Pyloric stricture secondary to healed pyloric channel ulcer, dilated. Check on biopsy, continue Prilosec for at least another 30 days.
At that time, a repeat endoscopy and final dilation will be accomplished. He will almost certainly need chronic H2 blocker therapy to avoid recurrence of this divesting complicated ulcer.
A patient with hypertension presents to the same day surgery department for removal of her gallbladder due to chronic gallstones.
She is examined preoperatively by her cardiologist to be cleared for surgery. A patient presents for esophageal dilation. The physician begins dilation by using a bougie. This attempt was unsuccessful. The physician then dilates the esophagus transendoscopically using a balloon 25mm. Surgical laparoscopy with a cholecystectomy and exploration of the common bile duct, for cholelithiasis.
The patient's brother is a perfect match and will be donating a portion of his liver for a graft. Segments II and III will be taken from the brother and then the backbench reconstruction of the graft will be performed, both a venous and arterial anastomosis. The orthotopic allotransplantation will then be performed on the patient. Following calculation of the planned transrectal ultrasound, guidance was provided for percutaneous placement of seeds into the prostate tissue.
Benign prostatic hypertrophy with outlet obstruction and hematuria. Spinal Description of procedure: The patient was placed on the operating room table in sitting position and spinal anesthesia induced. He was placed in the lithotomy position, prepped and draped appropriately.
Resection was begun at the posterior bladder neck and extended to the verumontanum a crest near the wall of the urethra. Posterior tissue was resected first from the left lateral lobe, then right lateral lobe, then anterior. Depth of resection was carried to the level of the circular fibers. Bleeding vessels were electrocauterized as encountered.
Care was taken to not resect distal to the verumontanum, thus protecting the external sphincter. At the end of the procedure, prostatic chips were evacuated from the bladder. Final inspection showed good hemostasis and intact verumontanum. The instruments were removed, Foley catheter inserted, the patient returned to the recovery area in satisfactory condition. The patient presents to the office for CMG cystometrogram.
Complex CMG cystometrogram with voiding pressure studies is done, intraabdominal voiding pressure studies, and complex uroflow are also performed. A year-old woman with biopsy-proven carcinoma of the vulva with metastasis to the lymph nodes has complete removal of the skin and deep subcutaneous tissues of the vulva in addition to removal of her inguinofemoral, iliac and pelvic lymph nodes bilaterally.
The diagnosis of carcinoma of the vulva with 7 of the nodes also positive for carcinoma is confirmed on pathologic review.
A woman with a long history of rectocele and perineal scarring from multiple episiotomies develops a rectovaginal fistula with perineal body relaxation. She has transperineal repair with perineal body reconstruction and plication of the levator muscles.
An year-old widow with uterine prolapse and multiple comorbid conditions has been unsuccessful in the use of a pessary for treatment elects to receive colpocleisis LeFort type to prevent further prolapse and avoid more significant surgery like hysterectomy. The treatment is successful. A 37 year old woman presents with abdominal pain, bleeding unrelated to menses and an abnormal pap showing LGSIL low grade squamous intraepithelial lesion.
Treatment is hysteroscopy with thermoablation of the endometrium and cryocautery of the cervix. This is performed without difficulty. A patient is diagnosed with an injury to the facial nerve. The surgeon performs a neurorrhaphy with nerve graft to restore innervation to the face using microscopic repair.
The surgeon created a 2 cm incision over the damaged nerve, dissected the tissues and located the nerve. The damaged nerve was resected and removed. A laminectomy is performed on the inferior end of L5. The microscope is used to perform microdissection. There was a large extradural cystic structure on the right side underneath the nerve root as well as the left.
The entire intraspinal lesion was evacuated. A patient with primary hyperparathyroidism undergoes parathyroid sestamibi nuclear medicine scan and ultrasound and is found to have only one diseased parathyroid. A minimally invasive parathyroidectomy is performed. A physician uses cryotherapy for removal trichiasis. A patient receives chemodenervation with Botulinum toxin injections to stop blepharospasms of the right eye.
What are the procedure and diagnosis codes? The surgeon performed an insertion of an intraocular lens prosthesis discussed with the patient before the six-week earlier cataract removal by the same surgeon. The physician performs an iridotomy using laser on both eyes for chronic angle closure glaucoma; procedure includes local anesthesia.
A physician extracts a tumor, using a frontal approach, from the lacrimal gland of a year-old patient. An anesthesiologist is personally performing monitored anesthesia care. A CRNA is personally performing a case, with medical direction from an anesthesiologist.
What modifier is appropriately reported for the CRNA services? An anesthesiologist is medically supervising six cases concurrently. What modifier is reported for the anesthesiologist's service? When an anesthesiologist is medically supervising six cases, what modifier is reported for the CRNA's medically directed service? The anesthesiologist performed all required steps for medical direction and was not medically directing any other services at the time.
Six-year-old girl twisted her arm on the play ground. She is seen in the ED complaining of pain in her wrist. X-ray is normal Assessment: Over the counter Anaprox. Recheck if no improvement. An infant is born six weeks premature in rural Arizona and the pediatrician in attendance intubates the child and administers surfactant in the ET tube while waiting in the ER for the air ambulance. During the 45 minute wait, he continues to bag the critically ill patient on percent oxygen while monitoring VS, ECG, pulse oximetry and temperature.
The infant is in a warming unit and an umbilical vein line was placed for fluids and in case of emergent need for medications. How is this coded? Trumph loses his yacht in a poker game and experiences a sudden onset of chest pain which radiates down his left arm. The paramedics are called to the casino he owns in Atlantic City to stabilize him and transport him to the hospital.
Art is in the ER to direct the activities of the paramedics. He spends 30 minutes in two-way communication directing the care of Mr.
Trumph is in full arrest with torsades de pointes ventricular tachycardia. Art spends another hour stabilizing the patient and performing CPR. What are the appropriate procedure codes for this encounter? Patient comes in today at four months of age for a checkup.
She is growing and developing well. Her mother is concerned because she seems to cry a lot when lying down but when she is picked up she is fine. She is on breast milk but her mother has returned to work and is using a breast pump, but hasn't seemed to produce enough milk.
