Scleromalacia perforans, right eye

This code describes a severe, destructive form of necrotizing scleritis affecting the right eye, characterized by thinning and perforation of the sclera without significant inflammation. It often occurs in patients with long-standing systemic autoimmune diseases, leading to exposure of the underlying uvea. The condition can result in significant vision loss or globe rupture.

Use this code when documentation explicitly states scleromalacia perforans affecting the right eye. This diagnosis is typically made by an ophthalmologist based on clinical examination findings, often in conjunction with a history of rheumatoid arthritis or other connective tissue disorders. Documentation should clearly indicate the specific eye affected.

• Ensure the documentation specifies "perforans" to differentiate from other forms of scleritis.
• Always confirm laterality (right eye) as separate codes exist for the left and bilateral eyes.
• Code any underlying systemic disease, such as rheumatoid arthritis, as a primary diagnosis if it is the cause of the scleromalacia.