Internal ophthalmoplegia (complete) (total), right eye

This code describes a complete paralysis of the intrinsic muscles of the right eye, specifically the ciliary muscle and iris sphincter. This condition results in fixed, dilated pupils and loss of accommodation, meaning the eye cannot adjust focus for near vision. It is often a manifestation of underlying neurological or pharmacological issues.

Use this code when documentation explicitly states complete internal ophthalmoplegia affecting the right eye. This typically occurs due to damage to the parasympathetic nerve supply to the eye, such as from oculomotor nerve palsy, certain systemic diseases, or topical anticholinergic medications. Clinical notes should detail the fixed, dilated pupil and inability to accommodate.

• Differentiate from partial internal ophthalmoplegia or isolated mydriasis, which may have different underlying causes and coding.
• Always code any underlying cause or associated condition, such as oculomotor nerve palsy (G51.0), in addition to this code.
• Ensure documentation specifies "complete" or "total" involvement of the intrinsic muscles of the right eye to support this specific code.