Ophthalmology Eye Exam Chart Note Sample Reports


REASON FOR VISIT:  The patient is a (XX)-year-old who is referred by Dr. Doe for evaluation of a choroidal nevus in the right eye.

PHYSICAL EXAMINATION:  Today, visual acuity is 20/40 in both eyes. Intraocular pressures are 18 in both eyes as well. Slit-lamp examination is remarkable for a very mild cataract in both eyes. Dilated funduscopic examination in the right eye reveals mild drusen in the posterior pole. In the far superior nasal periphery, there is a flat, pigmented lesion. This lesion could be either a choroidal nevus or congenital hypertrophy of the retinal pigment epithelium. Dilated funduscopic examination in the left eye revealed a small, flat choroidal nevus just superior to the fovea and drusen within the posterior pole.

IMPRESSION:
1.  Choroidal nevus versus congenital hypertrophy of the retinal pigment epithelium, right eye.
2.  Mild drusen, both eyes.
3.  Mild cataract, both eyes.

PLAN:  The lesion in the right eye is too far out to photograph today. It is flat and there is no lipofuscin and therefore I do not believe there is a significant risk for progression to choroidal melanoma. I did warn the patient of the possibility of progression of this nevus to melanoma and recommended followup on a yearly basis.

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REASON FOR VISIT:  The patient is a (XX)-year-old who is referred by Dr. Doe for evaluation of decreased vision in the right eye. The patient does have diabetes with a hemoglobin A1c in the 6 range now; however, it was 11.2 approximately a year and a half ago. In addition, the patient has high cholesterol.

PHYSICAL EXAMINATION:  Visual acuity is 20/20 in the right eye and 20/25 in the left. Intraocular pressures are normal. Slit-lamp examination is unremarkable. Dilated funduscopic examination in the right eye reveals a swollen optic nerve with cup-to-disk ratio of 0.1. Scattered dot hemorrhages are noted within the posterior pole. In the left eye, cup-to-disk ratio is 0.1 with a few dot hemorrhages and yellow exudate in the posterior pole.

A visual field test was done today. The visual field was a 30-2. In the right eye, it shows a superior scotoma respecting the horizontal meridian.

IMPRESSION:  Diabetic papillopathy, right eye.

PLAN:  I believe that these findings are consistent with small vessel disease secondary to diabetes. I have asked the patient to follow up with me in one month.

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REASON FOR VISIT:  The patient is a (XX)-year-old who returns today for evaluation of macular edema. He had cataract surgery approximately 6 weeks ago.

PHYSICAL EXAMINATION:  Today, visual acuity is 20/30 in the right eye and 20/60 in the left eye. Intraocular pressures are normal. Slit-lamp examination is remarkable for a well-centered posterior chamber intraocular lens in the left eye. There are mild anterior chamber cells and flare. Dilated funduscopic examination in the left eye reveals cystic macular edema centrally. There is no retained lens fragment.

Optical coherence tomography in the left eye confirms the presence of cystic macular edema. We did review the scan performed by Dr. Doe 1 week ago. There is no significant difference in the cystic macular edema pattern in comparison to that scan 1 week ago.

IMPRESSION:  Pseudophakic cystoid macular edema.

PLAN:  We recommend the patient continue using Pred Forte and Acular 4 times daily. We have asked the patient to follow up in approximately 4 weeks. At that time, we will perform another OCT. If there is still residual swelling, an intravitreal injection of Kenalog will be necessary.

Thank you again for allowing me to participate in the care of your patient.


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HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old gentleman, unrestrained passenger, ejected from a motor vehicle accident at approximately 8:00 a.m. this morning. The patient was evaluated in the emergency room in C-spine collar, supine. The patient had a trauma evaluation including radiologic studies. The CT scan was reviewed and found to show intact globes with a shallow anterior chamber in the right eye. There is no significant orbital or intraconal hemorrhage. The globes appeared normal shape with the exception of the anterior chamber in the right eye. There were no visible metallic or other foreign bodies within the globe or orbital cavity. There were no significant orbital fractures noted on the CT scan.

