Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; initial
CPT4 code
Name of the Procedure:
Ophthalmoscopy, extended with retinal drawing (e.g., for retinal detachment, melanoma), with interpretation and report; initial. Also known as Fundoscopy.
Summary
Ophthalmoscopy is a diagnostic procedure used to examine the back of the eye, including the retina, optic disc, and blood vessels, in detail. An extended ophthalmoscopy involves a thorough inspection with detailed retinal drawings to diagnose conditions like retinal detachment or melanoma.
Purpose
This procedure is used to detect and diagnose retinal conditions such as retinal detachment, melanoma, diabetic retinopathy, macular degeneration, and other retinal abnormalities. The goal is to provide a comprehensive assessment that informs treatment decisions and management.
Indications
- Symptoms such as flashing lights, floaters, or vision loss.
- Suspected retinal detachment or other retinal conditions.
- Follow-up of pre-existing retinal conditions.
- Patients with high risk factors such as severe myopia or a family history of retinal disorders.
Preparation
- Generally, no fasting is required.
- Patients may be advised to avoid certain medications prior to the procedure.
- Eye drops to dilate the pupils will be administered before the examination.
- It is recommended to have someone accompany the patient, as their vision may be temporarily blurred due to the dilating drops.
Procedure Description
- The patient is seated, and eye drops are applied to dilate the pupils.
- A special ophthalmoscope, which may be a direct or indirect type, is used to examine the back of the eye.
- The ophthalmologist may shine a series of lights into the eye to get a better view of different areas.
- During an extended examination, detailed drawings of the retina are made to document findings.
- The procedure includes a comprehensive interpretation and a formal report of the findings.
Tools used:
- Direct ophthalmoscope.
- Indirect ophthalmoscope.
- Retinal drawing tools.
No anesthesia or sedation is typically required, although numbing drops might be used for comfort.
Duration
The procedure typically takes 20-40 minutes.
Setting
Ophthalmoscopy is performed in an ophthalmologist's office or an outpatient clinic.
Personnel
- Ophthalmologist
- Ophthalmic Technician or Nurse (for assistance and preparation)
Risks and Complications
- Temporary discomfort from the bright lights.
- Allergic reaction to the dilating drops.
- Temporary blurred vision.
- Very rare risk of increased intraocular pressure (glaucoma attack).
Benefits
- Accurate diagnosis of retinal conditions.
- Early detection of potentially sight-threatening diseases.
- Informed treatment planning and management.
Recovery
- Vision may be blurry for a few hours post-procedure due to pupil dilation.
- Patients should avoid driving until vision returns to normal.
- Follow-up visits may be scheduled based on findings.
Alternatives
- Fundus photography: Captures images of the retina but may not provide as detailed a view as ophthalmoscopy.
- Optical Coherence Tomography (OCT): A non-invasive imaging test that provides detailed cross-sections of the retina.
- Visual Field Testing: Evaluates the peripheral vision and may help in identifying retinal damage.
Patient Experience
During the procedure, the patient might see bright lights and may feel slight discomfort due to the light exposure. Post-procedure, there may be a temporary blurring of vision. Comfort measures such as numbing drops or dimming the room lights are often used to minimize discomfort.