Weight 12 lbs 11 oz, Height 25in. Right eardrum is minimally pink, left eardrum is normal. The physician performs a detailed history, detailed exam and determines the patient has mild appendicitis. The physician prescribes antibiotics to treat the appendicitis in hopes of avoiding an appendectomy.
Blancos from the pulmonary service after a bout of pneumococcal pneumonia. She spends 45 minutes at the bedside explaining to Mr. Blancos and his wife the medications and IPPB therapy she ordered. Blancos is a resident of the Shady Valley Nursing Home due to his advanced Alzheimer's disease and will return to the nursing home after discharge.
On the same day Dr. Blancos to the nursing facility. She obtains a detailed interval history, does comprehensive examination and the medical decision making is moderate complexity. Patient is here today for follow-up of bilateral lower extremity swelling. The swelling responded to hydrochlorothiazide. I reviewed her lab and echocardiogram. The patient does have moderate pulmonary hypertension.
Patient is in no acute distress. Bilateral lower extremity swelling. This has resolved with diuretics, it may be secondary to problem 2. Etiology is not clear at this time, will work up and possibly refer to a pulmonologist.
Will evaluate the pulmonary hypertension. Patient will be scheduled for a sleep study. She is complaining of severe dizziness and feels like the room is spinning. She has had palpitations on and off for the past 12 months. For the ROS, she reports chest tightness and dyspnea but denies nausea, edema, or arm pain. She drinks two cups of coffee per day.
An extended exam of five organ systems are performed. This is a new problem. His spleen was severely damaged and a splenectomy was performed. During his hospitalization the patient experienced pain and shortness of breath, but with an antibiotic regimen of Levaquin, he improved. The attending physician performed a final examination and reviewed the chest X-ray revealing possible infiltrates and a CT of the abdomen ruled out any abscess.
He was given a prescription of Zosyn. The physician spent 20 minutes on the date of discharge. She makes an appointment to see Dr.
Lung for an initial visit. The patient has a constant cough due to smoking and some shortness of breath. No night sweats, weight loss, night fever, CP, headache, or dizziness. She has tried patches and nicotine gum, which has not helped. Patient has been smoking for 40 years and smokes 2 packs per day. She has a family history of emphysema. A limited three system exam was performed. Dr Lung discussed in detail the pros and cons of medications used to quit smoking. Counseling and education was done for 20 minutes of the 30 minute visit.
Prescriptions for Chantrix and Tetracylcine were given. The patient to follow up in 1 month. A chest X-ray and cardiac work up was ordered. Select the appropriate CPT code s for this visit. A pre-anesthesia assessment was performed and signed at Anesthesia start time is reported as The surgery finished at What is the anesthesia time reported?
Code Anesthesia for procedures on the major vessels of the neck; not otherwise specified has a base value of ten 10 units. The patient is a P3 status, which allows one 1 extra base unit.
Code , anesthesia for vaginal procedures, has a base value of three 3 units. The patient was admitted under emergency circumstances, qualifying circumstance code , which allows two 2 extra base units. A pre-anesthesia assessment was performed and signed at 2: Anesthesia start time is reported as 2: The surgery finished at 3: The surgeon has requested the anesthesia department place an arterial line.
The anesthesia department is called to insert a non-tunneled central venous CV catheter. An month-old patient presented for emergency surgery to repair a severely broken arm after falling from a third story window. What qualifying circumstance code s may be reported in addition to the anesthesia code? The perfusionist placed an arterial line. He is to have a chest X-ray due to chest tightness.
He otherwise states he feels well and is here to go over the results of his chest X-ray PA and Lateral performed in the office and the CT scan performed at the diagnostic center. The results of the chest X-ray were normal. CT scan was sent to the office and the physician interpreted and documented that the CT scan of the abdomen showed a small mass in his right upper quadrant. A patient has a history of chronic venous embolism in the superior vena cava SVC and is having a radiographic study to visualize any abnormalities.
In outpatient surgery the physician accesses the subclavian vein and the catheter is advanced to the superior vena cava for injection and imaging. The supervision and interpretation of the images is performed by the physician. What codes are reported for this procedure? She is also developing pain at rest. She denies any recent injury. There is pain with stair climbing and start up pain.
An AP, Lateral and Sunrise views of the right knee are ordered and interpreted. They reveal calcification within the vascular structures. There is decreased joint space through the medial compartment where she has near bone-on-bone contact, flattening of the femoral condyles, no fractures noted. The diagnosis is right knee pain secondary to underlying localized degenerative arthritis. Resting tomographic myocardial perfusion images were obtained following injection of 10 mCi of intravenous cardiolite.
At peak exercise, 30 mCi of intravenous cardiolite was injected, and post-stress tomographic myocardial perfusion images were obtained. Post stress gated images of the left ventricle were also acquired. Myocardial perfusion images were compared in the standard fashion. This is a technically fair study. There were no stress induced electrocardiographic changes noted.
There are no significant reversible or fixed perfusion defects noted. No evidence of myocardial ischemia or infarction. Normal left ventricular ejection fraction. After intravenous administration of 5. Flow imaging demonstrated markedly reduced flow to both kidneys bilaterally. An oncology patient is having weekly radiation treatments with a total of seven conventional fractionated treatments. Two fractionated treatments daily for Monday, Tuesday and Wednesday and one treatment on Thursday.
Magnetic resonance imaging of the chest is first done without contrast medium enhancement and then is performed with an injection of contrast. A CT scan confirms improper ossification of cartilages in the upper jawbone and left side of the face area for a patient with facial defects. The CT is performed with contrast material in the hospital.
A patient is positioned on the scanning table headfirst with arms at the side for an MRI of the thoracic spine and spinal canal.
A contrast agent is used to improve the quality of the images. The scan confirms the size and depth of a previously biopsied leiomyosarcoma metastasized to the thoracic spinal cord.
A young child is taken to the OR to reduce a meconium plug bowel obstruction. A therapeutic enema is performed with fluoroscopy. The patient is in position and barium is instilled into the colon through the anus for the reduction. How will these services be coded? A physician orders a quantitative FDP.
