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H47.293

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ICD-10-CM H47.293: Other Optic Atrophy, Bilateral

⚠️ CRITICAL CLINICAL ALERT

Bilateral optic atrophy represents SEVERE visual disability with high risk of functional blindness. Early recognition and urgent treatment of underlying causes is essential to prevent permanent bilateral vision loss.

Quick reference

ElementValue
ICD-10-CM codeH47.293
Official descriptorOther optic atrophy, bilateral
Parent categoryH47.29 - Other optic atrophy; H47.2 - Optic atrophy; H47 - Other disorders of optic nerve and visual pathways
ICD-10-CM chapterH00-H59 (Diseases of the eye and adnexa) → H46-H47 (Disorders of optic nerve and visual pathways)
LateralityBilateral (both eyes OU)
Billable✓ Yes (laterality-specific terminal code)
Clinical definitionOptic nerve degeneration affecting both eyes, either from disc swelling (secondary) OR retinal/choroidal disease (consecutive); excludes primary, glaucomatous, and hereditary types
Subtypes includedBilateral secondary optic atrophy (post-papilledema, post-optic neuritis, post-AION); Bilateral consecutive optic atrophy (retinal disease); Temporal pallor both eyes
HCC statusNot a CMS-HCC code (manifestation; underlying cause may be HCC-relevant)
Chronic conditionYes (irreversible bilateral optic nerve damage; severe permanent visual disability)
Functional impactHigh risk of legal blindness or functional blindness; significant impact on activities of daily living, driving, employment
PrognosisGuarded to poor; bilateral optic atrophy represents end-stage damage; extent of recovery depends on underlying cause, duration, and treatment timing

Short description

H47.293 codes bilateral other optic atrophy - optic nerve degeneration affecting both eyes that does NOT fit primary, glaucomatous, or hereditary classifications.

This includes:

  • Bilateral secondary optic atrophy: Follows chronic bilateral disc swelling (papilledema from IIH, bilateral optic neuritis, bilateral AION) with indistinct disc margins, grey disc color, glial proliferation.
  • Bilateral consecutive optic atrophy: Results from bilateral retinal/choroidal disease (bilateral CRAO, extensive bilateral PRP, bilateral retinochoroiditis) without preceding disc edema.
  • Bilateral temporal pallor of optic discs (specified in H47.29 descriptor).

Bilateral presentation indicates:

  • Systemic or symmetric pathology affecting both optic nerves.
  • Greater functional disability than unilateral disease.
  • Higher urgency for treatment to prevent total blindness.

Full description (clinical context)

Significance of bilateral optic atrophy

Bilateral optic atrophy is clinically distinct from unilateral disease:

Functional impact:

  • Severe visual disability - loss of binocular vision, depth perception, reading ability, driving capacity.
  • High risk of legal blindness (best-corrected VA <20/200 in better eye OR visual field <20° in better eye).
  • Loss of independence - inability to perform ADLs, employment limitations, need for low vision rehabilitation/assistance.

Etiologic considerations:

  • Bilateral papilledema → suggests elevated intracranial pressure (IIH, brain tumor, venous sinus thrombosis, hydrocephalus).
  • Bilateral optic neuritis → suggests neuromyelitis optica spectrum disorder (NMOSD), MOG antibody disease, sarcoidosis, CRION more than MS.
  • Bilateral sequential vision loss → toxic/nutritional, Leber hereditary optic neuropathy (though LHON is H47.22), bilateral AION (rare).

Treatment urgency:

  • Bilateral papilledema requires urgent ICP reduction to prevent bilateral blindness.
  • Bilateral optic neuritis (especially NMOSD) requires aggressive immunotherapy to prevent severe permanent deficits.

Types of bilateral other optic atrophy

1. Bilateral secondary optic atrophy

Definition: Bilateral optic atrophy that follows chronic bilateral optic disc swelling.

Pathophysiology:

  • Bilateral optic nerve fibers exhibit marked degeneration with profuse glial tissue proliferation.
  • Optic nerve head architecture lost bilaterally.
  • Disc margins indistinct/blurred bilaterally.
  • Disc color grey (not white).
  • Retinal vessels may be sheathed bilaterally.

Common causes of bilateral disc swelling:

Bilateral papilledema (most common bilateral cause)

Idiopathic intracranial hypertension (IIH) - MOST COMMON:

  • Demographics: Predominantly young obese females (90%); incidence 12-20 per 100,000 in obese women of childbearing age.
  • Pathophysiology: Elevated ICP (>25 cm H₂O) without mass lesion or hydrocephalus → bilateral papilledema (practically 100% of cases) → axoplasmic flow stasis → intraneuronal ischemia → RGC axon death → secondary optic atrophy if untreated.
  • Presentation: Headache (most common - 90%), transient visual obscurations (70% - brief episodes of bilateral vision darkening/blurring lasting seconds), pulsatile tinnitus (60%), diplopia from sixth nerve palsy (30%).
  • Visual field defects: Enlarged blind spot initially (earliest finding) → nerve fiber bundle defects (arcuate scotomas, nasal steps) → progressive peripheral constriction → central vision threatened late.
  • Fundus findings: Bilateral optic disc swelling, venous engorgement, loss of venous pulsation, hemorrhages over/adjacent to disc, blurred margins, disc elevation, Paton’s lines.
  • Papilledema can be asymmetric or rarely unilateral (3 cases reported; due to anatomic variations in optic canal diameter, lamina cribrosa compliance, optic nerve sheath anatomy).
  • Chronic untreated papilledema → secondary optic atrophy → permanent bilateral vision loss.

Brain tumors causing bilateral papilledema:

  • Glioblastoma, meningioma, metastases causing mass effect.
  • Posterior fossa tumors (brainstem glioma, medulloblastoma, ependymoma) obstructing CSF flow.
  • Pineal region tumors causing aqueductal stenosis.
  • Bilateral papilledema from elevated ICP (not direct optic nerve invasion).

Cerebral venous sinus thrombosis:

  • Thrombosis of sagittal, transverse, or sigmoid sinuses → impaired CSF absorption → elevated ICP → bilateral papilledema.
  • Risk factors: hypercoagulable states, pregnancy, oral contraceptives, infection, dehydration.
  • Venous sinus stenosis seen in 90-100% of IIH patients (debate whether cause or effect).

Hydrocephalus: >

  • Obstructive (aqueductal stenosis, tumor blocking ventricles) or communicating.
  • Bilateral papilledema from elevated ICP.

Meningitis/encephalitis:

  • Bacterial, viral, fungal, cryptococcal (especially in immunocompromised).
  • Inflammation → cerebral edema → elevated ICP → bilateral papilledema.

Bilateral optic neuritis

Neuromyelitis optica spectrum disorder (NMOSD) - KEY CONSIDERATION:

  • Autoimmune demyelinating disease distinct from MS; anti-AQP4 antibodies (80%+ cases).
  • Bilateral optic neuritis MORE COMMON than MS (bilateral simultaneous or sequential).
  • Severe visual loss at onset with poor recovery compared to MS.
  • Recurrent optic neuritis common → cumulative damage → bilateral optic atrophy.
  • More severe RNFL thinning than MS (RNFL <75 µm suggests NMOSD over MS).
  • MRI findings: Longitudinally extensive optic nerve lesions (≥2 segments - 75% of NMO vs 33% of MS), posterior optic nerve and chiasmal involvement common.
  • Associated myelitis: Longitudinally extensive transverse myelitis (≥3 vertebral segments).

