Inferior rectus muscle entrapment, left eye

This code describes a condition where the inferior rectus muscle of the left eye becomes trapped, often due to trauma such as an orbital fracture. This entrapment restricts the eye's movement, particularly upward gaze, and can lead to diplopia (double vision) and pain.

Apply this code when documentation clearly indicates mechanical restriction of the left inferior rectus muscle, typically confirmed by imaging (e.g., CT scan showing muscle incarceration in a fracture site) and clinical examination. This is often seen in cases of orbital blow-out fractures affecting the orbital floor.

• Ensure laterality is precisely documented (left eye).
• Distinguish from paresis or paralysis of the inferior rectus muscle, which would be coded differently.
• Always sequence this code after the primary injury (e.g., orbital fracture) if applicable.