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Ophthalmoscopy, extended; with drawing of optic nerve or macula (eg, for glaucoma, macular pathology, tumor) with interpretation and report, unilateral or bilateral

CPT4 code

Name of the Procedure:

Ophthalmoscopy, Extended with Drawing of Optic Nerve or Macula; also known as Funduscopy, for conditions such as glaucoma, macular pathology, or ocular tumors.

Summary

Ophthalmoscopy is a detailed eye examination where the ophthalmologist examines the back part of the eye, including the retina, optic disc, and macula, often drawing images for diagnostic purposes. The procedure helps in diagnosing various eye conditions and diseases.

Purpose

Ophthalmoscopy aims to diagnose and monitor eye conditions like glaucoma, macular degeneration, and ocular tumors. It provides crucial information about the health of the optic nerve and retinal structures.

Indications

  • Symptoms such as vision changes, eye pain, or visual field loss
  • Diagnosed conditions like glaucoma or macular degeneration
  • Monitoring the progression of known ocular diseases
  • Suspected ocular tumors

Preparation

  • No special fasting required
  • Patients may need to stop wearing contact lenses beforehand
  • Eye drops may be administered to dilate the pupils

Procedure Description

  1. The patient sits in a darkened room.
  2. The ophthalmologist uses an ophthalmoscope, a handheld device with a light, to examine the inside of the eye.
  3. Pupil dilation using eye drops ensures a better view.
  4. A detailed drawing of the optic nerve or macula is created for documentation.
  5. The ophthalmologist interprets the findings and formulates a report.

Duration

The procedure typically takes about 30-45 minutes.

Setting

The procedure is usually performed in an ophthalmologist's office or an outpatient clinic.

Personnel

  • Ophthalmologist
  • Medical assistant or nurse (for administering eye drops and supporting tasks)

Risks and Complications

  • Slight discomfort from bright lights
  • Temporary blurred vision from pupil dilation
  • Rare risk of allergic reaction to eye drops
  • Very rare risk of an increase in eye pressure

Benefits

  • Early and accurate diagnosis of serious eye conditions
  • Monitoring disease progression
  • Tailored treatment plans based on detailed observation

Recovery

  • Temporary sensitivity to light and blurred vision due to pupil dilation
  • Patients typically recover fully within a few hours
  • Follow-up depends on findings and overall treatment plan

Alternatives

  • Basic ophthalmoscopy (less detailed)
  • Optical coherence tomography (OCT)
  • Fundus photography

Patient Experience

Patients may experience mild discomfort from bright lights and temporary blurred vision. Proper pain management includes being informed about potential sensitivity to light and avoiding activities like driving until vision normalizes.

Medical Policies and Guidelines for Ophthalmoscopy, extended; with drawing of optic nerve or macula (eg, for glaucoma, macular pathology, tumor) with interpretation and report, unilateral or bilateral

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