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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

  1. Visual Acuity Test: Checks how well you can see using an eye chart.
  2. Pupil Dilation: Eye drops are administered to dilate the pupils.
  3. Fundoscopic Exam: Using an ophthalmoscope, the doctor examines the retina for any signs of retinopathy.
  4. Optical Coherence Tomography (OCT) (if needed): Advanced imaging to get detailed cross-sections of the retina.
  5. 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.

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