Optometric Resources

GLASSES RX ANISO Edu pt on condition and exam findings. Provided pt with spec rx - rx modified for pt adaptation. Instructed to wear full time. Edu pt on adaptation to new specs. Pt counseled that binocular vision would be improved with Cl wear vs. spec wear. BF/PAL Provided pt with spec rx. Instructed to wear full time. Discussed adaptation to lenses with patient. BF/PAL + OTC READERS OK Edu pt on condition and exam findings. Provided pt with spec rx for BF/PAL if desired to wear as needed/full time. OTC readers are also ok for near vision tasks; pt understands while wearing, distance vision will be blurry. GLASSES RX - LIMITED BY CATARACTS Edu pt on condition and exam findings. Pt understands that cataract development may limit BCVA. Provided pt with spec rx to maximize functional vision at this time. Instructed to wear full time. Pt counseled that rx will change after cataract surgery GLASSES RX - NONE REQUIRED Edu pt on condition and exam findings. No spec rx required at this time.

 FOREIGN BODY - REMOVED TODAY Foreign body removed in office today. BSCLs applied to affected eye - lens was soaked in ophthalmic antibiotic medication for 5 minutes prior to instillation. Patient was prescribed topical ophthalmic medication to be used as directed. RTC for foreign body subsequent encounter as directed. 

DRY EYE GENERAL Edu pt on condition and exam findings. Prescribed ATs to be used qid OU. Advised effects of ceiling fans. Emphasized to pt importance of lid hygiene as directed. RTC for f/u as indicated. DRY EYE - START RESTASIS Edu pt on exam findings. Prescribed Prednisone Acetate to be used tid OU and initiate therapy with Restasis bid OU. Recommended use of ATs pro OU to help lubricate throughout the day. Advised effects of ceiling fans. Emphazied to pt importance of lid hygiene as directed. RTC for f/u as indicated.  DRY EYE - MGD Edu pt on condition and exam findings. Prescribed ATs to be used tid OU. Advised effects of ceiling fans. Recommended use of warm compress bid - discussed with pt available options. Rx'ed oral medication to be taken as directed for MGD. Emphasized to pt importance of lid hygiene as directed. RTC for follow up as indicated.  DRY EYE WITH STEROID TREATMENT Edu pt on condition and exam findings. Prescribed topical steroid to be used as directed and pres

Edu pt on condition and exam findings. Discussed with pt that symptoms are consistent with digital eye strain secondary to prolonged computer computer use. Prescribed ***___*** to reduce ocular fatigue and recommended patient implementing the 20-20-20 rule into their daily work routine. Also recommended for pt to keep ATs near desk to be used prn.

DIABETES WITH PROLIFERATIVE CHANGES Edu pt on condition and exam findings. Counselled pt on risk of blindness and the importance of treating the underlying systemic condition. Emphasized to pt importance of systemic blood glucose control. Report was sent to pt's PCP regarding ocular findings. Pt referred to an ophthalmologist specializing in vitreo-retinal care for surgical intervention. Pt counseled on use of anti-VEGF and/or retinal laser for treatment of retinopathy; risks and benefits of treatment were discussed with the patient. Pt scheduled to RTC for monitoring and imaging services as indicated.  Appointment has been scheduled for pt at ***insert***. Pt understands cost associated with treatment and was provided detailed information in clinic today about when/where to proceed for surgical intervention. DIABETES WITH RETINOPATHY Edu pt on condition and exam findings. Counseled pt on risk of vision loss if underlying condition is not controlled. Emphasized importance of system

Edu pt on condition and exam findings. Counselled pt on importance of monitoring condition as directed. Stressed importance of BG and BP control. Pt may use an occlusion patch over one eye to relieve symptomatic diplopia. Instructed pt to immediately report any change in condition outside of expected and discussed symptoms. MRI of head is not indicated at this time but should be considered if new neurologic signs or symptoms develop or the severity of the palsy increases. RTC for additional testing as indicated. 

Pt edu about proper care and hygiene with contact lenses. Continue to monitor condition as directed. Pt edu to RTC asap for new onset red eye, pain, or irritation associated with CLs wear. 

CATARACTS - GENERAL: Edu pt on exam findings and condition. Pt was counseled that cataracts will progressively limit BCVA without surgical intervention. Pt was cautioned about driving and glare, especially at night. No surgical intervention is needed at this time - recommended waiting until functional vision is worse. Continue to monitor the condition as directed. If ADL's become impacted sooner than follow up appointment, patient edu to RTC for a dilated examination.  CATARACTS - SURGERY DEFERRED   Edu pt on condition and exam findings. Pt was counseled that cataracts will progressively limit BCVA without surgical intervention. Pt was cautioned about driving and glare, especially at night. Pt was counseled about the risks and benefits of surgery and IOL options. After discussion, the pt elected to defer cat sx at this time. Edu pt on importance of monitoring the condition. CATARACTS - SURGERY REFERRAL Edu pt on condition and exam findings. Pt was counseled that cataracts will prog

Edu pt on condition and exam findings. Prescribed topical steroid and allergy drop to be used as directed. Recommended use of ATs as needed. Discussed use of allergy drop and oral allergy medications PRN. Follow up as directed and RTC if any symptoms outside those discussed today are noted. 

1 Day: Educated pt about findings and reminded pt of post-operative instructions. Use medications as prescribed. RTC for 1 week post op. Edu pt to call clinic STAT if signs/symptoms occur outside of the expected discussed in office today - this includes but is not limited to decreasing vision and significant pain. 1 Week: Edu pt about findings and all post-operative instructions. Edu pt that all post-operative restrictions have been removed. Edu pt to d/c antibiotic coverage. Use other medications as prescribed. RTC clinic for 1 week post op. Edu pt to call clinic STAT if signs/symptoms occur outside of the expected discussed in office today - this includes but is not limited to decreasing vision and significant pain.  RTC for 1 mo cat sx PO. RTC sooner if new symptoms occur. 

