Name of the Condition

• Primary Open-Angle Glaucoma, Bilateral, Stage Unspecified (ICD-10: H40.1130)
• Commonly referred to as primary open-angle glaucoma (POAG).

Summary

Primary open-angle glaucoma is a chronic eye condition that progresses slowly and causes damage to the optic nerve, often due to increased eye pressure. When affecting both eyes, it is termed bilateral. It can lead to vision loss if not detected and treated early.

Causes

The exact cause of primary open-angle glaucoma is not fully understood but is believed to involve a combination of genetic and environmental factors. It may be associated with an imbalance between eye fluid production and drainage, resulting in increased intraocular pressure (IOP).

Risk Factors

• Age: More prevalent in adults over 40.
• Family history of glaucoma.
• Ethnicity: Higher prevalence in African American and Hispanic populations.
• Medical conditions: Diabetes, hypertension, and nearsightedness (myopia).

Symptoms

• Often asymptomatic in initial stages.
• Gradual peripheral vision loss, leading to tunnel vision.
• In advanced stages, central vision loss may occur.

Diagnosis

• Comprehensive eye examination including visual acuity test.
• Tonometry to measure intraocular pressure.
• Ophthalmoscopy to assess the optic nerve.
• Visual field test to identify vision loss.
• Imaging tests like Optical Coherence Tomography (OCT).

Treatment Options

• Medications: Eye drops to lower eye pressure by reducing fluid production or increasing drainage.
• Laser therapy: Trabeculoplasty to improve fluid drainage.
• Surgery: Trabeculectomy or implant surgery to create new drainage paths.

Prognosis and Follow-Up

• With timely treatment, progression can be slowed, and vision preserved.
• Regular follow-ups are critical for monitoring eye pressure and optic nerve health.

Complications

• Untreated, it can lead to significant and irreversible vision loss or blindness.
• May increasingly affect quality of life due to reduced vision.

Lifestyle & Prevention

• Regular comprehensive eye exams, especially if at risk.
• Healthy lifestyle with diet and exercise to maintain optimal eye health.
• Use protective eyewear to avoid eye injuries.

When to Seek Professional Help

• Noticeable changes in vision, especially peripheral.
• Any sudden eye pain, redness, or swelling.
• Risk individuals should have routine screening.

Additional Resources

• American Academy of Ophthalmology (aao.org)
• Glaucoma Research Foundation (glaucoma.org)

Tips for Medical Coders

• Ensure precise coding for bilateral involvement and stage unspecificity.
• Verify bilateral nature of the condition in documentation.
• Avoid assuming stage; use unspecified if not clearly indicated in the medical record.