Scleromalacia perforans, unspecified eye

This code describes a severe, progressive thinning and necrosis of the sclera, the white outer layer of the eye, without inflammation. It can lead to perforation of the globe and is often associated with systemic autoimmune diseases like rheumatoid arthritis. The condition can result in significant vision loss or blindness.

Use this code when documentation specifies scleromalacia perforans affecting an unspecified eye. This diagnosis is typically made by an ophthalmologist based on slit-lamp examination findings. Supporting documentation should include details of the scleral thinning and absence of active inflammation.

• Ensure the documentation explicitly states "scleromalacia perforans" and not other forms of scleritis or scleral thinning.
• If laterality is specified (right or left eye), use the more specific codes H15.051 or H15.052.
• Always code any underlying systemic disease, such as rheumatoid arthritis, as a primary or secondary diagnosis.