PHYSICAL EXAMINATION:  On exam, the patient's visual acuity was counting fingers at 2 feet in the right eye and 20/30 in the left eye without correction. Intraocular pressures were not measured in the right eye because of iris prolapse and peaked pupil temporally. Intraocular pressures by palpation in the left eye were approximately 20 mmHg. Slit-lamp examination revealed ruptured globe and opacity to the lens and shallow anterior chamber. There was no obvious lens protein in the anterior chamber; however, the anterior chamber was quite shallow. There was a dim red reflex. The patient was shielded and made n.p.o. and he was given antibiotics by the trauma service.

PLAN:  Urgent repair of ruptured globe, right eye. Transferred for operative repair of ruptured globe and if possible coordination of multiple traumas, including olecranon fracture, left, and scalp repair

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PROCEDURE:  Laser suture lysis, left eye.

Risks and benefits of the procedure were explained to the patient. The patient expressed understanding of these risks and signed a consent form.

DESCRIPTION OF PROCEDURE:  At noon, the patient was seated at the frequency doubled YAG laser and a drop of proparacaine was instilled in the left eye. The area of the flap suture was visualized with the Hoskins lens. The suture was cut with two applications of laser at 450 mW, green wavelengths, 0.1 second duration, 50 micron spot size. Conjunctiva was Seidel negative afterwards. The patient tolerated the procedure well.

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HISTORY OF PRESENT ILLNESS:  This (XX)-year-old patient comes in today accompanied by his wife for consultation on possible left eyelid surgery. He is status post proton beam irradiation for meningioma. He is concerned about the complete ptosis on the left side. When he lifts his eyelid up, he is aware of diplopia. He does have some dry eye symptoms on the left only with mucus production in the morning and occasional foreign body sensation.

PHYSICAL EXAMINATION:  Examination today showed a corrected acuity of 20/20, right eye, and 20/50, left eye. Margin reflex distance up 5 mm on the right, -5 on the left. No lagophthalmos with gentle closure. Levator function 16 mm in the right, 0 on the left. Orbicularis function 4+ bilaterally. Dysmotility on the left with -4 left supraduction, -2 left adduction, -3 left abduction, and -3 left infraduction. Occasional SPK inferior left cornea. Minimal Bell's phenomenon present. Normal frontalis action bilaterally.

IMPRESSION AND PLAN:  This is a (XX)-year-old patient status post proton beam for meningioma with left paralytic ptosis and ocular misalignment. Pre-existing dry eyes. Conservative treatment only is advised for this patient. We discussed the significant risks of increasing exposure even with minimal frontalis sling as well as the awareness of the diplopia that would result from lifting up the eyelid. This was discussed with him in detail today.

No further appointment is being made unless concerns develop. The patient was given a list of oculoplastic surgeons in the area should he choose to have a second opinion with regards to this

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SUBJECTIVE:  The patient returned to see me today in followup for her combined cataract extraction trabeculectomy, OS. She is taking Pred Forte, OS, q.2 hours, Xibrom OS b.i.d., and Trusopt OD b.i.d.

OBJECTIVE:  Her visual acuity corrected to count fingers in the left eye. Intraocular pressure was 13 mmHg OS. Slit-lamp examination showed a quiet conjunctiva with a moderate superior Seidel-negative bleb with diffuse microcysts. The cornea was clear and the anterior chamber was quiet. The lens field and the pupil was undilated, with dilation showed the lens to be subluxated, as previously noted. Fundus examination was consistent with prior examinations. 

ASSESSMENT AND PLAN:  We feel that the patient's pressure control is good since her recent trabeculectomy done a little more than a month ago. She does have residual decreased visual acuity in the left eye, which we suspect is due to her preoperative advanced glaucoma. However, she has also developed some significant posterior capsular fibrosis in this eye, and it may be reasonable to perform a YAG capsulotomy in the future, though we would not do this for a while.

We have asked the patient to continue her same medications and return to see you in two weeks. If she is stable at that point, we would suggest stopping the Xibrom and decreasing the Pred Forte to q.3 hours. We have asked the patient to return to see us in one month. In the meantime, please contact us if you have any question of my findings.

