Chapter 4 ICD-9-CM Coding Guidelines

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High risk

OphthalmologyDavid Duong, MD MS

University of California, San Francisco

Department of Emergency medicine

conflicts of interest

• no personal financial relationships for

products or services in this talk

objectives

• Pointers and pitfalls in:

• Eye trauma

• The red eye

• Visual loss

Diagnosis CORNEAL FOREIGN BODY

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foreign body removal

QuickTime™ and a decompressor

are needed to see this picture.

Pearls for

Rust Rings

• Rust Rings do not have to be removed

immediately

• Removal is often easier 1-2 days after

the injury and with a corneal drill

• Homatropine can help with ciliary

spasm

• Arrange follow-up in 1-2 days after

removalCan J Rural Med 2013

everting the lid



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subtarsal foreign body

corneal Foreign Body pitfalls

• Not everting the lid

• Not considering an intraocular FB

• Not considering corneal laceration

high risk lacerations? ALL OF THEM anatomy

ophtho or plastics need to be involved for

lacerations involving the:

tarsal plate

lid margin

nasolacrimal system

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canalicular laceration

eyelid laceration pitfalls

• Not assuming there are other ocular

injuries

• Not obtaining visual acuity

so get Va, assess EOM,

RAPD, etc.

Va helps to risk stratify for

eye emergencies

EM Clin NA. 2008

globe rupture

• decreased Va

• RAPD

• eccentric pupil

• bullous subconjunctival hemorrhage

• extrusion of vitreous

• hyphema

• Seidel test

Globe rupture

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seidel test



key actions

globe rupture

• Consult ophthalmology and order CT

• Protect the eye (eye shield, avoid eye

manipulation)

• Avoid ocular extrusion (antiemetics,

pain meds, sedation)

• Antibiotic prophylaxis

• Tetanus prophylaxis

Diagnosis HYPHEMA

HYPHEMA TREATMENT

<33% (Grade 1)

microhyphemagood prognosis

eye shield

HOB >30 deg

cycloplegia

ophtho referral

no NSAIDS

90% visual acuity prognosis 20/50 or better.

HOB >30 deg to prevent synechiae

cycloplegia only if no incr IOP

referral to monitor for incr IOP and rebleeding

within 5 days.

33-50% (Grade 2)

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HYPHEMA TREATMENT

>50% (Grade 3 & 4)

↑ IOP (>24)

sickle cell

ophtho consult

eye shield

HOB >30 deg

no NSAIDS

topical B-blocker if increased

IOP.

c/s may also recommend

steroid drops

HYPHEMA

PITFALLS

• Not obtaining an IOP or asking about

sickle cell disease or trait

• Discharging with NSAIDs

• Neglecting close ophthalmology follow-

up

• Not considering globe rupture or IOFB

The Red Eye

case of red eye

• 52-yo F with 1 day of severe right eye

pain, and decreased vision. On exam,

you see corneal cloudiness and diffuse

conjunctival injection with ciliary flush.

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medical treatment of acute

angle glaucoma

• How do you use the drops?

• How many times can you repeat the

drops?

• What about acetazolamide and

mannitol?


angle glaucoma

• Give separate eye drops 1 minute apart

(timolol, apraclonidine, prednisolone,

pilocarpine are acceptable)

• Give acetazolamide PO early

• Repeat drops once in 15 minutes


angle glaucoma

• Goal IOP is 35 mmHg or >25%

presenting IOP

• Consider mannitol IV if IOP is still high

• Call ophthalmology again

Choong et al. Eye. 1999

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vision loss

floaters



Hollands et al. JAMA 2009

approach to floaters and

flashes

• Bottom line is to determine when to

refer a vision threatening condition to

prevent further vision loss or restore

vision

Hollands et al. JAMA 2009

PVD can lead to retinal tears

14% prevalence

33-46% of retinal tears lead

to retinal detachment

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JAMA meta-analysis

• floaters vs flashes vs both is not

diagnostically helpful for retinal tear

• older age (>60) is not associated with

increased risk of retinal tear; younger

age is not less likely to have retinal tear

discuss evidence behind

recommendations from the

JAMA paper subjective visual acuity

baseline 14%

prevalence of

retinal tear in

those with

PVD

worse vision

no change

45% probability

of retinal tear

9% probability of

retinal tearHollands et al. JAMA 2009

vitreous hemorrhage or

pigment

baseline 14%

prevalence of

retinal tear in

those with

PVD

vitreous hemorrhage

LR = 10

vitreous pigment

LR = 44

62% probability

of retinal tear

88% probability

of retinal tear

besides allergy and glaucoma -

there is no absolute contraindication for pupillary

dilation for a good exam.