MOG antibody disease (MOGAD):

  • Anti-myelin oligodendrocyte glycoprotein antibodies.
  • Often presents with bilateral optic neuritis (simultaneous or sequential).
  • Recurrent episodes common.
  • Better prognosis than NMOSD but worse than MS; intermediate severity.

Multiple sclerosis (MS) - less commonly bilateral:

  • Unilateral optic neuritis more typical (MS is most common cause of optic neuritis overall but bilateral less common).
  • When bilateral: Usually sequential (not simultaneous); milder than NMOSD; better recovery (93% achieve ≥20/40 VA within 1 year).
  • MRI: Anterior (retrobulbar/canalicular) optic nerve lesions (70% MS vs 36% NMOSD); shorter lesions.
  • Bilateral optic atrophy can develop after multiple recurrent unilateral episodes or bilateral disease.

Chronic relapsing inflammatory optic neuropathy (CRION):

  • Steroid-responsive recurrent optic neuritis.
  • Relapses with steroid taper.
  • Requires long-term immunosuppression.
  • Can be bilateral.

Sarcoidosis:

  • Granulomatous inflammation.
  • Can cause bilateral optic neuritis.
  • Associated systemic manifestations (lung, skin, lymph nodes).

Infectious causes:

  • Syphilis, Lyme disease, tuberculosis, HIV, herpes zoster.
  • Can cause bilateral optic neuritis → atrophy.

Bilateral anterior ischemic optic neuropathy (rare)

Bilateral arteritic AION (giant cell arteritis):

  • High risk of sequential bilateral involvement without urgent treatment (fellow eye involved within days to weeks in 25-50% if untreated).
  • Elderly patients (>70 years), jaw claudication, scalp tenderness, temporal artery tenderness, elevated ESR/CRP.
  • Urgent high-dose IV steroids prevent second eye involvement.

Bilateral non-arteritic AION:

  • Uncommon; usually sequential (not simultaneous).
  • Fellow eye risk ~15% over 5 years.
  • Associated with “disc at risk” (small cup-to-disc ratio) bilaterally, diabetes, hypertension, sleep apnea.

2. Bilateral consecutive optic atrophy

Definition: Bilateral optic atrophy associated with bilateral retinal/choroidal disease without preceding disc swelling.

Pathophysiology:

  • Bilateral retrograde degeneration of RGC axons after bilateral retinal pathology destroys RGCs.
  • Optic discs waxy pale bilaterally with normal disc margins.
  • Marked bilateral attenuation of retinal arteries.

Common bilateral causes:

Bilateral retinitis pigmentosa:

  • Hereditary progressive bilateral retinal degeneration (autosomal recessive most common, also autosomal dominant, X-linked).
  • Symmetric bilateral disease by definition.
  • Night blindness, peripheral vision loss, tunnel vision bilaterally.
  • Fundus: bilateral bone spicule pigmentation, attenuated vessels, waxy disc pallor.
  • Leads to bilateral consecutive optic atrophy as RGCs die.

Bilateral central retinal artery occlusion (rare):

  • Extremely rare - suggests CNS lymphoma with bilateral optic nerve infiltration, severe embolic disease, or giant cell arteritis.
  • Medical emergency with devastating bilateral vision loss.
  • Fundus: bilateral cherry-red spots, retinal opacity/whitening.
  • Late findings: bilateral optic disc atrophy.

Extensive bilateral pan-retinal photocoagulation (PRP):

  • Laser treatment for bilateral proliferative diabetic retinopathy.
  • Destroys peripheral retina bilaterally → bilateral optic disc pallor/atrophy.
  • Side effects: bilateral peripheral visual field loss, bilateral night vision reduction.

Bilateral toxic/nutritional optic neuropathies:

  • Vitamin B12 deficiency - can trigger optic neuropathy; bilateral painless central vision loss; may trigger LHON in susceptible individuals.
  • Folate deficiency - similar presentation to B12 deficiency.
  • Thiamine deficiency (beriberi) - Wernicke encephalopathy with optic neuropathy.
  • Toxic exposures: Methanol (severe bilateral vision loss), ethambutol (dose-dependent bilateral), tobacco-alcohol amblyopia (bilateral central scotomas), arsenic, lead, chloramphenicol.
  • Typically bilateral, painless, progressive central vision loss with centrocecal scotomas.

Bilateral pathological myopia:

  • Extreme bilateral axial elongation with posterior staphyloma.
  • Bilateral choroidal atrophy, lacquer cracks, myopic macular degeneration.
  • Bilateral optic disc changes with peripapillary atrophy.

Clinical presentation of bilateral optic atrophy

Symptoms (bilateral manifestations)

Visual symptoms:

  • Bilateral vision loss - progressive or sudden (depending on cause).
  • Severe functional disability - inability to read, drive, recognize faces, perform ADLs.
  • Bilateral central vision loss (if papillomacular bundle involved bilaterally).
  • Bilateral peripheral visual field loss (if nerve fiber layer damaged).
  • Bilateral color vision defects.
  • Bilateral contrast sensitivity loss.
  • Nyctalopia (night blindness) if bilateral retinal disease.

Associated symptoms (depending on cause):

  • Headache (IIH, brain tumor, meningitis).
  • Transient visual obscurations (IIH) - bilateral brief episodes of vision darkening.
  • Pulsatile tinnitus (IIH).
  • Pain with eye movement (bilateral optic neuritis).
  • Diplopia (sixth nerve palsy from elevated ICP).

Exam findings (bilateral secondary optic atrophy)

Optic disc appearance (both eyes):

  • Bilateral grey/pale disc color (not white).
  • Bilateral indistinct/blurred disc margins (glial tissue overgrowth).
  • Bilateral loss of optic nerve head architecture.
  • Bilateral peripapillary gliosis.
  • Bilateral vessel sheathing or attenuation (may be present).

Pupillary findings:

  • Bilateral sluggish pupils (if both eyes equally affected).
  • RAPD may be present if asymmetric involvement (more affected eye shows RAPD).

Visual function:

  • Bilateral reduced visual acuity (severity variable; can range from mild to NLP).
  • Bilateral visual field defects (pattern depends on cause):
    • Enlarged blind spots bilaterally (papilledema).
    • Bilateral central scotomas (optic neuritis, nutritional/toxic).
    • Bilateral altitudinal defects (bilateral AION).
    • Bilateral peripheral constriction (advanced papilledema, retinitis pigmentosa).

Exam findings (bilateral consecutive optic atrophy)

Optic disc appearance (both eyes):

  • Bilateral waxy pale discs (yellowish-white).
  • Bilateral normal/sharp disc margins (no gliosis).
  • Bilateral marked attenuation of retinal arteries.
  • Bilateral normal physiologic cups preserved.

Underlying bilateral retinal disease visible:

  • Bilateral bone spicules (retinitis pigmentosa).
  • Bilateral retinal whitening/cherry-red spots (bilateral CRAO - acute phase).
  • Bilateral chorioretinal scars.
  • Bilateral PRP laser scars.

