Can someone help me code the following case? Thanks.
REOPERATIVE DIAGNOSES:
1. History of multiple surgeries, left eye, secondary to tractional retinal detachment with development of proliferative vitreoretinopathy, left eye, secondary to proliferative diabetic retinopathy.
2. Most recent surgery was pars plana vitrectomy with retinectomy and silicone oil, left eye.
3. Regressed proliferative diabetic retinopathy, left eye, status post treatment.
4. Pupillary seclusion from silicone oil, left eye.
POSTOPERATIVE DIAGNOSES:
1. History of multiple surgeries, left eye, secondary to tractional retinal detachment with development of proliferative vitreoretinopathy, left eye, secondary to proliferative diabetic retinopathy.
2. Most recent surgery was pars plana vitrectomy with retinectomy and silicone oil, left eye.
3. Regressed proliferative diabetic retinopathy, left eye, status post treatment.
4. Pupillary seclusion from silicone oil, left eye.
PROCEDURE PERFORMED:
1. A 23-gauge pars plana vitrectomy with silicone oil removal, and 4 air-fluid exchanges.
2. Insertion 2 temporal iris crease upper hooks, left eye, and their removal.
3. Dissection and breakage of pupillary seclusion and placement of peripheral iridectomy, left eye, at 6 o'clock with vitreous cutter.
COMPLICATIONS:
None.
ANESTHESIA:
General.
INDICATIONS:
with a history of multiple surgeries in her left eye secondary to a vitreous hemorrhage secondary to proliferative diabetic retinopathy who developed a tractional detachment and recurrent proliferative vitreal retinopathy. She has undergone multiple surgeries with multiple vitrectomies, a scleral buckle, and most recently a pars plana vitrectomy and retinotomy and air-silicone exchange about 4 months ago. The patient has had persistent pressure problems post-surgery. She has developed inflammation in her anterior chamber as well silicone oil in the anterior chamber that led to the formation of synechia from the iris to the lens. Her retina has remained attached. After discussion of the risks, benefits and alternatives, she wished to proceed with surgery to remove the oil and fix the anterior chamber problems. She was aware of the high chance of recurrent retinal detachment and possible repeat silicone oil fill. She is aware of the chances of hypotony and possible loss of eye. She gave verbal consent to proceed and informed consent was obtained. The reason why she wished to undergo the surgery was to help control her pressure and potentially give her a slight improvement of vision. She and her family were given the risks, benefits, and alternatives of this procedure. They gave verbal consent to proceed and informed consent was obtained.
DESCRIPTION OF PROCEDURE:
The patient was taken back to the operating room and identified by the surgeon, Her left eye had been previously dilated per treatment protocol. Her left eye was prepped and draped in the usual fashion for intraocular surgery. A lid speculum was placed in the left eye. There was almost 360 degrees of pupillary synechia to the lens capsule. The pupil was about 4 mm dilated. It was decided that most likely that we could not get a good view of the posterior pole if we left that alone. Plus there was about a 40% silicone oil fill. Two paracenteses were created with a Supersharp blade, one at approximately 9 o'clock, the other one at 5:30. Viscoelastic was injected in the vitreous cavity through the supranasal paracentesis and pressure was placed on the paracentesis at the 5:30 position. This allowed to cause eggression of most of the silicone oil. Another paracentesis was made at the 1 o'clock position. Using a Kuglen hook, the temporal superior and inferior synechia were broken. A little Healon was injected underneath the iris to lift it up. Two Grieshaber iris hooks were used to pull back the iris through the supratemporal paracentesis and infratemporal paracentesis. This opened it up.
I then placed 23-gauge trocars at the 2:30 and 9:30 positions, each 3.5 mm from the limbus and one at the 4 o'clock position. Through the infratemporal trocar, an infusion cannula was placed. Once visualized in the vitreous cavity it was used to infuse balanced salt solution with epinephrine to maintain intraocular pressure of 35 mmHg. The supratemporal trocar was plugged. A silicone extrusion cannula was attached to the supranasal trocar and the silicone was removed. Once this was accomplished, several air-fluid exchanges were performed, at least 4, in an attempt to remove as much silicone oil as humanly possible from the back of the eye. The eye remained attached. However, the optic nerve looked pale and the retinal vessels looked very atretic. Prior to the last fluid-air exchange, the 2 iris Grieshabers were removed. I used a vitrector to create a small peripheral iridectomy at the 6 o'clock position. All 3 paracenteses were hydrated. The wounds were found to be water tight. A final air-fluid exchange was performed. There did not appear to be any residual silicone. I then removed the trocars. Cutdowns had to be done with the superonasal and infratemporal sclerotomy sites. These were closed with 8-0 Vicryl sutures. The conjunctiva over them was also closed with interrupted 8-0 Vicryl sutures. Indirect ophthalmoscopy was performed, the nerve was perfused. The retina was attached. The patient was given 8 mg of Decadron and 100 mg of Ancef subconjunctivally infranasally with 30-gauge needle. Once this was accomplished, the patient was patched with 2 eye patches and a Fox shield. She was extubated and taken to the recovery room in good condition. She will sleep with her head up tonight. She will be discharged in the morning if al
REOPERATIVE DIAGNOSES:
1. History of multiple surgeries, left eye, secondary to tractional retinal detachment with development of proliferative vitreoretinopathy, left eye, secondary to proliferative diabetic retinopathy.
