PREOPERATIVE DIAGNOSIS : Intermittent exotropia, alternating fusion with decreas

Question

PREOPERATIVE DIAGNOSIS: Intermittent exotropia, alternating fusion with decreased stereopsis

POSTOPERATIVE DIAGNOSIS: Intermittent exotropia, alternating fusion with decreased stereopsis

PROCEDURE PERFORMED: Bilateral lateral rectus recession of 7.0 mm

ANESTHESIA: General endotracheal anesthesia

PROCEDURE: The patient was brought to the operating room and placed in the supine position where she was prepped and draped in the usual sterile fashion for strabismus surgery. Both eyes were exposed to the surgical field. After adequate anesthesia, one drop of 2.5 percent Neosynephrine was placed in each eye for vasoconstriction. Forced ductions were performed on both eyes, and the lateral rectus was found to be normal. An eye speculum was placed in the right eye and surgery was begun on the right eye. An inferotemporal fornix incision was performed. The right lateral rectus muscle was isolated on a muscle hook. The muscle insertion was isolated, and checked ligaments were dissected back. After a series of muscle hook passes using the Steven’s hook and finishing with two passes of a Green’s hook, the right lateral rectus was isolated. The epimesium, as well as Tenon’s capsule, was dissected from the muscle insertion and the checked ligaments were lysed. The muscle was imbricated on a 6-0 Vicryl suture with an S29 needle with locking bites at either end. The muscle was detached from the globe, and a distance of 7.0 mm posterior to the insertion of the muscle was marked. The muscle was then reattached 7.0 mm posterior to the original insertion using a cross-swords technique. The conjunctiva was closed using two buried sutures. Attention was then turned to the left eye where an identical procedure was performed. At the end of the case the eyes seemed slightly exotropic in position in the anesthetized state. Bounce back tests were normal. Both eyes were dressed with tetracaine drops and Maxitrol ointment. There were no complications. The patient tolerated the procedure well, was awakened from anesthesia without difficulty, and was sent to the recovery room. The patient was instructed in the use of topical antibiotics, and detailed postoperative instructions were provided. The patient will be followed up within a 48-hour period in my office.

What is the first listed diagnosis and code for ICD-10-CM?

Explanation / Answer

INTERMITTENT EXOTROPIA:

Intermittent means irregular and which is not continous and steady. Exotropia means it is a form of strabismus where the eyes are deviated from normal. Strabismus means abnormal alignment of the eyes which is also known as squint.

INTERMITTENT EXOTROPIA DEFINITION : Deviation of the eyes from normal alignment only for some time ICD CODE 10 CM- H50.332

STERIOPSIS: Perception of 3 dimensional picture due to the reception of brain visual stimuli ,combination of both eyes .eg binocular vision.

ICD CODE 10 CM - H53.32

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