ICD-10: H35.131

Retinopathy of prematurity, stage 2, right eye

Additional Information

Description

Retinopathy of prematurity (ROP) is a significant condition affecting premature infants, characterized by abnormal blood vessel development in the retina. The ICD-10 code H35.131 specifically refers to retinopathy of prematurity, stage 2, in the right eye. Below is a detailed clinical description and relevant information regarding this condition.

Overview of Retinopathy of Prematurity

Definition

Retinopathy of prematurity is a disease that primarily affects infants born prematurely, particularly those with a birth weight of less than 1500 grams or those born before 28 weeks of gestation. It occurs when the retinal blood vessels do not develop properly, leading to potential vision impairment or blindness if not treated appropriately.

Staging of ROP

ROP is classified into five stages, with stage 2 indicating moderate disease. The stages are defined as follows:

  • Stage 1: Mildly abnormal blood vessel growth.
  • Stage 2: More pronounced abnormal blood vessel growth, but not yet severe.
  • Stage 3: Severe abnormal blood vessel growth, which may lead to complications.
  • Stage 4: Partial retinal detachment.
  • Stage 5: Total retinal detachment.

In the case of H35.131, the diagnosis specifies that the infant is experiencing stage 2 ROP in the right eye.

Clinical Features of Stage 2 ROP

Symptoms

Infants with stage 2 ROP may not exhibit obvious symptoms, as the condition is often asymptomatic in its early stages. However, potential signs can include:

  • Abnormal eye movements
  • Poor visual tracking
  • Difficulty focusing on objects

Diagnosis

Diagnosis of ROP typically involves a comprehensive eye examination performed by a pediatric ophthalmologist. The examination may include:

  • Indirect ophthalmoscopy: A technique that allows the doctor to view the retina and assess the extent of blood vessel development.
  • Fundus photography: To document the condition of the retina.

Treatment Options

While stage 2 ROP may resolve on its own, close monitoring is essential. Treatment options may include:

  • Laser therapy: To reduce the risk of progression to more severe stages.
  • Cryotherapy: In some cases, freezing treatment may be used to halt abnormal blood vessel growth.

Coding and Billing Considerations

ICD-10 Code H35.131

The ICD-10 code H35.131 is used for billing and coding purposes to specify the diagnosis of retinopathy of prematurity, stage 2, in the right eye. Accurate coding is crucial for proper reimbursement and tracking of healthcare services provided to infants with this condition.

Documentation Requirements

When documenting this diagnosis, healthcare providers should ensure that the following information is included:

  • The stage of ROP (in this case, stage 2).
  • The affected eye (right eye).
  • Any relevant clinical findings or treatment plans.

Conclusion

Retinopathy of prematurity, particularly at stage 2, requires careful monitoring and management to prevent progression to more severe stages that could lead to vision loss. The ICD-10 code H35.131 serves as a critical tool for healthcare providers in documenting and billing for this condition. Early detection and intervention are key to improving outcomes for affected infants. Regular follow-up examinations are essential to ensure the health and development of the infant's vision.

Clinical Information

Retinopathy of prematurity (ROP) is a significant condition affecting premature infants, characterized by abnormal blood vessel development in the retina. The ICD-10 code H35.131 specifically refers to stage 2 ROP in the right eye. Understanding the clinical presentation, signs, symptoms, and patient characteristics associated with this condition is crucial for timely diagnosis and management.

Clinical Presentation

Definition and Staging

Retinopathy of prematurity occurs in infants born before 31 weeks of gestation or weighing less than 1,500 grams. The condition is classified into five stages, with stage 2 indicating moderate abnormal blood vessel growth. In this stage, the retina shows more pronounced changes compared to stage 1, but the condition has not yet progressed to the more severe stages that can lead to retinal detachment.

Signs and Symptoms

Infants with stage 2 ROP may not exhibit overt symptoms, as the condition primarily affects the retina, which does not have pain receptors. However, some potential signs and symptoms include:

  • Abnormal Eye Movements: Infants may display unusual eye movements or poor fixation.
  • Visual Impairment: While not always apparent, some infants may have reduced visual acuity or difficulty tracking objects.
  • Strabismus: Misalignment of the eyes may occur as the infant grows.
  • Retinal Changes: Fundoscopic examination may reveal the characteristic findings of stage 2 ROP, including:
  • Demarcation Line: A clear line between the vascularized and avascular retina.
  • Plus Disease: Increased vascular dilation and tortuosity of the retinal blood vessels, which may be present in more advanced cases but can also be assessed in stage 2.

Patient Characteristics

Certain characteristics are commonly associated with infants diagnosed with stage 2 ROP:

  • Gestational Age: Typically, infants born at less than 32 weeks of gestation are at higher risk.
  • Birth Weight: Low birth weight (less than 1,500 grams) is a significant risk factor.
  • Oxygen Therapy: Infants who have received supplemental oxygen are at increased risk for developing ROP.
  • Other Health Conditions: Conditions such as intraventricular hemorrhage or respiratory distress syndrome may also correlate with a higher incidence of ROP.

