Enophthalmos due to atrophy of orbital tissue, right eye

This code describes the inward displacement of the right eyeball within the orbit, specifically caused by a reduction in the volume of the orbital tissues. This atrophy can result from various underlying conditions, leading to a sunken appearance of the eye.

Assign this code when documentation clearly indicates enophthalmos of the right eye where the etiology is attributed to atrophy of the orbital tissues. This typically occurs following trauma, inflammation, or certain systemic diseases affecting orbital fat or muscle. Ensure the medical record specifies the affected eye.

• Differentiate from enophthalmos due to other causes, such as orbital fractures or congenital conditions.
• Always confirm the laterality (right eye) is explicitly documented.
• Look for documentation of the underlying cause of the orbital tissue atrophy, which may require an additional code.