Operative report Cataract extraction

Operative report 1

Preoperative Diagnosis

Visually significant age-related nuclear sclerotic cataract, right eye.

Postoperative Diagnosis

Same.

Procedure Performed

Extracapsular cataract extraction by phacoemulsification with implantation of posterior chamber intraocular lens, right eye.

Indication

The patient presented with a visually significant cataract causing progressive decline in visual acuity, glare, and difficulty with activities of daily living. After discussing the risks, benefits, and alternatives, informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and placed in the supine position. Monitored anesthesia care was provided, and topical anesthetic drops were instilled into the operative eye. A surgical time-out confirmed the correct patient, operative eye, and planned procedure.

The operative eye was prepped with 5% povidone-iodine solution and draped in the usual sterile ophthalmic fashion. A sterile lid speculum was inserted. The operating microscope was brought into position.

A temporal paracentesis was created using a 1.0-mm side-port blade. Preservative-free intracameral lidocaine was injected into the anterior chamber, followed by injection of a cohesive ophthalmic viscosurgical device (OVD) to deepen and stabilize the anterior chamber and protect the corneal endothelium.

A temporal clear corneal main incision measuring approximately 2.4 mm was then created using a keratome blade.

A cystotome was used to initiate the anterior capsulotomy, and a continuous curvilinear capsulorrhexis was completed using Utrata forceps, creating a well-centered anterior capsular opening.

Hydrodissection was performed with balanced salt solution until free rotation of the lens nucleus was achieved. Hydrodelineation was then carried out to separate the nucleus from the epinucleus.

The phacoemulsification handpiece was introduced into the anterior chamber. In situ phacoemulsification of the lens nucleus was performed using a divide-and-conquer technique. The nucleus was sculpted, divided into quadrants, and each quadrant was emulsified and aspirated without complication.

Residual cortical material was removed using automated irrigation and aspiration until the capsular bag was completely clean. The posterior capsule remained intact throughout the procedure.

The capsular bag was re-expanded with cohesive OVD. A foldable posterior chamber intraocular lens was loaded into an injector cartridge and inserted through the clear corneal incision into the capsular bag. Both haptics were positioned completely within the capsular bag, and the intraocular lens was centered satisfactorily.

Residual viscoelastic material was completely removed from the anterior chamber and from behind the intraocular lens using the irrigation/aspiration handpiece.

The anterior chamber was reformed with balanced salt solution. The corneal incisions were hydrated until watertight. The wounds were inspected and found to be Seidel negative without leakage. The intraocular lens remained well centered, and the anterior chamber was deep and stable.

Intracameral preservative-free antibiotic was administered. The lid speculum was removed. Topical antibiotic and corticosteroid drops were instilled, and a protective eye shield was applied.

The patient tolerated the procedure well without complications and was transferred to the recovery area in stable condition.

Findings

Visually significant nuclear sclerotic cataract successfully removed by phacoemulsification. Intact capsular bag and posterior capsule. Posterior chamber intraocular lens well centered within the capsular bag. No intraoperative complications.

Implants

Foldable posterior chamber intraocular lens implanted within the capsular bag, right eye.

Check your answer

CPT

66984 –RT Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation. 

Operative report 2

Preoperative Diagnosis

Mature age-related cataract, right eye.

Postoperative Diagnosis

Same.

Procedure Performed

Complex extracapsular cataract extraction by phacoemulsification with implantation of posterior chamber intraocular lens, right eye.

Indication

The patient presented with a visually significant mature cataract of the right eye causing profound reduction in vision and inability to perform activities of daily living. Due to the dense mature cataract, visualization of the anterior capsule was poor, necessitating the use of capsular dye to safely complete the procedure. The risks, benefits, and alternatives of surgery were discussed, and informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and placed in the supine position. Monitored anesthesia care was provided with topical ocular anesthesia. A surgical time-out was performed confirming the correct patient, operative eye, and planned procedure.

The operative eye was prepped with 5% povidone-iodine solution and draped in the usual sterile ophthalmic fashion. A sterile lid speculum was inserted, and the operating microscope was positioned.

A temporal paracentesis was created using a 1.0-mm side-port blade. Preservative-free intracameral lidocaine was instilled into the anterior chamber. A small air bubble was introduced into the anterior chamber, followed by instillation of trypan blue dye to stain the anterior lens capsule because of poor visualization associated with the mature cataract. After adequate staining, the dye was thoroughly irrigated from the anterior chamber using balanced salt solution.