Diagnosis and Management

Diagnosis of ROP is primarily through routine eye examinations performed by pediatric ophthalmologists, typically starting at 4-6 weeks of age for at-risk infants. The management of stage 2 ROP may involve close monitoring, as many cases resolve spontaneously. However, if progression is noted, treatment options such as laser therapy or cryotherapy may be considered to prevent further retinal damage.

Conclusion

Retinopathy of prematurity, particularly stage 2 in the right eye, presents a unique challenge in neonatal care. Early detection through regular screening and understanding the clinical signs and patient characteristics are essential for effective management. As ROP can lead to significant visual impairment if left untreated, ongoing research and advancements in neonatal care continue to improve outcomes for affected infants.

Approximate Synonyms

Retinopathy of prematurity (ROP) is a significant condition affecting premature infants, and the ICD-10 code H35.131 specifically refers to stage 2 ROP in the right eye. Understanding alternative names and related terms can enhance clarity in medical documentation and communication. Below are some alternative names and related terms associated with this condition.

Alternative Names for Retinopathy of Prematurity

  1. Premature Retinopathy: This term emphasizes the condition's association with premature birth.
  2. Retinopathy of Prematurity Stage 2: A more specific designation that indicates the severity of the condition.
  3. ROP Stage 2: An abbreviation commonly used in clinical settings to refer to the same condition.
  4. Retinal Disease in Premature Infants: A broader term that encompasses various retinal issues, including ROP.
  1. ICD-10 Codes:
    - H35.13: General code for retinopathy of prematurity, which includes all stages.
    - H35.132: Refers to stage 2 ROP in the left eye, providing a comparative coding reference.

  2. Stages of Retinopathy of Prematurity:
    - Stage 1: Mildly abnormal blood vessel growth.
    - Stage 2: Moderately abnormal blood vessel growth, which is what H35.131 specifies.
    - Stage 3: Severely abnormal blood vessel growth, which may lead to more serious complications.

  3. Ophthalmic Terminology:
    - Vascular Retinopathy: A term that can describe various retinal vascular conditions, including ROP.
    - Neovascularization: Refers to the formation of new blood vessels, a key feature in ROP progression.

  4. Clinical Terms:
    - Fundus Examination: A procedure used to assess the retina and diagnose conditions like ROP.
    - Extended Ophthalmoscopy: A diagnostic technique that may be employed to evaluate the severity of ROP.

  5. Related Conditions:
    - Retinal Detachment: A potential complication of advanced ROP.
    - Vision Impairment: A possible outcome of untreated ROP, highlighting the importance of early detection and intervention.

Conclusion

Understanding the alternative names and related terms for ICD-10 code H35.131 is crucial for healthcare professionals involved in the diagnosis and treatment of retinopathy of prematurity. This knowledge aids in accurate documentation, effective communication among medical teams, and enhances patient care strategies. If you need further information or specific details about ROP management or coding practices, feel free to ask!

Diagnostic Criteria

The diagnosis of Retinopathy of Prematurity (ROP), particularly for ICD-10 code H35.131, which specifies stage 2 ROP in the right eye, involves a combination of clinical evaluation and specific criteria. Here’s a detailed overview of the diagnostic criteria and considerations for this condition.

Understanding Retinopathy of Prematurity (ROP)

Retinopathy of Prematurity is a potentially blinding eye disorder that primarily affects premature infants. It occurs when abnormal blood vessels grow in the retina, which can lead to retinal detachment and vision loss if not treated appropriately. The condition is classified into stages, with stage 2 indicating moderate severity.

Diagnostic Criteria for ROP

1. Gestational Age and Birth Weight

  • ROP is most commonly seen in infants born before 28 weeks of gestation or those weighing less than 1500 grams at birth. Infants in these categories are at higher risk for developing ROP[1].

2. Fundoscopic Examination

  • A comprehensive eye examination using indirect ophthalmoscopy is essential. The examination should be performed by a qualified ophthalmologist, typically a pediatric retina specialist, to assess the retina's condition.
  • The examination focuses on identifying the presence of abnormal blood vessel growth and the extent of the disease[2].

3. Classification of ROP Stages

  • ROP is classified into five stages, with stage 2 characterized by:
    • The presence of abnormal blood vessels that are more pronounced than in stage 1.
    • The vessels may be tortuous and extend into the retina but do not yet cause significant retinal detachment[3].
  • The diagnosis of stage 2 ROP specifically requires the identification of these features in the right eye, as indicated by the ICD-10 code H35.131.

4. Zone of Involvement

  • ROP is also classified by the zone of the retina affected:
    • Zone I is the most severe and involves the area around the optic nerve.
    • Zone II is the area between Zone I and the ora serrata.
    • Zone III is the peripheral retina.
  • The zone affected can influence the management and prognosis of the condition[4].

5. Presence of Plus Disease

  • Plus disease is characterized by increased vascular dilation and tortuosity of the retinal blood vessels. The presence of plus disease can indicate a more severe form of ROP and may necessitate more aggressive treatment[5].

