I have this Cataract case, that I'm not sure how to code. Any help is appriciated! Thanks.



OPERATION PERFORMED: Attempted phacoemulsification with dropped nucleus, left eye, pars plana vitrectomy insertion of 21.5 Technis intraocular lens.

Preoperatively, the anterior-posterior length of the eye was determined using the IOL master. On the operative day, the patient received topical anesthesia consisting of tetracaine drops. The patient was brought to the operative suite where he was prepped and draped in the usual ophthalmic manner. A lid speculum was inserted into the left palpebral fissure. A temporal approach was used. Anterior chamber was entered at 5 o’clock with a diamond scalpel. A 1% Xylocaine 0.10 cc nonpreserved was injected in the anterior chamber followed by Viscoat. A temporal near clear corneal incision was made into the anterior chamber using a 3 mm metal keratome. With a cystotome needle on the Viscoat syringe, a continuous tear anterior capsulotomy was begun and then finished with the Utrata forceps. Hydrodissection was carried out using the balanced salt solution. The nucleus was grooved and in this process fell through the posterior capsule. The irrigating handpiece was left in the eye. Viscoat was used to act as a barrier to vitreous coming forward. The Phaco handpiece was then removed and the temporal incision was sutured. The 5 o’clock incision was enlarged, so that the irrigating line of the vitrectomy unit could be produced. A 3.0 mm posterior to the limbus at 130 was marked after small conjunctival opening was made. A diamond blade was used to enter the sclera into the vitreous chamber just large enough for the diameter of the vitreous cutting instrument. Vitrectomy was set on a slow motion vitrectomy with the bottle approximately 40 cm above the patient’s head. The cutting rate was 800. The aspiration rate was 15 and the vacuum set at ______ [inaudible] was placed posterior to the iris so that the tip could be seen far well away from the anterior capsule and vitrectomy was carried out. ______ [inaudible] was injected into the anterior chamber to stain vitreous and a small amount of additional vitrectomy was carried out. The incision was then opened and Provisc was placed in the anterior chamber. The anterior capsule and the capsulotomy were structurally sound, so the Technis lens 21.5 diopter was placed in the sulcus with the optic captured by the capsulotomy.

The corneal incision was then closed with a 10-0 nylon suture and the sclera closed with a 9-0 nylon suture. The conjunctiva was smoothed over and coagulated above the scleral suture. Miochol was placed in the anterior chamber. TobraDex ointment was placed on the cornea. The eye was patched and shield was taped in place. Consultation with retina colleague will be made today. The patient tolerated the procedure well and left the operating room in good condition.