A cohesive ophthalmic viscosurgical device (OVD) was injected to deepen and stabilize the anterior chamber and protect the corneal endothelium.

A 2.4-mm temporal clear corneal incision was created with a keratome blade.

A continuous curvilinear capsulorrhexis was initiated with a cystotome and completed with Utrata capsulorrhexis forceps. Visualization of the stained anterior capsule allowed controlled completion of the capsulorrhexis.

Gentle hydrodissection and hydrodelineation were performed using balanced salt solution. The dense nucleus was carefully mobilized within the capsular bag.

The phacoemulsification handpiece was introduced into the anterior chamber. Owing to the density of the mature cataract, additional phacoemulsification energy was required. Using a divide-and-conquer technique, deep central grooves were sculpted and the nucleus was mechanically divided into multiple quadrants. Each quadrant was sequentially emulsified and aspirated under direct microscopic visualization while maintaining chamber stability.

Residual cortical material was removed using automated irrigation and aspiration. The capsular bag was carefully inspected and found to be intact. Gentle posterior capsule polishing was performed to remove residual lens epithelial cells.

The capsular bag was re-expanded with cohesive OVD. A foldable posterior chamber intraocular lens was loaded into an injector and implanted into the capsular bag. Both haptics were confirmed to be completely within the capsular bag, and the lens was well centered.

Residual viscoelastic was thoroughly removed from the anterior chamber and from behind the intraocular lens using irrigation and aspiration.

Balanced salt solution was used to reform the anterior chamber. The corneal wounds were hydrated until watertight closure was achieved. The incisions were inspected and found to be Seidel negative. The anterior chamber remained deep and well formed, and the intraocular lens was stable and well centered.

Intracameral preservative-free antibiotic was administered. The lid speculum was removed. Topical antibiotic and corticosteroid drops were instilled, and a protective eye shield was applied.The patient tolerated the procedure well without complications and was transferred to the recovery area in stable condition.

Findings

Dense mature cataract successfully removed. Capsular staining with trypan blue was required to facilitate visualization of the anterior capsule. Posterior capsule remained intact. Posterior chamber intraocular lens was well centered within the capsular bag. No intraoperative complications.

Implants

Foldable posterior chamber intraocular lens implanted within the capsular bag, right eye.

Check your answer

66982 – Complex extracapsular cataract removal with insertion of intraocular lens prosthesis, requiring devices or techniques not generally used in routine cataract surgery (in this case, capsular staining with trypan blue to safely visualize the anterior capsule of a mature cataract).

Operative report 3

Preoperative Diagnosis

1. Visually significant age-related nuclear sclerotic cataract, right eye.

2. Poor pupillary dilation (intraoperative floppy iris syndrome/small pupil).

Postoperative Diagnosis

Same.

Procedure Performed

Complex extracapsular cataract extraction by phacoemulsification with implantation of posterior chamber intraocular lens utilizing mechanical pupil expansion with a Malyugin ring, right eye.

Indication

The patient presented with a visually significant cataract causing progressive visual impairment affecting activities of daily living. Preoperative examination demonstrated inadequate pupillary dilation despite maximal pharmacologic mydriasis, making routine cataract surgery unsafe. Mechanical pupil expansion was therefore required to safely visualize the lens and complete cataract extraction.

Description of the Procedure

After informed consent was obtained, the patient was brought to the operating room and placed in the supine position. Monitored anesthesia care was provided with topical anesthesia. A surgical time-out was performed confirming the correct patient, operative eye, and planned procedure.

The operative eye was prepped with 5% povidone-iodine solution and draped in the usual sterile ophthalmic fashion. A sterile lid speculum was inserted, and the operating microscope was positioned.

A temporal paracentesis was created using a 1.0-mm side-port blade. Preservative-free intracameral lidocaine was injected into the anterior chamber followed by injection of a cohesive ophthalmic viscosurgical device (OVD) to deepen the anterior chamber and protect the corneal endothelium.

Despite pharmacologic dilation, the pupil remained approximately 3 mm in diameter, providing inadequate visualization of the anterior capsule. Because of the small pupil, a **Malyugin ring** was inserted through the main incision using the manufacturer's injector. Each scroll of the ring was sequentially engaged at the pupillary margin, achieving uniform mechanical expansion of the pupil to approximately 6.5 mm and providing excellent exposure of the anterior capsule.