A patient's mother and sister have been treated for breast cancer. She has blood drawn for cancer gene analysis with molecular pathology testing. She has previously received genetic counseling. A patient with AIDS presents for follow up care. An NK natural killer cell total count is ordered. A patient has partial removal of his lung. The surgeon also biopsies several lymph nodes in the patient's chest which are examined intraoperatively by frozen section and sent with the lung tissue for Pathologic examination.
The pathologist also performs a trichrome stain. A couple with inability to conceive has fertility testing. The semen specimen is tested for volume, count, motility and a differential is calculated.
The findings indicate infertility due to oligospermia. In a legal hearing to determine child support there is a dispute about the child's paternity. The court orders a paternity test, and a nasal smear is taken from the plaintiff and the child. The plaintiff is confirmed as the father of the child.
A virus is identified by observing growth patterns on cultured media. What is this type of identification is called? A female patient fell on the floor as she got out of bed. She has no known head trauma. She noticed some slight stiffness in her joints and weakness in her lower extremity muscles, with slight stiffness in her arm joints. The physician decided to test for possible multiple sclerosis MS.
She was sent to a clinic providing somatosensory studies. The testing included upper and lower limbs. The physician evaluated the patient and ordered a 12 lead EKG. Findings included signs of acute cardiac damage. Appropriate initial management was continued by the ED physician who contacted the cardiologist on call in the hospital. Admission to the cardiac unit was ordered. No beds were available in the cardiac unit and the patient was held in the ED.
The cardiologist left the ED after completing the evaluation of the patient. Several hours passed and the patient was still in the ED. During an minute period, the patient experienced acute breathing difficulty, increased chest pain, arrhythmias, and cardiac arrest. The patient was managed by the ED physician during this minute period.
Included in the physician management were a new 12 lead EKG, endotracheal intubation and efforts to restore the patient's breathing and circulation for 20 minutes.
CPR was unsuccessful, the patient was pronounced dead after a total of 44 minutes critical care time, exclusive of other separately billable services. A patient with Sickle cell anemia with painful sickle crisis received normal saline IV, cc per hour to run over 5 hours for hydration in the physician's office. A patient with bilateral sensory hearing loss is fitted with a digital, binaural, behind the ear hearing aid.
The family just recently visited a family member that had a cat and dog. The mother wants to know if her son is allergic to cats and dogs. The child's skin was scratched with two different allergens. The physician waited 15 minutes to check the results. There was a flare up reaction to the cat allergen, but there was no flare up to the dog allergen.
The physician included the test interpretation and report in the record. He had received services at the clinic about 2 years ago. The patient related this episode happened once previously and his year-old brother has a pacemaker. A chest X-ray with 2 views and an EKG with rhythm strip were ordered equipment owned by the urgent care center. The physician detected no obvious abnormalities, but the patient was advised to see a cardiologist within the next 2 - 3 days.
The physician interpreted and provided a report for the rhythm strip and Chest X-ray. His physician ordered a PTCA percutaneous transluminal coronary angioplasty of the left anterior descending coronary artery. The procedure revealed atherosclerosis in the native vessel. It was determined a stent would be required to keep the artery open. The stent was inserted during the procedure. A pregnant female is Rh negative and at 28 weeks gestation.
The child's father is Rh positive. The mother is given an injection of a high-titer Rho D immune globulin, mcg, IM. A patient with hypertensive end stage renal failure, stage V, and secondary hyperparathyroidism is evaluated by the physician and receives peritoneal dialysis. The physician evaluates the patient once before dialysis begins. A patient with congestive heart failure and chronic respiratory failure is placed on home oxygen.
Prescribed treatment is 2 L nasal cannula oxygen at all times. A home care nurse visited the patient to assist with his oxygen management. The meaning of heteropsia or anisometropia is: Blindness in half the visual field c. Unequal vision in the two eyes b. Blindness in both eyes The radiology term "fluoroscopy" is described as: Technique using magnetism, radio waves and a computer to produce images b. An X-ray procedure allowing the visualization of internal organs in motion c.
A scan using an X-ray beam rotating around the patient d. Use of high-frequency sound waves to image anatomic structures Sialography is an X-ray of: Ventricles of the brain A projection is the path of the X-ray beam. If the projection is front to back it would be: Cytopathology is the study of: The process of preserving cells or whole tissues at extremely low temperatures is known as: A gonioscopy is an examination of what part of the eye: Anterior chamber of the eye c.
Interior surface of the eye d. Which cells produce hormones to regulate blood sugar? Which part of the brain controls blood pressure, heart rate and respiration?
What are chemicals which relay, amplify and modulate signals between a neuron and another cell? Which of the following conditions results from an injury to the head?
The symptoms include headache, dizziness and vomiting. Lacrimal glands are responsible for which of the following? Production of tears c. Production of vitreous b.
Production of zonules d. Production of mydriatic agents Which of the following does NOT contribute to refraction in the eye? A patient diagnosed with glaucoma has: A lens that is no longer clear c. Abnormally high intraocular pressure b. Bleeding vessels on the retina d. Which of the following is true about the tympanic membrane? It separates the middle ear from the inner ear b. It separates the external ear from the middle ear c. It sits within the middle ear d. Use both and when locating and assigning a diagnosis code.
Alphabetic Index and Appendix C c. Alphabetic Index and Tabular List d. Tabular List and Index to Procedures When a patient has a condition that is both acute and chronic and there are separate entries for both, how is it reported?
Code only the acute code c. Code both sequencing the acute first b. Code both sequencing the chronic first d. Code only the chronic code A patient with chronic back and neck pain developed a drug dependency on oxycodone opoid.
After being taken off the drug, he was seen in the clinic for withdrawal symptoms. A patient with metastatic bone cancer primary site unknown presents to the oncologist's office for a chemotherapy treatment.
On examination, the oncologist finds the patient to be severely dehydrated and cancels the chemotherapy. The patient will receive intravenous hydration in the office and reschedule the chemotherapy treatment. A patient with hypertensive heart disease is now experiencing accelerated hypertension due to papillary muscle dysfunction. A three-year-old is brought to the burn unit after pulling a pot of hot soup off the stove spilling onto to her body.
