External Ocular Photography Form

External ocular photography can be used to document the progress or deterioration of certain conditions of the external structures of the eye including the eyelids, lashes, sclerae, conjunctiva and cornea. It may also be used to document progress and deterioration of structures of the anterior chamber including the iris, and filtration angle. These photographs are commonly made using slit lamp photography, goniophotography, stereophotography or close-up photography. Regardless of the technique used for the picture taking, the pictures may be stored as prints, slides, videotape or digital medium.

External ocular photography is clinically useful for tracking slowly progressive conditions over prolonged periods of time, where it may be impractical to document progression with hand drawings due to the need to document fine detail, especialy where there is a lack of anatomic landmarks.

Anterior Scleritis

An UpToDate review on “Slit lamp examination” (Knoop, 2020) does not mention scleritis as an indication.

Epiblepharon with Trichiasis

An UpToDate review on “Approach to the child with persistent tearing” (Paysse et al, 2016) states that “Eyelid abnormalities -- Anatomic abnormalities of the eyelids may cause tearing, redness, and foreign body sensation. Trichiasis (ingrown eyelashes) can irritate the cornea, causing reflex tearing and redness, and may be caused by entropion or epiblepharon. Entropion is the in-turning of the eyelid; epiblepharon is a fold of skin along the lower lid margin, just below the eyelashes. Both of these conditions can be associated with trichiasis. Entropion, if significant, is treated with surgical repair. Children usually outgrow epiblepharon by 2 to 3 years of age without needing to undergo surgery”. This review does not mention external ocular photography as a management tool.

Floppy Eyelid Syndrome

Floppy eyelid syndrome (FES), a subtype of lax eyelid conditions, often involves over-weight individuals. It is a distressing condition that can cause significant morbidity and vision loss. The cause of FES is believed to be a mechanical disorder due to the eversion of the lids while sleeping. It is usually characterized by chronic eye irritation and an increased laxity of the upper eyelid that can be easily everted by applying minimal upward traction. Floppy eyelid syndrome has also been reported to be associated with obstructive sleep apnea-hypopnea syndrome. Blepharoptosis is one of the most common features, which links to FES, for which a thorough differential diagnosis has become important in directing proper medical treatment. Furthermore, FES can cause superficial corneal and conjunctival injuries; and external ocular photography can be used to document the appearance of the eyelid margin and inferior cornea, and to develop a treatment plan (Donnenfeld et al, 1991, Ezra et al, 2010, and Lee et al, 2018).

Keratoconjunctivitis Sicca

Rutar et al (2015) determined the ophthalmic manifestations of HIV in a cohort of long-term survivors of perinatally acquired HIV. A total of 22 patients with perinatally acquired HIV who were aged greater than or equal to 12 years were prospectively studied at a university clinic. They underwent complete ophthalmic examinations and fundus photography. Their medical histories, medications and CD4 counts were abstracted from the medical records. To evaluate for kerato-conjunctivitis sicca (KCS), both HIV patients and 44 healthy controls (matched by age, gender and contact lens wear) underwent Schirmer testing and ocular surface staining; 9 male and 13 female HIV patients with mean age of 16.6 years (SD, 3.4) were examined. Of the 22 HIV patients, 21 had been treated with highly active anti-retroviral therapy (HAART). Only 1 patient had a CD4 count nadir of less than 200 cells/µL. The mean visual acuity (VA) of the eyes of the HIV subjects was 20/22 (SD, 1.6 lines). No patient had cytomegalovirus retinitis; 4 of the 22 (18 %) HIV patients had strabismus. HIV subjects and controls had similar rates of abnormal Schirmer (9 % and 14 %, p = 0.62) and ocular staining scores (p = 0.29). The authors concluded that in the post-HAART era, long-term survivors of perinatally acquired HIV exhibited little vision-threatening disease, but had a high prevalence of strabismus.

