H35.371 — Puckering the macula, best eyeH35.372  Puckering that macula, left eyeH35.373  Puckering of macula, bilateral

TitleMacular Pucker

CategoryOther Retinal Disorders

DescriptionMacular wrinkle occurs as soon as a contracting epiretinal membrane distorts the underlying retina.

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Corneal edema is a clinical sign of corneal disease. The problem is identified by an increase in corneal thickness an additional to an abnormal build-up of fluid. The excess fluid produces a ede of the corneal tisssue and also can an outcome in a ns of stromal transparency that produces blurred vision or intuitive impairment.

Macular pucker is a clinico-anatomic summary of structural damages to the retina caused by epimacular proliferation or vitreomacular traction.

Epimacular proliferation is characterized by the formation of collagenous membranes on the surface ar of the retina as the membranes grow, they can develop contractile nature that develop traction pressures on the surface that the macula Traction on the macula can an outcome in traction maculopathies such together macular pucker, cellophane maculopathy, vitreomacular traction syndrome or macular hole
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 Common Names because that Epimacular ProliferationEpiretinal membraneCellophane maculopathyMacular puckerPreretinal macular gliosisPreretinal macular fibrosisSurface wrinkling maculopathyEpiretinal astrocytic membranePreretinal vitreous membraneSilk-screen retinopathy

The histopathological changes essential to develop epiretinal membranes usually begins with a posterior vitreous detachment. In some people, it’s thought that the separation of the vitreous membrane from the retinal surface ar damages the retina structurally.

Structural Damage to the Eye

Posterior vitreous detachment to produce focal areas of damage on the inside retinal surfaceImmune system solution to damaged areas results in inflammation reaction on the inside retinal surfaceGlial cells from the neurosensory retina thrive through breaks in the interior limiting membrane that the damaged retinaGlial cells incorporate with inflammation cells and also collagen cells to kind membranesMembranes kind attachments to the inside retinal surfaceMembranes proliferate in the main retina and also maculaMembranes contract over time and also create traction forces on retinal tissueUnderlying retina i do not care structurally damaged an additional to traction forces

Functional damages to the Eye

Traction ~ above the macula produces decreased visual acuity based upon the lot of force and its duration of actionVascular incompetence secondary to macular traction (especially in diabetic patients) outcomes in steady loss the acuityDiffuse macular edema usually results in lessened visionFoveal cysts usually results in reduced visionMacular detachment outcomes in reduced vision

The main goal that the diagnostic review in a patience with macular wrinkle is to achieve the following:

Evaluate epiretinal membrane density, thickness, and location in relationship to the retinaDetermine the visibility or lack of vascular incompetence an additional to the macular tractionDetermine the presence or lack of macular edema an additional to the traction Prescribe a treatment program to manage the traction maculopathy and also prevent permanent vision loss 

Patient History

The symptom of traction maculopathy differ from no symptoms to significant visual impairment. Patients with early condition may report blurred vision, diminished vision, or mild intuitive distortion. An ext advanced gift often produce metamorphopsia, micropsia, or various other abnormal visual distortions the shape and size.

Patients with traction maculopathy usually present with the following selection of decreased visual acuity. 

20/25 acuity or far better is present in 56-67% the patients20/40 acuity or far better is existing in 75-85% of patient 20/400 acuity or worse is current in 2-5% the patients

Clinical Appearance of the Retina

A broad, glial epiretinal membrane adheres to the retinal surface and also is anchored in the vascular arcades the the appropriate eye
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Macular pucker in in the best eye of a78-year-old v 20/40 intuitive acuity

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Norma macular figure in the left eye that a 78-year-old through 20/20 intuitive acuity

DIAGNOSTIC TESTS

Retinal Laser Scan

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Optical Coherence TomographyOCT experimentation can recognize the presence or lack of an epiretinal membraneOCT testing canectively measure the impacts of the epiretinal membrane on the macular surfaceSector plot analysis on the appropriate eye is abnormal- enhanced retinal thickness superiorly in the right maculaSector plot evaluation on the left eye is normalHigh resolution scan expose deformation that the retinal surface in the ideal eyeHigh resolution scan reveals regular foveal contour in the left eye

Classification that epiretinal membranes is based upon the apperance the the membrane and also the basic retina and blood vessels.