A 2.4-mm temporal clear corneal incision was then created using a keratome blade.

A continuous curvilinear capsulorrhexis was initiated with a cystotome and completed using Utrata capsulorrhexis forceps.

Hydrodissection and hydrodelineation were performed with balanced salt solution until free rotation of the nucleus was achieved.

The phacoemulsification handpiece was introduced into the anterior chamber. Using a divide-and-conquer technique, the nucleus was sculpted, divided into quadrants, and each quadrant was sequentially emulsified and aspirated under direct microscopic visualization.

Residual cortical material was removed using automated irrigation and aspiration. The posterior capsule remained intact throughout the procedure.

The capsular bag was re-expanded with cohesive OVD. A foldable posterior chamber intraocular lens was loaded into an injector cartridge and implanted completely within the capsular bag. The intraocular lens was centered satisfactorily.

Following lens implantation, the **Malyugin ring** was carefully disengaged from the pupillary margin and removed from the anterior chamber without complication. The iris was inspected and found to be intact without sphincter tears.

Residual viscoelastic material was completely removed from the anterior chamber and from behind the intraocular lens using irrigation and aspiration.

Balanced salt solution was used to reform the anterior chamber. The corneal incisions were hydrated until watertight closure was achieved. The wounds were inspected and found to be Seidel negative. The anterior chamber remained deep and stable with a well-centered posterior chamber intraocular lens.

Intracameral preservative-free antibiotic was administered. The lid speculum was removed. Topical antibiotic and corticosteroid drops were instilled, and a protective eye shield was applied.The patient tolerated the procedure well without intraoperative complications and was transferred to the recovery area in stable condition.

Findings

Visually significant nuclear sclerotic cataract with inadequate pharmacologic pupillary dilation requiring mechanical pupil expansion using a Malyugin ring. Cataract extraction and posterior chamber intraocular lens implantation were completed successfully without complication.

Implants

* Foldable posterior chamber intraocular lens implanted within the capsular bag.

* Temporary intraoperative Malyugin ring (removed at completion of the procedure).

Check your answer

The documentation supports 66982 because the surgeon used mechanical pupil expansion (Malyugin ring) due to inadequate pharmacologic dilation. The Malyugin ring is a temporary surgical device used to facilitate the procedure and is not reported separately from the cataract surgery.

1.Small pupil requiring mechanical pupil expansion with a Malyugin ring or iris hooks.

2.Mature white cataract requiring Trypan blue staining to visualize the anterior capsule.

3.Pediatric cataract requiring primary posterior capsulotomy and anterior vitrectomy.

Operative report 4

Preoperative Diagnosis

1. Visually significant age-related nuclear sclerotic cataract, right eye.

2. Primary open-angle glaucoma, moderate to severe stage, inadequately controlled on maximal tolerated medical therapy.

Postoperative Diagnosis

Same.

Procedure Performed

1. Extracapsular cataract extraction by phacoemulsification with implantation of posterior chamber intraocular lens, right eye.

2. Trabeculectomy with creation of filtering bleb, right eye.

Indication

The patient presented with progressive visual impairment secondary to a visually significant cataract and medically uncontrolled primary open-angle glaucoma despite maximal tolerated topical therapy. Because the patient required cataract surgery and additional intraocular pressure reduction, a combined phacoemulsification with posterior chamber intraocular lens implantation and trabeculectomy was recommended. The risks, benefits, alternatives, and potential complications were discussed, and informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and placed in the supine position. Monitored anesthesia care with a peribulbar anesthetic block was administered. A surgical time-out confirmed the correct patient, operative eye, and planned procedures.

The operative eye was prepped with 5% povidone-iodine solution and draped in the usual sterile ophthalmic fashion. A sterile lid speculum was inserted, and the operating microscope was positioned.

Cataract Extraction

A temporal paracentesis was created using a 1.0-mm side-port blade. Preservative-free intracameral lidocaine was injected into the anterior chamber followed by injection of a cohesive ophthalmic viscosurgical device (OVD) to deepen and stabilize the anterior chamber.

A 2.4-mm temporal clear corneal incision was fashioned using a keratome blade. A continuous curvilinear capsulorrhexis was created with a cystotome and completed using Utrata capsulorrhexis forceps.

