Operative report Glaucoma Procedure

Operative report 1

Preoperative Diagnosis

Primary open-angle glaucoma, severe stage, right eye, uncontrolled despite maximal tolerated medical therapy.

Postoperative Diagnosis

Same.

Procedure Performed

Trabeculectomy with intraoperative application of Mitomycin-C, right eye.

Indication

The patient has severe primary open-angle glaucoma with progressive optic nerve damage and persistently elevated intraocular pressure despite maximal tolerated topical glaucoma medications. Because of inadequate pressure control and continued risk of glaucomatous visual field loss, surgical intervention with trabeculectomy augmented with Mitomycin-C was recommended. 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 was administered, followed by a peribulbar anesthetic block to the operative eye. 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.

Attention was directed to the superior limbus. A superior fornix-based conjunctival peritomy was created using Westcott scissors. Tenon's capsule was carefully dissected posteriorly to expose bare sclera. Gentle bipolar cautery was used to obtain meticulous hemostasis while minimizing thermal injury.

Mitomycin-C solution (0.2 mg/mL) was applied using multiple surgical sponges placed beneath the conjunctiva and Tenon's capsule over the intended filtration site. The sponges remained in position for approximately two minutes. Following completion of the exposure time, all sponges were carefully removed, and the operative field was copiously irrigated with balanced salt solution to remove any residual Mitomycin-C.

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

A temporal paracentesis was created using a side-port blade, and balanced salt solution was injected to maintain anterior chamber stability.

A trabeculectomy ostomy was created beneath the scleral flap using a Kelly Descemet punch, establishing communication between the anterior chamber and the subconjunctival space.

A broad peripheral iridectomy was performed using Vannas scissors to prevent postoperative iris obstruction of the sclerostomy. The iridectomy was inspected and found to be complete with a patent surgical opening.

The scleral flap was repositioned and secured using interrupted 10-0 nylon sutures. Suture tension was carefully adjusted to allow controlled filtration while maintaining appropriate anterior chamber depth and preventing excessive aqueous outflow.

The anterior chamber was reformed with balanced salt solution through the paracentesis. Controlled aqueous filtration was observed beneath the scleral flap.

The conjunctiva and Tenon's capsule were meticulously advanced and closed at the limbus using interrupted and running 10-0 nylon sutures, creating a watertight closure.

Balanced salt solution was injected through the paracentesis to assess bleb function. A diffuse, elevated superior filtering bleb was noted with appropriate aqueous filtration. The conjunctival closure was inspected and found to be Seidel negative without evidence of wound leakage.

The anterior chamber remained deep and well formed. The pupil was round. Intraocular pressure was judged to be appropriate by digital palpation.

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

Findings

Successful superior trabeculectomy with intraoperative Mitomycin-C augmentation. A functioning superior filtering bleb was present with controlled aqueous filtration. The anterior chamber remained deep and well formed. No intraoperative complications were encountered.

Implants : None.

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CPT

66172 –RT

Mitomycin-C is not separately reportable. Its intraoperative application is considered an integral component of an augmented trabeculectomy and is included in CPT 66170.

If this were a repeat trabeculectomy in an eye with previous glaucoma filtering surgery, CPT 66172 would generally be appropriate instead.

Operative report 2

Preoperative Diagnosis

Neovascular glaucoma, right eye, with uncontrolled intraocular pressure despite maximal tolerated medical therapy.

Postoperative Diagnosis

Same.

Procedure Performed

Implantation of Ahmed glaucoma valve (aqueous shunt) with donor scleral patch graft, right eye.

Indication

The patient presented with severe neovascular glaucoma of the right eye secondary to retinal ischemic disease, with persistently elevated intraocular pressure despite maximal tolerated topical and systemic glaucoma therapy. Examination demonstrated extensive neovascularization of the iris and anterior chamber angle with progressive glaucomatous optic neuropathy. Because medical management failed to adequately control intraocular pressure, implantation of an Ahmed glaucoma valve was recommended to preserve remaining vision and reduce intraocular pressure. 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 was provided, and a peribulbar anesthetic block was administered to 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, and the operating microscope was positioned.

