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A penetrating keratoplasty procedure is carried out to replace the host cornea with a donor
cornea. The cornea is the clear, dome-shaped tissue covering the front of the eye. It is
kept moist and nourished by a thin layer of tears. It is kept smooth by the blinking of the
eyelids. The patient will experience decreased visual acuity if the cornea becomes
distorted in shape, scarred, or hazy (opaque) as a result of disease or injury. When this
happens a cornea transplant (penetrating keratoplasty) may become necessary to replace
the diseased or injured cornea with a healthy, clear cornea.
In the penetrating keratoplasty, the cornea is removed and replaced by a human donor
cornea called a graft. The diseased cornea is the recipient eye because it receives the graft
and the other person’s cornea is the donor cornea. An eye bank usually provides the
donor tissue for the penetrating keratoplasty. The corneas are usually obtained from
individuals who opted to give from deceased individuals who arranged for donation prior
to death or whose families gave permission.
The normal cornea does not contain blood vessels; which is thought to help the body not
recognize the foreign donor cornea. Race, sex, blood type, eye color, and near-and
farsightedness are not considered relevant in the selection of a cornea; because they do not
affect the outcome of the penetrating keratoplasty. Under normal conditions the
penetrating keratoplasty is performed on an outpatient basis under local anesthesia; but
can be performed in an inpatient setting using general anesthesia. The surgeon can use a
microscope during the performance of the procedure. A trephine is used to cut and
remove a piece from the donor cornea.
When only the front part of the corneal thickness is transplanted, it is called anterior
lamellar keratoplasty. When the back part is transplanted, it is called endothelial
keratoplasty. Some variations of the endothelial keratoplasty include: 1) DLEK (deep
lamellar endothelial keratoplasty; and 2) DSEK (Descemet’s stripping endothelial
keratoplasty).
Video of Penetrating Keratoplasty
PENETRATING KERATOPLASTY
WHAT TO EXPECT
1 Penetrating Keratoplasty
2 Diagnoses Associated with
a Keratoplasty?
3 Operation in Detail
4 Requests for Coding Topics
August 2015
Volume 2 Issue 8
By Cynthia Brown, MBA, RHIT, CCS
Gain Knowledge of Medical Coding Through E-Learning
CCHIS, P.O. Box 3019, Decatur, GA 30031 404-992-8984 Gain Knowledge of Medical Coding Through E -Learning Cynth ia@cyntcodinghealthinformat ionserv ices.com [phone]
CODING YESTERDAY’S NOMENCLATURE TODAY®
Coding of a Penetrating Keratoplasty
CODING NEWSLETTER FOR HEALTHCARE
CODING PROFESSIONALS
Page 2 Coding Yesterday’s Nomenclature Today
The coder should look for the following documented diagnoses:
Diagnosis ICD-9 CM ICD-10 CM Pseudophakic bullous cornea
edema (keratopathy) or
Aphakic bullous cornea edema
(keratopathy)
371.23 H18.10-.13
Fuchs endothelial dystrophy 371.57 H18.51
Other endothelial dystrophies 371.57 H18.50; H18.52-.59
Ectasia cornea 371.71 H18.711-.719
Keratoconus 371.60 371.61
371.62
H18.601-.609 K18.611-.619
H18.621-.629
Corneal degenerations 371.40-.49 H18.411-.419
H18.421-.429 H18.43
H18.441-.449
H18.451-.451 H18.461-.469
H18.49
Noninfectious ulcerative
keratitis
370.00 H16.001-.009
Other Indications:
Viral Keratitis (Code first underlying condition)
Microbial Keratitis (Code first underlying condition)
Post-infectious Keratitis
Congenital Opacities
Chemical Injuries
Mechanical Trauma
Retractive Indications
Re-graft related to allograft rejection
Re-graft unrelated to allograft rejection
The coder should also look for conditions documented as complications.
Intraoperative Complications:
Poor graft centration
Irregular trephination
Damage to lens
Damage to the donor tissue
Choroidal hemorrhage and effusion
Incarceration of iris tissue in the wound
Vitreous in the anterior chest
Postoperative Complications:
Glaucoma
Endopthalmitis
Primary Endothelial Failure
Persistent Epithelial Defect
Late Failure
Recurrency of primary disease
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371.57 (ICD-9) H81.51 (ICD-10)
Signs of Graft rejection: Redness, Sensitivity to light, Vision changes, and
Pain
Diagnoses Associated with a Keratoplasty?
