Ophthalmology Study

DISCHARGE SUMMARY

HISTORY OF THE PRESENT ILLNESS

The patient is 85-year-old white male who underwent scleral buckling of the left eye for retinal detachment in December and again in February.  A second scleral buckling operation was complicated by subretinal hemorrhage at the time of release of subretinal fluid.  The subretinal hemorrhage reabsorbed.  The patient did well until 2 weeks prior to admission, when he noted he could not see from the left eye.  Examination showed recurrence of the retinal detachment with an open retinal break at about the 5:30 position.

PAST OCULAR HISTORY

The left eye underwent cataract extraction with placement of an iris-fixated lens in the past.  The patient has had corneal edema of the left eye, more pronounced after each scleral buckling procedure.  He uses topical sodium chloride agents for the corneal edema.  The history of the right eye is that there is age-related macular degeneration.

PAST MEDICAL HISTORY

The patient has non-Hodgkin lymphoma, currently in remission.  He has had splenectomy.  He has had a tonsillar carcinoma treated surgically and with radiotherapy.  There is mild hypertension.

Current medications include allopurinol 300 mg daily, Tagamet
400 mg q.h.s., multivitamins daily, vitamin C, and the previously described topical agents for the left eye.

PHYSICAL EXAMINATION

Vision 20/60 in the right eye and the detection of hand motion in the left eye.  Intraocular pressure was normal in each eye.  Examination of the right eye showed mild lens changes and macular scar.  Examination of the left eye showed ptosis of the upper lid and malpositioning of the lower lid.  There was evidence of previous ocular surgery.  Slit-lamp examination showed aphakia with an iris-fixated lens.  There was corneal edema and thickening present.  Fundus examination showed total retinal detachment with the evidence of a previously placed scleral buckle from about 2 to 10 o’clock, reinforced with a radial sponge at 5 o’clock, and an open retinal break at about 5:30.

LABORATORY DATA

CBC:  There was mild elevation of the white blood count and slight reduction of the red count.  There was also reduced hemoglobin and hematocrit.  Urinalysis was negative.  Blood chemistries including electrolytes, glucose, and BUN were normal.  Chest x-ray showed mild changes consistent with obstructive pulmonary disease but no acute changes.  ECG showed right ventricular conduction defect and a left axis deviation.

HOSPITAL COURSE

Under general anesthesia, the scleral buckle was revised by removing the radial element at about 5 o’clock and replacing it with a trimmed #507 implant placed circumferentially.  This resulted in reinforcement of the buckle from about 4:30 to
6 o’clock, closing the retinal break.  A vitrectomy was also performed through the pars plana.  A gas-fluid exchange was performed, first using air, intravitreal and subretinal cannulated fluid extrusion.  A 30% mixture of expansile gas was then placed in the vitreous cavity.  A previously placed
#276 silicone implant and a #40 band were left in situ.  The buckle extended from 2 to 10 o’clock.

Postoperatively the retina was reattached, and the patient was discharged from the hospital to be followed as an outpatient.  Discharge medications included a cycloplegic agent and topical antibiotics with sodium chloride to the left eye.

FINAL DIAGNOSES

1. Retinal detachment, left eye.

2. Pseudophakia, left eye.

3. Corneal edema, left eye.

4. Macular degeneration, right eye.

OPERATION

Revision of scleral buckle, vitrectomy, air-gas-fluid exchange.

FOOTNOTE

Line 17 (Page 2).  Was was changed to were for subject-verb agreement.

Line 32 (Page 2).  The number 1 was deleted since the dictator failed to enumerate the operations.  Alternative:  Enumerate the operations.