source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWEE4.m@ 628

DVBCWEE4 ;ALB/RLC EYE EXAMINATION WKS TEXT - 1 ; 12 FEB 2007
 ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
 ;
 ;
TXT ;
 ;;Narrative:  An eye examination must be conducted by a licensed optometrist
 ;;or ophthalmologist.  Examinations for the evaluation of visual fields or
 ;;muscle function will be conducted only when there is a medical indication.
 ;;
 ;;A.  Review of Medical Records:
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;
 ;;    Comment on:
 ;;
 ;;    1.  General eye symptoms, pain, redness, swelling, discharge, watering, etc.
 ;;    2.  Duration and frequency of periods of incapacitation, and rest
 ;;        requirements.
 ;;    3.  Visual symptoms, including distorted or enlarged image, etc.
 ;;    4.  Current ophthalmologic treatment, side effects.
 ;;    5.  For neoplasms, state date of diagnosis, benign or malignant, type
 ;;        of treatment and last date of treatment.
 ;;    6.  History of hospitalizations or surgery, dates and location if known,
 ;;        reason or type of surgery.
 ;;    7.  For trauma, type and date.
 ;;    8.  For congestive or inflammatory glaucoma, duration and frequency of
 ;;        attacks.
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    Address each of the following, as applicable, and fully describe 
 ;;    current findings:
 ;;
 ;;    1.  Visual Acuity:
 ;;
 ;;        a. Examine each eye independently and record the refractive 
 ;;           information indicated below.
 ;;        b. Use conventional lenses for correction unless the patient
 ;;           has keratoconus, is well adapted to contact lenses and wishes
 ;;           to wear them, and contact lenses result in best corrected 
 ;;           visual acuity.
 ;;        c. Use Snellen's test type or its equivalent for distance and revised
 ;;           Jaegar Standard or its equivalent for near.
 ;;        d. Carry out an examination with the pupils dilated unless 
 ;;           contraindicated, and record the ophthalmic findings.
 ;;        e. For visual acuity worse than 5/200 in either or both eyes,
 ;;           report the distance in feet/inches (or meters/centimeters) 
 ;;           from the face at which the veteran can count fingers/detect 
 ;;           hand motion/read the largest line on the chart.  If the 
 ;;           veteran cannot detect hand motion or count fingers at any
 ;;           distance, state whether he or she has light perception.
 ;;        f. If keratoconus is present, state whether contact lenses 
 ;;           are required or adequate correction is possible by other means.
 ;;TOF
 ;;               Right Eye                FAR            NEAR
 ;;
 ;;        RIGHT EYE     UNCORRECTED    __________      _________
 ;;
 ;;        RIGHT EYE     CORRECTED      __________      _________
 ;;
 ;;
 ;;
 ;;               Left Eye                 FAR            NEAR
 ;;
 ;;        LEFT EYE      UNCORRECTED    __________      _________
 ;;
 ;;        LEFT EYE      CORRECTED      __________      _________
 ;;
 ;;
 ;;    2.  Diplopia:
 ;;
 ;;        a. Perform the measurement of muscle function using a 
 ;;           Goldmann Perimeter Chart and chart the areas in which diplopia
 ;;           exists.  Include the chart as part of the examination report 
 ;;           to be sent to the regional office.
 ;;        b. If diplopia is present, state whether it is constant or 
 ;;           intermittent, whether it is present at all distances or only 
 ;;           for near or distant vision, and whether it is correctable by 
 ;;           use of lenses or prisms.
 ;;        c. If diplopia is constant and not correctable, indicate which 
 ;;           of the sectors of the visual field are affected and provide the
 ;;           Goldmann perimeter chart showing the actual areas of diplopia,
 ;;           according to the format below.  Diplopia outside these areas
 ;;           should also be reported even though it is not considered disabling
 ;;           because it may be used in the evaluation of the underlying disease
 ;;           or injury.
 ;;
 ;;                    Diplopia                      | Amount
 ;;
 ;;        Central 20 Degrees|      |                |
 ;;        21 TO 30 Degrees  |      |                |
 ;;                          | DOWN |                |
 ;;                          |      | Right Lateral  |
 ;;                          |      | Left Lateral   |
 ;;                          |  UP  |                |
 ;;                          |      | Right Lateral  |
 ;;                          |      | Left Lateral   |
 ;;        31 TO 40 Degrees  |      |                |
 ;;                          | DOWN |                |
 ;;                          |      | Right Lateral  |
 ;;                          |      | Left Lateral   |
 ;;                          |  UP  |                |
 ;;                          |      | Right Lateral  |
 ;;                          |      | Left Lateral   |
 ;;
 ;;TOF
 ;;    3.  Visual Field Deficit:
 ;;
 ;;        a. Chart any visual field defect using a Goldmann Perimeter
 ;;           Chart and include the chart as part of the examination report
 ;;           to be sent to the regional office.
 ;;        b. For an aphakic eye which cannot be fitted with contact 
 ;;           lenses or intra-ocular implant, use the IV/4e test object.  
 ;;           For all other cases, use the III/4e test object.
 ;;        c. If the examiner determines that charting with other test 
 ;;           objects is indicated, those test results should be reported 
 ;;           on a separate chart.  All charts, along with an explanation 
 ;;           of the need for using a different test object and an 
 ;;           explanation of any discrepancies in results, should be 
 ;;           included as part of the examination report.
 ;;        d. All scotomas should be plotted carefully in order to 
 ;;           allow measurements to be made for adjustments in the 
 ;;           calculation of visual field defects.
 ;;
 ;;    4.  Details of eye disease or injury (including eyebrows, 
 ;;        eyelashes, eyelids, lacrimal duct) other than loss of visual acuity,
 ;;        diplopia, or visual field defect.
 ;;    5.  Enucleation.  Is prosthesis possible?
 ;;    6.  Record results of any other examination findings including tonometry,
 ;;        funduscopic, slit lamp.
 ;;
 ;;D.   Diagnostic and Clinical Tests:  (Other than for visual acuity, 
 ;;     diplopia, and visual fields, as described above.)
 ;;
 ;;     1. Include results of all diagnostic and clinical tests 
 ;;        conducted in the examination report.
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;     1.  For nystagmus, provide type.
 ;;
 ;;
 ;;
 ;;Signature:                                   Date:
 ;;END