1 gtt tropicamde + 1 gtt

phenylephrine and wait 20

minutes

Key actions

• Assess subjective visual acuity

• Assess visual acuity and peripheral

vision

• Fundiscopic exam +/- slit lamp

need pictures or videos or vitreous hemorrhage and

pigment - assess via slit lamp or direct ophthalmoscopy (Shafer’s or Shaffer’s sign)

root atlas has a video of retinal detachment

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pitfalls in the case of floaters

and flashes

• Not referring to ophthalmology with only

subjective visual acuity loss

• Not giving return precautions with a

PVD diagnosis (more floaters or vision

reduction)

Case of vision loss

• 72-yo F with sudden painless,

decreased left eye vision 2 hours. Va

OS = cannot read the eye chart or

count fingers, but can see hand motion.

Diagnosis CENTRAL RETINAL

ARTERY OCCLUSION

key actions

CRAO

• Rule-out temporal arteritis (including

ESR & CRP)

• Consider ocular massage (within 24

hrs)

• Ophtho consult (to consider AC

paracentesis or thrombolytics)

Fraser et al. Cochrane review. 2009

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pitfalls

CRAO

• Failing to consider embolic source of

CRAO

• ECG for AFib

• carotid imaging

• cardiac evaluation

Case of vision loss

• 38-yo F with decreased left eye vision

for 2d with mild eye pain. She has

decreased Va, a + RAPD on the left,

and swollen optic disc. nl slit lamp

exam.

relative afferent

pupillary defect



key actions

optic neuritis

• Neurology consult for MS and NMO

work-up

• Consider MRI with gadolinium

• Consider IV steroids

ONTT - 457 patients with optic neuritis

IV methylprednisolone was associated

with faster recovery in visual fxn and a

lower 2-year risk of development of

multiple sclerosis. but did not affect

long term outcome

Oral prednisone was associated with

an increased incidence of recurrent

optic neuritis and did not improve visual

outcomes compared to placebo

Beck et al. NEJM. 1993

Cochrane. 2012

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summary

• Key Actions and Pitfalls in:

• Eye trauma

• The red eye

• Vision loss

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podcasts@ucsf

particular thanks to those

who gave consent to be

photographed for

educational purposes

thank you for your

attention

[email protected]

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pediatrics

• CORNEAL ABRASIONS

• antibiotic ointments lubricate

• consider 1 drop of cycloplegia

• consider codeine elixir

Video of a baby crying before

this slide?

CORNEAL ABRASION

PITFALL

• Return precautions

• RED FLAG: persistent pain or

unwillingness or open the eye after

1 day of treatment

pediatric Eye trauma

PITFALL

• Consider sedation to fully evaluate the

eye

• Ketamine: total dose <3mg/kg does not

raise IOP

Nagdeve. J Ped Ophth Strab. 2006

pediatric vision testing

• Pediatric Eye Chart

• Fix and Follow (F/F)

• Blink to Light (BTL)

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fixation target



Fix and follow

Can start to fix and follow at

2 months

References

• 1. Magauran. Emerg Med Clin N Am. 2008; 26; 23.

• 2. Carley. Emerg Med J. 2001; 18: 273.

• 3. Guess S et al. Ocul Surf. 2007; 5(3): 240.

• 4. Choong YF et al. Eye. 1999; 13: 613

• 5. Hollands et al. JAMA. 2009; 302(20): 2243.

• 6. Germann et al. AJEM. 2007; 25: 834.

• 7. Fraser et al. Cochrane Database of systematic reviews. 2009.

• 8. Mohamed et al. Ophthalmology. 2007; 114(3):507.

• 9. Nagdeve et al. J Ped Ophth Strab. 2006; 43(4):219.

• 10. Brock G et al. Can J Rural Med. 2013; 18(4)

• 11. Gharaibeh A et al. Cochrane Database of systematic reviews. 2013.

• 12. Halstead SM et al. Acad EM. 2012; 19:1145-1150

• 13. Gal RL et al. Cochrane Database of systematic reviews. 2012. cells and flare



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Chapter 4 ICD-9-CM Coding Guidelines