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REASON FOR VISIT:  The patient is a (XX)-year-old who is referred back to me by Dr. Doe for evaluation of decreasing vision. I performed vitrectomy surgery with membrane peeling on the right eye. The patient in addition had cataract surgery in the past.

PHYSICAL EXAMINATION:  Today, visual acuity is 20/25 in both eyes. Intraocular pressures are normal. Slit-lamp examination is remarkable for a well-centered posterior chamber intraocular lens in the right eye and mild cataract in the left eye. Dilated funduscopic examination in the right eye reveals some persistent, either epiretinal membrane or wrinkling of the internal limiting membrane. There is a small refractile particle on the surface of the retina, but this may be related to forceps used during the membrane peel. In the left eye, there is a sharp foveal reflex.

IMPRESSION:
1.  Cataract.
2.  Pseudophakia, right eye.
3.  Status post vitrectomy, membrane peel, right eye.

PLAN:  I believe the patient is doing well and vision has actually improved to 20/25 in both eyes. I would be reluctant to initiate any treatment at this point in time. I have asked the patient to follow up with Dr. Doe in 6 months.

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SUBJECTIVE:  I had the pleasure of seeing this patient for a diabetic eye examination.

OBJECTIVE:  Best corrected visual acuity was found to be 20/20 in the right eye and 20/25 in the left eye. Pupils were equal, round, and reactive to light with no afferent pupillary defect. Extraocular muscles were smooth and full. Confrontation visual fields were full in both eyes. Intraocular pressures by applanation tonometry were 15 mmHg, both eyes. Slit-lamp examination demonstrated 2+ nuclear sclerotic cataracts in both eyes. Dilated fundus examination demonstrated small drusen in the macula of both eyes and a small scar superior in the macula, left eye.

ASSESSMENT AND PLAN:  My impression is that this patient has no diabetic retinopathy/drusen, both eyes. We prescribed home Amsler grid to be used on a regular basis and eat green leafy vegetables. We scheduled an appointment in one year due to diabetes.


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SUBJECTIVE:  The patient is a (XX)-year-old female who is here after having suffered what appears to be a transient ischemic episode. According to the patient, she has had poor vision in her right eye for many years. She has also had poor vision in her left, although not quite as poor as the right. It seems to be progressively getting worse. She claims she has had cataract surgery in both eyes. She is having more difficulty with doing her activities around the house.

OBJECTIVE:  Best-corrected visual acuity is 20/400 in the right and 20/80 in the left. Refraction in the office does not make much improvement in her vision. There is no afferent pupillary defect. Motility is full bilaterally. External examination reveals deep sockets bilaterally. She has some upper lid dermatochalasis, OU. On slit-lamp examination, corneas are clearly bilaterally. Anterior chambers are quiet and deep. Irises both reveal surgical iridectomies. She had posterior chamber lens implants in both eyes. Her left pupil is bound down to her lens implant. Dilated fundus examination reveals diffuse peripapillary atrophy bilaterally, as well as significant retinal pigment epithelial clumping and atrophy to bilateral maculae.

ASSESSMENT:
1.  Advanced dry macular degeneration, right greater than left.
2.  Pseudophakia.

PLAN:  Unfortunately, there is not much we can do to improve the patient's vision at this point. We do not recommend she get new glasses. We should follow up with her in approximately six months, however sooner, if she has any new problems or complaints.


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HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old who is referred by Dr. Doe for evaluation of retinoschisis versus a retinal detachment in the right eye. Of note, the patient has had cryopexy in the left eye previously by Dr. Doe for a retinal tear.

PHYSICAL EXAMINATION:  Dilated funduscopic examination in the right eye reveals retinoschisis inferiorly. There was a small dot of hemorrhage. Since the retinoschisis does extend fairly far posteriorly, I ordered an OCT today. The OCT clearly shows that this area is retinoschisis rather than a retinal detachment. Dilated funduscopic examination in the left eye reveals cryopexy scars from previous procedure by Dr. Doe.

IMPRESSION:
1.  Retinoschisis, right eye.
2.  History of cryopexy for retinal tear, left eye.

PLAN:  The signs and symptoms of retinal detachment were discussed in detail with the patient. I have asked the patient to follow up with me in 6 months.



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