Newborn twin girls delivered at 27 weeks, weighing grams for twin A and grams for twin B. Both were diagnosed with extreme immaturity. Baby boy is born by cesarean section in the hospital. The mother has a history of diabetes mellitus, which complicated the management of her pregnancy. In addition, the mother abused cocaine throughout her pregnancy.
The newborn was monitored for drug withdrawal, however no symptoms were noted and the toxicology report came back negative.
ABO incompatibility was documented, but the Coomb's test was negative. The diagnostic statement indicates respiratory failure due to administering incorrect medication. Valium was administered instead of Xanax. Category II codes, temporary national codes, and miscellaneous codes. Dental codes, morphology codes, miscellaneous codes, and permanent national codes. Permanent national codes, dental codes, category II codes.
Permanent national codes, miscellaneous codes, and temporary national codes. What does "non-facility" describe when calculating Physician Fee Schedule payments? What three components are considered when Relative Value Units are established? Physician work, Practice expense, Malpractice Insurance b. Geographic region, Practice expense, Malpractice Insurance c. Geographic region, Conversion factor, Physician fee schedule d. Physician work, Physician fee schedule, Conversion factor Reimbursement, if any, is determined by the payer The Surgical Global Package applies to services performed in what setting?
Ambulatory Surgical Centers d. All of the above What surgical status indicator represents the Surgical Global Package for endoscopic procedures without an incision? Use an unlisted code when a procedure is modified. Parenthetical instructions define each code listed in the codebook. Select the name of the procedure or service that most closely approximates the procedure or service performed. Select the name of the procedure or service that accurately identifies the service Practice Management The Medicare program is made up of several parts.
More than one iStent per eye is considered experimental and investigational because its safety and effectiveness has not been established. Aetna considers the adjunctive use of anti-fibrotic agents e. Aetna considers insertion of a drug-eluting implant, including punctal dilation and implant removal when performed, into the lacrimal canaliculus experimental and investigational for the treatment of glaucoma or ocular hypertension because its effectiveness has not been established.
It was once thought that glaucoma was generally due to increased intraocular pressure IOP ; however, the condition is also found in individuals with normal or low eye pressure.
Therefore, diagnosis of glaucoma does not rely on increased IOP and may be related to optic nerve damage. Glaucoma is one of the leading causes of blindness with loss of peripheral vision being a hallmark sign of glaucoma. It is a slow progressive, insidious optic neuropathy. Primary open-angle glaucoma is also known as chronic open-angle glaucoma and chronic simple glaucoma. Another form of glaucoma is acute angle-closure glaucoma AACG , which occurs as a dramatic, violent attack with closure of the entire angle.
In contrast to POAG, AACG manifests with symptoms of blurred vision with colored halos around lights, pain, redness, and often nausea and vomiting related to the pain.
Medication, in the form of eye drops, pills or both, is the most common early treatment for glaucoma. There are numerous medications available for treating glaucoma; all of which must be taken regularly. If medication fails, other interventions may be recommended. Acute angle-closure glaucoma is treated with oral or intravenous carbonic anhydrase inhibitors e. If pharmacotherapies fail, laser iridotomy can be performed to create an opening in the peripheral iris to relieve pupillary block.
Primary open-angle glaucoma is usually treated with ophthalmic medications. The first-line drugs include timolol a non-specific beta blocker and latanoprost a prostaglandin F2a agonist.
The second-line drugs entail brimonidine an alpha agonist and dorzolamide a topical carbonic anhydrase inhibitor. The third-line drugs include apraclonidine an alpha agonist , pilocarpine a cholinergic agonist , acetazolamide an oral carbonic anhydrase inhibitor , and epinephrine a non-specific adrenergic agonist. In a randomized controlled study, Doi et al concluded that the combination of bimatoprost and latanoprost in POAG increases IOP and should not be considered as a therapeutic option.
The Singapore Ministry of Health's guideline on glaucoma stated that laser trabeculoplasty may be used as an adjunct to medical therapy. The term aqueous drainage device refers to a broad class of tools used to facilitate aqueous flow out of the anterior chamber to control IOP. They may also be referred to as glaucoma drainage devices, tubes or shunts and may be valved or nonvalved.
Such drainage devices may be placed in individuals with advanced disease in whom medical and laser therapies are inadequate and who have an underlying diagnosis that increases the risk of failure of conventional surgery. The basic design of these devices is similar -- a silicone tube shunts aqueous humor from the anterior chamber to a fibrous capsule surrounding a synthetic plate or band positioned at the equatorial region of the globe.
The capsule serves as a reservoir for aqueous drainage. Many studies have demonstrated that these devices are comparable and are effective in treating patients with POAG. In a report on aqueous shunts in glaucoma by the AAO, Minckler et al provided an evidence-based summary of commercially available aqueous shunts currently used in substantial numbers Ahmed [New World Medical, Inc.
A total of 17 previously published randomized trials, 1 prospective non-randomized comparative trial, 1 retrospective case-control study, 2 comprehensive literature reviews, and published English language, non-comparative case series and case reports were reviewed and graded for methodologic quality. Aqueous shunts are used primarily after failure of medical, laser, and conventional filtering surgery to treat glaucoma and have been successful in controlling IOP in a variety of glaucomas.
The principal long-term complication of anterior chamber tubes is corneal endothelial failure. The most shunt-specific delayed complication is erosion of the tube through overlying conjunctiva. There is a low incidence of this occurring with all shunts currently available, and it occurs most frequently within a few millimeters of the corneo-scleral junction after anterior chamber insertion. Erosion of the equatorial plate through the conjunctival surface occurs less frequently.
The authors concluded that based on level I evidence, aqueous shunts seem to have benefits IOP control, duration of benefit comparable with those of trabeculectomy in the management of complex glaucomas phakic or pseudophakic eyes after prior failed trabeculectomies.