Coding specifics (coder workflow)

Code structure breakdown

Character positionValueMeaning
1stHDiseases of the eye and adnexa
2nd-3rd47Other disorders of optic nerve and visual pathways
4th.2Optic atrophy
5th9Other subtype (not primary, not glaucomatous, not hereditary)
6th3Bilateral (both eyes OU)

When to code H47.293

Use H47.293 when:

  • Provider documents “bilateral secondary optic atrophy” OR “secondary optic atrophy OU” OR “secondary optic atrophy both eyes”.
  • Provider documents “bilateral consecutive optic atrophy” OR “consecutive optic atrophy OU”.
  • Provider documents “bilateral other optic atrophy” OR “bilateral temporal pallor”.
  • Optic atrophy follows documented history of bilateral papilledema, bilateral optic neuritis, or bilateral AION.
  • Optic atrophy associated with bilateral retinal disease (bilateral retinitis pigmentosa, bilateral CRAO, bilateral extensive PRP).
  • Both optic discs show grey color with indistinct margins (secondary) OR waxy pallor with underlying bilateral retinal pathology (consecutive).

Supporting documentation phrases:

  • “Bilateral secondary optic atrophy following chronic papilledema from idiopathic intracranial hypertension.”
  • “Optic atrophy both eyes sequela of bilateral optic neuritis from neuromyelitis optica.”
  • “Consecutive optic atrophy OU due to bilateral retinitis pigmentosa.”
  • “Bilateral temporal pallor of optic discs.”
  • “Grey optic discs with blurred margins bilaterally consistent with secondary atrophy.”

When NOT to code H47.293 (use other codes)

Do not use H47.293 when: [896][1120]

ConditionUse insteadReason
Only right eye affectedH47.291Not bilateral; unilateral right
Only left eye affectedH47.292Not bilateral; unilateral left
Laterality not specifiedH47.299Unspecified eye (avoid when bilaterality documented)
Bilateral primary optic atrophy (no preceding disc swelling)H47.213”Primary” designation requires sharp disc margins, no prior edema
Bilateral glaucomatous optic atrophyH47.233Glaucoma-related atrophy
Bilateral hereditary optic atrophyH47.22Genetic causes (Kjer’s, LHON) - no laterality needed for H47.22
Unspecified bilateral optic atrophyH47.20Mechanism not documented (avoid when secondary/consecutive documented)

Critical distinction: Bilateral secondary vs primary

FeatureH47.213 (Primary bilateral)H47.293 (Other/secondary bilateral)
Preceding disc swellingNO - no history bilateral papilledema/neuritisYES - follows chronic bilateral disc edema
Disc marginsSharp, well-demarcated bilaterallyBlurred, indistinct bilaterally
Disc colorWhite/pale bilaterallyGrey bilaterally (secondary) or waxy (consecutive)
Disc architecturePreserved bilaterallyLost bilaterally (secondary)
Typical causesBilateral compression, bilateral ischemic (post-acute), toxic, traumaticBilateral papilledema, bilateral optic neuritis, bilateral retinal disease
ICD-10-CMDescriptionUse whenBillable
H47.29Other optic atrophy (category)Non-billable parent✗ No
H47.291Other optic atrophy, right eyeRight eye only✓ Yes
H47.292Other optic atrophy, left eyeLeft eye only✓ Yes
H47.293Other optic atrophy, bilateralBoth eyes (THIS NOTE)✓ Yes
H47.299Other optic atrophy, unspecified eyeAvoid when bilaterality documented✓ Yes

Other bilateral optic atrophy codes

ICD-10-CMDescriptionUse when
H47.213Primary optic atrophy, bilateralNo preceding disc swelling bilaterally; sharp margins
H47.22Hereditary optic atrophyDominant optic atrophy, LHON (no laterality needed)
H47.233Glaucomatous optic atrophy, bilateralGlaucoma-related bilaterally
H47.293Other optic atrophy, bilateralSecondary/consecutive bilaterally (THIS NOTE)

HCC information (risk adjustment)

H47.293 is NOT a CMS-HCC code.

Optic atrophy is a manifestation/sequela of underlying disease processes.

However, underlying bilateral causes may be HCC-relevant:

  • Multiple sclerosis (G35) - HCC-weighted.
  • Neuromyelitis optica spectrum disorder (G36.0).
  • Brain tumors (C71.x, D33.x) causing bilateral papilledema.
  • Diabetes mellitus (E08-E13) with bilateral proliferative diabetic retinopathy.
  • Giant cell arteritis (M31.6) causing bilateral AION.

Best practice:

  • Code H47.293 to document bilateral optic nerve damage manifestation.
  • Always code underlying condition separately for complete clinical picture and potential HCC capture.
  • Link bilateral atrophy to underlying bilateral cause in documentation.

Documentation requirements (work checklist)

Essential elements for H47.293

To support accurate coding:

  1. Explicit diagnosis statement

    • “Bilateral secondary optic atrophy” OR “Bilateral consecutive optic atrophy” OR “Bilateral other optic atrophy” OR “Optic atrophy OU.”
    • Specify “bilateral” or “both eyes” or “OU”.

  2. Bilaterality clearly stated

    • “Bilateral,” “both eyes,” or “OU” must be documented.
    • Document each eye separately if asymmetric but bilateral.

  3. Optic disc appearance described (both eyes)

    • For secondary atrophy: Bilateral grey disc color, bilateral indistinct/blurred margins, bilateral loss of disc architecture, bilateral peripapillary gliosis.
    • For consecutive atrophy: Bilateral waxy pale discs, bilateral normal/sharp margins, bilateral marked arterial attenuation, bilateral underlying retinal pathology.

  4. History of bilateral preceding disc swelling documented (for secondary atrophy)

    • “History of bilateral papilledema” / “History of bilateral optic neuritis” / “History of bilateral AION.”
    • Document resolution of bilateral disc swelling with subsequent bilateral atrophy development.
    • Timeline: “Bilateral papilledema present 2014-2024; evolved to bilateral secondary optic atrophy 2025.”

  5. Visual function documentation (both eyes separately)

    • Visual acuity OD: [value]
    • Visual acuity OS: [value]
    • RAPD: Present (specify which eye if asymmetric) or absent.
    • Visual field defects: Pattern and severity for each eye.
    • Color vision deficits: Document bilaterally.

  6. Underlying etiology documented and coded separately

    • For bilateral secondary atrophy: Bilateral papilledema (H47.13), bilateral optic neuritis (H46.13 if available or H46.8/H46.9), bilateral AION, idiopathic intracranial hypertension (G93.2), brain tumor, NMOSD (G36.0), MS (G35).
    • For bilateral consecutive atrophy: Bilateral retinitis pigmentosa (H35.52), bilateral CRAO (H34.13), status post bilateral extensive PRP (Z98.89 + diabetic retinopathy), bilateral nutritional deficiency.

  7. Diagnostic testing performed (both eyes)

    • OCT optic nerve: Bilateral RNFL thickness (reduced bilaterally), bilateral disc morphology.
    • Visual fields: Bilateral pattern and severity of defects.
    • VEP: Bilateral decreased amplitude or absent P100.
    • MRI brain/orbits: If papilledema, optic neuritis, or compressive lesion suspected.
    • Lumbar puncture: Opening pressure if papilledema.
    • Fundus photography: Bilateral disc appearance, vascular changes, retinal pathology.

  8. Functional impact assessment

    • Document severity of bilateral vision loss on function: “Unable to drive,” “Unable to read,” “Requires assistance with ADLs,” “Legally blind (VA <20/200 OU).”

