Name of the Condition

• Central Corneal Ulcer, Right Eye
• Also known as corneal ulcer or keratitis.

Summary

Central corneal ulcer in the right eye is a painful open sore on the cornea, which is the transparent layer forming the front of the eye. This condition can lead to redness, pain, vision disturbances, and potential scarring if left untreated.

Causes

• Bacterial infections, often from bacteria such as Staphylococcus or Pseudomonas, especially after eye injuries or improper contact lens usage.
• Viral infections, such as those caused by herpes simplex virus.
• Fungal infections following eye trauma, especially with organic material like sticks.
• Dry eye conditions or severe eye allergies can also predispose one to developing ulcers.

Risk Factors

• Wearing contact lenses, especially when they're not cleaned or handled properly.
• Having a history of eye injuries or surgeries.
• Frequent use of steroid eye drops.
• Underlying eye diseases, such as dry eye syndrome.
• Compromised immune system or nutritional deficiencies.

Symptoms

• Severe eye pain and redness in the right eye.
• Watery or purulent discharge.
• Blurred vision or decrease in vision.
• Sensitivity to light (photophobia).
• Feeling like something is in the eye (foreign body sensation).

Diagnosis

• Comprehensive eye examination.
• Slit-lamp examination to look closely at the cornea.
• Potential cultures or scrapings to identify causative organisms if infection is suspected.

Treatment Options

• Antibiotic, antiviral, or antifungal eye drops depending on the causative organism.
• Lubricating eye drops to aid comfort and healing.
• In severe cases, oral medications or even surgical interventions might be necessary.
• Avoidance of contact lenses during treatment.

Prognosis and Follow-Up

• With prompt and appropriate treatment, most corneal ulcers heal without significant vision loss.
• Follow-up appointments are crucial to monitor healing and prevent complications.
• Long-term prognosis depends on the severity and timely management of the ulcer.

Complications

• Scarring of the cornea, potentially leading to vision impairment.
• Spread of infection deeper into the eye, possibly leading to endophthalmitis.
• Risk of corneal perforation, which is a medical emergency.

Lifestyle & Prevention

• Proper contact lens hygiene, including regular cleaning and appropriate lens disposal.
• Avoid sleeping in contact lenses unless advised by a healthcare professional.
• Use protective eyewear in environments with high risk of eye injury.
• Regular eye check-ups, particularly for individuals with predisposing conditions.

When to Seek Professional Help

• Sudden onset of eye pain, redness, or vision changes.
• Persistent or severe symptoms, such as intense light sensitivity or discharge, should prompt immediate medical evaluation.

Additional Resources

• American Academy of Ophthalmology (aao.org)
• National Eye Institute (nei.nih.gov)

Tips for Medical Coders

• Ensure correct laterality by specifying the affected eye (right eye in this case) with the code H16.011.
• Verify documentation to confirm the presence of central corneal ulcer before coding.
• Avoid confusion with other forms of keratitis or non-central corneal ulcers, which may have different codes.