Attention was directed to the superotemporal quadrant. A fornix-based conjunctival peritomy was created at the limbus using Westcott scissors. Tenon's capsule was carefully dissected posteriorly to expose bare sclera. Hemostasis was achieved with gentle bipolar cautery.

The Ahmed glaucoma valve was inspected and primed with balanced salt solution until free flow through the valve mechanism was confirmed.

The valve plate was positioned beneath the superior and lateral rectus muscles approximately 8 to 10 mm posterior to the limbus. The implant was secured to the sclera with two interrupted 8-0 nylon sutures through the fixation eyelets, ensuring stable positioning without excessive tension.

The silicone drainage tube was measured and trimmed to the appropriate length with the bevel facing upward to facilitate proper anterior chamber placement.

A temporal paracentesis was created, and cohesive ophthalmic viscosurgical device was injected into the anterior chamber to maintain chamber depth.

A 23-gauge needle tract was created approximately 2 mm posterior to the limbus and directed into the anterior chamber parallel to the iris plane. The tube was carefully inserted through the needle tract and advanced into the anterior chamber. Final positioning demonstrated adequate tube length with appropriate clearance from both the corneal endothelium and the iris.

Tube patency and unobstructed aqueous flow were confirmed.

A donor scleral patch graft was fashioned to appropriate size and positioned over the exposed tube. The graft was secured to the sclera using interrupted 10-0 nylon sutures, providing complete coverage of the extraocular tube segment.

The conjunctiva and Tenon's capsule were advanced over the patch graft and meticulously closed using interrupted and running 8-0 polyglactin sutures, creating a watertight closure without tension.

Balanced salt solution was injected through the paracentesis to reform the anterior chamber. The tube position remained satisfactory, and the anterior chamber was deep and well formed. The conjunctival closure was inspected and found to be Seidel negative.

Subconjunctival injections of antibiotic and corticosteroid 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

Extensive iris and angle neovascularization consistent with advanced neovascular glaucoma. Successful implantation of an Ahmed glaucoma valve in the superotemporal quadrant with satisfactory tube position within the anterior chamber. Donor scleral patch graft securely covered the tube. The anterior chamber remained deep and well formed with no evidence of wound leakage or intraoperative complications.

Implants

* Ahmed glaucoma valve (aqueous drainage device).

* Donor scleral patch graft.

Check your answer

66180, 67255

• Neovascular glaucoma is one of the most common indications for implantation of an Ahmed glaucoma valve, because the valve mechanism helps reduce the risk of early postoperative hypotony in eyes with severe secondary glaucoma.

• The use of a donor scleral patch graft to cover the tube is standard surgical practice; whether it is separately reportable depends on payer policy and documentation.

Operative report 3

# OPERATIVE REPORT

## Preoperative Diagnosis

Advanced primary open-angle glaucoma, right eye, uncontrolled despite maximal tolerated medical therapy.

## Postoperative Diagnosis

Same.

## Procedure Performed

Transscleral diode laser cyclophotocoagulation (cyclophotocoagulation), right eye.

## Indication

The patient presented with advanced primary open-angle glaucoma and persistently elevated intraocular pressure despite maximal tolerated topical and systemic glaucoma therapy. Progressive glaucomatous optic neuropathy and visual field loss were documented. Because conventional medical management had failed to adequately control intraocular pressure, transscleral diode laser cyclophotocoagulation was recommended to reduce aqueous humor production and preserve remaining vision. 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 was administered, followed by a retrobulbar anesthetic block to the operative eye to provide adequate anesthesia and akinesia. A surgical time-out was performed confirming the correct patient, operative eye, and planned procedure.

The operative eye was prepped and draped in the standard sterile ophthalmic fashion. A sterile lid speculum was inserted.

A diode laser system equipped with a G-Probe was prepared and tested. Balanced salt solution was applied to the ocular surface for lubrication.

The limbus was carefully identified, and the G-Probe was positioned approximately 1.5 mm posterior to the limbus with the probe oriented toward the ciliary body.

Transscleral diode laser photocoagulation was sequentially applied over approximately 270 degrees of the ciliary body. Care was taken to avoid the 3 o'clock and 9 o'clock meridians to minimize the risk of injury to the long posterior ciliary nerves and vessels.

