DISCHARGE SUMMARY
The patient was admitted emergently and underwent vitrectomy and lensectomy and gas-fluid exchange. Postoperatively the patient underwent strict positioning with the face down as well as receiving parenteral Diamox and narcotics for pain postoperatively.
During the postoperative care, the patient developed high intraocular pressures due to gas expansion and required vitreous tap of gas x2 with good resolution of the intraocular pressure. Upon discharge she was in good condition.
Visual acuity in her right eye was light perception only and improved to at least 20/40+ in the left eye with correction. She had diffuse conjunctival injection and chemosis, more in the right eye than in the left. Cornea and anterior chamber were clear. Fundus exam revealed good view in both eyes. Both fundi were flat. Good cryoreaction was present in both eyes. Intraocular pressure on discharge was 15 in the right eye and 13 in the left eye.
The patient was discharged on a regular diet and activity ad lib, except to never be in the supine position.
FOOTNOTE
Line 18. This sentence (referring to the right eye and then the left eye) is confusing to some, and the transcriptionist on the job would seek clarification from the physician. It might be clearer if it read: “Visual acuity was light perception only in the right eye and improved to at least...”
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