2. Most recent surgery was pars plana vitrectomy with retinectomy and silicone oil, left eye.
3. Regressed proliferative diabetic retinopathy, left eye, status post treatment.
4. Pupillary seclusion from silicone oil, left eye.
POSTOPERATIVE DIAGNOSES:
1. History of multiple surgeries, left eye, secondary to tractional retinal detachment with development of proliferative vitreoretinopathy, left eye, secondary to proliferative diabetic retinopathy.
2. Most recent surgery was pars plana vitrectomy with retinectomy and silicone oil, left eye.
3. Regressed proliferative diabetic retinopathy, left eye, status post treatment.
4. Pupillary seclusion from silicone oil, left eye.
PROCEDURE PERFORMED:
1. A 23-gauge pars plana vitrectomy with silicone oil removal, and 4 air-fluid exchanges.
2. Insertion 2 temporal iris crease upper hooks, left eye, and their removal.
3. Dissection and breakage of pupillary seclusion and placement of peripheral iridectomy, left eye, at 6 o'clock with vitreous cutter.
COMPLICATIONS:
None.
ANESTHESIA:
General.
INDICATIONS:
with a history of multiple surgeries in her left eye secondary to a vitreous hemorrhage secondary to proliferative diabetic retinopathy who developed a tractional detachment and recurrent proliferative vitreal retinopathy. She has undergone multiple surgeries with multiple vitrectomies, a scleral buckle, and most recently a pars plana vitrectomy and retinotomy and air-silicone exchange about 4 months ago. The patient has had persistent pressure problems post-surgery. She has developed inflammation in her anterior chamber as well silicone oil in the anterior chamber that led to the formation of synechia from the iris to the lens. Her retina has remained attached. After discussion of the risks, benefits and alternatives, she wished to proceed with surgery to remove the oil and fix the anterior chamber problems. She was aware of the high chance of recurrent retinal detachment and possible repeat silicone oil fill. She is aware of the chances of hypotony and possible loss of eye. She gave verbal consent to proceed and informed consent was obtained. The reason why she wished to undergo the surgery was to help control her pressure and potentially give her a slight improvement of vision. She and her family were given the risks, benefits, and alternatives of this procedure. They gave verbal consent to proceed and informed consent was obtained.
DESCRIPTION OF PROCEDURE:
The patient was taken back to the operating room and identified by the surgeon, Her left eye had been previously dilated per treatment protocol. Her left eye was prepped and draped in the usual fashion for intraocular surgery. A lid speculum was placed in the left eye. There was almost 360 degrees of pupillary synechia to the lens capsule. The pupil was about 4 mm dilated. It was decided that most likely that we could not get a good view of the posterior pole if we left that alone. Plus there was about a 40% silicone oil fill. Two paracenteses were created with a Supersharp blade, one at approximately 9 o'clock, the other one at 5:30. Viscoelastic was injected in the vitreous cavity through the supranasal paracentesis and pressure was placed on the paracentesis at the 5:30 position. This allowed to cause eggression of most of the silicone oil. Another paracentesis was made at the 1 o'clock position. Using a Kuglen hook, the temporal superior and inferior synechia were broken. A little Healon was injected underneath the iris to lift it up. Two Grieshaber iris hooks were used to pull back the iris through the supratemporal paracentesis and infratemporal paracentesis. This opened it up.
I then placed 23-gauge trocars at the 2:30 and 9:30 positions, each 3.5 mm from the limbus and one at the 4 o'clock position. Through the infratemporal trocar, an infusion cannula was placed. Once visualized in the vitreous cavity it was used to infuse balanced salt solution with epinephrine to maintain intraocular pressure of 35 mmHg. The supratemporal trocar was plugged. A silicone extrusion cannula was attached to the supranasal trocar and the silicone was removed. Once this was accomplished, several air-fluid exchanges were performed, at least 4, in an attempt to remove as much silicone oil as humanly possible from the back of the eye. The eye remained attached. However, the optic nerve looked pale and the retinal vessels looked very atretic. Prior to the last fluid-air exchange, the 2 iris Grieshabers were removed. I used a vitrector to create a small peripheral iridectomy at the 6 o'clock position. All 3 paracenteses were hydrated. The wounds were found to be water tight. A final air-fluid exchange was performed. There did not appear to be any residual silicone. I then removed the trocars. Cutdowns had to be done with the superonasal and infratemporal sclerotomy sites. These were closed with 8-0 Vicryl sutures. The conjunctiva over them was also closed with interrupted 8-0 Vicryl sutures. Indirect ophthalmoscopy was performed, the nerve was perfused. The retina was attached. The patient was given 8 mg of Decadron and 100 mg of Ancef subconjunctivally infranasally with 30-gauge needle. Once this was accomplished, the patient was patched with 2 eye patches and a Fox shield. She was extubated and taken to the recovery room in good condition. She will sleep with her head up tonight. She will be discharged in the morning if al