1. Eye and Ocular Adnexa
Lamon Willis

2. Anatomy

3. Anatomy Eyeball – an inch (25mm) in diameter Sclera – white of the eye
Cornea – transparent
Anterior chamber
Pupil and Iris
Choroid – vascular layer
Retina – pigmented nerve layer
The eyeball is a spheroidal body located anteriorly in the orbit of the skull. It is about an inch (25 mm) in diameter and consists of anterior and posterior portions. It is suspended by six extrinsic muscles that control its movement. The outer layer of the posterior portion is tough connective tissue, the sclera (or “white of the eye); it is continuous anteriorly with the cornea. It is the white portion of the eye and is important in maintaining a stable pressure in the eye.
The cornea is transparent and highly sensitive to touch; covering the portion of the eye seen from the anterior side as the pupil and iris. The middle or vascular layer is the choroid, a very thin layer between the sclera and retina. The internal layer is the retina; this pigmented nerve layer lines the back of the eye sensing light and color, directly in contact with and sending messages along the optic nerve to the brain. The optic disc is an elevated visible portion of the optic nerve inside the eye. Images transmitted are inverted (upside down); the brain inverts these images back.
The anterior chamber is the area behind the cornea, anterior to the lens. It is filled with aqueous humor, a clear liquid similar to salt water.

4. Anatomy Optic nerve and Optic disc Iris – regulates light entering
Pupil
Vitreous humor – fills posterior segment
Ciliary body – suspensory ligaments of lens
Lens – changes shape
The iris is the colored part of the eye; doughnut-shaped and the space between its free edges is the pupil. The iris has two sets of smooth muscles: a radially arranged set is responsible for enlargement of the pupil and a circularly arranged set decrease pupil size when contracted. The iris regulates light allowed in the eye working like the lens of a camera. The pupil is an opening surrounded by the iris; it adjusts according to the iris. When you have an eye exam, the doctor (ophthalmologist or optometrist) places drops containing medication on the eye relaxing the iris, making the pupil large to be able to see inside the eye.
The posterior four-fifths of the eyeball is occupied by a transparent jelly-like material, the vitreous body. The vitreous membrane forms the suspensory ligament of the lens. Vitreous humor is a clear Jell-O-like substance filling the posterior segment of the eye. The ciliary body is directly continuous anteriorly with the choroid; its processes extend to the iris. They are important suspensory ligaments of the lens. The lens is not hard; it is able to change shape to accommodate focusing.

5. Anatomy Conjunctiva Muscles pink eye cul-de-sac external
The conjunctiva is a thin mucous membrane lining the inner surface of the eyelid. It folds back to cover a portion of the sclera and the anterior surface of the eyeball. The conjunctiva does not cover the cornea; it secretes a substance moisturizing the eye. “Bloodshot eyes” and “pink eye” occur with dilation of the vessels in the conjunctiva. The conjuctiva does not go all the way around the eye, if folds forming a cul-de-sac and doubles back inside the eyelids. When something gets in your eye or you lose a contact, it cannot go back behind the eye or further, the farthest it can go is to this cul-de-sac.
There are two groups of muscles associated with the eye, extrinsic and extrinsic. They work together, never one alone. Extrinsic eye muscles move the eyeball in its bony orbit; intrinsic eye muscles move structures within the eyeball. The external muscles consist of three sets: two side muscles, two top and bottom muscles and oblique. The lateral rectus muscle allows the eye to turn out and horizontally, temporally (towards the temple) and the medial rectal muscle medially (towards the bridge of the nose. If you turn your eye up and out, that is the superior rectus muscle; the inferior rectus muscle allows you to turn your eye down and out. The oblique muscles work a little differently allowing the eye to turn up an in for the inferior, or down and in for the superior oblique muscles. These six muscles together coordinate eye movements.

