Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy (DM)
CPT4 code
Name of the Procedure:
Dilated Retinal Eye Exam (Dilation with Fundus Examination, Fundoscopy)
Summary
A dilated retinal eye exam is a diagnostic procedure where an ophthalmologist or optometrist uses special eye drops to widen (dilate) the pupil. This allows for a thorough examination of the retina, optic nerve, and other internal structures of the eye to check for signs of retinopathy, especially in diabetic patients.
Purpose
The procedure is primarily used to detect and evaluate retinopathy, a common complication of diabetes that can lead to vision impairment and blindness if left untreated. The goal is to identify any signs of retinal damage early so that appropriate treatment can be started to prevent or manage vision loss.
Indications
- Diabetes mellitus (DM) patients, particularly those who have had diabetes for several years.
- Symptoms such as blurred vision, floaters, or visual disturbances.
- Routine diabetic eye check-ups.
- Patients with a family history of retinal diseases.
Preparation
- The patient is advised not to drive immediately after the exam, as vision may be temporarily blurred due to dilation.
- No fasting or medication adjustments are typically required.
- Patients should remove any contact lenses before the procedure.
- Bring sunglasses for comfort after the exam as eyesight might be sensitive to light.
Procedure Description
- Eye drops are administered to dilate the pupils, which takes about 15-30 minutes to take effect.
- The ophthalmologist or optometrist uses a slit-lamp microscope and an ophthalmoscope to examine the retina and optic nerve.
- High-resolution photographs or a retinal scan may be taken to document the condition of the retina.
- The procedure is painless, though the patient may experience temporary discomfort due to bright lights.
Duration
The entire exam typically takes about 30 to 60 minutes, including the time needed for pupil dilation.
Setting
The procedure is performed in an outpatient clinic or an eye specialist's office.
Personnel
- Ophthalmologist or Optometrist (Examiner)
- Ophthalmic Technician or Assistant (Support)
Risks and Complications
- Temporary blurred vision.
- Increased light sensitivity.
- Rare allergic reaction to the dilating drops.
- Increased intraocular pressure in very rare cases.
Benefits
- Early detection and management of retinopathy.
- Preventing progression of vision impairment.
- Providing a comprehensive understanding of the retinal health, which is crucial for diabetic patients. Improvements in vision health and proactive management of potential complications.
Recovery
- Vision typically returns to normal within a few hours.
- Sunglasses may help with light sensitivity.
- Follow-up appointments as needed based on findings.
Alternatives
- Non-dilated eye examinations, which do not provide as thorough a view of the retina.
- Optical coherence tomography (OCT), which can be used alongside or in lieu of dilation for certain examinations.
- Fluorescein angiography, another detailed diagnostic test for evaluating retinal blood vessels but more invasive and costly.
- Pros and cons: Non-dilated exams and OCT are less invasive but may not be as comprehensive.
Patient Experience
During the procedure, patients might feel a brief sting when the drops are applied. Bright lights might cause temporary discomfort. Post-procedure, expect some blurriness and light sensitivity, which generally resolves within a few hours. Comfort measures include resting in a dimly lit area and wearing sunglasses.