Hi list,
I am still new to Optho and learning
Any assistance is greatly appreciated!
Melissa Bedford,CCS,CPC
PREOPERATIVE DIAGNOSES:
1. Incision and drainage and steroid injection, left upper
lid.
2. Steroid injection, left lower lid.
3. Expression of glands all four lids.
POSTOPERATIVE DIAGNOSES:
1. Incision and drainage and steroid injection, left upper
lid.
2. Steroid injection, left lower lid.
3. Expression of glands all four lids.
OPERATIVE SURGEON:
ANESTHESIA TYPE:
General.
DESCRIPTION OF PROCEDURE:
The patient was identified in the preoperative holding area
where history and physical was performed by the operating
surgeon. Risks, benefits, and alternatives of all therapeutic
options were discussed. This includes bleeding, infection,
need for further surgery, current scarring and
hyperpigmentation related to steroid injection. Family
understood and wished to proceed. The patient was interviewed
by the anesthesia department, deemed to be stable, brought
back to the operating room, placed in supine position.
General anesthetic was induced. After this was done, the
patient was prepped and scrubbed in normal surgical manner.
Sterile drapes were applied. Initially, the flap of the
chalazion clamp was placed on the palpebral conjunctival
surface and contact applicators were used to express the
glands of all 4 eyelids. Interestingly, in the area of the
left lower lid medially, a quite a bit of material was noted
to express. Decision was made to inject this area with 50:50
mixture of Marcaine 0.25% with epinephrine and Kenalog 40
mg/mL of small volume was injected. The chalazion was
identified on the left upper eyelid was palpated, chalazion
clamp was placed, the eyelid was everted. Through the open
loop of the chalazion clamp and through the palpebral
conjunctival surface, an #11 Bard-Parker blade was used to
incise rectangular opening, Westcott scissors and forceps used
to remove the posterior wall of the tarsal blade. Chalazion
curette was used to remove the liquified contents of
chalazion, an amazing amount of material was noted to express.
Additionally when the chalazion was incised, milky
yellow-green material suggesting cellulitis was noted. The
area was cleaned out quite nicely and injected from the
cutaneous surface with the 50:50 mixture. Some AK-Poly-Bac
was applied topically to the left eye. The patient tolerated
the procedure well. The patient extubated in the operating
room and patient went to recovery room in stable condition.
If there are problems with dictation, please let me know. My
cell phone number is
I am still new to Optho and learning
Any assistance is greatly appreciated!
Melissa Bedford,CCS,CPC
PREOPERATIVE DIAGNOSES:
1. Incision and drainage and steroid injection, left upper
lid.
2. Steroid injection, left lower lid.
3. Expression of glands all four lids.
POSTOPERATIVE DIAGNOSES:
1. Incision and drainage and steroid injection, left upper
lid.
2. Steroid injection, left lower lid.
3. Expression of glands all four lids.
OPERATIVE SURGEON:
ANESTHESIA TYPE:
General.
DESCRIPTION OF PROCEDURE:
The patient was identified in the preoperative holding area
where history and physical was performed by the operating
surgeon. Risks, benefits, and alternatives of all therapeutic
options were discussed. This includes bleeding, infection,
need for further surgery, current scarring and
hyperpigmentation related to steroid injection. Family
understood and wished to proceed. The patient was interviewed
by the anesthesia department, deemed to be stable, brought
back to the operating room, placed in supine position.
General anesthetic was induced. After this was done, the
patient was prepped and scrubbed in normal surgical manner.
Sterile drapes were applied. Initially, the flap of the
chalazion clamp was placed on the palpebral conjunctival
surface and contact applicators were used to express the
glands of all 4 eyelids. Interestingly, in the area of the
left lower lid medially, a quite a bit of material was noted
to express. Decision was made to inject this area with 50:50
mixture of Marcaine 0.25% with epinephrine and Kenalog 40
mg/mL of small volume was injected. The chalazion was
identified on the left upper eyelid was palpated, chalazion
clamp was placed, the eyelid was everted. Through the open
loop of the chalazion clamp and through the palpebral
conjunctival surface, an #11 Bard-Parker blade was used to
incise rectangular opening, Westcott scissors and forceps used
to remove the posterior wall of the tarsal blade. Chalazion
curette was used to remove the liquified contents of
chalazion, an amazing amount of material was noted to express.
Additionally when the chalazion was incised, milky
yellow-green material suggesting cellulitis was noted. The
area was cleaned out quite nicely and injected from the
cutaneous surface with the 50:50 mixture. Some AK-Poly-Bac
was applied topically to the left eye. The patient tolerated
the procedure well. The patient extubated in the operating
room and patient went to recovery room in stable condition.
If there are problems with dictation, please let me know. My
cell phone number is