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Primary open-angle glaucoma, bilateral, moderate stage

ICD10CM code

Name of the Condition

  • Primary Open-Angle Glaucoma, Bilateral, Moderate Stage
  • Also known as: Chronic Open-Angle Glaucoma

Summary

Primary open-angle glaucoma (POAG) is a chronic eye condition characterized by increased pressure within the eye that leads to optic nerve damage. Being bilateral means it affects both eyes.

Causes

  • The exact cause is unknown, but it is associated with a gradual blockage of the eye’s drainage canals, resulting in increased intraocular pressure (IOP).

Risk Factors

  • Age: Commonly affects individuals over 40.
  • Family History: Genetic predisposition plays a role.
  • Race: Higher prevalence in African Americans and Hispanics.
  • Medical Conditions: Diabetes, hypertension, and myopia.

Symptoms

  • Often asymptomatic in the early stages.
  • Progressive loss of peripheral vision.
  • Tunnel vision in advanced stages.

Diagnosis

  • Comprehensive eye examination.
  • Tonometry to measure intraocular pressure.
  • Visual field testing.
  • Optical coherence tomography (OCT) to assess optic nerve damage.

Treatment Options

  • Medications: Eye drops to reduce intraocular pressure.
  • Laser Therapy: To improve drainage of aqueous fluid from the eye.
  • Surgery: Procedures like trabeculectomy to create a new drainage pathway.

Each treatment aims to lower intraocular pressure to prevent further optic nerve damage.

Prognosis and Follow-Up

  • With early detection and consistent treatment, vision can often be preserved.
  • Regular monitoring by an ophthalmologist is essential to manage IOP and track disease progression.

Complications

  • Severe visual impairment or blindness if left untreated or unmanaged.
  • Impact on quality of life due to vision loss.

Lifestyle & Prevention

  • Regular eye examinations, especially for those over 40 or with risk factors.
  • Protect eyes from injuries and UV exposure.
  • Manage systemic conditions like diabetes and hypertension diligently.

When to Seek Professional Help

  • Sudden loss of vision or severe eye pain requires immediate medical attention.
  • Routine eye check-ups if you belong to high-risk groups.

Additional Resources

Tips for Medical Coders

  • Ensure both the diagnosis of bilateral glaucoma and the stage (moderate) are documented.
  • Verify proper notation of laterality (bilateral) and stage to avoid miscoding errors.
  • Remember that coding can differ if complications or comorbidities are present.

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