Scleritis with corneal involvement, bilateral

This code signifies inflammation of the sclera (the white outer layer of the eye) that has extended to involve the cornea in both eyes. Scleritis with corneal involvement is a severe form of ocular inflammation that can lead to significant vision impairment and structural damage if not promptly treated.

Apply this code when documentation clearly indicates bilateral scleritis with specific mention of corneal involvement, such as keratitis or corneal thinning secondary to the scleritis. This diagnosis is typically supported by ophthalmological examination findings, including slit-lamp biomicroscopy and imaging studies.

• Ensure documentation specifies bilateral involvement; otherwise, use the appropriate unilateral code.
• Distinguish from episcleritis, which is a less severe, superficial inflammation and does not involve the cornea.
• Code any underlying systemic conditions (e.g., autoimmune diseases) that may be causing the scleritis as primary diagnoses, with this code as a secondary diagnosis.