Conclusion

The diagnosis of Retinopathy of Prematurity, particularly for stage 2 in the right eye (ICD-10 code H35.131), relies on a thorough clinical assessment, including gestational age, fundoscopic examination, classification of the disease stage, and evaluation of the zone of involvement. Early detection and monitoring are crucial for managing ROP effectively and preventing potential vision loss. Regular follow-up examinations are recommended for at-risk infants to ensure timely intervention if the condition progresses.

For further information on coding and billing related to ROP, healthcare providers can refer to specific coding guidelines and resources tailored to pediatric ophthalmology[6].

Treatment Guidelines

Retinopathy of prematurity (ROP) is a significant concern in neonatal care, particularly for premature infants. The condition is characterized by abnormal blood vessel development in the retina, which can lead to vision impairment or blindness if not treated appropriately. The ICD-10 code H35.131 specifically refers to stage 2 ROP in the right eye. Here’s a detailed overview of standard treatment approaches for this condition.

Understanding Retinopathy of Prematurity

Staging of ROP

ROP is classified into five stages, with stage 1 being the least severe and stage 5 representing total retinal detachment. Stage 2 indicates more advanced disease, where there is a clear presence of abnormal blood vessels, but the retina is not yet detached. Early detection and intervention are crucial to prevent progression to more severe stages.

Standard Treatment Approaches

1. Monitoring

For infants diagnosed with stage 2 ROP, careful monitoring is essential. This typically involves regular eye examinations by a pediatric ophthalmologist or a retina specialist. The frequency of these examinations may vary based on the infant's gestational age and the severity of the ROP. Monitoring helps in assessing whether the condition is stable or progressing.

2. Laser Therapy

If the ROP progresses or if there is a risk of progression to stage 3, laser photocoagulation therapy may be employed. This treatment involves using a laser to destroy the peripheral areas of the retina where abnormal blood vessels are growing. By reducing the oxygen demand of the retina, laser therapy can help prevent further complications, including retinal detachment.

3. Cryotherapy

In some cases, cryotherapy may be used as an alternative to laser therapy. This involves applying extreme cold to the peripheral retina to induce scarring and reduce the growth of abnormal blood vessels. However, laser therapy is more commonly used due to its precision and effectiveness.

4. Anti-VEGF Injections

Anti-vascular endothelial growth factor (anti-VEGF) injections, such as Eylea® (aflibercept), have emerged as a treatment option for ROP. These medications inhibit the growth of abnormal blood vessels by blocking the action of VEGF, a protein that promotes blood vessel formation. This approach is particularly useful in cases where laser therapy may not be feasible or effective.

5. Surgical Intervention

In advanced cases where there is a risk of retinal detachment, surgical intervention may be necessary. Procedures such as vitrectomy can be performed to remove the vitreous gel and relieve traction on the retina, potentially saving vision.

Conclusion

The management of stage 2 ROP, as indicated by ICD-10 code H35.131, involves a combination of monitoring and potential intervention strategies, including laser therapy, cryotherapy, anti-VEGF injections, and surgical options if necessary. Early detection and timely treatment are critical in preventing the progression of ROP and preserving vision in affected infants. Regular follow-up with a specialist is essential to ensure the best outcomes for these vulnerable patients.

Related Information

Description

  • Abnormal blood vessel development in retina
  • Affects premature infants born before 28 weeks
  • Stage 2 ROP indicates moderate disease
  • Moderate abnormal blood vessel growth, not severe
  • Right eye affected in H35.131 code
  • Asymptomatic in early stages, poor visual tracking
  • Laser therapy or cryotherapy may be used for treatment

Clinical Information

  • Retinopathy of prematurity affects premature infants
  • Abnormal blood vessel development in the retina
  • Stage 2 ROP indicates moderate abnormal growth
  • May not exhibit overt symptoms initially
  • Infants may display unusual eye movements or poor fixation
  • Reduced visual acuity or difficulty tracking objects
  • Strabismus or misalignment of the eyes
  • Demarcation line between vascularized and avascular retina
  • Plus disease with increased vascular dilation and tortuosity
  • Low gestational age (<32 weeks) increases risk
  • Low birth weight (<1,500 grams) is a significant risk factor
  • Oxygen therapy increases risk of ROP development

Approximate Synonyms

  • Premature Retinopathy
  • Retinopathy of Prematurity Stage 2
  • ROP Stage 2
  • Retinal Disease in Premature Infants
  • Vascular Retinopathy

Diagnostic Criteria

  • Infants born before 28 weeks of gestation
  • Infants weighing less than 1500 grams at birth
  • Comprehensive eye examination using indirect ophthalmoscopy
  • Abnormal blood vessel growth in the retina
  • Tortuous and extended retinal vessels in stage 2 ROP
  • Zone I: most severe, around optic nerve
  • Zone II: between Zone I and ora serrata
  • Zone III: peripheral retina
  • Presence of plus disease indicates more severe ROP

Treatment Guidelines

  • Monitor infants with stage 2 ROP
  • Use laser therapy to prevent progression
  • Apply cryotherapy as alternative treatment
  • Administer anti-VEGF injections to inhibit growth
  • Perform surgical intervention for detachment

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It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with questions about your medical condition.