EDTA Chelation Procedure Sample Report

DATE OF PROCEDURE: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Band keratopathy, right eye.

POSTOPERATIVE DIAGNOSIS: Band keratopathy, right eye.

PROCEDURE PERFORMED: EDTA chelation of right eye.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: Monitored anesthesia care and topical.

COMPLICATIONS: None.

BLOOD LOSS: None.

SPECIMENS: None.

INDICATIONS FOR PROCEDURE: This is a (XX)-year-old Hispanic female with progressive visual loss in her right eye secondary to band keratopathy.

DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was brought back to the operating room in the supine position. A drop of tetracaine was placed in the right eye. The right eye was prepped and draped in the usual sterile fashion for a procedure of the right eye.

A lid speculum was then placed in the right eye. A crescent blade was then used to remove the epithelium over the band keratopathy in the right eye. A 3 mL syringe with a polishing tip was then used with EDTA to polish and gently remove the band keratopathy. EDTA was used in a concentration of 4:1. Then, 4 mL of EDTA and 16 mL of sterile preservative-free BSS were mixed prior to the procedure. The EDTA with polishing was used until all of the band keratopathy was removed. The area was inspected and found to be in good condition with mild corneal edema and epithelial basement membrane irregularly from the band keratopathy.

The area was then rinsed thoroughly with BSS. A drop of Vigamox and Voltaren were placed in the eye. The lid speculum was removed. An 8.4 Night & Day bandage contact lens was placed in the eye. The area was cleaned, and an eye shield was placed over the eye. The patient left the operating room in good condition.

The patient was instructed to return the following day for a postoperative check in the eye clinic. She was given her three drops, including Pred Forte, Vigamox, and Voltaren and instructed to use them four times a day.


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