POSTOPERATIVE DIAGNOSIS: Cataract, O.S., consistent with 20/50 visual acuity.

OPERATION PERFORMED: Phacoemulsification of cataract of the left eye with placement of a 6-mm acrylic lens in the bag, haptics in the sulcus.

ANESTHESIA GIVEN: Local monitored anesthesia care.

ESTIMATED BLOOD LOSS: Less than 1 cc.

COMPLICATIONS: Posterior capsular tear.

INDICATIONS FOR PROCEDURE: The patient is a 54-year-old white female who presented to my office with a complaint of decreased vision in her left eye. On examination, she was noted to have significant cataract formation of the left eye, consistent with a visual acuity of 20/50. After discussing these findings with the patient, including the risks, benefits, and options available to her, she wished to proceed with the above-named procedure.

DESCRIPTION OF OPERATIVE PROCEDURE: The patient was taken back to the operative area and was prepped and draped in the usual sterile fashion, following adequate anesthesia obtained utilizing a mixture of 2% Xylocaine jelly along with intravenous sedation. Following this, a lid speculum was placed between the two eyelids of the left eye and I approached the eye from the temporal position.

A Super Blade was used to perform a paracentesis at the four o'clock position and a 2.85-mm keratome blade was used to perform a clear corneal temporally located incision. Healon 5 was now instilled into the capsular bag and balanced salt solution was used to perform a soft shell. The cystitome capsulorrhexis forceps were then used to perform a round 4.5-mm anterior capsulotomy and then balanced salt solution was used to hydrodissect between the capsule and cortex, and this offered excellent hydrodissection. At this point, a 30-degree Kelman high-efficiency phacoemulsification tip was introduced into the eye and phacoemulsification was carried out in a divide-and-conquer technique over 4.5 seconds with an average power of 5.9%. During removal of the final quadrant of nucleus, a posterior capsular tear was noted distal from the corneal incision. At this point, the phacoemulsification tip was removed and an additional paracentesis was performed at the two o'clock position. Irrigation and aspiration was then utilized to remove the remaining cortical material and all cortical material, including nuclear segments, were removed. Healon 5 was now instilled into the anterior chamber and at this point, no vitreous had presented to the wound. An Alcon Model MA60 AC lens with a diopter power of 19.5 and a length of 13-mm was then inserted into the capsular bag after the corneal incision was enlarged to 3.4-mm. The optic was placed inside the capsular bag with the haptics resting in the sulcus. The Healon 5 was then removed using the bimanual irrigation and aspiration handpiece and then Miochol was instilled into the anterior chamber to replace the aqueous and offered good pupillary constriction.

The operative eye was then treated with Ocuflox drops, povidone-iodine solution, as well as a Fox shield. The patient tolerated the procedure and returned to the recovery area in a stable condition.

POSTOPERATIVE DIAGNOSIS: Bilateral upper eyelid ptosis.

OPERATION PERFORMED: Bilateral external levator resection.

ANESTHESIA GIVEN: Local monitored anesthesia care.

ESTIMATED BLOOD LOSS: Less than 5 cc.

COMPLICATIONS: None.

INDICATIONS FOR PROCEDURE: The patient is a 61-year-old white female who presented to my office with a complaint of decreased vision in both eyes secondary to drooping eyelids. On examination, the patient was noted to have a significant ptosis with absence of lid crease and a levator function of 12 mm per side. After discussing these findings with the patient and obtaining visual fields, taped and untaped, and confirming that a significant superior field defect was present in both eyes and obtaining clinical photographs, the patient agreed to have the above-named procedure performed after explanation of the risks and benefits.

DESCRIPTION OF OPERATIVE PROCEDURE: The patient was taken back to the operative area and was prepped and draped in the usual sterile fashion following adequate anesthesia obtained utilizing a mixture of 50/50 2% Xylocaine with epinephrine and 0.75% Marcaine. Prior to this, the eyelid region to be resected was identified and marked with a marking pen.

With the patient in the supine position, a #15 blade was then used to cut through skin along the fusiform section of eyelid tissue to be removed in the right eye. Good hemostasis was obtained utilizing the fine-point Bovie electrocautery instrument. Addressing the superior one-half of the fusiform section, a plane was dissected down to pre-aponeurotic fat and then the levator aponeurosis was identified. It was noted to have fatty infiltration and significant atrophy. At this point, the tarsus was identified by excising the fusiform section of orbicularis previously marked. A dissection plane through the orbicularis at the superior aspect of the tarsus was performed and this was advanced to the inferior margin of the tarsus. This plane was dissected laterally and temporally and nasally. A good hemostasis was again obtained throughout the procedure. At this point, double-armed 6-0 silk sutures on a TG-140 needle were then utilized to pass through the superior aspect of the levator aponeurosis and then this was passed through tarsus. The fellow sutures were passed laterally and nasally to the centrally passed suture. At this point, the sutures were tightened and the desired level of lid elevation and contour were obtained. These sutures were then tied permanently and cut.