Common auditor red flags

  • “Bilateral optic atrophy” without specifying primary/secondary/consecutive/glaucomatous → query for specificity.
  • Documented history of bilateral papilledema/optic neuritis but coded as H47.213 (primary) → should be H47.293 (secondary).
  • No documentation of bilaterality → cannot code H47.293 without “bilateral,” “both eyes,” or “OU” documentation.
  • Underlying bilateral cause not coded separately → missed documentation of HCC-relevant diagnosis.
  • Only one eye described in exam but coded as bilateral → query provider for clarification or code unilateral.

Associated CPT codes (common pairings)

E/M and comprehensive eye exam codes

CPTDescriptionContext for H47.293
99202-99205New patient office visitInitial evaluation bilateral vision loss/optic atrophy
99212-99215Established patient visitFollow-up bilateral optic atrophy
92002-92004New ophthalmological servicesComprehensive bilateral eye exam
92012-92014Established ophthalmological servicesOngoing bilateral optic atrophy monitoring

Bilateral optic nerve diagnostic imaging

Optical Coherence Tomography (OCT) for bilateral optic atrophy:

CPTDescriptionClinical useBilateral modifier
92133OCT posterior segment, optic nervePrimary test bilateral optic atrophy - RNFL thickness both eyesAdd modifier -50 (bilateral procedure) [722]
92134OCT posterior segment, retinaBilateral ganglion cell layer analysisAdd modifier -50
92250Fundus photographyBilateral disc appearance documentationAdd modifier -50 or bill units=2

OCT findings in bilateral secondary/consecutive atrophy:

  • Bilateral reduced RNFL thickness (confirms bilateral axonal loss).
  • Bilateral disc morphology changes: Loss of architecture (secondary) or preserved cup (consecutive).
  • Bilateral macular OCT: GCIPL thinning bilaterally.

Bilateral visual field testing

CPTDescriptionBilateral documentation
92081Visual field examination, limitedBill with modifier -50 or units=2
92082Visual field examination, intermediateHumphrey 24-2 bilateral - add modifier -50
92083Visual field examination, extendedBilateral 10-2 or Goldmann - add modifier -50

Bilateral visual field patterns by cause:

  • Bilateral papilledema: Bilateral enlarged blind spots → bilateral nerve fiber bundle defects.
  • Bilateral optic neuritis: Bilateral central or centrocecal scotomas.
  • Bilateral AION: Bilateral altitudinal defects (rare).
  • Bilateral nutritional/toxic: Bilateral centrocecal scotomas.

Electrophysiology testing

CPTDescriptionBilateral findings
95930Visual evoked potential (VEP)Bilateral decreased amplitude or absent P100; increased latency bilaterally if demyelination [1104]

VEP in bilateral optic atrophy:

  • Confirms bilateral optic nerve dysfunction objectively.
  • Bilateral optic neuritis: Bilateral prolonged P100 latency from demyelination.
  • Bilateral secondary atrophy: Bilateral severely reduced or absent amplitude.
  • Asymmetry: May show different patterns if sequential involvement.

Advanced bilateral imaging

CPTDescriptionIndication for H47.293 workup
70450-70453CT head/orbitsTrauma, bilateral sinus disease
70540-70543MRI brain with/without contrastBilateral papilledema (brain tumor, hydrocephalus, venous thrombosis); bilateral optic neuritis (bilateral optic nerve enhancement, MS/NMO plaques)
70540-70543MRI orbits with fat suppressionBilateral optic neuritis detection - bilateral optic nerve T2/STIR hyperintensity, bilateral gadolinium enhancement

MRI findings distinguishing NMOSD vs MS:

  • NMOSD: Bilateral longitudinally extensive optic nerve lesions (≥2 segments), bilateral posterior optic nerve/chiasmal involvement (75% NMO vs 33% MS).
  • MS: Bilateral anterior (retrobulbar) lesions, shorter bilateral lesions.

Lumbar puncture

CPTDescriptionUse in H47.293
62270Spinal puncture, lumbar, diagnosticBilateral papilledema workup - measure opening pressure (elevated >25 cm H₂O in IIH); CSF analysis; therapeutic LP reduces ICP

Serologic testing

TestCPTIndication for bilateral cases
Anti-AQP4 antibody86235NMOSD diagnosis - positive in 80%+ NMO cases
Anti-MOG antibody86235MOGAD diagnosis
Vitamin B1282607Bilateral nutritional optic neuropathy
Folate82746Bilateral nutritional optic neuropathy
ESR/CRP85651/86140Bilateral arteritic AION (giant cell arteritis)

Treatment overview (coding context)

Bilateral optic atrophy is IRREVERSIBLE - treatment focuses on urgent management of underlying cause to prevent further bilateral damage and total blindness.

By underlying bilateral etiology:

Bilateral secondary optic atrophy from bilateral papilledema

URGENT TREATMENT REQUIRED to prevent bilateral blindness.

Medical management (IIH):

  • Acetazolamide (Diamox) - FIRST-LINE evidence-based therapy:
    • Start 500 mg PO BID.
    • Increase by 250 mg weekly to maximum 4000 mg daily (or 2000 mg daily if not tolerated).
    • IIHTT trial (2014): Showed benefit of acetazolamide + weight loss for improving visual status in mild bilateral visual field loss from IIH.
    • Reduces CSF production by 6-57%.
    • Side effects: hypokalemia, paresthesias, metallic taste, nausea.
  • Weight loss - cornerstone of IIH treatment:
    • 6-10% weight loss → remission in most patients. [1192]
    • Bariatric surgery if lifestyle measures fail. [1192]
  • Topiramate or furosemide (Lasix) - second-line if acetazolamide intolerant. [1174]
  • Serial LPs (lumbar punctures) - therapeutic CSF removal temporarily reduces ICP.

Surgical management (IIH with progressive bilateral vision loss despite medical therapy):

  • Optic nerve sheath fenestration (ONSF):
    • For predominantly bilateral visual symptoms.
    • Creates windows in optic nerve sheaths bilaterally to decompress nerves.
    • Improves visual fields in ~67% of cases; improves papilledema in 95%.
    • Protects vision but doesn’t improve headaches.
  • CSF diversion procedures:
    • Lumboperitoneal (LP) shunt or ventriculoperitoneal (VP) shunt.
    • For headaches ± bilateral visual loss.
    • Improves visual fields in 69-71%; improves papilledema in 90-91%.
    • Risk of shunt malfunction, infection, over-drainage.
  • Dural venous sinus stenting:
    • For IIH with bilateral venous sinus stenosis and high pressure gradient.
    • 87% overall symptom improvement; 90% cure rate for bilateral papilledema in systematic review of 207 cases.
    • Major complications 1.4%; recurrence after one stent 11%.
    • Reserved for patients with bilateral papilledema who failed medical therapy or intolerant to medications.

Treat underlying bilateral cause of papilledema:

  • Brain tumor → neurosurgical resection/radiation/chemotherapy.
  • Venous sinus thrombosis → anticoagulation.
  • Hydrocephalus → shunt placement.
  • Meningitis → antimicrobial therapy.

Bilateral secondary optic atrophy from bilateral optic neuritis

Acute phase treatment (to prevent bilateral permanent damage):

  • High-dose IV methylprednisolone 1 gram daily × 3-5 days followed by oral prednisone taper.
    • Speeds bilateral visual recovery.
    • Reduces MS development risk in following 2 years (if MRI shows demyelinating lesions).
  • Avoid oral prednisone alone - increases recurrence risk.

