Download Oak Park Surgery Center 860 Oak Park Blvd., Suite 102 Arroyo Gran

Oak Park Surgery Center
860 Oak Park Blvd., Suite 102
Arroyo Grande, CA 94320 ♦ (805) 474-6383
OPERATIVE REPORT
PATIENT NAME:
MEDICAL RECORD NUMBER:
DATE OF SURGERY:
GRASSLE, ASTRID
0015786
June 30, 2016
SURGEON:
ASSISTANT:
ANESTHESIOLOGIST:
ANESTHESIA:
ADAM D. ABROMS, M.D.
NONE
NOLAN HIGA, M.D.
GENERAL
PREOPERATIVE DIAGNOSES:
1. Exotropia with lateral incomitance.
2. Right hypertropia.
3. Mechanical strabismus status post retinal detachment repair with scleral buckle.
POSTOPERATIVE DIAGNOSES:
1. Exotropia with lateral incomitance.
2. Right hypertropia.
3. Mechanical strabismus status post retinal detachment repair with scleral buckle.
OPERATIVE PROCEDURES:
1. Exploration of Right superior rectus with removal of scar tissue.
2. Recession of Left lateral rectus, 5.0 mm, on adjustable suture.
3. Recession of Left inferior rectus, 3.0 mm.
4. Strabismus surgery in setting of prior extraocular muscle surgery (scleral buckle).
ESTIMATED BLOOD LOSS: 20 cc.
COMPLICATIONS: None.
PROCEDURE PERFORMED: The patient was brought to the operating suite where general
anesthesia was induced. The patient was prepped and draped in the usual sterile manner. A
lid speculum was placed in the right eye.
A superotemporal conjunctival fornix incision was created with scissors and carried through
anterior Tenon’s fascia down to bare sclera. There was significant scar tissue in the
superotemporal quadrant due to prior scleral buckle repair with scar tissue involving conjunctiva,
anterior Tenon’s capsule, extraocular muscles, and sclera. A sharp dissection was carried
down to bare sclera and scar tissue was excised. Multiple muscle hook passes were required
to locate and isolate the right superior rectus. This muscle was found to be very scarred and
not fully intact with an unclear insertion. After removal of scar tissue, it was felt that recession of
this muscle would be too unpredictable and no further surgery was performed on the right eye.
Conjunctiva was swept closed. The lid speculum was transferred to the left eye.
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Oak Park Surgery Center
860 Oak Park Blvd., Suite 102
Arroyo Grande, CA 94320 ♦ (805) 474-6383
OPERATIVE REPORT
PATIENT NAME:
MEDICAL RECORD NUMBER:
DATE OF SURGERY:
GRASSLE, ASTRID
0015786
June 30, 2016
An inferotemporal conjunctival fornix incision was created with scissors and carried through
anterior Tenon’s fascia down to bare sclera. The left lateral rectus was isolated on serial
muscle hooks and cleaned of its anterior fascial attachments with sharp dissection. A 6-0 Vicryl
double-armed S-29 suture was woven through the left lateral rectus at its insertion with locking
ties at either edge. The muscle was disinserted from sclera with scissors. The muscle was
reattached with sclera by passing both needles intrasclerally in standard crossed-swords
manner. The muscle was tied on an adjustable slip knot and allowed to hang back. The muscle
was adjusted to a 5.0 mm recession and tied securely.
Through the same conjunctival incision, the left inferior rectus was isolated on serial muscle
hooks and cleaned of its anterior fascial attachments with sharp dissection. A lengthy sharp
dissection was then carried posteriorly to free the muscle from the lower lid retractors
completely. A 6-0 Vicryl double-armed S-29 suture was woven through the left inferior rectus at
its insertion with locking ties at either edge. The muscle was disinserted from sclera with
scissors. The muscle was reattached with sclera 3.0 mm posterior to the original insertion by
passing both needles intrasclerally in standard crossed-swords manner. The muscle was tied
securely at this location. Conjunctiva was closed with interrupted 6-0 Vicryl suture.
At conclusion of surgery, all drapes and instrumentation were removed. Betadine 5% solution,
and Ofloxacin ophthalmic drops, and Xylocaine 2% gel were applied to both eyes. The patient
emerged from anesthesia uneventfully and left the operating room in stable condition.
_________________________
Adam D. Abroms, M.D.
AA/mes
D: 06/30/16
T: 07/01/16
Tracking #: WS376670
cc:
Gayle Cekada, M.D.
cc:
Michael Rohla, O.D.
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