Level I evidence indicates that there are no advantages to the adjunctive use of anti-fibrotic agents or systemic corticosteroids with currently available shunts. Too few high-quality direct comparisons of various available shunts have been published to assess the relative efficacy or complication rates of specific devices beyond the implication that larger-surface-area explants provide more enduring and better IOP control. Long-term follow-up and comparative studies are encouraged.
A review by the AAO Minckler et al, concluded that Level I evidence indicates that there are no advantages to the adjunctive use of antifibrotic agents with currently available shunts. The AAO assessment stated that two of three randomized controlled trials concluded that antifibrotic agents have no beneficial long-term outcome effect when used with aqueous shunts citing Cantor, et al.
The AAO assessment stated that, among published randomized controlled trials, only the study of Duan, et al. The AAO assessment Minckler, et al. The ExPress glaucoma filtration device, a stainless steel nonvalved shunt, is inserted through a conjunctival flap to drain aqueous from the anterior chamber without removal of any scleral or iris tissue. This device is a single-piece, stainless steel, translimbal implant that is placed using an inserter. Although its ease of implantation is greatly desired, its long-term efficacy and risk of complications have yet to be determined.
The Ex-PRESS mini glaucoma shunt is a micron diameter tube made from implantable stainless steel that is less than 3 mm long, and is loaded on a specially designed disposable inserter. The device reduces IOP by diverting excess aqueous humor from the anterior chamber to a subconjunctival bleb.
Originally, the Ex-PRESS was designed for a direct limbus insertion through the irido-corneal angle under a conjunctival flap to drain aqueous from the anterior chamber to the subconjunctival space. However, because of long-term complications, including conjunctival erosions, hypotony, tube dislocation, conjunctival scarring or fibrosis within the tube, the device was re-designed.
The new device is inserted via an external approach in the superficial scleral flap through the trabeculum into the anterior chamber.
The overall average number of glaucoma medications dropped significantly from 1. In a retrospective comparative series of eyes, Maris et al compared the Ex-PRESS mini implant Model R 50 placed under a partial-thickness scleral flap with standard trabeculectomy.
Success was defined as IOP greater than or equal to 5 mm Hg and less than or equal to 21 mm Hg, with or without glaucoma medications, without further glaucoma surgery or removal of implant.
Early post-operative hypotony was defined as IOP less than 5 mm Hg during the first post-operative week. The average follow-up was The number of post-operative glaucoma medications in both groups was not significantly different. The authors concluded that the Ex-PRESS implant under a scleral flap had similar IOP lowering efficacy with a lower rate of early hypotony compared with trabeculectomy. Safety estimates were measured by OR for post-operative complications.
Statistical analysis was performed using the RevMan 5. The Ex-PRESS procedure was found to be associated with lower number of post-operative interventions and with a significantly lower frequency of hyphema than trabeculectomy, whereas other complications did not differ statistically. Complication rates were similar for the 2 types of surgery, except for a lower frequency of hyphema in the Ex-PRESS group.
Transciliary fistulization transciliary filtration, Singh filtration uses a thermo-cauterization device called the Fugo Blade to create a filter track from the sclera through the ciliary body to allow aqueous fluid to drain from the posterior chamber of the eye. This differs from conventional filtering surgeries in which aqueous fluid is filtered from the anterior chamber. Transciliary filtration creates an opening in the region of the pars plana of the ciliary body, the least vascularized part of the uveal tract and very close to the site of aqueous formation.
An opening in this region provides almost direct passage outwards without risking uveal tissue prolapse. Currently, the literature is limited to case series reports by the same author on the technical feasibility of the procedure Singh et al, , , However, the manufacturer was not required to submit to the FDA the evidence of efficacy that is necessary to support a premarket approval application PMA.
The Fugo Blade utilizes plasma energy surrounding a thin, blunt ablation filament about as thick as a human hair to dissolve tissue bonds. The blade generates a cloud of plasma, which produces a microablation path comparable to the effect of a miniature excimer laser. The proposed benefit of the Fugo Blade is that there is very little bleeding, and compared with traditional trabeculectomy, Fugo Blade TCF is quicker to perform and eliminates the risk of anterior chamber collapse, since aqueous fluid drains from behind rather than from in front of the iris.
However, at the present time, there is insufficient evidence in the peer-reviewed medical literature on the TCF procedure. An AAO's technology assessment on "Novel glaucoma procedures" Francis et al, noted that the disadvantages of FUGO Blade TCF are that it is an external filtration procedure with bleb formation, risk of over-filtration, and hypotony.
Trabectome is the name of the device and procedure during which a strip of tissue along the edge of the iris is removed in an attempt to reestablish normal pressure and drainage in affected eyes. In a retrospective, cohort study, Jea and colleagues compared the effect of ab interno trabeculectomy with trabeculectomy.
A total of patients who underwent ab interno trabeculectomy study group were compared with patients who underwent trabeculectomy with intra-operative mitomycin as an initial surgical procedure trabeculectomy group.
Inclusion criteria were open-angle glaucoma, aged greater than or equal to 40 years, and uncontrolled on maximally tolerated medical therapy. Exclusion criterion was concurrent surgery. Clinical variables were collected from patient medical records. Secondary outcome measures included number of glaucoma medications and occurrence of complications.
Mean follow-up was Intra-ocular pressure decreased from The success rates at 2 years were More additional glaucoma procedures were performed after ab interno trabeculectomy The authors concluded that ab interno trabeculectomy has a lower success rate than trabeculectomy.
In a retrospective, non-comparative cases-series study, Grover et al introduced a minimally invasive, ab interno approach to a circumferential degree trabeculotomy and reported the preliminary results. A total of 85 eyes of 85 consecutive patients with uncontrolled OAG and underwent gonioscopy-assisted transluminal trabeculotomy GATT for whom there was at least 6 months of follow-up data were included in this analysis. These investigators performed retrospective chart review of patients who underwent GATT by 4 of the authors between October and October The surgery was performed in adults with various OAG.
