Enophthalmos due to trauma or surgery, left eye

This code describes the inward displacement or sinking of the left eyeball within the orbit, specifically when caused by a traumatic injury or a surgical intervention. This condition can result from orbital fractures, orbital fat atrophy post-trauma, or complications following orbital or ocular surgery.

Use this code when documentation clearly states enophthalmos affecting the left eye, and the etiology is directly linked to a prior trauma (e.g., orbital blow-out fracture) or a surgical procedure (e.g., orbital decompression, enucleation). Supporting documentation should detail the history of trauma or surgery and confirm the presence of enophthalmos.

• Always sequence the underlying cause (e.g., orbital fracture, surgical complication code) before this code, if applicable.
• Distinguish from enophthalmos due to other causes (e.g., congenital, inflammatory) which have different codes.
• Ensure laterality is accurately documented and coded; this code specifically refers to the left eye.