How do we classify blindness - H54 according to ICD – 10

Размещено на http://www.allbest.ru/

How do we classify blindness - H54 according to ICD - 10

Pitakova Ivelina MD, ophthalmology Eye Clinic “St. Nicholas”

Keywords: blindness, ICD-10, low vision, DR, ARAID Ключоек думы: слепота, МКБ-10,1CD-H54, ДР, АМД

Visual acuity is a measure of the ability of the visual sensory system to distinguish the smallest details of visual objects. Visual acuity and field of vision are considered the two criteria by which groups of the visually impaired are classified. According to the best visual acuity with the correction of the better-sighted eye, there are two main types of visual deficits - blindness and low vision. Globally, approximately 1.3 billion people are estimated to live with some form of visual impairment. Most people with visual impairments are over 50 years of age.

The definitions of low vision and blindness are very varied. The World Health Organization provides the following definition (1): according to the WHO, reduced vision is defined as visual acuity <0.3 (logMAR ~ to 0.52) and / or field of vision <20°, and blindness as visual acuity <0.05 (logMAR ~ to 1.30) and / or field of vision <10°. Blindness, Latin Anopia, is a condition of functional loss of visual perception, which may be due to ophthalmic or neurological causes. Different definitions of reduced vision and blindness exist in countries around the world. For instance in the United States (2) the definition is as follows: “Low vision refers to visual impairment that cannot be corrected by surgery, pharmaceuticals, glasses or contact lenses; it is often characterized by partial vision, such as blurred vision, blind spots or tunnel vision.” The Canadian National Institute for the Blind (3) says that “... vision between 20/60 and 20/190 is called partial blindness or low vision. If the change in vision is up to 20/200 or worse, the person will still have some vision but will be classified as blind if their field of vision or the perimeter they can see is less than 20° - despite the fact that their vision is better than 20/200”. According to Greek law, a blind person is defined as a person whose visual acuity is less than 1/20 in the better eye with the best possible correction. (4) A person even with satisfactory visual acuity, but with peripheral vision limited to 10 degrees or less, is presumed to be blind.

Israel has maintained a register of the blind since 1987. Patients are monitored by ophthalmologists and recorded if they have a visual acuity of < or = 0.05 (20/400) or a field of view with a radius of <20 degrees. This report includes data on 18,891 persons registered between 1987 and 1999. The main causes of blindness in the complete registry are age-related macular degeneration (AMD) and glaucoma (14%), followed by diabetic retinopathy (11%). (5) The Tajimi-town study on the prevalence and causes of low vision and blindness in the Japanese adult population identified low vision and blindness as BCVA for the better eye from 20/60 to 20/400 and worse from 20/400, respectively. (6)

Blindness classification

ICD-10

The International Statistical Classification of Diseases and Related Health Problems (7) was first introduced in 1893. The ICD-10 was developed in 1992 by WHO and consists of 21 sections (Table 1), using the letter H in class 7, Diseases of the eye and its appendages. The IBC is revised periodically, and after many revisions, the 11th version is already underway.

Table 1. ICD-10

On June 2018 in Geneva, the World Health Organization announced the new International Classification of Diseases (ICD-11). It is fully electronic and formally submitted in May 2019 to the World Health Assembly for adoption by Member States. ICD-11 is scheduled to take effect on January 1, 2022. The changes regarding the ophthalmology section are that vision impairment is already classified into two groups: long-distance and near.

A. Reduce vision for far away:

Mild - visual acuity less than 6/12

Moderate - visual acuity less than 6/18

High - visual acuity less than 6/60

* Blindness - visual acuity less than 3/60

Close vision reduction: Visual acuity less than N6 or N8 at 40 cm with existing correction.

The N-marking system uses the New Times Roman font, which is the United Kingdom standard. N6 is the norm. N10 is assumed to be 2x the size of N5, and the required magnification is determined by the formula: Mag. = present VA / required VA or e.g. N48 / N6 = 8x magnification.

WHO classification of visual impairments The WHO classification covers the categories of low vision, blindness and unqualified vision loss (8) - Table 2.

Table 2.

Categories of visual impairment - WHO

TELK - Medical Examiner Regulation

According to the ordinance for the medical expertise of TELK (9), the groups of visual disability in Bulgaria are three:

First group of disability - complete or practically definitive blindness of both eyes or visual acuity of the better-sighted eye no more than 0.04, at inability to correct or concentrically narrow the field of view to 10°.

Second group of disability - definitive reduction in visual acuity in the better-sighted eye from 0.04 to 0.09 with tolerable correction or concentric narrowing of the visual field above 10° to 20°.

Third group of disability - unilateral luck of eyeball, atrophy or subatrophy of the eyeball. Definitive total blindness or reduction in the visual acuity of one eye, not exceeding 0.04, if the field of view cannot be corrected or narrowed to 7°.