Hydrodissection and hydrodelineation were performed with balanced salt solution until free rotation of the lens nucleus was achieved.

The lens nucleus was removed using in situ phacoemulsification with a divide-and-conquer technique. Residual cortical material was removed using automated irrigation and aspiration. The posterior capsule remained intact throughout the procedure.

The capsular bag was inflated with cohesive OVD, and a foldable posterior chamber intraocular lens was implanted completely within the capsular bag. The lens was noted to be well centered. Residual viscoelastic was removed from the anterior chamber and behind the intraocular lens using irrigation and aspiration.

The temporal corneal incision was hydrated and confirmed to be watertight.

Trabeculectomy

Attention was then directed to the superior limbus. A superior conjunctival peritomy was created at the limbus, and Tenon's capsule was carefully dissected posteriorly to expose bare sclera. Hemostasis was achieved with gentle bipolar cautery.

A partial-thickness rectangular scleral flap measuring approximately 4 × 4 mm was fashioned with a crescent blade and carefully dissected anteriorly into clear cornea while maintaining uniform thickness.

Mitomycin-C–soaked surgical sponges were placed beneath the conjunctiva and Tenon's capsule over the intended filtration site for the predetermined exposure time. The sponges were then removed, and the operative field was copiously irrigated with balanced salt solution.

A trabeculectomy ostomy was created beneath the scleral flap using a Kelly punch, establishing communication between the anterior chamber and the subconjunctival space. A peripheral surgical iridectomy was performed to prevent postoperative blockage of the sclerostomy by the iris.

The scleral flap was secured with interrupted 10-0 nylon sutures. Suture tension was adjusted to achieve controlled aqueous egress while maintaining adequate anterior chamber depth.

The conjunctiva and Tenon's capsule were meticulously advanced and closed with interrupted and running 10-0 nylon sutures, creating a watertight closure. Balanced salt solution was injected through a paracentesis to confirm formation of a diffuse superior filtering bleb. The bleb demonstrated appropriate elevation without evidence of conjunctival leakage. The anterior chamber remained deep and well formed.

Subconjunctival antibiotic and corticosteroid injections were administered away from the filtering bleb. The lid speculum was removed. Topical antibiotic and corticosteroid drops were instilled, and a protective eye shield was applied.

The patient tolerated both procedures well without intraoperative complications and was transferred to the recovery area in stable condition.

Findings

Visually significant nuclear sclerotic cataract successfully removed by phacoemulsification. Posterior chamber intraocular lens implanted within the capsular bag. Successful superior trabeculectomy with peripheral iridectomy and formation of a functioning filtering bleb. The anterior chamber remained well formed with no evidence of wound leak or other intraoperative complications.

Implants

Foldable posterior chamber intraocular lens implanted within the capsular bag, right eye.

Check your answer

66984 – Extracapsular cataract removal with insertion of intraocular lens prosthesis (routine phacoemulsification).

66170 – Trabeculectomy ab externo in the absence of previous surgery.

If an antimetabolite such as Mitomycin-C is used during the trabeculectomy, it is considered part of the trabeculectomy procedure and is not reported separately.

Operative report 5

Preoperative Diagnosis

1. Visually significant age-related nuclear sclerotic cataract, right eye.

2. Mild to moderate primary open-angle glaucoma, right eye, inadequately controlled on topical ocular hypotensive medications.

Postoperative Diagnosis

Same.

Procedure Performed

1. Extracapsular cataract extraction by phacoemulsification with implantation of posterior chamber intraocular lens, right eye.

2. Implantation of trabecular micro-bypass stent (iStent), right eye.

Indication

The patient presented with a visually significant cataract resulting in progressive visual impairment and mild to moderate primary open-angle glaucoma requiring topical medical therapy. A combined cataract extraction with intraocular lens implantation and trabecular micro-bypass stent placement was recommended to improve vision while reducing intraocular pressure and medication burden. The risks, benefits, alternatives, and potential complications were discussed with the patient, and informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and placed in the supine position. Monitored anesthesia care with topical anesthesia was administered. A surgical time-out was performed confirming the correct patient, operative eye, and planned procedures.

The operative eye was prepped with 5% povidone-iodine solution and draped in the standard sterile ophthalmic fashion. A sterile lid speculum was inserted, and the operating microscope was positioned.

