MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Choroidal melanoma of right eye with limited nodular extraocular extension.
POSTOPERATIVE DIAGNOSIS:
Choroidal melanoma of right eye with limited nodular extraocular extension.
PROCEDURE PERFORMED:
Enucleation of right eye with implantation of 22 mm diameter bioceramic sphere.
SURGEON:
John Doe, MD
ASSISTANT:
None.
ANESTHESIA:
General plus retrobulbar Marcaine.
COMPLICATIONS:
None.
DESCRIPTION OF OPERATION:
The patient was brought to the operating room and was positioned on the operating table. Cardiac and blood pressure monitoring devices were applied. General inhalational anesthesia was induced without complications. The patient was prepped and draped in the usual fashion for a procedure of the right eye.
A lid speculum was inserted between the lids of the eye to expose the eye. The fundus was examined by indirect ophthalmoscopy, and the intraocular tumor was verified. The lid speculum was temporarily removed, and retrobulbar injection of 0.75% Marcaine plain was administered at this time. The lid speculum was reinserted between the lids to expose the eye.
A conjunctival peritomy was created with Westcott scissors, and the subconjunctival connective tissues were dissected down to bare sclera in the 4 quadrants. The 4 rectus muscles were sequentially secured with separate 5-0 Vicryl double-arm double locking sutures, and the muscles was then disinserted from the sclera with the Westcott scissors. The superior oblique and inferior oblique muscles were sequentially secured and disinserted from the sclera with Westcott scissors.
Using a hemostat for traction on the stump of the medial rectus muscle, the globe was gently elevated in the orbit. The enucleation scissors were introduced from the medial approach. The optic nerve was cut in the orbit with the enucleation scissors, and the globe was delivered from the orbit. The orbital tissues were compressed for several minutes until hemostasis had been achieved.
A 22 mm diameter bioceramic sphere was inserted into the orbit. The horizontal rectus muscles were secured in near end-to-end apposition over the implant using the previously mentioned 5-0 Vicryl sutures. Similarly, the vertical rectus muscles were secured in near end-to-end apposition over the implant using the previously mentioned 5-0 Vicryl sutures.
The Tenon’s tissue was closed with multiple interrupted sutures of 5-0 Vicryl over the implant and muscles. Finally, the conjunctiva was closed with a running suture of 5-0 Vicryl. The lid speculum was removed. Bacitracin-Polymyxin ointment was applied to the surface of the conjunctiva. A large conformer was placed on the surface of the conjunctiva. The lids were patched with a sterile eye pad and Elastoplast tape dressing.
The patient tolerated the procedure well. He was awakened from general anesthesia without difficulty and was transferred to postanesthesia recovery in satisfactory condition.
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