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 Grade 0 membranesTranslucent membrane not linked with any type of retinal distortionKnown together cellophane maculopathy due to the fact that of cellophane-like sheen reflect from the retinal surface as the membrane is visualized ophthalmoscopically.Patient is 70-year-old white female with 20/25 intuitive acuity
   
Patient in the complying with images is a 42-year-old black woman 

Grade 1 membranes

20/30 intuitive acuityVitreous membrane causes a wrinkling or puckering the the retinal surface ar via macular tractionMacular traction force is tangential to the macular surfaceTraction top top macular tissues produces gradual structural damage to the tissueFunctional loss of vision second to macular damages is concerned the soot of the traction forces and also their term of action
 
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 Optical Coherence TomographyShallowing the foveal depression in the left maculaNo cystoid macular edemaNo operation treatment at this time unless patient is intolerant of intuitive blur or distortion 
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 Patient in the following images is a 72-year-old black color woman

Grade 2 membranes

20/50 visual acuityVitreous membrane has actually a thick, opaque appearanceRetinal edemaOccasional little hemorrhagesOccasional cotton-wool spots
   
Bilateral Presentation that Epiretinal Membrane20/25 visual acuity in the left eyeGrade 1 membrane in the left eyeGrade 2 membrane in the right eye 
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 Optical Coherence TomographyOCT scan expose epiretinal membrane overlying the right maculaSector plot analysis is abnormal — diffuse boost in macular thickness measured in micronsHigh resolution scan is abnormal — deformation of the retinal profile with a ns of the foveal depressionMacular thickness map is abnormal — increased probability that pathology based on comparison come normative database
   
Optical Coherence TomographyOCT scan expose an epiretinal membrane surrounding the left maculaSector plot analysis is normalProfile that the retinal surface ar is normalMacular thickness map is normal 
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Differential diagnoses would incorporate other illness that re-publishing the clinical indications of macular pucker. This would include diseases or conditions that develop abnormal vitreomacular interfaces

Cystoid macula edemaPosterior uveitis Retinal vascular occlusive diseaseDiabetic retinopathy

Palliative Treatment

Observation in the early stages of the condition and once there is minimal traction ~ above the macula

Pharmacologic Treatment

On January 1, 2013, the FDA authorized JETREA (ocriplasmin) for the treatment of symptomatic vitreomacular adhesion. JETREA is a proteolytic enzyme yielded in a solitary 3.5mg/mL sheep that alters the biochemistry the the vitreous to produce a pharmacologic vitreolysis.

JETREA Intravitreal Injection

Liquefies vitreousProduces a separation between the vitreous cortex and the inner limiting membraneResolution of vitremacular traction in 26% of cure group during Phase III clinical studies

Potential side impacts include the following

Intraocular inflammationIntraocular infectionIntraocular hemorrhageIncreased intraocular pressureLens subluxationFloatersRetinal detachmentChanges in shade vision

Surgical Treatment

Pars Plana Vitrectomy through Membrane Peel

Potential side impacts include the following

Intraocular inflammationIntraocular infectionIntraocular hemorrhageRetinal detachmentExtended recovery period

1. Facts about Macular Pucker. National Eye Institute. Apr 2012. Http://www.nei.nih.gov/health/pucker/pucker.asp. Critical accessed august 17, 2014.2. Joyce K. Gurwood A. A Look at VMT Syndrome. 15 Oct 2011. Http://www.revoptom.com/content/c/30708/. Last accessed respectable 17, 2014.3. Convertino J. Marcus S. Wong A. Go OCT assist Diagnose VMTS? RevOptom. 15 jan 2007. Http://www.revoptom.com/content/d/news_review/c/15537/. Last accessed august 12, 2014.4. Vitreomacular traction syndrome. Nationwide Retina Institute. Http://nationalretina.com/RetinalConditions/VitreomacularTractionSyndrome.aspx. Critical accessed April 3, 2014.5. Morris R, Witherspoon CD, Kuhn F, Nelson S, Priester B, Mayne R. Traction maculopathy. Retinology Today. 6. Vitreomacular traction. Williamson Eye Institute. Http://www.williamsoneyeinstitute.com/retina-center/vitreomacular-traction. Last accessed April 3, 2014.


ICD-9 DIAGNOSIS CODES

362.56Macular puckering


ASSOCIATED CPT CODES

92250Fundus photography

92225Extended ophthalmoscopy

92134Macula OCT scan

92083Visual field examination

92275Electroretinography

92283Color vision examination


ASSOCIATED instance REPORTS

Preoperative evaluation and postoperative monitoring for epiretinal membrane surgery


DISEASE INDEX

Ocurrence

The ubiquity of macular pucker is 2% that the population greater than 55-years-old.

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Distribution

Macular wrinkles is not evenly spread throughout the population. Its circulation increases v age.

Risk Factors

Advancing ageVitreous detachmentRetinal detachmentUveitisDiabetics through retinal complications