Severe/refractory bilateral cases (especially NMOSD):

  • Plasmapheresis (plasma exchange):
    • For bilateral neuromyelitis optica, MOGAD, or severe MS-related bilateral ON not responding to steroids.
    • Perform within 6 weeks of onset.
    • More aggressive therapy needed for NMOSD due to worse prognosis.
  • IVIG (intravenous immunoglobulin) - alternative to plasmapheresis.

Long-term management to prevent recurrent bilateral episodes:

  • For MS: Disease-modifying therapies (DMTs) - beta-interferon, glatiramer acetate, natalizumab, ocrelizumab, etc.
  • For NMOSD:
    • Azathioprine + low-dose prednisone (first-line in resource-limited settings).
    • Rituximab (anti-CD20 monoclonal antibody) - highly effective for preventing relapses.
    • Eculizumab, inebilizumab, satralizumab - newer FDA-approved NMOSD-specific therapies.
    • AVOID beta-interferon and glatiramer - worsen NMOSD.
  • For MOGAD: Rituximab, azathioprine, mycophenolate, or IVIG maintenance.
  • For CRION: Long-term immunosuppression (steroid-sparing agents).

Bilateral secondary optic atrophy from bilateral AION

Bilateral arteritic AION (giant cell arteritis):

  • URGENT high-dose IV methylprednisolone 1000 mg daily × 3-5 days followed by oral prednisone 60-80 mg daily.
  • Temporal artery biopsy within 1-2 weeks (do not delay treatment).
  • CRITICAL: Prevents fellow eye involvement (high risk of bilateral blindness without treatment).
  • Treatment does NOT recover lost vision in already-affected eyes.

Bilateral non-arteritic AION:

  • No proven treatment for NAION.
  • Risk factor modification: Control diabetes, hypertension, hyperlipidemia, treat sleep apnea bilaterally.

Bilateral consecutive optic atrophy from bilateral retinal disease

Bilateral retinitis pigmentosa:

  • No cure; management supportive.
  • Low vision rehabilitation (magnification, contrast enhancement).
  • Vitamin A supplementation controversial.
  • Genetic counseling.

Bilateral nutritional deficiencies:

  • Vitamin B12 supplementation (if deficient) - may halt progression if treated early.
  • Folate supplementation.
  • Thiamine supplementation (if Wernicke’s).
  • Remove toxic exposures if toxic etiology.

Supportive care for bilateral optic atrophy patients

Low vision rehabilitation (CRITICAL for bilateral cases):

  • Magnification devices (CCTV, electronic magnifiers, telescopic glasses).
  • Contrast enhancement.
  • Occupational therapy for ADLs.
  • Mobility training (white cane, orientation).
  • Vision rehabilitation specialist referral - ESSENTIAL for bilateral functional blindness.

Disability services:

  • Social services referral.
  • Disability benefits assessment.
  • Vocational rehabilitation if working-age.

Driving:

  • Prohibit driving if bilateral vision does not meet state requirements (typically requires VA ≥20/40 in at least one eye AND visual field ≥120° horizontal in some states, ≥140° in others).

Protective measures:

  • Fall prevention (bilateral peripheral vision loss).
  • Home safety assessment.
  • Assistive technology.

Sample ICD-10 combinations (work scenarios)

Scenario 1: Bilateral secondary optic atrophy from IIH with bilateral papilledema

ICD-10-CM codes:

  • H47.293 - Other optic atrophy, bilateral (secondary atrophy)
  • G93.2 - Idiopathic intracranial hypertension (benign intracranial hypertension)
  • H47.13 - Papilledema associated with increased intracranial pressure, bilateral (if papilledema still present)
  • E66.01 - Morbid obesity due to excess calories (if applicable; IIH risk factor)
  • H53.483 - Generalized contraction of visual field, bilateral

CPT:

  • 99215 - Established patient visit, high complexity
  • 92133-50 - OCT optic nerve bilateral (bilateral reduced RNFL, bilateral loss of disc architecture)
  • 92082-50 - Visual fields bilateral (bilateral nerve fiber bundle defects)
  • 70553 - MRI brain with contrast (r/o mass, venous sinus evaluation)
  • 62270 - Lumbar puncture (opening pressure 35 cm H₂O; elevated)

Rationale: Bilateral secondary optic atrophy (H47.293) is sequela of chronic bilateral papilledema from IIH (G93.2); code both conditions; document bilateral functional impact.

Scenario 2: Bilateral secondary optic atrophy from bilateral optic neuritis in NMOSD patient

ICD-10-CM codes:

  • G36.0 - Neuromyelitis optica [Devic] (primary diagnosis)
  • H47.293 - Other optic atrophy, bilateral (secondary to bilateral optic neuritis)
  • H53.463 - Homonymous bilateral field defects (if bilateral central scotomas)

CPT:

  • 99214 - Established patient visit
  • 92133-50 - OCT optic nerve bilateral (severe bilateral RNFL thinning; bilateral temporal thinning)
  • 95930 - VEP (bilateral prolonged P100 latency, bilateral reduced amplitude)
  • 70553 - MRI brain/orbits with contrast (bilateral longitudinally extensive optic nerve lesions, spinal cord lesions)
  • 86235 - Anti-AQP4 antibody (positive)

Rationale: NMOSD (G36.0) is underlying autoimmune disease; bilateral optic atrophy (H47.293) is sequela of severe bilateral optic neuritis; NMOSD has worse bilateral prognosis than MS.

Scenario 3: Bilateral consecutive optic atrophy from bilateral retinitis pigmentosa

ICD-10-CM codes:

  • H35.52 - Pigmentary retinal dystrophy (retinitis pigmentosa)
  • H47.293 - Other optic atrophy, bilateral
  • H53.483 - Generalized contraction of visual field, bilateral (bilateral tunnel vision)
  • H53.60 - Unspecified night blindness (nyctalopia from RP)

CPT:

  • 92014 - Comprehensive ophthalmological exam
  • 92133-50 - OCT optic nerve bilateral (bilateral waxy disc pallor, bilateral RNFL thinning)
  • 92134-50 - OCT retina bilateral (bilateral inner/outer retinal layer thinning)
  • 92082-50 - Visual fields bilateral (bilateral severe peripheral constriction)
  • 95930 - VEP (bilateral reduced amplitude)

Rationale: Retinitis pigmentosa (H35.52) causes bilateral progressive RGC death → bilateral consecutive optic atrophy (H47.293); bilateral functional blindness common.

Scenario 4: Bilateral secondary optic atrophy from brain tumor with bilateral papilledema

ICD-10-CM codes:

  • C71.2 - Malignant neoplasm of temporal lobe (or specific location code)
  • H47.293 - Other optic atrophy, bilateral
  • H47.13 - Papilledema associated with increased intracranial pressure, bilateral (if still present)
  • G93.5 - Compression of brain (mass effect)
  • H53.483 - Generalized contraction of visual field, bilateral

CPT:

  • 99215 - Established patient visit
  • 92133-50 - OCT optic nerve bilateral (bilateral reduced RNFL, bilateral grey discs)
  • 92082-50 - Visual fields bilateral (bilateral enlarged blind spots, bilateral arcuate defects)
  • 70553 - MRI brain with contrast (demonstrate tumor, assess size)

Rationale: Brain tumor (C71.2) caused elevated ICP → bilateral papilledema → bilateral secondary optic atrophy (H47.293); code tumor first as life-threatening underlying cause.

