MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Open angle glaucoma, right eye.
POSTOPERATIVE DIAGNOSIS:
Open angle glaucoma, right eye.
OPERATION PERFORMED:
Trabeculectomy, right eye.
SURGEON:
John Doe, MD
ASSISTANT:
None.
ANESTHESIA:
General.
ANESTHESIOLOGIST:
Jane Doe, MD
INDICATIONS FOR OPERATION:
Uncontrolled glaucoma.
DESCRIPTION OF OPERATION: The patient was taken to the operating suite where general anesthetic was induced. The patient was prepped and draped in standard fashion for ocular surgery. The eyelids were parted with a Maumenee-Park lid speculum. A 4-0 silk superior rectus bridle suture was placed and the eye was then retracted.
A peritomy was performed 8 mm from the limbus directly superiorly. Conjunctiva was dissected anteriorly. Tenon’s capsule was removed. Hemostasis was obtained with mild electrocautery. A 3.5 mm rectangular scleral flap of half scleral thicknesses was dissected out into clear cornea. A paracentesis was performed inferotemporally. The anterior chamber was deepened with an air bubble. A pledget was soaked with mitomycin-C. The pledget was placed over the scleral flap, beneath conjunctiva, and left in place for 2 minutes, after which time the pledget was removed and the area was irrigated with copious balanced salt solution. A 1 x 3 mm resection of trabecular meshwork was excised.
A peripheral iridectomy was performed. The scleral flap was then closed with five 10-0 nylon sutures. The knots were buried. Tenon’s capsule was closed with two 8-0 Vicryl sutures and conjunctiva was closed with a running horizontal mattress 10-0 nylon suture. The anterior chamber was deepened with balanced salt solution. A nice, diffuse bleb resulted and tested watertight.
Decadron 2 mg was injected subconjunctivally in the inferotemporal quadrant. The eye was then dressed with atropine 1% solution, Maxitrol ointment, a torpedo dressing, mild pressure patch and shield. The patient tolerated the procedure well, was awakened by Anesthesia and taken to the recovery room in stable condition.
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