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1DVBCWEE1 ;ALB/CMM EYE EXAMINATION WKS TEXT - 1 ; 6 MARCH 1997
2 ;;2.7;AMIE;**12**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;B. Medical History (Subjective Complaints):
9 ;;
10 ;; Comment on:
11 ;; 1. Pain.
12 ;; 2. Duration and frequency of periods of incapacitation, and rest
13 ;; requirements.
14 ;; 3. Visual symptoms, including distorted or enlarged image, etc.
15 ;; 4. Current ophthalmologic treatment.
16 ;; 5. For malignant neoplasms, state type of treatment and last date.
17 ;; If treatment is current, describe.
18 ;;
19 ;;C. Physical Examination (Objective Findings):
20 ;;
21 ;; Address each of the following, as applicable, and fully describe
22 ;; current findings:
23 ;; 1. Visual Acuity:
24 ;; a. Examine each eye independently and record the refractive
25 ;; information indicated below.
26 ;; b. Use conventional lenses for correction unless the patient
27 ;; has keratoconus, is well adapted to contact lenses and wishes
28 ;; to wear them, and contact lenses result in best corrected
29 ;; visual acuity.
30 ;; c. Use Snellen's test type or its equivalent.
31 ;; d. Carry out an examination with the pupils dilated unless
32 ;; contraindicated, and record the ophthalmic findings.
33 ;; e. For visual acuity worse than 5/200 in either or both eyes,
34 ;; report the distance in feet/inches (or meters/centimeters)
35 ;; from the face at which the veteran can count fingers/detect
36 ;; hand motion/read the largest line on the chart. If the
37 ;; veteran cannot detect hand motion or count fingers at any
38 ;; distance, state whether he or she has light perception.
39 ;; f. If keratoconus is present, state whether contact lenses
40 ;; are required or adequate correction is possible by other means.
41 ;;
42 ;;
43 ;; NEAR FAR
44 ;;
45 ;; RIGHT EYE UNCORRECTED __________ _________
46 ;;
47 ;; RIGHT EYE CORRECTED __________ _________
48 ;;
49 ;;
50 ;;
51 ;; NEAR FAR
52 ;;
53 ;; LEFT EYE UNCORRECTED __________ _________
54 ;;
55 ;; LEFT EYE CORRECTED __________ _________
56 ;;
57 ;;
58 ;; 2. Diplopia:
59 ;; a. Perform the measurement of muscle function using a
60 ;; Goldmann Perimeter Chart and chart the areas in which diplopia
61 ;; exists. Include the chart as part of the examination report
62 ;; to be sent to the regional office.
63 ;; b. If diplopia is present, state whether it is constant or
64 ;; intermittent, whether it is present at all distances or only
65 ;; for near or distant vision, and whether it is correctable by
66 ;; use of lenses or prisms.
67 ;; c. If diplopia is constant and not correctable, indicate
68 ;; which sectors of the visual field are affected and provide
69 ;; the Goldmann perimeter chart showing the actual areas of
70 ;; diplopia, according to the format below. Diplopia outside
71 ;; these areas should also be reported even though it is not
72 ;; considered disabling because it may be used in the evaluation
73 ;; of the underlying disease or injury.
74 ;;
75 ;; CENTRAL 20 DEGREES _________
76 ;;
77 ;; 21 TO 30 DEGREES
78 ;; DOWN
79 ;; RIGHT LATERAL _________
80 ;;
81 ;; LEFT LATERAL _________
82 ;;
83 ;; UP
84 ;; RIGHT LATERAL _________
85 ;;
86 ;; LEFT LATERAL _________
87 ;;
88 ;; 31 TO 40 DEGREES
89 ;; DOWN
90 ;; RIGHT LATERAL _________
91 ;;
92 ;; LEFT LATERAL _________
93 ;;
94 ;; UP
95 ;; RIGHT LATERAL _________
96 ;;
97 ;; LEFT LATERAL _________
98 ;;
99 ;;
100 ;; 3. Visual Field Deficit:
101 ;; a. Chart any visual field defect using a Goldmann Perimeter
102 ;; Chart and include the chart as part of the examination report
103 ;; to be sent to the regional office.
104 ;; b. For an aphakic eye which cannot be fitted with contact
105 ;; lenses or intra-ocular implant, use the IV/4e test object.
106 ;; For all other cases, use the III/4e test object.
107 ;; c. If the examiner determines that charting with other test
108 ;; objects is indicated, those test results should be reported
109 ;; on a separate chart. All charts, along with an explanation
110 ;; of the need for using a different test object and an
111 ;; explanation of any discrepancies in results, should be
112 ;; included as part of the examination report.
113 ;; d. All scotomas should be plotted carefully in order to
114 ;; allow measurements to be made for adjustments in the
115 ;; calculation of visual field defects.
116 ;; 4. Details of eye disease or injury (including eyebrows,
117 ;; eyelashes, eyelids) other than loss of visual acuity, diplopia,
118 ;; or visual field defect:
119 ;;
120 ;;D. Diagnostic and Clinical Tests: (Other than for visual acuity,
121 ;;diplopia, and visual fields, as described above.)
122 ;;
123 ;; 1. Include results of all diagnostic and clinical tests
124 ;; conducted in the examination report.
125 ;;
126 ;;E. Diagnosis:
127 ;;
128 ;;Signature: Date:
129 ;;END
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