Coding Yesterday’s Nomenclature Today
Operation in Detail After informed consent was obtained, the patient was brought to the operating room and laid on the table in the
supine position. The patient was then administered general anesthesia by the anesthesia service and was intubated.
The patient was then prepped and draped in the usual sterile fashion for surgery on the right eye. A Schott lid
speculum was inserted. The patient's corneal diameter was measured with a corneal caliber and found to be 12.3 mm horizontally by 11.8 mm vertically. There was significant corneal ectasia with central sub-epithelial and
stromal scarring. Healon and a corneal shield were placed on the cornea. A scleral fixation ring was chosen and
sutured with eight interrupted 5-0 Dacron sutures, with partial thickness scleral bites. The cornea was examined again, and the optical axis was marked with a sterile marking pen and the tips of a forceps. The patient's pupil was
noted to be slightly nasal. The host cornea was marked by applying brief gentle pressure with an 8.0 mm trephine.
The mark was repositioned until satisfactory centering was achieved. A 12-prong radial marker was marked with a sterile marker, and the cornea was marked to assist in donor-host suture symmetry and alignment. The donor
cornea was trephined with an 8.0 mm trephine after being placed in a donor corneal punch that had been marked
with a marker in the punch holes. The cornea was placed in the punch endothelial side up. The donor rim was sent for culture on a culture plate. The donor button was covered with Healon and OptiSeal and placed aside. Next, the
host cornea was trephined with an 8.0 mm trephine until the anterior chamber was entered. Miochol was injected
through the initial opening to constrict the pupil and protect the lens. The edge of the trephine recipient cornea was lifted with an ionized and 0.12 forceps and corneal scissors were used to excise the recipient button, leaving a
slightly beveled edge. The cornea was noted to be extremely floppy, indicating a very thick cornea. Vannas
scissors were used to trim a tag of remaining tissue superonasally. The anterior chamber, remaining recipient corneal rim and sclera out to the fixation ring were coated with Healon. The donor tissue was lifted from the
corneal punch with a spatula and transferred onto the recipient bed atop the viscoelastic. The four interrupted 10-0
nylon cardinal sutures were placed first. These were left intentionally loose. Twelve additional radial interrupted 10-0 nylon sutures were placed snugly. Care was taken to pass sutures approximately 50% depth in the donor
stroma and 90% depth into the host tissue. The cardinal sutures were found to be torqued, as expected, once the
remaining sutures had been placed. They were cut and replaced with the proper tension. Several temporal sutures were tightened as well, as the patient's keratoconus required this adjustment. Slight override of the donor tissue
was noted at the 2 o'clock position; therefore, an additional 10-0 interrupted suture was placed at that point. A
plastic ring was then used to check for astigmatism, and slight against-the-rule astigmatism was detected, as the ring reflex was seen to be ovalized vertically and slightly inferonasally. Two inferonasal sutures were placed,
making them tighter, and the ring was again used to check for astigmatism. This time, the reflex was nearly
perfectly circular. The wound was closed with additional 10-0 nylon running suture with 90% stromal depth radial bites, with a knot buried at the 9 o'clock position on the donor side. The running suture tension was evenly
distributed by adjusting the tension of each bite with tying forceps. The interrupted suture knots were buried on
the donor side. The anterior chamber was reformed with BSS on a 30-gauge cannula, irrigating all of the Healon from the eye. An intracameral injection of vancomycin 10 mg/mL was given. The wound was checked with a
Weck-Cel sponge and fluorescein strip for leaks. There was a micro leak at the 4 o'clock position, and an
additional 10-0 nylon interrupted suture was used to close this. At the end of the procedure, the wound was Seidel negative. The donor cornea was noted to be edematous throughout the case. The entire epithelial surface was
absent. The endothelial cell count, however, was good when the tissue was accepted, and it is anticipated that the edema will resolve with time. The scleral ring was removed and the lid speculum was also removed. The drapes
were gently removed. Multiple drops of topical anesthetic were instilled into the eye. A drop of Alphagan and a
drop of Timoptic 0.5% ophthalmic solutions were used, as well as Polysporin ophthalmic ointment. Wet and dry sponges were used to clean the eye. A piece of 1 inch Transpore tape was used to close the eyelid. Next, a light
eye patch was taped in place and covered with a metal eye shield. The patient was extubated without
complications and taken to the PACU in good condition.
ICD-9 PCS: 11.64 ICD-10 PCS: 08R83KZ
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Penetrating Keratoplasty
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