2025 ICD-10-CM code H04.123
(Valid) Effective Date: N/A Diseases of the eye and adnexa - Disorders of eyelid, lacrimal system and orbit 7 Feed
Dry eye syndrome of bilateral lacrimal glands.
Medical necessity for treatment of dry eye syndrome is established by the presence of signs and symptoms, such as dryness, irritation, burning, foreign body sensation, and visual disturbances, impacting the patient's quality of life.The severity of the condition and the chosen treatment should be documented and justified.
Diagnosis and treatment of dry eye syndrome involves a comprehensive eye examination, including assessment of the eyelids and cornea. Treatment options range from over-the-counter artificial tears to prescription medications like antibiotics or anti-inflammatory eye drops, tear-stimulating drugs, and eye inserts.The underlying cause, such as aging, hormonal changes, environmental factors, medication side effects, or systemic conditions like rheumatoid arthritis, diabetes, and thyroid disease, should also be considered and addressed.
In simple words: Dry eye syndrome means your eyes don't make enough tears or the tears dry up too quickly. This causes inflammation in the tear glands and the surface of both eyes. It can make your eyes feel dry, irritated, and burny. You might also have blurry vision, be sensitive to light or feel like something is in your eye.
Dry eye syndrome, also known as tear film insufficiency, is characterized by inflammation of the lacrimal glands and ocular surfaces of both eyes, leading to a deficiency in tear production or excessive tear evaporation.This condition can result in irritation, burning, foreign body sensation, redness, light sensitivity, watery eyes, and blurred vision. In severe cases, the cornea can be damaged, leading to impaired vision.
Example 1: A 65-year-old female presents with complaints of dry, itchy eyes, burning sensation, and occasional blurred vision in both eyes. Upon examination, the ophthalmologist diagnoses her with dry eye syndrome of bilateral lacrimal glands.Artificial tears are prescribed for initial management., A patient with rheumatoid arthritis experiences worsening dry eye symptoms in both eyes. The rheumatologist consults with an ophthalmologist, who diagnoses dry eye syndrome of the bilateral lacrimal glands secondary to the underlying autoimmune condition.Prescription anti-inflammatory eye drops are initiated., A patient taking antihistamines for seasonal allergies develops dry eye syndrome affecting both eyes.The physician advises discontinuing the antihistamines and recommends artificial tears to alleviate the symptoms.
Documentation should include the patient's symptoms, the findings of the eye examination (including assessment of eyelids and cornea), and any associated underlying conditions.The laterality (both eyes affected) should be explicitly stated.
- Specialties:Ophthalmology, Optometry, Rheumatology, Family Medicine, Internal Medicine
- Place of Service:Office, Outpatient Hospital, Inpatient Hospital