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canaloplasty converted into a Trabeculectomy

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    Default canaloplasty converted into a Trabeculectomy
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    I was told to code all three procedures on this. I dont think I should. I think I should just code a cataract (66984) with a trabeculectomy(66170). Please let me know what you think ? thanks again for your time in other words is 66170 bundled with 66174-canaloplasty



    PREOPERATIVE DIAGNOSES: 1. Visually significant cataract, OS.
    2. Open-angle glaucoma, OS.

    POSTOPERATIVE DIAGNOSES: 1. Visually significant cataract, OS.
    2. Open-angle glaucoma, OS.
    3. Incomplete canal because of which a canaloplasty could not be completed.

    PROCEDURES PERFORMED: 1. Phacoemulsification with a posterior chamber intraocular lens implantation, left eye.
    2. Canaloplasty with no stent, left eye
    3. Trabeculectomy with mitomycin-C, left eye.

    ANESTHESIA: MAC.

    COMPLICATIONS: None.

    DESCRIPTION OF PROCEDURE: Informed consent was obtained from the patient. The patient was wheeled into the operating room. The left eye was prepped and draped in a standard fashion for this procedure. Lids and eyelashes were secured with the help of a lid speculum. Preservative-free lidocaine, one drop x3 was placed on the surface of the cornea and the conjunctiva. A paracentesis was performed in the inferotemporal quadrant. Viscoelastic was injected into the anterior chamber. A 2.75 mm Alcon keratome was used to enter the anterior chamber in the superotemporal quadrant. Continuous capsulorrhexis was performed with the help of the cystotome. Hydrodissection was performed with the help of BSS on a cannula. The nucleus was removed with the help of phacoemulsification. Remaining cortical material was removed with the help of irrigation/aspiration. A posterior chamber implant was inserted into the capsular bag without any complications. The rest of the viscoelastic was removed from the anterior chamber. The wound was hydrated and closed with the help of a single interrupted 10-0 nylon suture. At the end of the operation, the cornea was clear. The anterior chamber was deep and well formed. The intraocular lens was in stable position within the capsular bag and there was a bright red reflex. Attention now was directed towards the performance of the glaucoma surgery.

    A 7-0 Vicryl stay suture was placed in the supranasal limbus. The eye was rotated inferiorly. Limbal peritomy was performed at the 12 o’clock position. Sub-Tenon’s preservative-free lidocaine injection was given followed by posterior dissection in the same plane. Adequate hemostasis was achieved with help of an electrocautery. A 5 mm x 5 mm partial thickness corneoscleral flap was dissected. Then, a 4 mm x 4 mm inner corneoscleral flap was dissected. During this dissection, the roof of the Schlemm’s canal was removed. Dissection was carried forward into clear cornea to create a 0.3 mm Descemet’s window. The canal itself was identified and dilated using viscocanalostomy techniques. Microcatheter was then threaded through the canal. The microcatheter went through the canal easily and exited out of the nasal opening. With the microcatheter was being pulled out, it was noticed that the catheter prolapsed into the anterior chamber over through the trabecular meshwork completing an ab interno trabeculotomy kind of a procedure. Since the canal itself opened to almost 360 degrees into the anterior chamber, we could not complete the canaloplasty with the stent. The microcatheter was withdrawn. Decision was made to convert the operation into a trabeculectomy.

    The anterior chamber was entered in the Descemet’s window that was created followed by keratectomy and peripheral iridectomy. Scleral flap was secured back to the sclera with the help of four interrupted 10-0 nylon sutures. At this stage, Weck-cel sponge soaked in mitomycin-C was placed under the conjunctiva and on top of the sclera flap and left in place for approximately 20 seconds and removed. Then, the operative site was copiously irrigated with the help of BSS on a cannula. Then, the conjunctiva was secured back to the limbus with the help of interrupted 10 0 nylon sutures. 0.1 cc of Decadron followed by BSS were injected into the anterior chamber. At the end of the operation, the cornea was clear. The anterior chamber was deep and well formed. Intraocular lens was in stable position within the capsular bag and there was a bright red reflex. A drop of pilocarpine and TobraDex ointment were placed in the eye and the eye was covered with the help of a shield. The patient was transferred to the recovery room without any complications.
    Last edited by codedog; 11-10-2011 at 04:10 PM.

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