Microphthalmos

This code represents a congenital anomaly characterized by an abnormally small eyeball. It can affect one or both eyes and may be associated with other ocular or systemic malformations.

Use this code when documentation clearly indicates a diagnosis of microphthalmos, a developmental defect resulting in a globe that is smaller than normal. This diagnosis is typically made by an ophthalmologist based on clinical examination and imaging studies.

• Do not code this with cryptophthalmos syndrome (Q87.0) as per the Excludes1 note.
• Specify laterality (right, left, or bilateral) if documented, using the appropriate subcategory.
• Look for associated congenital anomalies or syndromes that may also need to be coded.