A temporal paracentesis was created using a 1.0-mm side-port blade. Preservative-free intracameral lidocaine was injected into the anterior chamber followed by injection of a cohesive ophthalmic viscosurgical device (OVD) to deepen the anterior chamber and protect the corneal endothelium.

A 2.4-mm temporal clear corneal incision was created using a keratome blade. A continuous curvilinear capsulorrhexis was initiated with a cystotome and completed using Utrata capsulorrhexis forceps.

Hydrodissection and hydrodelineation were performed with balanced salt solution until the lens nucleus rotated freely within the capsular bag.

The nucleus was removed by in situ phacoemulsification using a divide-and-conquer technique. Residual cortical material was removed with automated irrigation and aspiration. The posterior capsule remained intact throughout the procedure.

The capsular bag was inflated with cohesive OVD. A foldable posterior chamber intraocular lens was loaded into an injector and implanted completely within the capsular bag. Proper positioning of both haptics was confirmed, and the intraocular lens was noted to be well centered.

Additional viscoelastic was injected to maintain the anterior chamber and gently deepen the nasal angle. The patient's head was rotated approximately 30 degrees away from the surgeon, and the operating microscope was tilted approximately 35 degrees toward the surgeon to allow direct gonioscopic visualization of the nasal iridocorneal angle. A surgical gonioprism was placed on the cornea.

Under direct gonioscopic visualization, the trabecular meshwork and Schlemm's canal were identified. The **iStent delivery system** was introduced through the existing temporal clear corneal incision. The trabecular micro-bypass stent was advanced into the nasal trabecular meshwork and implanted into Schlemm's canal. Proper seating of the stent was confirmed with visualization of the snorkel remaining within the anterior chamber. Mild reflux of blood from Schlemm's canal was observed, confirming appropriate placement and patency.

Residual viscoelastic material was completely removed from the anterior chamber and from behind the intraocular lens using irrigation and aspiration.

Balanced salt solution was used to reform the anterior chamber. The corneal incisions were hydrated until watertight closure was achieved. The wounds were inspected and found to be Seidel negative without leakage. The anterior chamber remained deep and stable, the intraocular lens was well centered, and the implanted trabecular micro-bypass stent remained in satisfactory position.

Intracameral preservative-free antibiotic was administered. The lid speculum was removed. Topical antibiotic and corticosteroid drops were instilled, and a protective eye shield was applied.

The patient tolerated the procedure well without intraoperative complications and was transferred to the recovery area in stable condition.

Findings

Visually significant nuclear sclerotic cataract successfully removed by phacoemulsification. Posterior chamber intraocular lens implanted within the capsular bag. Successful implantation of a trabecular micro-bypass stent into Schlemm's canal with appropriate positioning and function. No intraoperative complications.

Implants

* Foldable posterior chamber intraocular lens implanted within the capsular bag.

* One trabecular micro-bypass stent (iStent) implanted into Schlemm's canal.

Check your answer

66984 – Extracapsular cataract removal with insertion of intraocular lens prosthesis (routine phacoemulsification).

0191T – Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork (e.g., iStent), initial implant.

Coding note: If two iStents are implanted during the same procedure, the second device is typically reported with +0376T (each additional trabecular micro-bypass stent, internal approach), when applicable under current CPT guidance and payer policy.

Operative report 6

Preoperative Diagnosis

1. Visually significant age-related nuclear sclerotic cataract, right eye.

2. Moderate primary open-angle glaucoma, right eye.

Postoperative Diagnosis

Same.

Procedure Performed

1. Extracapsular cataract extraction by phacoemulsification with implantation of posterior chamber intraocular lens, right eye.

2. Ab interno goniotomy utilizing a Kahook Dual Blade, right eye.

Indication

The patient presented with progressive visual impairment secondary to a visually significant cataract and moderate primary open-angle glaucoma requiring multiple topical ocular hypotensive medications. Combined cataract extraction with intraocular lens implantation and goniotomy was recommended to improve visual function while enhancing aqueous outflow and lowering intraocular pressure. The risks, benefits, alternatives, and potential complications were discussed, and informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and placed in the supine position. Monitored anesthesia care with topical anesthesia was administered. A surgical time-out was performed confirming the correct patient, operative eye, and planned procedures.