Main outcome measures included IOP, glaucoma medications, visual acuity, and intra-operative as well as post-operative complications. Eighty-five patients with an age range of 24 to 88 years underwent GATT with at least 6 months of follow-up. In this group, the IOP decreased by In the secondary glaucoma group of 28 patients, IOP decreased by The cumulative proportion of failure at 1 year ranged from 0. The authors concluded that the preliminary results and safety profile for GATT, a minimally invasive circumferential trabeculotomy, are promising and at least equivalent to previously published results for ab externo trabeculotomy.
Bussel et al evaluated outcomes of ab interno trabeculectomy AIT with the trabectome following failed trabeculectomy. The meta-analysis used a random-effects model to achieve conservative estimates and assess statistical heterogeneity. The overall arithmetic mean baseline IOP for stand-alone Trabectome was The weighted mean IOP difference from baseline to study end-point was 9.
These new approaches to angle surgery have been demonstrated in preliminary case series to safely lower IOP in the mid-teens with far fewer complications than expected with trabeculectomy and without anti-fibrotics. Trabectome and iStent are relatively non-invasive, aim to improve access of aqueous to collector channels and do not preclude subsequent standard surgery. SOLX potentially offers an adjustable aqueous outflow from the anterior chamber into the suprachoroidal space.
The disadvantages of the SOLX gold shunt are the presence of a permanent implant in the anterior chamber and suprachoroidal space with the risk of erosion or exposure, and that the mechanism of action is not well-delineated. The databases were last searched on 24 October They included randomized controlled trials comparing trabeculectomy with beta radiation to trabeculectomy without beta radiation.
Data were pooled using a fixed-effect model. People who had trabeculectomy with beta irradiation had a lower risk of surgical failure compared to people who had trabeculectomy alone pooled risk ratio RR 0. Beta irradiation was associated with an increased risk of cataract RR 2. The authors concluded that trabeculectomy with beta irradiation has a lower risk of surgical failure compared to trabeculectomy alone.
Iridotomy, iridectomy or iridoplasty may be necessary for angle-closure glaucoma. Current guidelines AAO, describe the indication for laser peripheral iridoplasty in the treatment of acute angle closure crisis AACC when laser iridotomy is not possible or if the AACC cannot be medically broken. However, there is insufficient evidence for the use of laser peripheral iridoplasty in the nonacute setting. In a Cochrane review, Ng and colleagues evaluated the effectiveness of laser peripheral iridoplasty in the treatment of narrow angles i.
There were no date or language restrictions in the electronic searches for trials. These researchers included only RCTs in this review. They excluded studies that included only patients with acute presentations, using laser peripheral iridoplasty to break acute crisis. The trial reported laser peripheral iridoplasty as an adjunct to laser peripheral iridotomy compared to iridotomy alone. The study reported no superiority in using iridoplasty as an adjunct to iridotomy for IOP, number of medications or need for surgery.
The authors concluded that there is currently no strong evidence for laser peripheral iridoplasty's use in treating angle-closure. On behalf of the AAO, Francis and cooleagues reviewed the published literature and summarized clinically relevant information about novel, or emerging, surgical techniques for the treatment of open-angle glaucoma and described the devices and procedures in proper context of the appropriate patient population, theoretic effects, advantages, and disadvantages.
Literature searches of the PubMed and the Cochrane Library databases were conducted up to October with no date or language restrictions. These searches retrieved citations, of which 23 were deemed topically relevant and rated for quality of evidence by the panel methodologist. All of the devices studied showed a statistically significant reduction in IOP and, in some cases, glaucoma medication use. The success and failure definitions varied among studies, as did the calculated rates.
Various types and rates of complications were reported depending on the surgical technique. On the basis of the review of the literature and mechanism of action, the authors also summarized theoretic advantages and disadvantages of each surgery. The authors concluded that the novel glaucoma surgeries studied all show some promise as alternative treatments to lower IOP in the treatment of open-angle glaucoma. It is not possible to conclude whether these novel procedures are superior, equal to, or inferior to surgery such as trabeculectomy or to one another.
The studies provide the basis for future comparative or randomized trials of existing glaucoma surgical techniques and other novel procedures. CyPass Micro-Stent is a small drainage device inserted under goinioscopic view through a clear corneal incision using a retractable guidewire. Once in place, it is designed to directly connect the anterior chamber to the suprachoroidal space between the sclera and choroid to increase uveoscleral outflow, thereby purportedly decreasing IOP.
The device is inserted under goinioscopic view through a clear corneal incision into the suprachoroidal space and is proposed for use alone or at the time of cataract surgery. This is the first device approved for use in combination with cataract surgery to reduce IOP in adult patients with mild or moderate open-angle glaucoma and a cataract who are currently being treated with medication to reduce IOP. A total of 10 patients with secondary open-angle glaucoma traumatic, steroid, pseudoexfoliative, and pigmentary glaucoma of recent onset who underwent ab interno implantation iStent were included in this analysis.
Patients were assessed following the procedure on days 1, 7, and 15 and months 1, 3, 6, and 12, and examinations included visual acuity, IOP measurement using Goldmann tonometry, number of glaucoma medications, and complications. Wilcoxon rank-test for data with abnormal distribution was used for the analysis of IOP and glaucoma medications at baseline versus 3, 6, and 12 months following the procedure.
The mean baseline IOP was The mean number of hypotensive medications at baseline was 2. Statistically significant reductions in the number of medications of 1. No significant changes in visual acuity were noted.
The most common complications comprised mild hyphema in 7 eyes and transient IOP greater than or equal to 30 mm Hg in 3 eyes on post-operative day 1. Obstruction of the lumen of the stent with a blood clot was seen in 3 eyes, and all instances resolved spontaneously.
The authors concluded that the iStent is a safe and effective treatment option in patients with secondary open-angle glaucoma, and reduces the topical treatment burden in one hypotensive medication.
Francis and Winarko stated that in POAG, the site of greatest resistance to aqueous outflow is thought to be the trabecular meshwork. Augmentation of the conventional trabecular outflow pathway would facilitate physiologic outflow and subsequently lower IOP. Ab interno Schlemm's canal surgery including 2 novel surgical modalities, Trabectome trabeculotomy internal approach and Trabecular Micro-bypass Stent iStent , is designed to reduce IOP by this approach.