6. Anatomy Lacrimal gland Glaucoma Refraction 20/20 intraocular pressure
The lacrimal gland is located under the upper eyelid and below the eyebrow bilaterally, in the outer most corner of the eye. Fluid secreted serves to clean the eye and moisturize the cornea and conjuctiva. Lacrimation, is secretion of tears; when this term is used, it usually means in excess. When tears run down the face, they also drain out the nose – thus the need for a Kleenex when crying. Lacrimation can be excessive or too little; lacrimal plugs can be placed to block tears; artificial tears may be used when natural tears are lacking. Moisture and fluid is important to eye health. Blinking evenly spreads fluid over the eye. Glaucoma is an eye disease characterized by increased intraocular (inside the eye) pressure resulting in atrophy of the optic nerve and can result in blindness. Dehydration or dryness of eyes can result in difficulty with visual acuity and damage the eye. Pressure problems in the eye can affect oxygen delivery to the eye causing problems. Reduction of fluid in the eye affects shape and will affect vision. Refraction is the deflection of light when it passes from one medium into another. In order for this to work properly in the eye, the cornea, aqueous, lens and vitreous, that light passes through, must be clear. In the doctor’s office, refraction is use of lenses to improve vision. LASIK is surgical reshaping of the cornea to change refraction, improve vision and eliminate the need for glasses. Wearing contacts or glasses alters refraction to improve vision.
If one has 20/20 vision (considered normal), what does it mean? Eye exams are done with eye charts; a person is placed at a distance of 20 feet away from the chart, covers one and reads the chart. 20/20 vision means a person is able to see at 20 feet what a person with normal vision can see. A score of 20/40 indicates the patient can see at 20 feet what a person with normal vision can see at 40 feet. A score of 20/200 is considered legally blind. Eyes are tested separately and may have different “scores.”

7. Anatomy External ear Middle ear Oval window tragus auricle or pinna
Tympanic membrane
Ossicles – malleus, incus, stapes
Eustachian tube
Oval window
The ears are sensory organs comprising the auditory system. The ear has three regions, external ear, middle ear and inner ear. All three regions are involved in hearing, only the inner ear is concerned with balance. You can see most of the external ear (external acoustic meatus, auricle or pinna); it serves to protect the eardrum and middle ear. It is also a sound collecting system funneling sound waves to travel through the ear canal to the tympanic membrane (or eardrum). It is composed of cartilage and loose fitting skin. The tragus is a small projection just in front of the ear canal. The lobule of the ear hangs inferiorly, piercing this structure is popular. The auricle opens into the external auditory canal providing a passageway for sound waves to enter the ear. The external auditory canal courses through the temporal bone of the skull approximately one inch in length and a half inch in diameter. This canal extends to the tympanic membrane or eardrum which separates the external ear from the middle ear. Tiny hairs and modified sweat glands line the canal; the glands secrete cerumen, or earwax preventing dust and other foreign objects from entering the ear. Too much earwax can impede sound transmission and hearing.
The middle ear begins at the tympanic membrane. It is an air filled chamber in the temporal bone. Besides the tympanic membrane, the middle ear contains three tiny bones and the eustachian tube. The tympanic membrane is made of connective tissue with rich blood vessels and nerves. It is connected to the throat and nasopharynx via the eustachian tube. Connection of the ear and throat make the ears susceptible to infections like otitis media due to bacteria traveling up the Eustachian tube to the ear. The tympanic membrane vibrates in response to sound waves converted into mechanical vibrations. Vibrations are passed through the middle to the inner ear by the three tiny middle ear bones. Middle ear bones, or ossicles, are the smallest bones in the body and are called: malleus (hammer); incus (anvil); and stapes (stirrup) named for their shape. Vibration from the tympanic membrane is transferred to the ossicles and then to the oval window, a membrane separating the middle ear from the inner ear. The auditory or eustachian tube functions to equalize the pressure on both sides of the tympanic membrane, this allows air to pass from the pharynx into the middle ear. This tube is normally collapsed, with swallowing or chewing the tube opens allowing air to move as needed.