The operative eye was prepped with 5% povidone-iodine solution and draped in the standard sterile ophthalmic fashion. A sterile lid speculum was inserted, and the operating microscope was positioned.

Cataract Extraction

A temporal paracentesis was created using a 1.0-mm side-port blade. Preservative-free intracameral lidocaine was injected into the anterior chamber followed by injection of a cohesive ophthalmic viscosurgical device (OVD) to deepen the anterior chamber and protect the corneal endothelium.

A 2.4-mm temporal clear corneal incision was created using a keratome blade. A continuous curvilinear capsulorrhexis was initiated with a cystotome and completed using Utrata capsulorrhexis forceps.

Hydrodissection and hydrodelineation were performed using balanced salt solution until the nucleus rotated freely within the capsular bag.

The cataractous lens was removed by in situ phacoemulsification utilizing a divide-and-conquer technique. Residual cortical material was removed using automated irrigation and aspiration. The posterior capsule remained intact.

The capsular bag was expanded with cohesive OVD. A foldable posterior chamber intraocular lens was loaded into an injector cartridge and implanted completely within the capsular bag. Proper positioning of both haptics was confirmed, and the intraocular lens was noted to be well centered.

Goniotomy

Additional cohesive OVD was injected to maintain the anterior chamber and deepen the nasal angle. The patient's head was rotated approximately 30 degrees away from the surgeon, and the operating microscope was tilted approximately 35 degrees toward the surgeon to optimize visualization of the nasal angle.

A direct surgical gonioprism was placed on the corneal surface. Under gonioscopic visualization, the trabecular meshwork and Schlemm's canal were clearly identified.

A **Kahook Dual Blade** was introduced through the existing temporal clear corneal incision and advanced across the anterior chamber toward the nasal angle. The blade tip was engaged into the trabecular meshwork and advanced within Schlemm's canal. Approximately 4 clock hours of trabecular meshwork were excised in a controlled fashion, creating a continuous goniotomy and establishing direct communication between the anterior chamber and Schlemm's canal. The excised strip of trabecular meshwork was removed from the anterior chamber. Mild reflux hemorrhage from Schlemm's canal was observed, confirming successful entry into the canal.

Residual viscoelastic and microscopic blood reflux were completely removed from the anterior chamber and from behind the intraocular lens using irrigation and aspiration.

Balanced salt solution was used to reform the anterior chamber and achieve physiologic intraocular pressure. The corneal incisions were hydrated until watertight closure was obtained. The wounds were inspected and found to be Seidel negative without leakage. The anterior chamber remained deep and well formed. The posterior chamber intraocular lens was well centered, and the goniotomy site demonstrated satisfactory appearance.

Intracameral preservative-free antibiotic was administered. The lid speculum was removed. Topical antibiotic and corticosteroid drops were instilled, and a protective eye shield was applied.

The patient tolerated the procedure well without intraoperative complications and was transferred to the recovery area in stable condition.

## Findings

Visually significant nuclear sclerotic cataract successfully removed by phacoemulsification. Posterior chamber intraocular lens implanted within the capsular bag. Successful ab interno goniotomy involving approximately 4 clock hours of the nasal trabecular meshwork with appropriate visualization of Schlemm's canal and expected mild blood reflux. No intraoperative complications.

Implants

* Foldable posterior chamber intraocular lens implanted within the capsular bag, right eye.

Check your answer

• 66984 – Extracapsular cataract removal with insertion of intraocular lens prosthesis (routine phacoemulsification).

• 65820 – Goniotomy.

This reflects one of the most common modern combined cataract + MIGS procedures for moderate primary open-angle glaucoma, with the operative steps mirroring typical real-world documentation for a Kahook Dual Blade (KDB) goniotomy.

Operative report 7

Preoperative Diagnosis

1. Visually significant age-related nuclear sclerotic cataract, right eye.

2. Severe primary open-angle glaucoma, uncontrolled despite maximal tolerated medical therapy.

Postoperative Diagnosis

Same.

Procedure Performed

1. Extracapsular cataract extraction by phacoemulsification with implantation of posterior chamber intraocular lens, right eye.

