Name of the Procedure:

Dilated Macular or Fundus Exam Not Performed
Common Name(s): Eye Exam Not Done, Fundus Exam Not Conducted
Technical/Medical Term: G8398

Summary

This record indicates that a dilated macular or fundus exam, which is a detailed eye examination of the retina and macula, was not performed during the patient’s visit.

Purpose

The dilated macular or fundus exam is used to diagnose and manage various eye conditions such as macular degeneration, diabetic retinopathy, and glaucoma. In this case, the purpose is to document that this specific exam was not done. The expected outcome for documentation purposes is accurate medical records.

Indications

• Patient encounters for routine eye check-ups where this exam is optional.
• Situations where the patient declines the exam.
• Contraindications due to patient-specific clinical factors.
• For documentation of quality measures in a healthcare setting.

Preparation

Since this text indicates the procedure was not performed, no preparation is necessary for the unperformed procedure. In a typical setting, patient preparation might include avoiding driving immediately after the exam due to dilated pupils.

Procedure Description

A dilated macular or fundus exam typically involves:

1. Administering eye drops to dilate the pupils.
2. Using special instruments like an ophthalmoscope to examine the retina and macula in detail.
3. Possibly taking photographs or imaging scans of the eye.

Tools: Ophthalmoscope, slit-lamp biomicroscope.
Anesthesia or Sedation: Not applicable.

Duration

A typical dilated macular or fundus exam lasts about 20-30 minutes. Since this document indicates the exam was not performed, no duration is attributed.

Setting

Such exams are usually performed in an ophthalmologist's office, an outpatient clinic, or an eye care center.

Personnel

• Ophthalmologist or Optometrist.
• Ophthalmic Technician or Assistant.

Risks and Complications

For the unperformed procedure:

• No medical risks or complications since the exam was not performed.

Benefits

Expected benefits of documenting the absence of the procedure:

• Maintaining accurate patient records.
• Clarity in medical documentation for future reference.

Recovery

For the unperformed procedure:

• No recovery is necessary. For a typical exam: Patients might experience blurry vision due to dilated pupils, which can last for a few hours.

Alternatives

Other examinations or non-invasive imaging techniques might be used to assess the retina and macula without dilation. Pros and Cons depend on the specific alternatives and patient needs.

Patient Experience

Since the exam was not performed:

• No discomfort or sensory experiences related to the eye exam are relevant. For a typical exam: Slight discomfort from eye drops and temporary blurred vision due to pupil dilation.

Pain Management and Comfort Measures:

• In a typical scenario, patients are advised to rest until their vision clears and to use sunglasses to mitigate light sensitivity due to dilation.