Scenario 5: Bilateral consecutive optic atrophy from bilateral nutritional deficiency (vitamin B12)

ICD-10-CM codes:

  • E53.8 - Deficiency of other specified B group vitamins (vitamin B12 deficiency)
  • H47.293 - Other optic atrophy, bilateral
  • H53.463 - Homonymous bilateral field defects (bilateral centrocecal scotomas)

CPT:

  • 92014 - Comprehensive ophthalmological exam
  • 92133-50 - OCT optic nerve bilateral (bilateral RNFL thinning, bilateral temporal pallor)
  • 92082-50 - Visual fields bilateral (bilateral centrocecal scotomas)
  • 82607 - Vitamin B12 level (low)

Rationale: Vitamin B12 deficiency (E53.8) causes bilateral nutritional optic neuropathy → bilateral consecutive optic atrophy (H47.293); may trigger LHON in susceptible individuals.

Sample documentation (clinic note template)

Chief Complaint: Bilateral vision loss / Follow-up bilateral optic atrophy.

HPI: [Age]-year-old [male/female] with bilateral secondary optic atrophy [OR bilateral consecutive optic atrophy] presenting for evaluation. Patient reports [onset/progression] bilateral vision loss. Significant functional disability - [unable to drive / unable to read / requires assistance with ADLs].

History: Patient has documented history of [bilateral papilledema from idiopathic intracranial hypertension / bilateral optic neuritis from neuromyelitis optica / bilateral retinitis pigmentosa / bilateral nutritional deficiency / etc.]. [Describe bilateral timeline: “Bilateral papilledema present 2022-2024; bilateral disc swelling resolved but both optic discs now pale grey with indistinct margins bilaterally consistent with bilateral secondary atrophy.“]

Past Ocular History:

  • Other optic atrophy, bilateral (diagnosed [date]; type: secondary [or consecutive]; etiology: [specify])
  • [Prior bilateral papilledema / Prior bilateral optic neuritis / Bilateral retinitis pigmentosa]

Past Medical History:

  • [Idiopathic intracranial hypertension / Neuromyelitis optica / Multiple sclerosis / Vitamin B12 deficiency / Obesity]

Medications:

  • [Acetazolamide / Rituximab / MS DMTs / B12 supplementation / etc.]

Social History:

  • Functional status: [Unable to drive / Requires low vision aids / Receives disability benefits / Uses white cane]

Exam:

  • Visual Acuity:
    • OD: [20/XX, count fingers, hand motion, light perception, NLP]
    • OS: [20/XX, count fingers, hand motion, light perception, NLP]
    • Bilateral severe vision loss - [legally blind (VA <20/200 OU) / functionally blind]
  • Pupils:
    • Bilateral sluggish pupils [OR RAPD present [OD/OS] if asymmetric]
  • Color Vision:
    • OD: [Reduced/absent]
    • OS: [Reduced/absent]
    • Bilateral color vision deficiency
  • Confrontation Visual Fields:
    • OD: [Central scotoma / Enlarged blind spot / Arcuate defect / Altitudinal defect / Constricted / Full to confrontation]
    • OS: [Same pattern description]
    • Bilateral visual field defects
  • Dilated Fundus Exam - BOTH EYES:
    • Optic Discs (Bilateral secondary atrophy pattern):
      • OD: Grey/pale disc color. Indistinct, blurred disc margins with peripapillary gliosis. Loss of optic nerve head architecture. Cup-to-disc ratio [X]. Retinal vessels [may be sheathed / attenuated]. No current disc edema (resolved from prior bilateral papilledema/neuritis).
      • OS: [Same or similar description]. Findings consistent with bilateral secondary optic atrophy. OR
    • Optic Discs (Bilateral consecutive atrophy pattern):
      • OD: Waxy pale disc. Sharp, well-defined disc margins. Marked attenuation of retinal arteries. Normal physiologic cup preserved.
      • OS: [Same description]. Findings consistent with bilateral consecutive optic atrophy.
    • Maculae (both eyes): [Findings consistent with underlying bilateral retinal disease if consecutive atrophy]
    • Periphery (both eyes): [Bilateral bone spicule pigmentation if RP / Bilateral chorioretinal scars / Bilateral PRP laser scars]

Ancillary Testing:

  • OCT Optic Nerve (CPT 92133-50):
    • OD: Reduced RNFL thickness - Average [XX µm]. [Loss of disc architecture if secondary / Preserved cup if consecutive].
    • OS: Reduced RNFL thickness - Average [XX µm]. [Same pattern].
    • Bilateral findings consistent with optic atrophy.
  • Visual Fields (CPT 92082-50 or 92083-50):
    • OD: [Pattern: enlarged blind spot, central scotoma, arcuate, altitudinal, peripheral constriction]. MD [value] dB, PSD [value] dB, VFI [value]%.
    • OS: [Pattern and values].
    • Bilateral visual field defects.
  • VEP (CPT 95930): [If performed]
    • OD: Decreased amplitude / Absent P100 response [+ prolonged latency if demyelination].
    • OS: [Same findings].
    • Confirms bilateral optic nerve dysfunction.
  • MRI Brain/Orbits: [If performed]
    • [Findings: brain tumor, hydrocephalus, bilateral optic nerve T2 hyperintensity, bilateral gadolinium enhancement, MS/NMO plaques, bilateral venous sinus stenosis]
  • Labs:
    • [Lumbar puncture: Opening pressure [XX] cm H₂O if papilledema]
    • [Anti-AQP4 antibody: Positive/negative if NMOSD suspected]
    • [Anti-MOG antibody: Positive/negative if MOGAD suspected]
    • [Vitamin B12: [XX] pg/mL if nutritional suspected]
    • [ESR/CRP: Elevated if giant cell arteritis]

Assessment:

  • Other optic atrophy, bilateral (H47.293) - secondary [or consecutive] type
  • [Underlying bilateral diagnosis] (specify code: G93.2 IIH, G36.0 NMOSD, G35 MS, H35.52 RP, E53.8 B12 deficiency, C71.x brain tumor, etc.)
  • Bilateral severe visual disability - [legally blind / functionally blind]
  • [H53.483 Generalized contraction of visual field, bilateral - if applicable]

Etiology: [Sequela of chronic bilateral papilledema from IIH / Sequela of bilateral optic neuritis from NMOSD / Consecutive to bilateral retinitis pigmentosa / Consecutive to bilateral nutritional deficiency / etc.]

Type: [Bilateral secondary optic atrophy - follows bilateral disc swelling from papilledema/optic neuritis / Bilateral consecutive optic atrophy - retrograde bilateral degeneration from bilateral retinal disease]

Functional Impact: Severe bilateral visual disability. Patient [unable to drive / unable to read standard print / requires low vision aids / uses white cane / receives disability benefits]. Bilateral vision loss significantly impacts independence and quality of life.

Prognosis: Guarded to poor; bilateral optic atrophy represents irreversible end-stage bilateral optic nerve damage. Bilateral vision loss is permanent. Focus on treating underlying condition to prevent further bilateral progression and maximize remaining bilateral visual function through rehabilitation.