2. Implantation of glaucoma drainage device (Ahmed glaucoma valve tube shunt) with scleral patch graft, right eye.

Indication

The patient presented with progressive visual impairment due to a visually significant cataract and severe primary open-angle glaucoma with persistently elevated intraocular pressure despite maximal tolerated topical therapy. Because of uncontrolled glaucoma requiring surgical intervention, combined cataract extraction with intraocular lens implantation and glaucoma drainage device implantation was recommended to restore vision and achieve long-term intraocular pressure control. The risks, benefits, alternatives, and potential complications were discussed, and informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and placed in the supine position. Monitored anesthesia care with a peribulbar anesthetic block was administered. A surgical time-out confirmed the correct patient, operative eye, and planned procedures.

The operative eye was prepped with 5% povidone-iodine solution and draped in the usual sterile ophthalmic fashion. A sterile lid speculum was inserted, and the operating microscope was positioned.

Cataract Extraction

A temporal paracentesis was created using a 1.0-mm side-port blade. Preservative-free intracameral lidocaine was injected into the anterior chamber followed by injection of a cohesive ophthalmic viscosurgical device (OVD).

A 2.4-mm temporal clear corneal incision was created using a keratome blade. A continuous curvilinear capsulorrhexis was performed with a cystotome and completed using Utrata forceps.

Hydrodissection and hydrodelineation were performed until free rotation of the nucleus was achieved.

The lens nucleus was removed using phacoemulsification with a divide-and-conquer technique. Residual cortical material was removed using automated irrigation and aspiration. The posterior capsule remained intact.

The capsular bag was expanded with cohesive OVD, and a foldable posterior chamber intraocular lens was implanted completely within the capsular bag. Residual viscoelastic material was removed using irrigation and aspiration. The temporal corneal incision was hydrated and confirmed to be watertight.

Glaucoma Drainage Device Implantation

Attention was directed to the superotemporal quadrant. A superior conjunctival peritomy was created at the limbus, and Tenon's capsule was carefully dissected posteriorly to expose bare sclera. Hemostasis was achieved using bipolar cautery.

The Ahmed glaucoma valve was primed with balanced salt solution to confirm valve function. The implant plate was positioned beneath the superior and lateral rectus muscles approximately 8 to 10 mm posterior to the limbus and secured to the sclera with interrupted 8-0 nylon sutures.

The tube was trimmed with the bevel facing upward to the appropriate length for anterior chamber placement.

A 23-gauge needle tract was created into the anterior chamber through the sclera approximately 2 mm posterior to the limbus. The tube was advanced through the needle tract and positioned within the anterior chamber, ensuring adequate clearance from both the corneal endothelium and the iris.

The tube position was confirmed to be satisfactory with unobstructed aqueous flow.

A donor scleral patch graft was fashioned and secured over the exposed tube using interrupted 10-0 nylon sutures to reduce the risk of tube erosion.

The conjunctiva and Tenon's capsule were advanced and meticulously closed with interrupted and running 8-0 polyglactin sutures, completely covering the patch graft and tube. The closure was confirmed to be watertight.

The anterior chamber remained deep and well formed. The intraocular lens was centered within the capsular bag. The tube shunt was in excellent position with no evidence of leakage or obstruction.

Subconjunctival antibiotic and corticosteroid injections were administered away from the implant site. The lid speculum was removed. Topical antibiotic and corticosteroid drops were instilled, and a protective eye shield was applied.

The patient tolerated the procedure well without intraoperative complications and was transferred to the recovery area in stable condition.

Findings

Visually significant nuclear sclerotic cataract successfully removed by phacoemulsification with posterior chamber intraocular lens implantation. Successful implantation of an Ahmed glaucoma valve tube shunt with donor scleral patch graft. Tube positioned appropriately within the anterior chamber. The anterior chamber remained deep and stable with no intraoperative complications.

## Implants

* Foldable posterior chamber intraocular lens implanted within the capsular bag.

* Ahmed glaucoma valve glaucoma drainage device.

* Donor scleral patch graft.

Check your answer

66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (routine phacoemulsification)

66180 Aqueous shunt to extraocular reservoir (e.g., Ahmed or Baerveldt glaucoma drainage device)

67255 Scleral reinforcement with graft (used when a separate donor scleral or corneal patch graft is placed over the tube, if separately reportable under payer policy)

This is a common operative scenario for advanced or medically uncontrolled glaucoma, particularly when the surgeon chooses a glaucoma drainage device instead of a trabeculectomy because of the severity of disease or a higher risk of trabeculectomy failure.

