T13-2A OPERATIVE REPORT, CATARACT EXTRACTION AND LENS IMPLANT

T13-2A OPERATIVE REPORT, CATARACT EXTRACTION AND LENS IMPLANT

PROCEDURE PERFORMED: Cataract removal by phacoemulsification with posterior chamber intraocular lens implantation (Allergan mode SI90NB, +15 diopter, serial #1895008)
ANESTHESIA: Topical
ESTIMATED BLOOD LOSS: Minimal
COMPLICATIONS: None
PROCEDURE: In the operating room, after intravenous sedation, the patient was prepped and draped in the usual sterile fashion for an intraocular procedure of the left eye. A lid speculum was placed. A Weck-cel soaked with lidocaine 4% MPF was placed at the limbus, in the area of both the planned phaco incision and the planned sideport incision. The conjunctiva was opened with the Wescott scissors, and electrocautery was used to control scleral bleeding. A 3.0 keratome was used to enter the chamber. Lidocaine 1% preservative-free was injected into the eye. A sideport incision was then made. Viscoelastic was used to exchange the aqueous. A continuous tear capsulotomy was performed. The nucleus was hydrodissected and removed with phacoemulsification using an ultrasound time of 1.9 with an actual phaco percentage of 11%. The remaining cortical material was removed with irrigation/aspiration. The capsule was polished and vacuumed as appropriate. A very small amount of lidocaine 1% preservative-free was again injected into the eye. Viscoelastic was used to deepen the chamber, and the posterior chamber intraocular lens was unfolded into the capsular bag and dialed into position. Irrigation/aspiration was used to remove the remaining viscoelastic. The wound was tested and found to be watertight. The patient left the operating room in stable condition, having tolerated the procedure well.
T13-2A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________