Safonova et al (2016) noted that laser confocal tomography of the cornea enables studying ultrathin sections of corneal layers, which provides additional reliable information on tissue changes in KCS. These researchers evaluated the significance of laser confocal tomography of the cornea in the diagnosis and monitoring of KCS. They investigated 38 eyes of 30 patients with severe KCS. The patients were divided into 2 groups: Group 1 (15 patients, 19 eyes) was prescribed cyclosporine А 0.05 % instillations 2 times daily, artificial tears, and soft contact lenses, and Group 2 (15 patients, 19 eyes) received only instillations of cyclosporine А 0.05% 2 times daily and artificial tears. Besides standard ophthalmic examination, additional tests were performed, namely Schirmer's test, tear break-up time test, fluorescein eye stain test, tear osmolarity test (TearLab System, USA), and Heidelberg retinal tomography of the cornea (HRT, Heidelberg Engineering GmbH, Germany). HRT findings revealed a 3 times shorter epithelization period and faster recovery of corneal transparency in Group 1 as compared to Group 2 (1.5 and 4.5 months, respectively). There was also an evident reduction in the number of immune cells in the cornea, most pronounced in group 1 at 3 months, which was indicative of inflammation termination. The authors concluded that the use of HRT of the cornea in KCS patients allowed real-time cellular level observation of corneal changes, which together with clinical findings and diagnostic tests not only confirmed the diagnosis but also determined treatment effectiveness. It has been also found that soft contact lenses accelerated epithelization of the cornea and relieved inflammation of the ocular surface in KCS patients under cyclosporine A 0.05 % instillation therapy.

An UpToDate review on “Diagnosis and classification of Sjögren's syndrome” (Baer , 2017a) states that “KCS is characterized primarily by a deficiency in tear production, while hypovitaminosis A is characterized by disordered conjunctival and corneal epithelial turnover, leading to keratinization and a loss of conjunctival goblet cells, resulting in tear mucin deficiency”; it does not mention ocular photography as a management tool.

An UpToDate review on “Clinical manifestations of Sjögren's syndrome: Exocrine gland disease” (Baer, 2017b) does not mention ocular photography as a management tool.

Furthermore, an American Academy of Ophthalmology’s guideline on “Dry eye syndrome” (AAO, 2013) had no recommendation for external ocular photography, either for diagnosis or follow-up.

Ocular Rosacea

UpToDate reviews on “Management of rosacea” (Maier, 2021) and “Rosacea: Pathogenesis, clinical features, and diagnosis” (Dahl, 2021) do not mention external ocular photography as a management tool.

Recurrent Dacryoadenitis

StatPearls’ webpage on “Dacryoadenitis” (Patel and Patel, 2022) does not mention external ocular photography as an evaluation tool.

Recurrent Episcleritis

StatPearls’ webpage on “Episcleritis” (Schonberg and Stokkermans, 2022) does not mention external ocular photography as an evaluation tool.

White-Sutton Syndrome

White-Sutton syndrome (WHSUS) is a rare neurodevelopmental disorder that affects different systems of the human body. It is mainly characterized by developmental delay, intellectual disability, cranio-facial abnormalities and commonly features of autism spectrum disorder (ASD). However, there is a lack of evidence to support the use of external ocular photography in member with de novo White-Sutton syndrome.

Scope of Policy

This Clinical Policy Bulletin addresses external ocular photography.

Medical Necessity

Aetna considers external ocular photography medically necessary for the following indications to track and serially compare the changes of the condition, where the results may have an impact on management and clinical outcomes:

Acid chemical burn of cornea and conjunctival sac

Acute inflammation of orbit, unspecified

Adherent leucoma

Adhesions of iris, unspecified

Alkaline chemical burn of cornea and conjunctival sac

Anterior dislocation of lens

Anterior pigmentation

Anterior synechiae

Argentous deposits

Band-shaped keratopathy

Benign neoplasm of conjunctiva

Benign neoplasm of cornea

Benign neoplasm of eye, part unspecified

Benign neoplasm of eyeball, except retina and choroid

Benign neoplasm of eyelid, including canthus

Benign neoplasm of lacrimal duct

Benign neoplasm of lacrimal gland

Benign neoplasm of orbit

Benign neoplasm of other specified parts of eye

Benign neoplasm of skin of other and unspecified parts of face

Blepharitis

Blisters, with epidermal loss due to burn (second degree) of eye (with other parts of face, head, and neck)

Bullous keratopathy

Burn of unspecified degree of eye (with other parts of face, head, and neck)

Burn with resulting rupture and destruction of eyeball

Carcinoma in situ of eye

Carcinoma of eyelid, including canthus

Central corneal ulcer

Central opacity of cornea

Chemical burn of eyelids and periocular area

Cicatricial pemphigoid

Congenital ptosis

Conjunctival melanosis

Constant exophthalmos

Corneal abscess

Corneal deformity, unspecified

Corneal degeneration, unspecified

Corneal deposit, unspecified

Corneal dystrophy, unspecified

Corneal ectasia

Corneal edema due to wearing of contact

Corneal edema, unspecified

Corneal membrane change, unspecified

Corneal neovascularization, unspecified

Corneal opacity, unspecified

Corneal staphyloma

Corneal ulcer, unspecified

Deep necrosis of underlying tissues due to burn (deep third degree) of eye (with other parts of face, head, and neck), without mention of loss of body part

