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Findings of dilated macular or fundus exam communicated to the physician or other qualified health care professional managing the diabetes care (EC)

CPT4 code

Name of the Procedure:

Dilated Macular or Fundus Exam (Ophthalmic Exam)

Summary

A dilated macular or fundus exam is an eye examination where the pupils are dilated using special eye drops to allow an ophthalmologist or optometrist to view the back of the eye (the retina and macula). This procedure is crucial for detecting eye conditions related to diabetes and communicating findings to the healthcare professional managing the patient's diabetes care.

Purpose

This exam helps to identify and monitor eye conditions related to diabetes, such as diabetic retinopathy. The goals are to catch any issues early, prevent vision loss, and manage complications effectively.

Indications

  • Patients with diabetes (Type 1 or Type 2)
  • Symptoms like blurred vision, floaters, or sudden vision changes
  • Routine annual screening for diabetic patients

Preparation

  • Patients should bring a list of current medications.
  • Wear sunglasses to the appointment, as the dilation may cause light sensitivity.
  • Arrange transportation, as vision may be temporarily impaired.

Procedure Description

  1. The patient receives eye drops to dilate the pupils.
  2. After about 15-30 minutes, the pupils are fully dilated.
  3. The healthcare professional examines the back of the eye using a special magnifying lens and a bright light.
  4. Detailed images or scans may be taken for further evaluation.

Duration

Approximately 1-2 hours, including the time for pupil dilation and the examination itself.

Setting

Outpatient clinic or ophthalmology office.

Personnel

  • Ophthalmologist or optometrist

Risks and Complications

  • Temporary blurred vision and light sensitivity
  • Rare risk of increased eye pressure
  • Possible allergic reactions to dilating drops

Benefits

  • Early detection of diabetic eye disease
  • Prevention of vision loss through timely management
  • Improved diabetes management through comprehensive care

Recovery

  • Vision may be blurred for a few hours post-exam.
  • Avoid driving until vision returns to normal.
  • Follow-up appointments may be scheduled based on findings.

Alternatives

  • Undilated eye exams, though less thorough.
  • Regular monitoring of blood sugar levels and routine check-ups with a diabetic care team.
  • Use of advanced imaging technology without dilation, though it's less common.

Patient Experience

Patients may feel mild discomfort from the eye drops and experience temporary blurred vision and light sensitivity. Pain is minimal, and the healthcare professional will provide comfort measures as needed.

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