Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; subsequent
CPT4 code
Name of the Procedure:
Ophthalmoscopy, extended, with retinal drawing (e.g., for retinal detachment, melanoma), with interpretation and report; subsequent. Commonly referred to as a detailed eye exam or extended ophthalmoscopy.
Summary
Ophthalmoscopy is a thorough examination of the retina and the back of the eye using a special instrument called an ophthalmoscope. This detailed version includes a retinal drawing to visually document any abnormalities such as retinal detachment or melanoma, followed by a professional interpretation and report.
Purpose
The primary purpose of this procedure is to diagnose and monitor diseases or conditions affecting the retina, such as retinal detachment or ocular melanoma. The goal is to visually document the state of the retina, detect any changes or abnormalities early, and formulate an appropriate treatment plan based on the findings.
Indications
- Symptoms like flashes of light, sudden vision loss, or areas of darkness in vision.
- Known or suspected retinal conditions such as retinal detachment or melanoma.
- Follow-up examination for patients with a history of retinal issues or treatments affecting the retina.
Preparation
- Patients may need to avoid driving afterward due to the use of dilating eye drops.
- Inform the doctor of any medications being taken, as certain drugs can affect eye pressure.
- No fasting or specific pre-procedure tests are generally required, but a comprehensive eye history and possibly a visual acuity test may be conducted.
Procedure Description
- The patient is seated comfortably, and eye drops are administered to dilate the pupils.
- The ophthalmologist uses an ophthalmoscope to shine a light into the eye, allowing a clear view of the retina.
- A detailed drawing of the retina is made, documenting any abnormalities such as tears, detachments, or suspicious lesions.
- The findings are interpreted, and a report is generated explaining the condition of the retina.
Tools/Equipment:
- Ophthalmoscope
- Retinal drawing tools (may involve digital imaging)
Anesthesia/Sedation:
- Typically, no anesthesia is required; the procedure is non-invasive.
Duration
The procedure usually takes about 30 to 45 minutes.
Setting
The procedure is typically performed in an outpatient clinic or an eye specialist's office.
Personnel
- Ophthalmologist (eye specialist conducting the procedure)
- Ophthalmic technician or nurse (assisting with preparation and documentation)
Risks and Complications
- Temporary discomfort or light sensitivity due to pupil dilation.
- Rarely, allergic reaction to the dilating drops.
- Rare risk of increasing intraocular pressure in susceptible individuals.
Benefits
- Early detection and monitoring of retinal conditions, potentially preventing vision loss.
- Accurate documentation of the retinal status to guide treatment decisions.
- Non-invasive method with minimal discomfort.
Recovery
- Patients may experience blurred vision and light sensitivity for a few hours post-procedure.
- Sunglasses are recommended to protect from bright light.
- Normal activities can typically be resumed soon after, with the avoidance of driving until vision clears.
Alternatives
- Standard ophthalmoscopy (without extended documentation).
- Optical coherence tomography (OCT) for detailed imaging of retinal layers.
- Fundus photography for capturing color images of the retina.
Patient Experience
During the procedure, patients might feel slight discomfort from the bright light of the ophthalmoscope. Post-procedure, there can be temporary blurred vision and light sensitivity. Comfort measures include the use of sunglasses and resting the eyes.