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Operative Report, Senile Cataracts Phacoemulsification is used in the following cataract surgery. LOCATION: Outpatient, Hospital PATIENT: Ingrid Cady ATTENDING PHYSICIAN: Rita Wimer, MD SURGEON: Rita Wimer, MD PREOPERATIVE DIAGNOSIS: Senile nuclear cataract, right eye POSTOPERATIVE DIAGNOSIS: Senile nuclear cataract, right eye PROCEDURE PERFORMED: Extracapsular cataract extraction by phacoemulsification (Figure 13-3), right eye (model SI40RB, +14.5 diopters, serial no. 38982) and implantation of intraocular lens. ANESTHESIA: Topical ESTIMATED BLOOD LOSS: Minimal COMPLICATIONS: None PROCEDURE: In the operating room, a drop of lidocaine 4%-MPF was applied to the eye. The patient was prepped and draped in the usual sterile fashion for an intraocular procedure of the right eye. A lid speculum was placed. A Weck-cel soaked with lidocaine 4%-MPF was placed at the limbus, both in the area of the planned phaco incision and planned side port incision. A keratome was used to enter the chamber at the arcade. A small amount of preservative-free lidocaine 1% was injected in the anterior chamber. The aqueous was exchanged with viscoelastic material, and a side port incision was made with a 15-degree angle blade. A continuous tear capsulotomy was made with a bent needle and the Utrata forceps. The nucleus was hydrodissected and removed with phacoemulsification using an ultrasound time of 2.4 minutes and a phaco percentage of 15%. The remaining cortical material was removed with irrigation and aspiration. The capsule was polished and vacuumed as indicated. A small additional amount of lidocaine 1% was again injected into the anterior chamber. Viscoelastic was used to deepen the chamber, and the posterior chamber intraocular lens was unfolded into the capsular bag and dialed into position. Irrigation and aspiration were used to remove the remaining viscoelastic. The globe was pressurized and the cornea hydrated to ensure a good seal. The wound was tested and found to be watertight. TobraDex drops were placed on the surface of the eye. The patient left the operating room in stable condition without complications, having tolerated the procedure well. SERVICE CODE(S): ______________________________________ ICD-10 CODE

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