Round hole, bilateral

This code indicates the presence of a round hole in the retina affecting both eyes. This retinal defect is a full-thickness break in the neurosensory retina, often occurring spontaneously or due to vitreous traction. It can lead to retinal detachment if not treated.

Apply this code when documentation explicitly states a "round hole" is present in the retina of both the right and left eyes. This diagnosis is typically made during an ophthalmoscopic examination. Ensure the physician's notes clearly specify the bilateral involvement.

• Differentiate from retinal tears (H33.31-) which are often horseshoe-shaped and have different clinical implications.
• Always confirm bilateral involvement; if only one eye is affected, use the appropriate unilateral code (H33.321 or H33.322).
• Code any associated retinal detachment (H33.0- or H33.1-) separately, with the round hole typically sequenced after the detachment if it's the cause.