DATE OF PROCEDURE:
PATIENT NAME:
PREOPERATIVE DIAGNOSIS: Visually significant combined cataract with regular astigmatism and glaucoma of the eye.
POSTOPERATIVE DIAGNOSIS: same
PROCEDURE: Complex Phacoemulsification with insertion of Toric intraocular lens eye
ATTENDING SURGEON:
RESIDENT SURGEON:
ASSISTANT SURGEON:
ANESTHESIA: Topical anesthesia with monitored anesthesia care
INDICATIONS FOR PROCEDURE: Patient has a history of visually significant cataract eye, who presented to the eye clinic with blurry vision in the eye. The risks, benefits and alternatives to cataract surgery were thoroughly discussed with the patient and he elected to proceed with cataract surgery in the eye.
OPERATIVE FINDINGS: Cataract in the ??? eye. Toric PCIOL in the bag aligned at degrees.
COMPLICATIONS: None
DETAILS OF THE PROCEDURE:
Patient ??? was correctly identified.
The principal meridians of the cornea were marked while sitting upright.
The patient was brought to the operating room at which point he was given sedation per anesthesia. A complete time-out was performed.
Patient was given sedation and retrobulbar block was administered consisting of 50:50 lidocaine and Marcaine and 0.1cc of vitrase.
Topical tetracaine, 5% betadine, and viscous lidocaine were instilled in the ??? eye. The patient was prepped and draped in the usual sterile ophthalmic fashion. A lid speculum was placed in the ??? eye.
A temporal paracentesis wound was created at ??? using an MVR blade and 0.12 forceps. OMIDRIA and epinephrine/lidocaine were injected into the anterior chamber.
Trypan blue was injected into the anterior chamber under an air bubble and irrigated with BSS.
The anterior chamber was filled with stableVisc and a temporal clear corneal wound was created using a ??? keratome blade with 0.12 mm forceps for stabilization.
A ??? Malyugin ring was placed for pupillary expansion.
A continuous curvilinear capsulorrhexis was performed using a combination of a cystotome needle and Utrata forceps. Gentle hydrodissection and was performed using balanced salt solution on a blunt tipped cannula.
clearVisc was injected into the anterior chamber to protect the cornea.
The lens was removed using phacoemulsification power with the ??? technique. The cortical material was removed using irrigation and aspiration. The capsular bag was filled with stableVisc viscoelastic.
The lens implant was confirmed as an ??? posterior chamber lens (SN ???, EXP ???). The lens was injected into the capsular bag and rotated into the appropriate position with a Lester hook. The lens axis was noted to be ??? degrees.
The scope was repositioned for view with gonioscopy prism and patient's head was turned. OVD was injected to better visualize the angle. iStent procedure was performed with placement of two iStents two clock hours apart in the nasal angle at the level of the trabecular meshwork. Glaukos iStent Inject W serial # __________ expiration __________. After insertion, a plume of blood was visualized through the snorkel indicating placement in Schlemm's canal. After clearing away the blood with additional viscoelastic, the iStents were noted to be inserted with the flange flush with the TM.
The Malyugin ring was then removed from the eye.
The remaining clearVisc was removed using irrigation and aspiration. The anterior chamber was filled with balanced salt solution and the wounds were hydrated. Moxifloxacin (???, lot ???, exp. ???) was injected. At this point the incisions were found to be watertight and the intraocular pressure was normal. Triamcinolone (???, lot ???, exp. ???) was injected into the infratemporal sub-tenon's space. The drapes and speculum were removed from the eye and the Betadine solution was washed from the skin with sterile saline. A drop of brimonidine, diclofenac, and prednisolone was placed in the eye, ointment was applied and the eye was patched and shielded.
The patient tolerated the surgery well, and he transferred to the PACU in satisfactory condition. The attending was present for the entire procedure.
The patient was instructed to follow-up in the eye clinic as scheduled.
Prednisolone acetate 1%, taper weekly QID/TID/BID/daily/stop.
Diclofenac, QID until out.
Moxifloxacin, QID for 1 week then stop.
Polytrim
Patient has history of LASIK. Please obtain ARx at post-op week 1.
Surgical Time: minutes
EPT:
APT:
US Avg: %
Irr: cc
EBL: cc