In contrast to external filtration surgeries such as trabeculectomy and aqueous tube shunt, these procedures are categorized as internal filtration surgeries and are both performed from an internal approach via gonioscopic guidance. Published results suggest that these surgical procedures are both safe and efficacious for the treatment of open-angle glaucoma. Augustinus and Zeyen reviewed the different aspects that influence the choice and sequence of surgical treatment in patients with co-existing open-angle glaucoma and cataract.
The effect of phaco-emulsification on IOP and on a pre-existing bleb was discussed and phaco-trabeculectomy and trabeculectomy were compared. Moreover, the most recent surgical pressure lowering techniques in combination with phaco-emulsification were reviewed: Medline database was used to search for relevant, recent articles.
The authors concluded that a sustained IOP decrease of 1. The higher the pre-operative pressure, the greater the IOP lowering will be. A phaco-emulsification on a trabeculectomized eye will often lead to reduced bleb function and an IOP rise of on average 2 mm Hg after 12 months. Compared to a trabeculectomy, phaco-trabeculectomy will have a less IOP lowering effect and a higher complication rate.
The combination of Cypass and Hydrus with phaco-surgery may have a more significant IOP lowering effect but long-term results are not yet published. Combining Canaloplasty with phaco-emulsification is a more challenging surgery but if a tension suture can be placed, an IOP decrease around 10 mm Hg might be expected. In a prospective, non-comparative, uncontrolled, non-randomized, interventional case series study, Arriola-Villalobos and associates evaluated the long-term safety and effectiveness of combined cataract surgery and Glaukos iStent implantation for co-existent open-angle glaucoma and cataract.
Subjects older than 18 years with co-existent uncontrolled mild or moderate open-angle glaucoma including pseudoexfoliative and pigmentary and cataract underwent phaco-emulsification and intra-ocular lens implantation along with ab-interno gonioscopically guided implantation of 1 Glaukos iStent. The variables recorded during a minimum of 3 years of follow-up were: Mean IOP was reduced from The mean number of pressure-lowering medications used by the patients fell from 1.
Mean BCVA significantly improved from 0. No complications of surgery were observed. The authors concluded that combined cataract surgery and Glaukos iStent implantation seems to be an effective and safe procedure to treat co-existent open-angle glaucoma and cataract. In a prospective randomized controlled multi-center 29 sites clinical trial, Craven et al evaluated the long-term safety and effectiveness of a single trabecular micro-bypass stent with concomitant cataract surgery versus cataract surgery alone for mild-to-moderate open-angle glaucoma.
Eyes with mild-to-moderate glaucoma with an unmedicated IOP of 22 mm Hg or higher and 36 mm Hg or lower were randomly assigned to have cataract surgery with iStent trabecular micro-bypass stent implantation stent group or cataract surgery alone control group. Patients were followed for 24 months post-operatively. The incidence of adverse events was low in both groups through 24 months of follow-up.
Overall, the mean IOP was stable between 12 months and 24 months Ocular hypotensive medication was statistically significantly lower in the stent group at 12 months; it was also lower at 24 months, although the difference was no longer statistically significant. The authors concluded that patients with combined single trabecular micro-bypass stent and cataract surgery had significantly better IOP control on no medication through 24 months than patients having cataract surgery alone.
Both groups had a similar favorable long-term safety profile. Drug-eluting punctual plugs made of resorbable material are inserted into the lacrimal punctum tear duct and purportedly emit sustained release medications for a 30 - 60 day period until degrading and exiting via the nasolacrimal system.
These devices are currently being studied but have not received FDA approval. Ocular Therapeutics is currently conducting clinical trials regarding the insertion of a drug-eluting implant, including punctual dilation and implant removal when performed, into the lacrimal canaliculus. The clinical trials are investigating the use of dexamethasone intracanalicular plugs for the treatment of post-operative inflammation and pain and travoprost intracanalicular plugs for reduction of intraocular pressure in patients with glaucoma or ocular hypertension.
Ocular Therapeutix recently announced that the American Medical Association AMA approved a Category III CPT code for the insertion of a drug-eluting implant which could be used in clinical trials to establish use and provide a mechanism for reimbursement for insertion of these intracanalicular plugs following FDA approval.
Munoz-Negrete et al evaluated the safety and effectiveness of non-penetrating deep sclerectomy NPDS in 3 consecutive eyes with pre-existing and uncontrolled glaucoma after Descemet stripping with automated endothelial keratoplasty DSAEK.
Non-penetrating deep sclerectomy with intra-scleral implant and topical adjunctive intra-operative mitomycin C 0. Intra-ocular pressure and number of glaucoma medication were registered before and after NPDS with at least 1-year follow-up. Intra-operative and post-operative complications were also registered. Four anti-glaucoma drugs were used in 2 cases and 3 in the other one.
Two patients required post-operative anti-glaucoma medications 1 drug in 1 case and 2 drugs in the other one. Neodymium-doped yttrium aluminum garnet laser goniopuncture was needed in 2 patients and it had to be repeated in 1 of them. No complications related to NPDS were observed. A corneal graft rejection was observed 5 months after NPDS in 1 case that resolved without sequelae with intensive corticosteroid eye-drop therapy.
They stated that larger series and a longer follow-up would be needed to set the actual role of surgery in DSAEK patients. There are reports of the use of adjuncts before, during, or after surgery, such as beta irradiation and antimetabolites 5-fluorouracil and mitomycin C , to increase the rate of surgical success. There is great variation in use and choice of adjuncts worldwide, and adjuncts can be associated with a higher complication rate. Zhang and colleagues stated that cataract and glaucoma are leading causes of blindness worldwide, and their co-existence is common in elderly people.
Glaucoma surgery can accelerate cataract progression, and performing both surgeries may increase the rate of post-operative complications and compromise the success of either surgery. However, cataract surgery may independently lower intra-ocular pressure IOP , which may allow for greater IOP control among patients with co-existing cataract and glaucoma. The decision between undergoing combined glaucoma and cataract surgery versus cataract surgery alone is complex.
