ICD 10 CM H02.413 | Description & Clinical Information

ICD 10 H02.413 describes a medical condition characterized by the drooping of the upper eyelid over the eyeball, which is caused by an eyelid mass such as a neurofibroma or hemangioma, and is referred to as mechanical ptosis of an eyelid, with the provider documenting the presence of this condition in both eyelids.

Official Description Of H02.413

The ICD 10 CM book defines ICD 10 code H02.413 as:

Clinical Information

The diagnosis describes by the ICD 10 CM H02.413 code is mechanical ptosis, a condition caused by different factors such as eyelid neoplasms (neurofibroma or hemangioma), scarring as a result of surgery, inflammation, or injury. The severity of the condition determines the symptoms experienced by the patient.

Individuals with minor ptosis of both eyelids may not suffer from any symptoms except for the appearance of drooping lids that make the affected eye appear smaller than normal and create a skinfold between the eyebrow and eyelid. However, if the drooping eyelid covers the pupil, it impairs vision, leading to tension headaches. Patients should seek medical attention immediately if they experience vision impairment.

Upon visiting a healthcare provider, they will diagnose the patient’s condition by gathering their medical history, examining the signs and symptoms, and conducting an eye and eyelid examination process. During the examination, the healthcare provider will take measurements to determine the distance between the lid margin(s) and the center of the pupil. Additionally, they may apply phenylephrine (a type of decongestant) under the lid to observe the reaction.

There is no medical treatment for eyelid ptosis except to treat the underlying disease, if one exists. The correct technique in treating mechanical ptosis depends on the cause of the ptosis. Corrective surgery includes blepharoplasty, levator aponeurosis, and muscle resection, among other surgical techniques. The healthcare provider will determine the appropriate surgical approach depending on the cause of the ptosis.

For patients who do not prefer surgery, healthcare providers may provide glasses with a crutch attachment to hold the lid up. This option allows the patient to avoid invasive surgical procedures and still manage ptosis.

In conclusion, mechanical ptosis is a condition that affects the eyes and eyelids. Although the symptoms and severity vary from patient to patient, treatment options remain available. If you suspect that you have mechanical ptosis, it is crucial to seek medical attention immediately. With proper diagnosis and treatment, the condition can improve or even disappear entirely.