# cataract with no implant ?



## codedog (Nov 21, 2011)

Patient had a phacoemulication of the cataract , with no implant but used trypan  blue  and also a vitrectomy was done. Looking at CPT code 66850 , would the trypan blue and vitrectomy  be bundled with this ?

PREOPERATIVE DIAGNOSIS:	Traumatic dense cataract of the right eye.

POSTOPERATIVE DIAGNOSES:	Aphakic right eye along with retinal detachment, right eye.

PROCEDURES PERFORMED:	Phacoemulsification of the cataract, right eye with trypan blue use and vitrectomy.

INDICATIONS: o presented to my office complaining of poor vision in  right eye for sometime now.   has a history of having trauma at the age of 25 years old and since then he has had poor vison in the right eye.  Patient thinks it has gotten progressively worse, although patient is not sure of that.  Examination in the office reveals a fairly healthy and good visual acuity, left eye.  The right eye has light perception, but the cataract is incredibly dense with no views to posterior pole.  Intraocular pressures were normal on the left with slight elevation on the right.  Because of the dense cataract, it was elected to perform a cataract operation and if everything is normal, to put an implant in that eye.

OPERATIVE PROCEDURE:  The patient's right eye was dilated with Mydriacyl and Neo-Synephrine and also Ocufen eye drops applied preoperatively.  About 30 minutes prior to surgery and then again just before surgery, 2% Xylocaine jelly was applied to the right eye.  He was then brought to the operating room and there the area around his right eye was then prepped and draped in the usual ocular manner.  An operating microscope was put into position.  One 4-0 Ethibond suture was placed to the lateral rectus muscle retraction.  A #75 blade was then used to enter the anterior chamber at about 2 o'clock position and Viscoat was then injected to fill the anterior chamber.  Calipers of 3.0-mm were then used to mark the limbus around the 165-degree mark and then a guarded Grieshaber blade was then used to create a groove this length just inside the clear cornea.  A bent Grieshaber was then used to dissect forward towards the extent of the cornea and to create a corneal flap and the anterior chamber was entered through this flap using 2.6-mm keratome.

Addendum, because of the fairly very very dense cataract prior to injecting any viscoelastic, trypan blue was then injected into the anterior chamber and allowed to sit for about 30 seconds and then it was irrigated out.

At this point, capsulorrhexis forceps was then introduced and center of the anterior capsule was grasped and torn and capsulorrhexis was then created.  BSS was then injected underneath the capsule in order to separate the cataract from its cortical shell.

It was noted that the medial portion of the nucleus was different in the sense that it has had cortical staining and it was appeared to be adherent to the capsular complex on this side, but BSS was then injected underneath the capsule in order to help separate the cataract from its cortical shell.  The phacoemulsification unit was then introduced and the nucleus was sculpted from about the 9 to the 4 o'clock position creating a trough.  I was unable to crack the nucleus at this point, although not completely all went through and then additional trough was then created from about 9 to about the 2 o'clock position allowing me to crack nucleus here.  The nucleus could not dislodge and I was unable to bring out the piece.  So, additional phacoemulsification was performed and an additional saline was injected underneath the capsule.  Eventually, I was able to dislodge the nucleus and it rotated some, I was able to remove this piece medially.  Removing the piece medially, I suspected that the entire capsule complex had been lost or it was lose, but I continued to remove the nucleus.  By the time I removed 90%, it was obvious that the whole medial capsule complex had torn and was not existent.  Eventually, all of the nucleus was removed with some difficulty.  The total CDE was 96.25.

The vitreous was detached and all pushed forward in towards the anterior chamber.  So at this point, vitrectomy was then performed removing the vitreous and any small pieces of nucleus that remained.  Some additional cortex was then removed from the medial aspect of the wound.

Examination through the scope, posterior pole revealed retina to be in folds and there was an obvious retinal detachment.  So at this point, it was elected not to put an intraocular lens.  So at this point, Miostat was injected in order to get pupil constricted and also keep the intraocular pressure low.  The wounds were then checked for watertightness.  The main wound at once we thought appeared to be fairly intact, but I was concerned about it, so one 11-0 nylon suture was then placed with knots rotated and buried.  This created a nice watertight wound.  TobraDex ointment was applied to the eye.  The eye was then shielded.  He was then returned to his room having tolerated the procedure well.


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## johnmeyer (Nov 22, 2011)

The trypan blue might be bundled into the 66850, but I don't think the viterctomy should be. I found 67005 and 67010 for the viterctomy and I see no where in the CPT manual that says you can't code 67005 or 67010 with 66850.


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