Coloboma of optic disc, bilateral

This code signifies a congenital defect of the optic disc, characterized by a notch or gap in the optic nerve head, affecting both eyes. This malformation results from incomplete closure of the embryonic fissure during development. It can lead to varying degrees of visual impairment.

Apply this code when documentation explicitly states a diagnosis of bilateral coloboma of the optic disc. This is typically identified during an ophthalmological examination, often in pediatric patients or individuals presenting with unexplained vision loss. Supporting documentation should include findings from fundoscopy or imaging confirming the bilateral nature of the coloboma.

• Ensure the documentation clearly specifies "bilateral" involvement; otherwise, a unilateral code may be more appropriate.
• Distinguish from other congenital optic disc anomalies like optic nerve hypoplasia or morning glory syndrome.
• Code any associated visual disturbances or complications separately, such as amblyopia or retinal detachment, if documented.