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Low risk for retinopathy (no evidence of retinopathy in the prior year) (DM)
CPT4 code
Name of the Procedure:
Annual Diabetic Eye Exam (Retinopathy Screening)
Summary
This is a routine examination conducted yearly for patients with diabetes to check for any signs of retinopathy—a common complication of diabetes that affects the eyes. The procedure involves a detailed examination of the retina by an eye specialist.
Purpose
To detect early signs of diabetic retinopathy or other eye-related complications in diabetic patients. The goal is to manage and treat any potential issues promptly to prevent vision loss and maintain overall eye health.
Indications
- Patients diagnosed with diabetes (both Type 1 and Type 2).
- Individuals who have had diabetes for more than 5 years.
- Patients experiencing visual changes or abnormalities.
Preparation
- No specific preparation required.
- Patients may need to remove contact lenses or eyeglasses.
- Pupils may be dilated using eye drops to allow for a thorough examination of the retina.
Procedure Description
- Visual Acuity Test: Checks how well you can see using an eye chart.
- Pupil Dilation: Eye drops are administered to dilate the pupils.
- Fundoscopic Exam: Using an ophthalmoscope, the doctor examines the retina for any signs of retinopathy.
- Optical Coherence Tomography (OCT) (if needed): Advanced imaging to get detailed cross-sections of the retina.
- Fluorescein Angiography (if needed): Injection of a dye followed by photographing the retina to detect leaking blood vessels.
Duration
Approximately 30–60 minutes.
Setting
Outpatient clinic or optometrist/ophthalmologist’s office.
Personnel
- Optometrist or Ophthalmologist
- Ophthalmic technician or nurse (to assist with pupil dilation and testing)
Risks and Complications
- Slight discomfort from the bright lights.
- Temporary blurred vision due to pupil dilation.
- Rare allergic reaction to the dilating drops.
Benefits
- Timely detection of diabetic retinopathy and other eye conditions.
- Preventive care to avoid severe vision loss.
- Provides a baseline for future eye health comparisons.
Recovery
- Temporary sensitivity to light and blurred vision due to pupil dilation (several hours).
- No significant downtime; normal activities can typically be resumed immediately after the exam.
- Follow-up appointment as advised by the doctor if any abnormalities are found.
Alternatives
- Regular visits with a primary care doctor for diabetes management and monitoring without specialized eye exams. However, this is not recommended as it may miss early signs of retinopathy.
Patient Experience
- Minimal discomfort during the exam.
- Pupil dilation causes temporary light sensitivity and blurred vision; sunglasses are recommended.
- Eye comfort measures and rest are suggested post-exam if needed.
We hope this information helps you understand the annual diabetic eye exam and its importance for maintaining ocular health.