Plan:

  • Treat underlying bilateral cause (URGENT if active process):
    • [Bilateral papilledema: Continue acetazolamide 2000 mg PO daily; encourage weight loss; consider ONSF or CSF diversion if progressive bilateral vision loss despite maximal medical therapy]
    • [Bilateral optic neuritis: Continue NMOSD-specific therapy (rituximab, eculizumab, etc.); avoid MS therapies that worsen NMOSD; monitor for bilateral relapses]
    • [Bilateral nutritional deficiency: Vitamin B12 1000 mcg IM monthly; monitor levels; dietary counseling]
    • [Bilateral brain tumor: Coordinate with neuro-oncology for treatment; monitor bilateral papilledema]
  • Monitor both eyes closely - serial bilateral OCT and bilateral visual fields every [3-6 months] to assess stability vs progressive bilateral damage.
  • Low vision rehabilitation (CRITICAL):
    • Referral to low vision specialist for bilateral magnification devices (CCTV, electronic magnifiers).
    • Occupational therapy for ADL training with bilateral vision loss.
    • Mobility training (white cane, orientation) for bilateral peripheral vision loss.
    • Assistive technology assessment.
  • Disability services referral:
    • Social services for disability benefits assessment.
    • Vocational rehabilitation if working-age.
    • Home safety assessment for bilateral vision loss.
  • Driving prohibition - patient counseled that bilateral vision does not meet state driving requirements; patient agrees to cease driving.
  • Patient education provided regarding permanent nature of bilateral optic atrophy, importance of treating underlying bilateral condition, need for ongoing bilateral monitoring, and resources available for bilateral visual disability.

ICD-10-CM:

  • H47.293 - Other optic atrophy, bilateral
  • [Underlying cause code: G93.2, G36.0, G35, H35.52, E53.8, C71.x, etc.]
  • [H53.483 - Generalized contraction of visual field, bilateral - if applicable]

CPT:

  • [92014 or appropriate E/M]
  • 92133-50 - OCT optic nerve bilateral
  • 92082-50 - Visual field examination bilateral
  • [Other bilateral procedures as performed]

Billing & compliance pearls

  • H47.293 is NOT HCC but underlying bilateral cause (NMOSD, MS, IIH, brain tumor) is clinically significant and may be HCC-relevant - always code bilateral etiology separately. [1120][1185]
  • “Bilateral” must be documented - “bilateral,” “both eyes,” or “OU” required; document each eye separately if asymmetric but bilateral.
  • Bilateral secondary optic atrophy indicates prior bilateral disc swelling - must document history of bilateral papilledema/optic neuritis with timeline. [1120][1185]
  • Bilateral functional impact should be documented - “legally blind OU,” “unable to drive,” “requires low vision aids,” “uses white cane” - supports medical necessity for bilateral rehabilitation services.
  • Use modifier -50 for bilateral procedures - 92133-50, 92082-50, etc. for bilateral testing. [722]
  • Bilateral papilledema requires urgent treatment documentation - medical necessity for acetazolamide, surgical interventions to prevent bilateral blindness. [1185][1192][1200]
  • NMOSD vs MS distinction is critical - different treatments; NMOSD has worse bilateral prognosis; document anti-AQP4 status, bilateral MRI findings. [1188][1196][1197]
  • Bilateral visual field testing essential - documents bilateral functional deficit; supports disability claims; medical necessity for bilateral monitoring. [1164][1174]
  • Low vision rehabilitation is medically necessary for bilateral optic atrophy - document referrals and functional limitations to support coverage. [1120][1185]

Key sources (compact format)

