CPC sample question # 9

Preoperative Diagnosis: Cataract, left eye.

Postoperative Diagnosis: Cataract, left eye.

Anesthesia: Retrobulbar, IV sedation.

Anesthesia: Phacoemulsification with intraocular lens implantation in the left eye.

Indications: The patient is an elderly is an elderly female who has had blurry vision in the left eye for six months causing her difficulty while driving and reading. Her best correct visual acuity is 20/40 with a glare of 20/80. She has a 2+ posterior subcapsular cataract.

Description of procedure: The patient was taken to the operating suite and placed in the supine position. A 50:50 mixture of 2 percent Lidocaine and 0.75 percent Marcaine, both without Epinephrine, was prepared. After adequate sedation, 4 cc of this mixture was injected in a retrob-ulbar fashion. Gentle ocular massage was applied to the eye for several minutes.

After adequate ocular akinesia was obtained, the patient was prepped and in the usual sterile fashion for ocular surgery.  A wire lid speculum was inserted into the left eye. A supersharp blade was used to create an inferior paracentesis port. Viscoelastic was used to deepen the anterior chamber and a clear cornea temporal incision was made. The cystotome needle and forceps were used to create a continuous capsulorhexis. Balanced salt solution was used to hydrodissect and hydrodelineate the nucleus. The nucleus was then noted to rotate freely within the bag.

The phacoemulsification hand-piece was introduced into anterior chamber and the nucleus was carefully removed. The remaining cortex was removed using the irrigation/aspiration hand-piece. A capsule polisher was used to remove posterior capsular opacities off the lens. Viscoelastic was injected into the anterior chamber. The wound was enlarged with a keratome. The intraocular lens, with a power of 23.0 diopters, was removed from its bag, inspected for flaws and rinsed thoroughly with balanced salt solution.

The lens was folded and inserted through the temporal incision into the capsular bag and removed into position with the Lester hook. The lens was noted to be in good condition. The irrigation/aspiration hand-piece was reintroduced into the eye to remove the remaining Viscoelastic.

The wound was hydrated with balanced salt solution and found to be watertight with gentle pressure and Weck-cel sponges. A mixture of Solu-Medrol and Ancef was injected into the inferior conjunctiva. The lid speculum was removed. Maxitrol ointment was placed into the left eye, along with a light pressure patch and shield.

All sponge, needle, and instrument counts were correct. The patient left the operating room in excellent codition and there were no complications, Estimated blood loss was zero.