PREOPERATIVE DIAGNOSIS(ES):
History of eye trauma.
POSTOPERATIVE DIAGNOSIS(ES):
History of eye trauma with possible weakened retina.
PROCEDURE(S)/OPERATION(S) PERFORMED:
Exam under anesthesia with a laser retinopexy.
OPERATIVE FINDINGS:
Eye trauma with possible weakened retina.
SPECIMENS:
None.
DRAINS:
None.
FLUIDS:
Per Anesthesia.
ESTIMATED BLOOD LOSS:
Minimal.
CONDITION:
Stable.
COMPLICATIONS:
None.
PREOPERATIVE HISTORY:
Mr. xxxx is a 2-year-old male with a history of pencil to
the eye. After long discussion with the parents and mom, it was
decided to go ahead with an exam under anesthesia with possible
laser for any weakened areas of the retina. The risks that were
discussed were vision loss, partial or total need for multiple
procedures, infection, pain. Despite this, they wished to go
ahead with the procedure.
SUMMARY:
The patient was brought to the OR, prepped and draped in the
usual fashion. Exam under anesthesia was looked in both eyes.
There is no cataract. Anterior chamber was clear. The lens was
cleared. Cornea was clear. The conjunctivae and sclerae were
normal. The posterior pole of the optic nerve vessels, the
retina, and vitreous were all normal. There was no discharge in
the eye. The area of impact of the pencil has healed as well
with a small area of conjunctiva still healing, however, in the
left eye in the far periphery, there are 2 areas of the retina
that appeared white and demarcated. Both of these areas were
lasered. They are approximately *** the patient tolerated this
well. There were 35 spots of 150 milliwatt power, 200 ***
placed. The patient tolerated this well. There was no
complication.
History of eye trauma.
POSTOPERATIVE DIAGNOSIS(ES):
History of eye trauma with possible weakened retina.
PROCEDURE(S)/OPERATION(S) PERFORMED:
Exam under anesthesia with a laser retinopexy.
OPERATIVE FINDINGS:
Eye trauma with possible weakened retina.
SPECIMENS:
None.
DRAINS:
None.
FLUIDS:
Per Anesthesia.
ESTIMATED BLOOD LOSS:
Minimal.
CONDITION:
Stable.
COMPLICATIONS:
None.
PREOPERATIVE HISTORY:
Mr. xxxx is a 2-year-old male with a history of pencil to
the eye. After long discussion with the parents and mom, it was
decided to go ahead with an exam under anesthesia with possible
laser for any weakened areas of the retina. The risks that were
discussed were vision loss, partial or total need for multiple
procedures, infection, pain. Despite this, they wished to go
ahead with the procedure.
SUMMARY:
The patient was brought to the OR, prepped and draped in the
usual fashion. Exam under anesthesia was looked in both eyes.
There is no cataract. Anterior chamber was clear. The lens was
cleared. Cornea was clear. The conjunctivae and sclerae were
normal. The posterior pole of the optic nerve vessels, the
retina, and vitreous were all normal. There was no discharge in
the eye. The area of impact of the pencil has healed as well
with a small area of conjunctiva still healing, however, in the
left eye in the far periphery, there are 2 areas of the retina
that appeared white and demarcated. Both of these areas were
lasered. They are approximately *** the patient tolerated this
well. There were 35 spots of 150 milliwatt power, 200 ***
placed. The patient tolerated this well. There was no
complication.
