H04.532 Neonatal obstruction of left nasolacrimal duct

ICD10CM code

#### Name of the Condition
- Neonatal Obstruction of Left Nasolacrimal Duct
- Also known as Congenital Nasolacrimal Duct Obstruction (CNLDO).

#### Summary
Neonatal obstruction of the left nasolacrimal duct is a condition occurring in newborns characterized by a blockage in the tear duct on the left side. This can cause excessive tearing and potential infection.

#### Causes
- Congenital blockage or malformation of the nasolacrimal duct.
- Mucosal buildup or membrane preventing the duct from opening.
- Structural anomalies present at birth.

#### Risk Factors
- Prematurity.
- Family history of nasolacrimal duct obstruction.
- Conditions affecting craniofacial structure.

#### Symptoms
- Constant tearing in one eye (left side).
- Mucus discharge from the affected eye.
- Redness or swelling around the eye.
- Crusting on the eyelids.

#### Diagnosis
- Physical examination by a pediatrician or ophthalmologist.
- Fluorescein dye disappearance test.
- Probing and irrigation of the nasolacrimal duct.

#### Treatment Options
- Observation and time, as many cases resolve spontaneously.
- Massage techniques over the lacrimal sac.
- Antibiotic eye drops if infection is present.
- Surgical intervention (probing) if conservative treatments fail.

#### Prognosis and Follow-Up
- Most infants improve without surgical intervention as they grow.
- Regular follow-up to monitor resolution of symptoms.
- Surgical probing is generally successful if needed.

#### Complications
- Persistent tearing and discomfort.
- Risk of recurrent eye infections if untreated.
- Rarely, chronic dacryocystitis (infection of the tear sac).

#### Lifestyle & Prevention
- Gentle cleaning of eye discharge to prevent irritation.
- No specific lifestyle changes or preventive measures as it is congenital.

#### When to Seek Professional Help
- Persistent tearing beyond a few months of age.
- Signs of infection such as redness, swelling, and discharge.
- Eye discomfort affecting the child’s well-being.

#### Additional Resources
- American Academy of Ophthalmology (aao.org)
- Pediatric Eye Disease Investigative Group (PEDIG)

#### Tips for Medical Coders
- Verify laterality; ensure coding accurately reflects the left-sided obstruction.
- Distinguish between neonatal and other age categories to avoid coding errors.
- Review documentation for signs of infection or additional related diagnoses.

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