Operative report 8

Preoperative Diagnosis

1. Visually significant age-related nuclear sclerotic cataract, right eye.

2. Mild to moderate primary open-angle glaucoma, right eye.

Postoperative Diagnosis

Same.

Procedure Performed

1. Extracapsular cataract extraction by phacoemulsification with implantation of posterior chamber intraocular lens, right eye.

2. Endoscopic cyclophotocoagulation (ECP), right eye.

Indication

ndicationThe patient presented with progressive visual impairment secondary to a visually significant cataract and primary open-angle glaucoma requiring multiple topical ocular hypotensive medications. Because the patient required cataract surgery and additional intraocular pressure reduction, combined phacoemulsification with posterior chamber intraocular lens implantation and endoscopic cyclophotocoagulation was recommended. The risks, benefits, alternatives, and potential complications were discussed, and informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and placed in the supine position. Monitored anesthesia care with topical anesthesia was administered. A surgical time-out was performed confirming the correct patient, operative eye, and planned procedures.

The operative eye was prepped with 5% povidone-iodine solution and draped in the usual sterile ophthalmic fashion. A sterile lid speculum was inserted, and the operating microscope was positioned.

Cataract Extraction

A temporal paracentesis was created using a 1.0-mm side-port blade. Preservative-free intracameral lidocaine was injected into the anterior chamber followed by injection of a cohesive ophthalmic viscosurgical device (OVD) to deepen and stabilize the anterior chamber.

A 2.4-mm temporal clear corneal incision was created using a keratome blade. A continuous curvilinear capsulorrhexis was performed with a cystotome and completed using Utrata capsulorrhexis forceps.

Hydrodissection and hydrodelineation were performed until free rotation of the lens nucleus was achieved.

The cataractous lens was removed using in situ phacoemulsification with a divide-and-conquer technique. Residual cortical material was removed using automated irrigation and aspiration. The posterior capsule remained intact.

The capsular bag was expanded with cohesive OVD, and a foldable posterior chamber intraocular lens was implanted completely within the capsular bag. Proper positioning of both haptics was confirmed.

Endoscopic Cyclophotocoagulation

Additional cohesive OVD was injected into the ciliary sulcus to improve visualization of the ciliary processes.

The endoscopic cyclophotocoagulation probe was introduced through the existing temporal clear corneal incision and advanced carefully into the ciliary sulcus posterior to the iris. Under direct endoscopic visualization, the ciliary processes were clearly identified.

An **810-nm diode laser** integrated with the endoscopic probe was activated. Laser photocoagulation was applied sequentially to the ciliary processes over approximately **270 degrees** of the ciliary body. Laser energy was titrated to achieve uniform whitening and gentle shrinkage of each treated ciliary process while avoiding excessive tissue disruption or audible tissue "pops."

The endoscope was rotated as needed to visualize additional ciliary processes until the planned treatment area had been completed. Following laser treatment, the probe was removed without complication.

Residual viscoelastic material was completely removed from the anterior chamber and from behind the intraocular lens using irrigation and aspiration.

Balanced salt solution was used to reform the anterior chamber. The corneal incisions were hydrated until watertight closure was achieved. The wounds were inspected and found to be Seidel negative. The anterior chamber remained deep and well formed, and the posterior chamber intraocular lens remained well centered.

Intracameral preservative-free antibiotic was administered. The lid speculum was removed. Topical antibiotic and corticosteroid drops were instilled, and a protective eye shield was applied.

The patient tolerated the procedure well without intraoperative complications and was transferred to the recovery area in stable condition.

Findings

Visually significant nuclear sclerotic cataract successfully removed by phacoemulsification with implantation of a posterior chamber intraocular lens. Endoscopic cyclophotocoagulation was successfully performed over approximately 270 degrees of the ciliary processes with satisfactory tissue response. No intraoperative complications were encountered.

Implants

* Foldable posterior chamber intraocular lens implanted within the capsular bag, right eye.

Check your answer

66988

When phacoemulsification with IOL implantation and endoscopic cyclophotocoagulation (ECP) are performed during the same operative session on the same eye, they are reported with one bundled.

CPT code: 66988.

Do not report 66984 + 66711 together for the same eye in this scenario.

66988 already includes:

Cataract extraction by phacoemulsification

Intraocular lens implantation

Endoscopic cyclophotocoagulation (ECP)