pajohnson
Guru
Hi all,
Just want to be sure that the probing and dialation of the lacrimal canaliculus in included in code 68700. Your input is appreciated!!
PREOPERATIVE DIAGNOSIS:
1. Ectropion of the left lower lid causing exposure keratopathy and epiphora of the left eye.
2. Left lower eyelid lacrimal stenosis/stenosis of proximal lacrimal canaliculus of left lower lid.
POSTOPERATIVE DIAGNOSIS:
1. Ectropion of the left lower lid causing exposure keratopathy and epiphora of the left eye.
2. Left lower eyelid lacrimal stenosis/stenosis of proximal lacrimal canaliculus of left lower lid.
PROCEDURE PERFORMED:
1. Lateral tarsal strip procedure of left lower eyelid in repair of ectropion.
2. Left lower eyelid lacrimal punctal incision, dilation and probing of lacrimal canaliculus with repair of left inferior lacrimal canaliculus.
PREOPERATIVE HISTORY: Patient has the above mentioned problems. He has tearing down on his cheek from the left eye that really bothers him and this is due to the above mentioned problems. He really has an absent lacrimal proximal canaliculus and punctum, perhaps due to previous dry eye treatment and this needs to be repaired as well as the ectropion of the left lower lid. The risks and benefits of doing nothing were explained to the patient and the risks and benefits of the surgeries were explained to the patient and all of his questions were answered. He elected to have the surgery.
OPERATIVE SUMMARY: Patient was brought back and given sedation. Sterile proparacaine drops were placed in both eyes and then 2% Xylocaine with epinephrine was injected transconjunctivally along the medial aspect of the left lower lid and also along the lateral aspect of the left lower lid and transcutaneously in the left lateral canthal area via a short 30 gauge needle. Next, a full face prepping and draping was performed in the usual sterile ophthalmic fashion.
A lateral canthotomy was performed along the lateral aspect of the left lower lid. The lower limb of the lateral canthal tendon was cut at the level of the periosteum. Cautery was used to achieve hemostasis. The anterior and posterior lamella was lysed and the anterior lamella had a little wedge of tissue removed. Next, the conjunctiva and retractors were cut away from the lower part of the tarsal tongue and then the epithelium was scrapped away posteriorly with a 15 blade and it was trimmed away from the superior aspect of the tarsus. A little bit of excessive tarsus was removed. Next, a punctal dilator was attempted to dilate the lacrimal punctum, but really there was no way this could be done so an 11 blade was then used to excise the punctum in the proximal canaliculus to try to get this open. Next, a Bowman probe was passed in here and I tried to really open this up and dilate it. Found the proximal 3 mm of the canaliculus to be really absent, but I was able to reconstruct the canaliculus and also put a Bowman probe in there after the punctal dilator was removed to probe the proximal canaliculus and also the distal canaliculus. This was then removed and about a triangular wedge of the back surface of the lacrimal ampulla was removed to make it plenty large and then several interrupted 6-0 Vicryl sutures were used to suture the widened proximal canaliculus to repair it. These sutures were tied down and cut on the knot, taking care that the knot would not rub the eye.
Next, two 5-0 Prolene sutures were passed through the tarsal tongue laterally and through periosteum to over correct in elevation and tightness. These were tied down and cut on the knot. Next, several interrupted and inverted 4-0 Vicryl sutures were passed through the deep orbicularis muscle in the lateral canthal area and these sutures were tied down and cut on the knot and took tension off the skin wound which was then closed with several interrupted 4-0 Vicryl and 6-0 Vicryl and also 6-0 nylon sutures. In this way, the lateral canthal tissue was brought together nicely.
Please note that where there was bleeding, hemostasis was achieved through cautery.
Next, the wounds were cleaned up and then antibiotic ointment was placed over them and a metal shield was given to wear when sleeping so as not to rub the eye by accident. The patient went to the recovery room.
Just want to be sure that the probing and dialation of the lacrimal canaliculus in included in code 68700. Your input is appreciated!!
PREOPERATIVE DIAGNOSIS:
1. Ectropion of the left lower lid causing exposure keratopathy and epiphora of the left eye.
2. Left lower eyelid lacrimal stenosis/stenosis of proximal lacrimal canaliculus of left lower lid.
POSTOPERATIVE DIAGNOSIS:
1. Ectropion of the left lower lid causing exposure keratopathy and epiphora of the left eye.
2. Left lower eyelid lacrimal stenosis/stenosis of proximal lacrimal canaliculus of left lower lid.
PROCEDURE PERFORMED:
1. Lateral tarsal strip procedure of left lower eyelid in repair of ectropion.
2. Left lower eyelid lacrimal punctal incision, dilation and probing of lacrimal canaliculus with repair of left inferior lacrimal canaliculus.
PREOPERATIVE HISTORY: Patient has the above mentioned problems. He has tearing down on his cheek from the left eye that really bothers him and this is due to the above mentioned problems. He really has an absent lacrimal proximal canaliculus and punctum, perhaps due to previous dry eye treatment and this needs to be repaired as well as the ectropion of the left lower lid. The risks and benefits of doing nothing were explained to the patient and the risks and benefits of the surgeries were explained to the patient and all of his questions were answered. He elected to have the surgery.
OPERATIVE SUMMARY: Patient was brought back and given sedation. Sterile proparacaine drops were placed in both eyes and then 2% Xylocaine with epinephrine was injected transconjunctivally along the medial aspect of the left lower lid and also along the lateral aspect of the left lower lid and transcutaneously in the left lateral canthal area via a short 30 gauge needle. Next, a full face prepping and draping was performed in the usual sterile ophthalmic fashion.
A lateral canthotomy was performed along the lateral aspect of the left lower lid. The lower limb of the lateral canthal tendon was cut at the level of the periosteum. Cautery was used to achieve hemostasis. The anterior and posterior lamella was lysed and the anterior lamella had a little wedge of tissue removed. Next, the conjunctiva and retractors were cut away from the lower part of the tarsal tongue and then the epithelium was scrapped away posteriorly with a 15 blade and it was trimmed away from the superior aspect of the tarsus. A little bit of excessive tarsus was removed. Next, a punctal dilator was attempted to dilate the lacrimal punctum, but really there was no way this could be done so an 11 blade was then used to excise the punctum in the proximal canaliculus to try to get this open. Next, a Bowman probe was passed in here and I tried to really open this up and dilate it. Found the proximal 3 mm of the canaliculus to be really absent, but I was able to reconstruct the canaliculus and also put a Bowman probe in there after the punctal dilator was removed to probe the proximal canaliculus and also the distal canaliculus. This was then removed and about a triangular wedge of the back surface of the lacrimal ampulla was removed to make it plenty large and then several interrupted 6-0 Vicryl sutures were used to suture the widened proximal canaliculus to repair it. These sutures were tied down and cut on the knot, taking care that the knot would not rub the eye.
Next, two 5-0 Prolene sutures were passed through the tarsal tongue laterally and through periosteum to over correct in elevation and tightness. These were tied down and cut on the knot. Next, several interrupted and inverted 4-0 Vicryl sutures were passed through the deep orbicularis muscle in the lateral canthal area and these sutures were tied down and cut on the knot and took tension off the skin wound which was then closed with several interrupted 4-0 Vicryl and 6-0 Vicryl and also 6-0 nylon sutures. In this way, the lateral canthal tissue was brought together nicely.
Please note that where there was bleeding, hemostasis was achieved through cautery.
Next, the wounds were cleaned up and then antibiotic ointment was placed over them and a metal shield was given to wear when sleeping so as not to rub the eye by accident. The patient went to the recovery room.