[1180]: ECGWaves H47.293 other optic atrophy bilateral classification H47 optic nerve disorders
[1181]: AAPC H47.293 official descriptor WHO classification billable code bilateral both eyes
[1182]: Unbound Medicine H47.293 other optic atrophy bilateral billable terminal code
[1183]: FindACode H47.293 ICD-10-CM hierarchy diagnosis code bilateral
[896]: AAPC H47.29 other optic atrophy category temporal pallor descriptor child codes (H47.291-H47.293 laterality)
[1120]: NCBI StatPearls optic atrophy secondary bilateral disc swelling papilledema/optic neuritis grey disc indistinct margins bilateral loss architecture bilateral glial proliferation bilateral vessel sheathing consecutive bilateral retinal disease waxy pale bilateral normal margins bilateral arterial attenuation
[1159]: Papilledema bilateral optic disc swelling elevated ICP bilateral venous engorgement bilateral hemorrhages bilateral blurred margins bilateral Paton’s lines persistent bilateral swelling permanent bilateral visual impairment bilateral enlarged blind spot bilateral nerve fiber bundle defects
[1185]: NCBI StatPearls papilledema elevated ICP bilateral presentation axoplasmic flow stasis intraneuronal ischemia bilateral RGC axon death secondary optic atrophy chronic untreated papilledema permanent bilateral vision loss IIH unilateral papilledema rare anatomic variations optic canal diameter lamina cribrosa compliance
[1164]: PMC papilledema epidemiology bilateral feared morbidity bilateral enlarged blind spot bilateral nerve fiber bundle defects treatment acetazolamide weight loss bilateral ONSF bilateral CSF diversion
[1174]: EyeWiki papilledema bilateral acetazolamide bilateral ONSF bilateral LP/VP shunt bilateral venous sinus stenting bariatric surgery
[1192]: IIH idiopathic intracranial hypertension bilateral papilledema young obese females bilateral transient visual obscurations bilateral pulsatile tinnitus acetazolamide 6-57% CSF reduction weight loss 6-10% remission bilateral optic atrophy untreated bilateral venous sinus stenosis 90-100% bilateral stenting 87% bilateral symptom improvement 90% bilateral papilledema cure
[1200]: PMC papilledema IIH treatment IIHTT trial acetazolamide weight loss bilateral mild visual loss bilateral venous sinus stenting bilateral stenosis bilateral pressure gradients 87% bilateral improvement 90% bilateral papilledema cure bilateral ONSF 67% bilateral visual field improvement 95% bilateral papilledema improvement bilateral LP/VP shunt 69-71% bilateral visual field improvement 90-91% bilateral papilledema improvement
[1203]: Practical Neurology IIH treatment acetazolamide 500mg BID increase 250mg weekly 4g daily maximum bilateral papilledema resolution bilateral ONSF bilateral visual fields 2/3 improvement bilateral papilledema 95% bilateral LP/VP shunt 69-71% bilateral visual fields 90-91% bilateral papilledema
[1187]: Unbound Medicine 5-Minute Clinical optic atrophy chronic papilledema bilateral secondary ONA increased ICP bilateral tumor bilateral aneurysm bilateral hydrocephalus bilateral pseudotumor cerebri bilateral IIH bilateral infectious bilateral meningitis bilateral postsystemic
[1104]: Optic neuritis MRI bilateral unilateral more common MS bilateral more common NMOSD MOGAD bilateral T2-hyperintense bilateral gadolinium-enhancing bilateral MS plaques bilateral spinal cord bilateral IV methylprednisolone bilateral visual recovery 93% 20/40 1 year bilateral residual deficits bilateral contrast sensitivity bilateral color vision bilateral visual fields
[1188]: NMOSD neuromyelitis optica spectrum bilateral optic neuritis bilateral simultaneous bilateral sequential anti-AQP4 antibodies 80%+ bilateral severe visual loss bilateral poor recovery bilateral recurrent ON bilateral severe residual bilateral visual dysfunction bilateral permanent bilateral deficits
[1189]: Devic’s disease NMOSD bilateral optic neuritis bilateral severe visual loss bilateral involvement bilateral permanent bilateral visual deficits compared MS
[1195]: Cleveland Clinic bilateral optic neuritis NMOSD MOG syndrome bilateral sarcoidosis bilateral paraneoplastic bilateral infections bilateral CRION bilateral toxic/metabolic
[1196]: PMC neuromyelitis optica MS bilateral ON bilateral retinal changes bilateral OCT bilateral RNFL thinning bilateral ganglion cell layer bilateral microcystic macular edema bilateral NMO vs MS bilateral recurrent bilateral severe bilateral residual bilateral visual dysfunction bilateral MRI bilateral longitudinally extensive bilateral posterior nerve bilateral chiasmal
[1197]: Neurology NMO MS optic neuritis MRI bilateral NMO bilateral longitudinally extensive ≥2 bilateral optic nerve segments 75% NMO vs 33% MS bilateral posterior bilateral nerve bilateral chiasmal MS bilateral anterior bilateral retrobulbar bilateral canalicular 70% MS vs 36% NMO
[1199]: PMC inflammatory optic neuritis MS NMO bilateral RNFL thickness <15µm bilateral distinguishing bilateral overlap bilateral group level
[1193]: Multiple sclerosis MS demyelinating bilateral optic neuritis less common bilateral
[1116]: LHON Leber hereditary mitochondrial bilateral subacute bilateral vision loss bilateral sequential 75% cases bilateral simultaneous 25% cases bilateral median 8 weeks bilateral severe bilateral optic atrophy bilateral permanent bilateral VA ≤20/200 bilateral mtDNA 11778 3460 14484 bilateral ND4 ND1 ND6 bilateral oxidative phosphorylation bilateral RGC bilateral maculopapillary bundle bilateral degeneration
[1140]: Mitochondrial optic neuropathies LHON bilateral acute bilateral subacute bilateral vision loss bilateral incomplete penetrance bilateral young males bilateral 2nd-4th decade bilateral rapid bilateral one eye followed bilateral second eye bilateral months bilateral VA stable bilateral poor <20/200 bilateral residual bilateral central visual field defect bilateral m.14484/ND6 bilateral visual recovery
[1201]: PMC toxic nutritional LHON bilateral vitamin B12 bilateral folate bilateral deficiency bilateral trigger bilateral LHON bilateral m.11778 bilateral m.14484 bilateral primary mutations bilateral severe bilateral B12 bilateral LHON-like bilateral optic neuropathy bilateral m.14468 bilateral phenotype bilateral ROS bilateral risk bilateral developing bilateral ophthalmological bilateral bilateral optic disc pallor bilateral concentric bilateral visual field defect bilateral deep bilateral generalized bilateral defect bilateral RNFL bilateral thinning bilateral retinal ganglion bilateral loss bilateral fundus bilateral diffuse bilateral pallor bilateral both bilateral optic nerves bilateral Humphrey bilateral profound bilateral defect bilateral both eyes
[1204]: NORD LHON bilateral painless bilateral subacute bilateral central vision bilateral young adult bilateral slowly progressive bilateral central scotomas bilateral mild bilateral optic atrophy bilateral 20 years bilateral moderate bilateral loss bilateral bilateral bilateral tempo bilateral symmetry bilateral mitochondrial bilateral optic neuropathy bilateral nutritional bilateral deficiencies bilateral metabolism bilateral dysfunction bilateral acquired bilateral genetic
[1170]: PION posterior ischemic bilateral optic neuropathy bilateral treatment bilateral blood bilateral transfusions bilateral A-PION bilateral GCA bilateral steroids bilateral temporal bilateral artery bilateral biopsy bilateral prevent bilateral progression bilateral second eye bilateral involvement bilateral high-dose bilateral corticosteroids bilateral taper bilateral 1 year
[889]: ION ischemic bilateral optic neuropathy bilateral acute bilateral painless bilateral vision loss bilateral VA bilateral VF bilateral defect bilateral color vision bilateral RAPD bilateral swollen bilateral optic nerve head bilateral posterior bilateral ION bilateral no bilateral initial bilateral disc bilateral edema bilateral subsequent bilateral atrophy
[1103]: NAION non-arteritic bilateral anterior bilateral ischemic bilateral optic neuropathy bilateral coronary bilateral artery bilateral disease bilateral cerebrovascular bilateral disease bilateral sleep bilateral apnea bilateral diabetes bilateral hypertension bilateral risk bilateral factors bilateral no bilateral universally bilateral accepted bilateral scientifically bilateral proven bilateral treatment bilateral managing bilateral underlying bilateral risk bilateral factors bilateral control bilateral blood bilateral pressure bilateral managing bilateral diabetes bilateral treating bilateral sleep bilateral apnea bilateral hyperbaric bilateral oxygen bilateral levodopa bilateral carbidopa bilateral aspirin bilateral transvitreal bilateral optic bilateral neurotomy bilateral bevacizumab bilateral vitrectomy bilateral IONDT bilateral spontaneous bilateral visual bilateral function bilateral deterioration bilateral 12% bilateral 125 bilateral control bilateral eyes bilateral worsened bilateral 24% bilateral 119 bilateral eyes bilateral decompressive bilateral surgery bilateral corticosteroids bilateral debate
[1143]: CRAO central retinal artery bilateral occlusion bilateral painless bilateral acute bilateral vision bilateral loss bilateral cherry-red bilateral spot bilateral 90% bilateral retinal bilateral opacity bilateral 58% bilateral arterial bilateral attenuation bilateral 32% bilateral disc bilateral edema bilateral 22% bilateral emboli bilateral optic bilateral atrophy bilateral emboli bilateral carotid bilateral origin bilateral complete bilateral retinal bilateral ischemia bilateral RGC bilateral death bilateral 90-100 bilateral minutes bilateral onset bilateral prognosis bilateral poor bilateral 2/3 bilateral 20/400 bilateral 1/6 bilateral 20/40
[1176]: Karger bilateral CRAO bilateral CNS bilateral lymphoma bilateral optic bilateral nerve bilateral infiltration bilateral MRI bilateral cortical bilateral leptomeningeal bilateral fundus bilateral fluorescein bilateral angiography bilateral whole-brain bilateral irradiation bilateral systemic bilateral chemotherapy bilateral progressive bilateral bilateral bilateral CRAO bilateral NLP bilateral vision
[1178]: PMC sudden consecutive bilateral amaurosis bilateral CRAO bilateral medical bilateral emergency bilateral stroke bilateral equivalent bilateral typical bilateral fundoscopic bilateral cherry-red bilateral spot bilateral retinal bilateral opacity bilateral arterial bilateral attenuation bilateral disc bilateral edema bilateral OCT bilateral increased bilateral inner bilateral retina bilateral thickness bilateral disc bilateral swelling bilateral acute bilateral phase bilateral retinal bilateral atrophy bilateral thinning bilateral weeks bilateral arteritic bilateral CRAO bilateral worst bilateral prognosis bilateral AAION bilateral retina bilateral and bilateral ONH bilateral ischemia bilateral high-dose bilateral corticosteroid bilateral critical bilateral avoid bilateral bilateral bilateral blindness
[1175]: PMC optic neuritis diagnosis bilateral treatment bilateral plasmapheresis bilateral within bilateral 6 bilateral weeks bilateral CRION bilateral steroid-responsive bilateral azathioprine bilateral rituximab bilateral NMOSD bilateral NMO-spectrum bilateral erythropoietin bilateral simvastatin bilateral pilot bilateral trials bilateral optic bilateral nerve bilateral regeneration
[722]: HCPCS Level I CPT numeric Level II alphanumeric modifier -50 bilateral procedure

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