Deep necrosis of underlying tissues due to burn (deep third degree) of eye (with other parts of face, head, and neck), with loss of a body part

Deep vascularization of cornea

Degeneration of pupillary margin

Degenerative changes of chamber angle

Degenerative changes of ciliary body

Dermatochalasis of upper eyelids

Descematocele

Diffuse interstitial keratitis

Double pterygium, to follow in lieu of surgery

Endothelial corneal dystrophy

Ectropion

Entropion

Erythema due to burn (first degree) of eye (with other parts face, head, and neck)

Essential or progressive iris atrophy

Exophthalmic ophthalmoplegia

Exophthalmos, unspecified

Exudative cysts of iris or anterior chamber

Floppy eyelid syndrome

Folds and rupture of Bowman's membrane

Folds in Descemet's membrane

Full-thickness skin loss due to burn (third degree NOS) of eye (with other parts of face, head, and neck)

Giant papillary conjunctivitis

Goniosynechiae

Granular corneal dystrophy

Herpes simplex disciform keratitis

Herpes zoster keratoconjunctivitis

Hyphema

Hypopyon

Hypopyon ulcer

Idiopathic corneal edema

Idiopathic cysts

Implantation cysts

Interstitial keratitis, unspecified

Iridoschisis

Juvenile epithelial corneal dystrophy

Kayser-Fleischer ring

Keratoconus, acute hydrops

Keratoconus, stable condition

Keratoconus, unspecified

Keratomalacia NOS

Lagophthalmos (cicatricial, mechanical, and paralytic)

Late effect of other and unspecified external causes

Lattice corneal dystrophy

Limbal and corneal involvement in vernal conjunctivitis

Localized adhesions and strands of conjunctiva

Localized vascularization of cornea

Macular corneal dystrophy

Malignant neoplasm of conjunctiva, unless excision is planned

Malignant neoplasm of the cornea, unless excision is planned

Marginal corneal ulcer

Minor opacity of cornea

Miotic cysts of pupillary margin

Mooren's ulcer

Mycotic corneal ulcer

Neurotrophic keratoconjunctivitis

Nodular degeneration of cornea

Orbital cellulitis

Other and unspecified superficial injuries of eye

Other anterior corneal dystrophies

Other burn of cornea and conjunctival sac

Other burns of eyelids and periocular area

Other calcareous degeneration of cornea

Other corneal degenerations

Other deposits associated with metabolic disorders

Other disorders of iris and ciliary body

Other forms of keratitis (e.g., superficial punctate keratopathy)

Other posterior corneal dystrophies

Other stromal corneal dystrophies

Pannus (corneal)

Perforated corneal ulcer

Peripheral degenerations of cornea

Peripheral opacity of cornea

Peripheral pterygium, progressive, to follow in lieu of surgery

Phacolytic glaucoma

Phlyctenular keratoconjunctivitis

Pigmentary iris degeneration

Posterior dislocation of lens

Posterior pigmentations

Posterior synechiae

Pseudopterygium

Pterygium, unspecified, to follow in lieu of surgery

Ptosis of eyelid

Pupillary abnormalities

Pupillary membranes

Recession of chamber angle

Recurrent erosion of cornea

Recurrent pterygium, to follow in lieu of surgery

Ring corneal ulcer

Rubeosis iridis

Rupture in Descemet's membrane

Scleral melanosis

Sclerosing keratitis

Secondary corneal edema

Stromal pigmentations

Subluxation of lens

Superficial injury of conjunctiva

Superficial injury of cornea

Superficial injury of eyelids and periocular area

Symblepharon

Thyrotoxic exophthalmos

Unspecified burn of eye and adnexa

Unspecified corneal disorder

Unspecified disorder of iris and ciliary body

Unspecified keratitis

Vascular anomalies of eyelid.

External ocular photography has no proven value for other indications (e.g., anterior scleritis, collapsed orbital wall, enophthalmos following orbital floor fracture, epiblepharon with trichiasis, sinonasal tumor, evaluating conjunctival hemorrhage, keratoconjunctivitis sicca, recurrent dacryoadenitis and recurrent episcleritis, monitoring pinguecula, ocular rosacea, for use following rectus muscle surgery for exotropia, and White-Sutton syndrome).

Aetna considers external ocular photography not medically necessary for the sole purpose of documenting the existence of an ocular condition in order to enhance the medical record.