Discussed Condition and possible & probable causes for new onset floaters. Patient understands that condition can also be idiopathic in nature and typically normal with age or in moderate to advanced myopic eyes. Reviewed signs and symptoms of retinal tear/detachment and the importance of prompt evaluation should there be an increase in floaters, flashes of light, or decreasing peripheral vision. Follow up in 4-6 weeks for dilation to evaluate the status of vitreous and retinal health.  Stable: Stable condition. Patient was reminded to report any acute changes to floaters or vision with or without flashes of light.  

 Discussed condition, possible causes, and expected time link for resolution. Recommend artificial tears and cold compresses, remind pt to report any acute changes in vision, pain, or recurrent episodes.  The patient's condition was explained in detail. The pt was advised to call or f/u sooner than prescribed for any signs of worsening including new pain, redness, or decreased vision. 

 New spec rx. RTC in 1 yr for annual CEE.

Recommended consistency with BID artificial tears to avoid dryness, irritation, and inflammation. Recommend patient continue with UV protection eye wear.

 IOLs are clear and well centered with stable BCVA - monitor yearly.

Patient understands that consistency of dosing and compliance of use are important to maintain a stable condition and minimize involved symptoms.

 Discussed the importance of compliance with medications and follow up care with PCP or medical provider. Reviewed importance of optimal cardiovascular health (including specific control of blood pressure, cholesterol, and blood glucose) in the prevention of ocular complications. RTC in 1 yr for CEE.

Very low risk of malignant transformation with lesion being flat, no SRF, no orange pigment, regular margins, & pt is asymptomatic. Monitor condition yearly for changes in color, texture, dimension, and size & for pt symptoms. Reviewed condition & exam findings with patient and emphasized the need for yearly monitoring (or earlier if symptoms arise) to rule out malignant transformation. Pt understood all instructions.  PARENT: Very low risk of malignant transformation with lesion being flat, no SRF, no orange pigment, regular margins, & pt is asymptomatic. Monitor condition yearly for changes in color, texture, dimension, and size & for pt symptoms. Reviewed condition & exam findings with patient/parent/guardian and emphasized the need for yearly monitoring (or earlier if symptoms arise) to ensure there are no changes. Pt/parent/guardian understood all instructions. 

Discussed nature of condition and related risks of acute angle closure that could potentially cause irreversible vision loss. Reviewed associated symptoms of an acute angle closure  (HAs, vomiting, pain, etc...) attack, in which such an event should be considered an ocular emergency that would require urgent medical care. Edu pt to take caution when transitioning from dark to light environments such as when leaving a movie theater. Consider DFE only after performing gonioscopy.  Monitor as needed with gonioscopy & anterior segment OCT.

MGD: Implement lid hygiene regimen consisting of warm compresses and lid scrubs. Dispense Ocusoft wipes for nightly use for thorough cleansing. Pt understands that oral antibiotic treatment will be considered if condition worsens.

Pt's lid condition was explained in detail. Pt understands that physiological changes can be related to natural aging, family history (genetics), trauma, or infections. Recommended annual f/u to monitor for changes & progression. Will consider referral to oculoplastics if condition worsens and interferes with vision and/or visual comfort.

Lattice (new finding): Patient understands that lattice with or without holes indicates that retinas are more fragile in nature and thus pose a higher risk of tears, breaks, and detachments. Patient understands that acute changes to vision or floaters with or without flashes of light could indicate a retinal compromise and should seek immediate care with an eye care provider. Pt understands that yearly fundus evaluations are necessary to appropriately monitor condition. F/u in 12 months or PRN. Lattice (stable finding): Condition is stable. Pt was reminded to report any acute changes to vision including new onset floaters or flashes and/or increase in frequency or severity of floaters/flashes. Edu pt to report changes in vision with or without associated flashes of light.

Rx: Restasis, BID. Patient understands that consistency of dosing and compliance of use are important to maintain stability of condition and minimize involved symptoms.

Hordeolum: Implement warm compresses. Rx antibiotic ointment. Rx oral antibiotic medication and f/u 1 week or prn. Pt understands that infected nodules usually arise from an underlying lid condition such as MGD or Blepharitis that would require chronic lid cleaning regimen consisting of warm compresses and lid scrubs.

 Recommend OTC artificial tears: Patient understands that consistency of dosing and compliance with drops are important to maintain stability of condition and minimize symptoms. Consider prescription rx if minimal to no improvement occurs in signs & symptoms. Rx: Xiidra. Pt understands that consistency of dosing and compliance of use are important to maintain stability of condition and minimize involved symptoms.

 Pt understands importance of annual diabetic eye exam due to diabetic status.

Chalazion: Implement lid cleansing regimen consisting of warm compresses and lid scrubs. Rx antibiotic ointment to apply to affected area for 7 days. Consider referral for incision/curettage of nodule if no improvement in 3-5 weeks. Recommend Ocusoft Plus wipes for nightly use for maintenance and prevention.

Stable BCVA - recommend pt continue with UV protective eye wear and f/u in 12 months to evaluate for changes or progression of condition.

Implement lid hygiene regimen to consist of warm compresses and lid scrubs. Rx antibiotic ointment to apply to lid/lash area for 7 days. Dispense Ocusoft wipes samples for nightly use for more throrough cleansing. Pt understands that condition is chronic and requires consistency and compliance of the recommended lid care regimen. 

Recommended Polycarbonate material for lenses due to amblyopic status. Patient understands importance of polycarbonate material for protective measure of visually functional eye and thus recommend constant wear of glasses.