Stenosis of bilateral lacrimal sac

This code represents a narrowing or obstruction of both lacrimal sacs, which are small reservoirs that collect tears before they drain into the nasal cavity. This bilateral stenosis impedes the normal outflow of tears, leading to epiphora (excessive tearing) and potential recurrent infections. It can be congenital or acquired due to inflammation, trauma, or tumors.

Use this code when documentation clearly indicates a diagnosis of lacrimal sac stenosis affecting both eyes. This diagnosis is typically made based on clinical examination, patient symptoms of bilateral epiphora, and confirmed by dacryocystography or lacrimal irrigation. Ensure the medical record specifies the bilateral nature of the condition.

• Differentiate from lacrimal duct stenosis (H04.56-) or lacrimal gland disorders (H04.1-).
• Ensure documentation specifies "bilateral" for accurate code assignment; otherwise, laterality-specific codes should be used.
• Consider sequencing with codes for associated conditions, such as dacryocystitis (H04.3-) if present.