Ophthalmic Coding Specialist Practice Test

What should be documented prior to inserting punctal plugs?

1. Syptoms of dry eye

2. History of allergies

3. Previous surgeries

4. Current medications

The correct answer is: Syptoms of dry eye

Documenting symptoms of dry eye prior to inserting punctal plugs is crucial because it provides a clear clinical reason for the intervention. Punctal plugs are primarily used to treat dry eye syndrome by blocking the tear drainage ducts to retain moisture on the surface of the eye. Understanding the patient's specific symptoms, such as itchiness, burning, or fluctuating vision due to dryness, helps to establish the severity of their condition and the appropriateness of using punctal plugs as a treatment option. While the history of allergies, previous surgeries, and current medications are also important aspects of a patient's health history that could impact treatment decisions, they do not directly justify the need for punctal plugs in the same way that documenting dry eye symptoms does. It is essential to address the primary issue at hand—dry eye—when considering the insertion of these devices, as it provides context for the procedure and helps in evaluating the efficacy of the treatment afterwards.