lens.  The wound was opened to allow for an anterior chamber intraocular lens.  This was inserted without any problems in the anterior chamber and the wound was closed with three interrupted 10-0 nylon sutures.  The wound was tested for water tightness.  The water tightness was complete.  Miochol was inserted in the eye thus constricting the pupil and it appeared to be complete.  The speculum was removed.  Antibiotic medication was placed on the eye.  A shield and a patch were placed on the eye and the drapes were removed.  The reminder procedure without complications and there was no vitreous loss.  The patient was taken to the Recovery Room where he recovered without any problems.