The skin was then closed utilizing interrupted 6-0 Prolene sutures by incorporating skin, orbicularis, and levator aponeurosis on the inferior portion and then skin on the superior portion of this interrupted suture. A simple running suture was then passed through skin, utilizing a 6-0 Prolene suture. The same procedure was performed for the patient on the fellow eye. It should be noted that the patient received 12 mg of Decadron intravenously on-call in the OR as well as 1 gram of Kefzol intravenously in the OR on-call.

The patient tolerated the procedure well without complications and returned to the recovery area in stable condition.

OPERATION PROPOSED: Repair of wound dehiscence with debridement of necrotic tissue as well as reformation of the lateral canthal angle and formation of a periosteal flap to support the lateral canthal angle.

POSTOPERATIVE DIAGNOSIS: Dehiscence of lateral canthal angle bilaterally.

OPERATION PERFORMED: Repair of wound dehiscence with debridement of necrotic tissue as well as reformation of the lateral canthal angle and formation of a periosteal flap to support the lateral canthal angle.

ANESTHESIA GIVEN: Local monitored anesthesia care.

INDICATIONS FOR PROCEDURE: The patient is a 79-year-old white male who underwent uneventful horizontal shortening procedures of the lower lids bilaterally for entropion. The patient had the typical resection of eyelid tissue and tarsal tissue and formation of the lateral canthal angle, utilizing a single interrupted 4-0 Polydek suture at each end, as well as reformation of lateral canthal angle with interrupted 6-0 Vicryl suture and simple closure of the skin with interrupted 6-0 Prolene. The patient was seen one week postoperatively and the skin incisions were removed. The patient was to return in one week for a followup examination to evaluate his progress and on the examination the day prior to this procedure, the patient was noted to have dehiscence of the lateral canthal angle bilaterally. Of note, it appeared as though the 4-0 Polydek had "cheese-wired" through the lower lid bilaterally. These findings were explained to the patient and it was decided to take him to surgery today to repair and reconstruct the lateral canthal angle.

DESCRIPTION OF OPERATIVE PROCEDURE: The patient was taken back to the operative area and was prepped and draped in the usual sterile fashion, following adequate anesthesia obtained utilizing a 50/50 mixture of 2% Xylocaine with epinephrine and 0.75% Marcaine.

Following this, attention was directed towards the lateral aspect of the lower eyelid. This area was placed on lateral traction and debridement of the necrotic and fragile tissue was performed and this offered some bleeding at the debridement sites. Good hemostasis was then obtained utilizing a fine-point Bovie electrocautery instrument. With the eyelid placed on lateral traction with Adson forceps, iris scissors were used to dissect a plane between the orbicularis and tarsus and then a subciliary incision was formed, approximately 3-mm past this point. Good hemostasis was then obtained. At this point, any sutures identified from the previous surgery, which were buried, were removed as the case proceeded.

Attention was now directed utilizing a #15 blade to form a skin incision at the lateral canthal angle and following along the previously closed surgery site. There was significant bleeding throughout the case as the patient was on aspirin and good hemostasis was obtained. Attention was now directed towards dissecting a plane down to periosteum but not through, along this skin incision plane, again obtaining good hemostasis throughout. During this procedure, the 4-0 Polydek suture which was previously placed was noted to be in good placement of the periosteum and it was then confirmed that "cheese-wiring" of the suture had occurred through the tarsus laterally. At this point, a periosteal flap was then formed, utilizing a #15 blade at the lateral canthal angle, lateral orbital wall, and a Freer elevator was used to reflect this flap upon itself. As the procedure progressed, a double-armed 4-0 Polydek suture was then passed in a spiral fashion of the lateral lower lid and then this double-armed 4-0 Polydek suture was passed through periosteum. The suture was then tightened, tied, and then cut. This offered good apposition of the lid to the lateral orbital wall and then the previously formed periosteal flap was reflected over the tarsus of the lateral aspect of this lower lid. This was affixed into place with a double-armed 6-0 Vicryl suture which was passed from the posterior aspect of the eyelid through conjunctiva and tarsus and then through the periosteum. This double-armed suture was then tied with the suture knot on top of the periosteum which was reflected to enhance the stability of this previously dehisced lower lid. Again, good hemostasis was obtained throughout the procedure.

At this point, the skin was then closed, after formation of the lateral canthal angle was formed, with an interrupted 6-0 Vicryl suture and the skin was then closed with interrupted 6-0 Vicryl sutures covering orbicularis to orbicularis and then interrupted 6-0 Prolene sutures through the skin. This was performed with a single-armed skin hook, placing the previous incision on lateral traction. The same procedure was carried out for the fellow eye and the patient tolerated the procedure well without complications and returned to the recovery area in a stable condition.

The patient did receive topical Bacitracin antibiotic ointment over the eye as well as the sutures. A Telfa pad was placed over the eyes as well as ice compresses.

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Copyright 2005, Copied with Permission from the web site,
"Patients and Medical Transcription" at http://www.mt-stuff.com

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Rosemarie