Purpose

The purpose of our retrospective study is to track the distribution and ratio of enrolment in outpatients: H54. - blindness, H36.0 - diabetic retinopathy (DR) and H35.3 - macular degeneration (AMD) over a ten- year period. Our hypothesis is that the diagnosis of H54 blindness is not adequately classified and reflected in outpatient examinations in all its seven sub-codes.

Materials and method

diabetic retinopathy macular degeneration

The data from the outpatient examinations of all ophthalmologists working on the NHIF (health insurance fund) from the MEDEX software product at the Eye Clinic “St. Nicholas” in Varna for the period 1 September 2008 to 1 September 2018. The results obtained were statistically processed using Microsoft Excel 2013 software. They are presented in a form illustrated with the appropriate graphs.

Results

For the ten-year follow-up period, all reported outpatient examinations for a total of 13 ophthalmologists working at the NHIF were 155,843 examinations. Of these, the ratio of the diagnoses monitored is as follows: H36.0 - a total of 4,020, with a leading diagnosis of 1,839, with an accompanying 2,181; H35.3 - a total of 4,878, with a leading diagnosis of 1,374, and an accompanying diagnosis of 3,504; H54. - 170 patients, with 56 leading and 114 accompanying diagnosis.

The distribution of the diagnosis of blindness H54. by sub-code and type of review for a ten-year period is as follows. Figure 1

Figure 1. ICD-H54. Breakdown by type of review over a ten-year period

What is notable is the lack of coding, or a minimum with H54.6 and H54.7, undefined and unspecified vision loss. The total number of patients with single-blindness is twice that of double-blindness.

Figure 2. Leading and accompanying diagnosis of blindness during a ten-year period

The same distribution by type of examination is primary and secondary examinations. The number of given for the DR and AMD in Figure 3. It is noteworthy Lasers for DR examinations is 14, while for AMD there that DR has more laser high quality procedures than are 3 and for H54 only one review.

Figure 3. Distribution by type of DR and AMD examinations

In age-related macular degeneration, primary examinations predominate, followed by high quality procedures. The results of the data showed extremely low values of dispensary examinations for ten years in both DR-11 patients and AMD-19 patients and H54 dispensary patients are missing. It should be noted that all three diagnoses are subject to medical examination by the NHIF if the ophthalmologist decides.

The total number of all high quality procedures passed through the clinic is 4,057, which is 3% of all examinations. Due to the social burden of the diagnoses under investigation, a large number of them are highly specialized (VSD). According to Gragoudas ES 2004 (10), timely pan-retinal laser therapy and adequate intra-vitreal injections with anti-VEGF drugs could prevent long-term vision loss in patients with DR. Of all laser specialized therapy, there were 1,223 for DR, 780 for AMD and only 4 patients in low-vision H54.

There is a steady trend in the incidence of H54 diagnosis during the period. (Figure 4.) We can see from the documents that always the same ophthalmologists define patients as leading or accompanying. The sudden increase in the reflection of blindness in ambulatory documents after 2018 coincides with increased work and interest in the visual rehabilitation of the visually impaired in the clinic. Over the years, the other two diagnoses, DR and AMD have reflective dynamics.

Figure 4. Number of blind patients by years

Discussion

We chose to compare two ICDs: H54 blindness with H36.0 and H35.3, as these are considered to be diagnoses of serious social importance. Epidemiological studies show that DR and AMD most often lead to blindness or severe or irreversible vision loss. According to Limburg H. et al. major causes of functional low vision (FLV) <6/18 for Latin America are age-related macular degeneration (mean incidence of 26%), glaucoma (23%), diabetic retinopathy (19%), and other diseases in the posterior segment 15% (11) Therefore, a greater correspondence between them was expected, for example in the documents with H36.0 or H35.3 they would be present and H54 as well, at least to some point.

The large difference in the number of diagnoses is striking compared to the ten-year period. H54 - blindness - shows only 170, and H36.0 - diabetic retinopathy - a total of 4,020 and H35.3 - macular degeneration - 4,878. If at the beginning of the monitoring period in 2008 this is supposed, and acceptable at the end of 2018, there should be a trend towards increasing the incidence of blindness in outpatient examinations. We could assume that within ten years, some patients with DR and AMD would have reduced vision in one or both eyes, or blindness in one eye or other visual impairments.

According to Tracy ML (12) among people with diabetes, the incidence of visual impairment due to diabetic retinopathy increased from 6.4 (95% CI 2.413.9) to 100,000 in 2004 to 11.7 (95% CI 5.9- 21.0) per in 2013. The incidence of blindness resulting from diabetic retinopathy ranged from 31.9 per 100,000 (95% CI 21.6-45.7) in 2004 to 14.9 per 100,000 (95%) CI 8,2-25,1) in 2013. The data of Nencheva Bn. (Varna 2014) support the hypothesis that diabetic retinopathy is the third most common cause of single-blindness in women in the three groups studied, and the senile macular degeneration is on the fourth position - men and women are affected in a similar ratio. The results of our study show that the total number of patients with single-blindness is twice that of double-blindness. These data differ from those reported by Nencheva Bn. (13), according to which there is no significant difference in the percentage ratio between two-eyed - 53.10% and one-eyed blindness - 46.90% for the studied period.