A total of **22 laser applications** were delivered. Laser energy was initiated at **approximately 1,750 mW** with a duration of **2.0 seconds** per application. Energy was titrated as needed based on tissue response. Audible tissue "pops" were minimized by reducing laser power whenever excessive energy delivery was encountered.

The treatment was distributed evenly over the superior, inferior, and temporal quadrants while avoiding previously identified areas of scleral thinning.

Following completion of laser treatment, the ocular surface was irrigated with balanced salt solution. Subconjunctival dexamethasone and antibiotic were administered.

Topical antibiotic, corticosteroid, and cycloplegic drops were instilled. The lid speculum was removed, 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

Advanced primary open-angle glaucoma with uncontrolled intraocular pressure. Successful transscleral diode laser cyclophotocoagulation was completed over approximately 270 degrees of the ciliary body using 22 laser applications with satisfactory intraoperative tissue response. No intraoperative complications were encountered.

## Implants

None.

Check your answer

66710 Ciliary body destruction; cyclophotocoagulation, transscleral vitrectomy.

This operative report supports CPT 66710, which is used for transscleral cyclophotocoagulation (CPC) performed with a diode laser (e.g., G-Probe). This procedure is most commonly performed for advanced, refractory, or medically uncontrolled glaucoma, particularly in patients who are poor candidates for trabeculectomy or glaucoma drainage device implantation or who have failed previous glaucoma surgeries.

Operative report 4

Preoperative Diagnosis

Primary angle-closure glaucoma (narrow-angle glaucoma), right eye.

Postoperative Diagnosis

Same.

Procedure Performed

Surgical peripheral iridectomy, right eye.

Indication

The patient presented with anatomically narrow anterior chamber angles and primary angle-closure glaucoma resulting in elevated intraocular pressure. Because the patient was not an appropriate candidate for laser peripheral iridotomy due to poor visualization and inadequate laser penetration, surgical peripheral iridectomy was recommended to establish an alternative pathway for aqueous humor flow from the posterior chamber to the anterior chamber, eliminate pupillary block, deepen the anterior chamber angle, and reduce the risk of recurrent angle closure. 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 a peribulbar anesthetic block was administered. 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 superior limbal paracentesis was created using a 15-degree blade. A cohesive ophthalmic viscosurgical device was injected into the anterior chamber to maintain chamber depth and protect the corneal endothelium.

A superior clear corneal limbal incision measuring approximately 2.8 mm was fashioned using a keratome blade. Fine Colibri forceps and microsurgical instruments were used to gently grasp the peripheral iris through the surgical incision.

A small segment of peripheral iris was carefully externalized through the wound. Using Vannas scissors, a full-thickness peripheral iridectomy was performed, creating a patent opening in the superior peripheral iris. The excised iris tissue was removed from the operative field.

The iridectomy site was inspected under the operating microscope and confirmed to be widely patent without residual iris strands obstructing the opening. The iris was allowed to reposition naturally within the anterior chamber.

Residual ophthalmic viscosurgical device was removed from the anterior chamber using balanced salt solution and irrigation/aspiration. The anterior chamber was reformed and maintained at physiologic pressure.

The corneal incision was hydrated and confirmed to be watertight. The wound was inspected and found to be Seidel negative without leakage. The anterior chamber remained deep and well formed, and the peripheral iridectomy remained widely patent.

Subconjunctival antibiotic and corticosteroid injections were 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

Narrow anterior chamber angle consistent with primary angle-closure glaucoma. Successful superior surgical peripheral iridectomy performed with creation of a patent full-thickness iris opening. The anterior chamber remained well formed with no evidence of wound leak or intraoperative complications.

Implants

None.

Check your answer

66625

Laser peripheral iridotomy (LPI) is the most common treatment for primary angle-closure glaucoma and is typically performed in the clinic rather than the operating room.

• Surgical peripheral iridectomy (CPT 66625) is generally reserved for situations where laser treatment cannot be performed or has failed, such as:

  • Dense corneal edema preventing laser visualization.

  • Extremely thick or heavily pigmented iris.

  • Failed or non-patent prior laser iridotomy.

  • Intraoperative management during other ocular procedures.