Preoperative assessment of functional or medical indication(s) for surgery prior to the cataract surgery with intraocular lens placement (must be performed within 12 months prior to cataract surgery) (EC)
CPT4 code
Name of the Procedure:
Preoperative Assessment of Functional or Medical Indications for Surgery Prior to Cataract Surgery with Intraocular Lens Placement
Summary
A preoperative assessment conducted within 12 months before cataract surgery to evaluate a patient's overall health and specific surgical needs, ensuring they are fit for the procedure.
Purpose
This evaluation addresses the need to ensure patients are medically fit for cataract surgery, aiming to identify any potential risks or complications. The primary goal is to optimize patient outcomes and increase the success rates of cataract surgery with intraocular lens placement.
Indications
- Decreased visual acuity affecting daily activities
- Diagnosis of cataracts with significant opacification of the lens
- Patients aged 18 or older who are candidates for intraocular lens implantation
Preparation
- Fasting may be required for certain blood tests.
- Stop or adjust certain medications as advised by the healthcare provider.
- Undergo diagnostic tests such as blood work, ECG, and a comprehensive eye examination.
- Provide a complete medical history, including current medications and previous surgeries.
Procedure Description
- Initial Consultation: Review of medical history and current medications.
- Physical Examination: General health assessment and specific eye examination.
- Diagnostic Tests: May include blood tests, ECG, chest X-ray, and imaging of the eyes.
- Evaluating Surgical Risks: Assessing the patient’s ability to tolerate anesthesia and surgery.
- Comprehensive Eye Examination: Refraction tests, slit-lamp exam, and measuring the intraocular pressure.
Tools and equipment used may include:
- Ophthalmoscope
- Slit-lamp
- Visual acuity charts
- Blood testing kits
Typically, no anesthesia or sedation is required for the preoperative assessment itself.
Duration
The preoperative assessment usually takes between 1 to 2 hours, depending on the extent of tests and consultations needed.
Setting
The procedure is performed in an outpatient clinic or an ophthalmologist’s office.
Personnel
- Ophthalmologist
- Nurse or medical assistant
- Lab technicians (for blood work and ECG)
Risks and Complications
- Mild discomfort from blood draws or ocular pressure tests
- Rare risk of allergic reaction to diagnostic dyes used in imaging
- Potential for discovering underlying health issues that may delay surgery
Benefits
- Ensures patient safety by identifying and mitigating potential surgical risks.
- Optimizes surgical outcomes by thoroughly preparing the patient.
- Provides a clear understanding of the patient's health status relative to the upcoming cataract surgery.
Recovery
- No significant recovery period is required post-assessment.
- Patients may resume normal activities immediately unless advised otherwise.
- Follow-up consultations as needed based on findings from the assessments.
Alternatives
While the preoperative assessment is critical, alternatives include:
- Opting for non-surgical vision correction methods.
Delaying surgery if non-surgical interventions can temporarily improve vision.
The main advantage of preoperative assessment is minimizing risk, while alternatives might not provide a comprehensive overview of the patient’s readiness for surgery.
Patient Experience
Patients might experience some anxiety about tests or potential findings. Minimal physical discomfort is possible, mainly from blood draws or ocular tests. Medical staff will provide pain management and comfort measures as needed.