Vitreomacular adhesion, bilateral

This code signifies the presence of vitreomacular adhesion (VMA) affecting both eyes. VMA is an anomalous posterior vitreous detachment where the vitreous gel remains abnormally attached to the macula, potentially causing tractional forces on the retina. This condition can lead to visual distortion or decreased acuity.

Use this code when documentation explicitly states bilateral vitreomacular adhesion. This diagnosis is typically made via optical coherence tomography (OCT) imaging, which visualizes the persistent vitreous attachment to the macula. The physician's assessment and diagnostic findings should clearly indicate involvement of both eyes.

• Ensure documentation specifies "bilateral" involvement; otherwise, use the appropriate unilateral code.
• Differentiate from vitreomacular traction (VMT), which implies a more significant pulling force and often requires a different code.
• Always review the OCT report and physician's interpretation to confirm the diagnosis and laterality.