Berlin eye hospital discharge report
Post-Enucleation Pathology Report
<More to come>
I translated the important parts as best as I could. It contains some text that is on the 2nd page, which I haven't scanned yet because I only needed page 1.
We report on the patient xxxxxxxxxxxxxx, resident: xxxxxxxxxxxxxx, which was in our treatment from 11.05.2019 to 17.05.2019.
On 14.05.2019 a wound exploration with wound care, anterior chamber irrigation and administration of vancomycin 0.05ml and dexamethasone 0.25ml in all-cause anesthesia was performed on the left eye
Intraoperatively, an extensive scleranecrosis occurred. The patient received vancomycin, cefuroxime, and prednisolone over 6 days. Local was treated with floxal, gentamicin and inflanefran forte.
No pathogen was found.
Front section left eye:
Bulbus soft, conjoined blue, adapted, cornea smooth, clear, anterior chamber deep, no irritation, pupil dilated, some reaction to light, lens dulled
Fundus left eye:
no ingot, b-scan: choroid swelling, glaskorperin filtrates