8. Anatomy Inner ear Labyrinth Membranous labyrinth – hair cells
Vibrations into nerve impulse
Cochlea, Vestibule, Semicircular canal
Balance – utricle, saccule
Oval window, round window
The inner ear is an intricate maze of fluid-filled tubes running through the temporal bone of the skull. This bony labyrinth is filled with fluid called perilymph. Inside this bony labyrinth is a second set of tubes called the membranous labyrinth filled with endolymph. This membranous labyrinth contains the actual hearing cells, or hair cells of the Organ of Corti. Movement of these hair cells converts the vibrations into a nerve impulse. The bony labyrinth has three parts; the front portion is the snail-shaped cochlea, the rear portion the semicircular canal; interconnecting the cochlea and the semicircular canal is the vestibule. The vestibule contains sense organs responsible for balance called the utricle and the saccule. The inner ear has two membrane covered outlets into the air filled middle ear, the oval window and the round window. The stapes in the middle ear vibrates on the oval window affecting fluid in the inner ear transmitting that vibration. The round window serves as the pressure valve bulging outward as fluid pressure rises in the inner ear. Nerve impulses from the inner ear travel along the cochlear nerve (8th cranial nerve) for hearing and to the vestibular nerve (8th cranial nerve) for equilibrium. The semicircular canals and vestibule function to sense movement as an acceleration or deceleration with position changes.

9. CPT Procedures An eye typically is removed for one of three reasons:
the eye has a malignancy;
the eye is blind and very painful, or
the eye is blind and disfiguring.

10. CPT Procedures There are three types of removals (65091–65114):
Evisceration—The contents of the eyeball are scooped out but the sclera shell remains connected to the eye muscles, so the prosthesis, fitted into the globe, will have natural movement.
Enucleation—The connections (muscles, vessels, and optic nerve) are severed and the entire eyeball is removed en mass.

11. CPT Procedures
Exenteration—Surrounding skin, fat, muscle and bone is removed.
In any removal, a temporary implant may be placed to protect the void that may later hold a permanent implant.
This temporary implant is included in the procedure and not reported separately.
The implant codes reference permanent implants with aesthetic properties.

12. CPT Procedures
Today, whenever a laser can be used to surgically cauterize, cut, destroy, or repair the eye, it will be used instead of a knife.
When you are reviewing the codes in CPT’s Eye and Ocular Adnexa section, assume any procedure with a laser approach is preferred to an open approach.

13. CPT Procedures Some surgeries require incisions.
Removal of a lens with a cataract requires an incision, so the lens can be extracted and an IOL inserted.
Even so, cataract surgery is done microscopically today, and tiny incisions in the limbus are all that is required.

14. CPT Procedures Injections are sometimes required to numb the eye.
A retrobulbar or Tenon’s capsule injection are two common approaches for delivery of anesthetic.
These nerve blocks are bundled into the procedures and not reported separately.

15. CPT Procedures
The majority of procedures performed on the anterior segment of the eye are microsurgeries performed using an operating microscope.
The scope, otherwise reported with 69990, would not be reported separately.

16. CPT Procedures
Surgeries on the iris and trabecular meshwork, including goniotomy, are usually a therapeutic treatment for glaucoma to improve the flow of aqueous in the eye.
Sometimes aqueous is removed for therapy in paracentesis. This procedure also can be performed diagnostically.

17. CPT Procedures
There are many procedures performed on the ocular adnexa.
The extraocular muscles may be lengthened or shortened.
In some cases, the procedure is not completed until the patient is awakened and lengthy sutures extruding from the back of the eye adjusted to ensure perfect binocular vision.
These adjustable sutures are reported with add-on code

18. CPT Procedures
The eyelids and conjunctiva are included in the adnexal codes.
In prosthetics following evisceration, the conjunctiva may traverse an artificial cornea.
When conjunctiva is damaged, buccal mucosa may be harvested and used as a graft (68325).

19. CPT Procedures
Procedures to remove excess skin from the eyelid (blepharoplasty) are found in the integumentary chapter.
Blepharoplasty codes in the Eye and Adnexa section involve more complex structures within the eye.