Scleromalacia perforans, left eye

This code describes a severe, progressive form of scleritis characterized by thinning and necrosis of the sclera, leading to perforation of the globe. It is an inflammatory condition affecting the left eye, often associated with systemic autoimmune diseases.

Use this code when documentation specifies scleromalacia perforans affecting the left eye. This diagnosis is typically made by an ophthalmologist based on slit-lamp examination findings and often in conjunction with a history of rheumatoid arthritis or other connective tissue disorders.

• Ensure laterality is clearly documented as "left eye" to support this specific code.
• Always code any underlying systemic disease, such as rheumatoid arthritis (M05.0-M06.9), as a primary or secondary diagnosis.
• Distinguish from other forms of scleritis (H15.00-H15.04) which do not involve perforation or severe thinning.