Another inconsistency appears, too, in the study: an increase in the number of TELK decisions and ocular disability over the years. Again, according to Nencheva Bn., there is a difference in primary disability between the two periods in the study, with a significant increase in disability in both sexes during the second period. This is most pronounced in men with vision 0-0.05. According to the Medical Examiner Regulation (TELK), there should be a severe reduction in vision or blindness that is a diagnosis of H54 should be available. However, it does not often fit into the documentation of the period we have investigated. Data for the period of both studies is almost comparable, and so are the region and the diagnoses examined.

There are no strict rules and controls on how to enter diagnoses in ambulatory lists as leading, accompanying diseases, or how many diagnoses to enter and which codes to choose. No requirement exists for diagnoses to be made for ICD when completing free and paid examinations without software programs. Usually they are written in Latin, or even only in Bulgarian without ICD-coding. This is why there is a divergence of declared diagnoses and often the real state of the disease. Each ophthalmologist, according to examination and preferences, describes the patient's diagnoses, ranking them in importance as leading and accompanying, in his primary and secondary examinations.

After a thorough search of several medical databases by keywords ICD-10, H 36.0, H35.3, H5, Blindness, statistic data, etc., single publications on the subject were found, but it is difficult to compare how diagnoses are made in different countries, and how often they are diagnosed by health software products. For example, for Denmark (14), the present blindness model is assumed to be visual acuity < or = 6/60. It was examined on the basis of 1,585 application forms for the Danish Society of the Blind in 1993. Blindness statistics are generally very sensitive to the definitions of blindness used. Changing the definition of blindness to visual acuity <6/60 reduced the number of formally blind patients by 32%, and using the WHO definition of visual acuity <3/60, only 562 individuals (35%) would be considered blind.

It would be interesting to compare the data from our study with another, whether in a private, municipal or university centre, in order to understand and identify whether these results tend to classify and report blindness data or are isolated, reflecting personal preferences in the writing of ICDs. The data with which we could compare our results are from Clinic „Nova Clinic“-Varna and TELK-Varna. We have results for a five-year period from Nova Clinic, which covers 9,219 patients. Of these, the distribution of ICDs is given in Table. 3.

Table 3.Data on ICDs for Clinic Nova - Varna for 5 year period

The results confirm the trend of prescribing diagnoses. Data collected from the TELK software product is very scarce, given the late digitalization of the system. Electronic data has been collected and processed since the beginning of 2018 and until May 2019. The results are H36.0 - 7, H35.3 - 24, H54 here has not been noted for this short period.

Conclusion

Of the many patients who underwent outpatient consultations for a long period of time, the incidence of DR, AMD and blindness H54 diverge significantly. Blindness as a diagnosis of H54 is not reflected in the inspection documents and, at the same time, reduced visual acuity is a decisive requirement for the TELK Commission and other social institutions.

Literature

1.www. Who.int/blindness/causes/priority/en/index4. html.

www.lowvision.org.

www.cnib.ca.

ACCELERATE project. Development of Library Services to Visually Impaired People: guide for Hellenic libraries https://www.lib.uom.gr/accelerate/deliverables/Ttt_en. doc

Farber MD. National Registry for the Blind in Israel: estimation of prevalence and incidence rates and causes of blindness. Ophthalmic Epidemiol. 2003 Oct;10(4):267-77. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14628969

Iwase A, Araie M, Tomidokoro A, Yamamoto T, Shimizu H, Kitazawa Y, et al. Prevalence and Causes of Low Vision and Blindness in a Japanese Adult Population. Ophthalmology. 2006 Aug;113(8):1354- 1362.e1. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16877074

https://icd.who.int/docs/ICD-11 Implementation or Transition Guide_v105.pdf

WHO. Change the Definition of Blindness. World Heal Organ. 1972, Available from: http://www.who.int/blindness/Change the Definition of Blindness.pdf

Methodology for Accreditation of Medical Institutions Section I General. 2012;(1):6-16. Available from: http://www.mh.government.bg/media

W. J, Gragoudas, Ufret-Vincenty RL, Miller ES. Photosensitizers in photodynamic therapy of choroidal neovascularization. Vol. 44, International Ophthalmology Clinics. International Ophthalmology Clinics; 2004 p. 63-80

Limburg H, Espinoza R Functional low vision in adults from Latin America: findings from population-based surveys in 15 countries,Rev Panam Salud Publica. 2015 Jun;37(6):371-8.

Tracey ML, McHugh SM, Trends in blindness due to diabetic retinopathy among adults aged 18-69 years over a decade in Ireland. 2016 Nov;121:1-8.

Nencheva Bn. Blindness and Low Vision in Eastern Bulgaria - A Contemporary Approach, 2014, MU-Varna

Rosenberg T, Klie F.

The incidence of registered blindness caused by age- related macular degeneration. Acta Ophthalmol Scand. 1996 Aug;74(4):399-402УДК 614.7

Размещено на Allbest.ru