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Macular cyst, hole, or pseudohole, right eye

ICD10CM code

Name of the Condition

  • Macular cyst, hole, or pseudohole, right eye
  • Also known as macular hole, retinal hole, or vitreomacular traction

Summary

  • This condition involves the formation of a small break or cyst in the macula, the central part of the retina responsible for detailed vision. It can lead to a decrease in central vision and distortion of images in the right eye.

Causes

  • Causes include age-related degeneration, vitreous detachment, eye trauma, high myopia, and complications from eye surgeries. Idiopathic macular holes occur without a clear cause.

Risk Factors

  • Increased age, especially over 60 years old
  • Gender, with females at higher risk
  • Previous eye injuries
  • Prior retinal detachment
  • High myopia (severe nearsightedness)

Symptoms

  • Blurry or distorted vision in the central field of view
  • A dark or empty area in the center of vision
  • Difficulty reading or recognizing faces
  • Straight lines appearing wavy or bent

Diagnosis

  • Comprehensive eye examination
  • Optical coherence tomography (OCT), which provides detailed images of the retina
  • Amsler grid test to detect vision changes

Treatment Options

  • Vitrectomy surgery to remove the vitreous gel and allow the macula to heal
  • Gas bubble placement within the eye to apply pressure and close the macular hole
  • In some cases, observation without immediate treatment if the hole is small

Prognosis and Follow-Up

  • Generally good prognosis if treated with vitrectomy, with significant improvement in vision for many patients
  • Regular follow-up visits are crucial to monitor the healing process and detect any complications early.

Complications

  • If untreated, can lead to permanent central vision loss
  • Possible development of retinal detachment or cataracts post-surgery
  • Recurrence of macular hole after surgical repair

Lifestyle & Prevention

  • Protect eyes from trauma
  • Regular eye check-ups, especially for individuals with high risk factors
  • Control of systemic conditions like diabetes

When to Seek Professional Help

  • Sudden changes in vision or visual distortions
  • Difficulty in performing daily activities due to vision changes

Additional Resources

  • American Academy of Ophthalmology (www.aao.org)
  • Retina International (www.retina-international.org)
  • Macular Society (www.macularsociety.org)

Tips for Medical Coders

  • Ensure laterality is accurately coded: in this case, the right eye.
  • Verify whether the condition involves a cyst, hole, or pseudohole for precise coding.
  • Common coding errors include incorrect specification of laterality or overlooking associated conditions like vitreomacular traction.

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