Hypotony of eye due to ocular fistula, bilateral

This code signifies a condition where both eyes experience abnormally low intraocular pressure (hypotony) resulting from an ocular fistula. An ocular fistula is an abnormal communication or tract that allows aqueous humor to leak from the eye, leading to decreased pressure. This can be a complication of surgery, trauma, or inflammation.

Use this code when documentation clearly indicates hypotony in both eyes caused by an identified ocular fistula. This typically occurs post-surgically (e.g., trabeculectomy complications), following penetrating ocular trauma, or in cases of severe ocular inflammation leading to tissue breakdown. Documentation should specify the presence of a fistula and bilateral involvement.

• Ensure the medical record explicitly states "bilateral" involvement of hypotony due to an ocular fistula.
• Distinguish this from hypotony due to other causes (e.g., H44.41- for hypotony due to other ocular disease) or unspecified hypotony (H44.40-).
• Code any underlying cause of the ocular fistula (e.g., surgical complication, trauma) as an additional diagnosis.