Therefore, it is important to compare the effectiveness of these 2 interventions to aid clinicians and patients in choosing the better treatment approach. In a Cochrane review, these investigators evaluated the relative safety and effectiveness of combined surgery versus cataract surgery phacoemulsification alone for co-existing cataract and glaucoma.
The secondary objectives included cost-analyses for different surgical techniques for co-existing cataract and glaucoma. They did not use any date or language restrictions in the electronic searches for trials. They last searched the electronic databases on October 3, They checked the reference lists of the included trials to identify further relevant trials. These researchers used the Science Citation Index to search for references to publications that cited the studies included in the review.
They also contacted investigators and experts in the field to identify additional trials. The authors included RCTs of participants who had open-angle, pseudoexfoliative, or pigmentary glaucoma and age-related cataract. The comparison of interest was combined cataract surgery phacoemulsification and any type of glaucoma surgery versus cataract surgery phacoemulsification alone.
Two review authors independently assessed study eligibility, collected data, and judged risk of bias for included studies. They used standard methodological procedures expected by the Cochrane Collaboration.
These investigators included 9 RCTs, with a total of participants eyes , and follow-up periods ranging from 12 to 30 months; 7 trials were conducted in Europe, 1 in Canada and South Africa, and 1 in the United States. These researchers graded the overall quality of the evidence as low due to observed inconsistency in study results, imprecision in effect estimates, and risks of bias in the included studies.
Glaucoma surgery type varied among the studies: All of these studies found a statistically significant greater decrease in mean IOP post-operatively in the combined surgery group compared with cataract surgery alone; the MD was No study reported the proportion of participants with a reduction in the number of medications used after surgery, but 2 studies found the mean number of medications used post-operatively at 1 year was about 1 less in the combined surgery group than the cataract surgery alone group MD None of the studies reported the mean change in visual acuity or visual fields.
However, 6 studies reported no significant differences in visual acuity and 2 studies reported no significant differences in visual fields between the 2 intervention groups post-operatively data not analyzable. The effect of combined surgery versus cataract surgery alone on the need for re-operation to control IOP at 1 year was uncertain RR 1.
Also uncertain was whether eyes in the combined surgery group required more interventions for surgical complications than those in the cataract surgery alone group RR 1. No study reported any vision-related quality of life data or cost outcome. Complications were reported at 12 months 2 studies , 12 to 18 months 1 study , and 2 years 4 studies after surgery.
Due to the small number of events reported across studies and treatment groups, the difference between groups was uncertain for all reported adverse events. The authors concluded that there is low quality evidence that combined cataract and glaucoma surgery may result in better IOP control at 1 year compared with cataract surgery alone.
The evidence was uncertain in terms of complications from the surgeries. Furthermore, this Cochrane review has highlighted the lack of data regarding important measures of the patient experience, such as visual field tests, quality of life measurements, and economic outcomes after surgery, and long-term outcomes 5 years or more.
They stated that additional high-quality RCTs measuring clinically meaningful and patient-important outcomes are needed to provide evidence to support treatment recommendations.
Saheb and Ahmed noted that there is an increasing interest and availability of micro-invasive glaucoma surgery MIGS procedures. It is important that this increase is supported by sound, peer-reviewed evidence.
These researchers defined MIGS, reviewed relevant publications in the period of annual review and discussed future directions. The results of the pivotal trial comparing iStent combined with phaco-emulsification to phacoemulsification alone showed a significantly higher percentage of patients with unmedicated IOP of less than or equal to 21 mm Hg, and a comparable safety profile.
A number of publications reviewed the importance of the location of implantable devices, intra-operative gonioscopy, cost-effectiveness and quality-of-life studies, and randomized clinical trials.
The authors concluded that MIGS procedures offer reduction in IOP, decrease in dependence on glaucoma medications and an excellent safety profile. Their role within the glaucoma treatment algorithm continues to be clarified and differs from the role of more invasive glaucoma surgeries such as trabeculectomy or glaucoma drainage devices.
Images were graded on a scale of 0 to 4 for morphological features indicative of fluid presence within, or drainage through, the SCS. A total of 35 patients underwent ab-interno micro-stent implantation. Mean age was Baseline mean IOP was The mean composite score for all features was 2. The majority of patients maintained aqueous fluid through 12 months. The authors concluded that OCT imaging provided adequate visualization of the angle, the SCS and aqueous fluid drainage after implantation of a suprachoroidal micro-stent into the SCS.
The drawbacks of this study included its retrospective nature and short-term follow-up 12 months. Furthermore, while standardized for the purposes of this study, the grading of OCT images did not follow a validated systematic approach due to the lack of such grading scales. The authors used the size of the micro-stent as a standard measure, since its size was consistent across all subjects and independent of OCT software or print-outs. The individual measuring the images was masked as to the post-operative time of the image, however, there may have been a bias toward larger measures when the micro-stent was fully visible.
Finally, images were not available for all subjects, with a gradual decrease in available images at later time-points. There could have been some selection bias in this study for imaging of patients with poorer post-operative outcomes. This bias needs to be considered as researchers evaluate the grades of the available images, especially at later time-points.
In a multi-center, prospective, consecutive case-series study, Hoh and co-workers evaluated through 2 post-operative years the clinical outcomes associated with a novel SCS micro-stent for the surgical treatment of OAG when implanted in conjunction with cataract surgery.
A total of subjects eyes with OAG and requiring cataract surgery with month post-operative data were included. A combined phacoemulsification procedure, with intra-ocular lens insertion and CyPass Micro-Stent implantation into the SCS of the study eye, was performed.
Glaucoma medications were stopped post-operatively, but could be re-started if needed, at the investigator's discretion. The micro-stent was successfully implanted in all eyes. At 24 months, 82 subjects remained in the study. No sight-threatening AEs occurred. The most common AEs were transient hypotony Subjects were enrolled beginning July , with study completion in March After completing cataract surgery, subjects were intra-operatively randomized to phacoemulsification only control or SCS micro-stenting with phacoemulsification micro-stent groups 1: Micro-stent implantation via an ab interno approach to the SCS allowed concomitant cataract and glaucoma surgery.