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[613]1DVBCWEE4 ;ALB/RLC EYE EXAMINATION WKS TEXT - 1 ; 12 FEB 2007
2 ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
3 ;
4 ;
5TXT ;
6 ;;Narrative: An eye examination must be conducted by a licensed optometrist
7 ;;or ophthalmologist. Examinations for the evaluation of visual fields or
8 ;;muscle function will be conducted only when there is a medical indication.
9 ;;
10 ;;A. Review of Medical Records:
11 ;;
12 ;;B. Medical History (Subjective Complaints):
13 ;;
14 ;; Comment on:
15 ;;
16 ;; 1. General eye symptoms, pain, redness, swelling, discharge, watering, etc.
17 ;; 2. Duration and frequency of periods of incapacitation, and rest
18 ;; requirements.
19 ;; 3. Visual symptoms, including distorted or enlarged image, etc.
20 ;; 4. Current ophthalmologic treatment, side effects.
21 ;; 5. For neoplasms, state date of diagnosis, benign or malignant, type
22 ;; of treatment and last date of treatment.
23 ;; 6. History of hospitalizations or surgery, dates and location if known,
24 ;; reason or type of surgery.
25 ;; 7. For trauma, type and date.
26 ;; 8. For congestive or inflammatory glaucoma, duration and frequency of
27 ;; attacks.
28 ;;
29 ;;C. Physical Examination (Objective Findings):
30 ;;
31 ;; Address each of the following, as applicable, and fully describe
32 ;; current findings:
33 ;;
34 ;; 1. Visual Acuity:
35 ;;
36 ;; a. Examine each eye independently and record the refractive
37 ;; information indicated below.
38 ;; b. Use conventional lenses for correction unless the patient
39 ;; has keratoconus, is well adapted to contact lenses and wishes
40 ;; to wear them, and contact lenses result in best corrected
41 ;; visual acuity.
42 ;; c. Use Snellen's test type or its equivalent for distance and revised
43 ;; Jaegar Standard or its equivalent for near.
44 ;; d. Carry out an examination with the pupils dilated unless
45 ;; contraindicated, and record the ophthalmic findings.
46 ;; e. For visual acuity worse than 5/200 in either or both eyes,
47 ;; report the distance in feet/inches (or meters/centimeters)
48 ;; from the face at which the veteran can count fingers/detect
49 ;; hand motion/read the largest line on the chart. If the
50 ;; veteran cannot detect hand motion or count fingers at any
51 ;; distance, state whether he or she has light perception.
52 ;; f. If keratoconus is present, state whether contact lenses
53 ;; are required or adequate correction is possible by other means.
54 ;;TOF
55 ;; Right Eye FAR NEAR
56 ;;
57 ;; RIGHT EYE UNCORRECTED __________ _________
58 ;;
59 ;; RIGHT EYE CORRECTED __________ _________
60 ;;
61 ;;
62 ;;
63 ;; Left Eye FAR NEAR
64 ;;
65 ;; LEFT EYE UNCORRECTED __________ _________
66 ;;
67 ;; LEFT EYE CORRECTED __________ _________
68 ;;
69 ;;
70 ;; 2. Diplopia:
71 ;;
72 ;; a. Perform the measurement of muscle function using a
73 ;; Goldmann Perimeter Chart and chart the areas in which diplopia
74 ;; exists. Include the chart as part of the examination report
75 ;; to be sent to the regional office.
76 ;; b. If diplopia is present, state whether it is constant or
77 ;; intermittent, whether it is present at all distances or only
78 ;; for near or distant vision, and whether it is correctable by
79 ;; use of lenses or prisms.
80 ;; c. If diplopia is constant and not correctable, indicate which
81 ;; of the sectors of the visual field are affected and provide the
82 ;; Goldmann perimeter chart showing the actual areas of diplopia,
83 ;; according to the format below. Diplopia outside these areas
84 ;; should also be reported even though it is not considered disabling
85 ;; because it may be used in the evaluation of the underlying disease
86 ;; or injury.
87 ;;
88 ;; Diplopia | Amount
89 ;;
90 ;; Central 20 Degrees| | |
91 ;; 21 TO 30 Degrees | | |
92 ;; | DOWN | |
93 ;; | | Right Lateral |
94 ;; | | Left Lateral |
95 ;; | UP | |
96 ;; | | Right Lateral |
97 ;; | | Left Lateral |
98 ;; 31 TO 40 Degrees | | |
99 ;; | DOWN | |
100 ;; | | Right Lateral |
101 ;; | | Left Lateral |
102 ;; | UP | |
103 ;; | | Right Lateral |
104 ;; | | Left Lateral |
105 ;;
106 ;;TOF
107 ;; 3. Visual Field Deficit:
108 ;;
109 ;; a. Chart any visual field defect using a Goldmann Perimeter
110 ;; Chart and include the chart as part of the examination report
111 ;; to be sent to the regional office.
112 ;; b. For an aphakic eye which cannot be fitted with contact
113 ;; lenses or intra-ocular implant, use the IV/4e test object.
114 ;; For all other cases, use the III/4e test object.
115 ;; c. If the examiner determines that charting with other test
116 ;; objects is indicated, those test results should be reported
117 ;; on a separate chart. All charts, along with an explanation
118 ;; of the need for using a different test object and an
119 ;; explanation of any discrepancies in results, should be
120 ;; included as part of the examination report.
121 ;; d. All scotomas should be plotted carefully in order to
122 ;; allow measurements to be made for adjustments in the
123 ;; calculation of visual field defects.
124 ;;
125 ;; 4. Details of eye disease or injury (including eyebrows,
126 ;; eyelashes, eyelids, lacrimal duct) other than loss of visual acuity,
127 ;; diplopia, or visual field defect.
128 ;; 5. Enucleation. Is prosthesis possible?
129 ;; 6. Record results of any other examination findings including tonometry,
130 ;; funduscopic, slit lamp.
131 ;;
132 ;;D. Diagnostic and Clinical Tests: (Other than for visual acuity,
133 ;; diplopia, and visual fields, as described above.)
134 ;;
135 ;; 1. Include results of all diagnostic and clinical tests
136 ;; conducted in the examination report.
137 ;;
138 ;;E. Diagnosis:
139 ;;
140 ;; 1. For nystagmus, provide type.
141 ;;
142 ;;
143 ;;
144 ;;Signature: Date:
145 ;;END
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