__/29/_____ John Doe    #00-00-7

SUBJECTIVE: Six-month periodic intraocular pressure check for ocular hypertension.  Patient has not scheduled consultation for cataract and capsulotomy. 

OBJECTIVE: Slit-lamp Examination - Lids, lashes, adnexa, conjunctiva, cornea, and iris are clear OU.  The anterior chamber is deep and quiet.  Angles are 4 temporally.  Scleral spur with four-mirror gonioscopy OU.  Lens shows nuclear and cortical cataract OD.  Intraocular lens is centered OS.  2+ capsular fibrosis OS. 

ASSESSMENT: 1) Ocular hypertension with reassuring intraocular pressures today.  2) Cataract OD.  3) Pseudophakia with after cataract extreme vision OS.

PLAN: 1) Cataract consultation/laser capsulotomy consultation scheduled with Wolfe Clinic.  2) Return to the clinic postoperatively for follow-up OD.

__________, O.D./ht:___

__/02/____  ______________  #00-00-19-9

SUBJECTIVE: The patient is a ten-year-old female with complaint of headaches, one to two per week, when reading, frontally. Patient reports headache duration of approximately thirty minutes, Tylenol does help with relief.  FAMILY HISTORY of esophoria in patient's older sister.

OBJECTIVE: Cover test is 2-4 esophoria at distance and near. Extraocular motilities are smooth and full.  Visual fields are full to confrontation.  Pupils are equal, round, and reactive to light.  Negative afferent pupillary defect.  Slit-lamp Examination - Lids, lashes, conjunctiva, cornea, iris, and lens are all clear.  The anterior chamber is clear and quiet.  Angles are 4 temporally.  Internal with dilation, cup-to-disk is 0.5 and 0.6.  The posterior pole and macula are clear with a positive foveal light reflex.  The periphery is clear to past equator OU.

ASSESSMENT: 1) Hyperopia.  2) Esophoria.  3) Ocular health no apparent pathology.  4) Headaches likely related to uncorrected hyperopia.

PLAN: 1) Subjective prescription given.  Recommend initially wearing for near and gradually building up to full-time wear. 2) Discussed at length with patient and patient's mother the benefits of correction due to symptoms and relation to findings today.  3) Vision examination in one year.

___________, O.D./ht:____

__/09/____  John Doe    #0-00-74-0

SUBJECTIVE: The patient is a 71-year-old male with history of glaucomatous optic nerve head cupping and no family history of glaucoma.  Patient currently takes daily antioxidant multivitamins for dry age-related macular degeneration.  History of choroidal nevus OD.  HISTORY and REVIEW OF SYSTEMS are updated in the chart.  Current spectacles are one year old.

OBJECTIVE: Patient is oriented times three and in a good mood.  Cover test is orthophoric at distance.  Extraocular motilities are smooth and full.  Visual fields are full to confrontation. Pupils are equal, round, and reactive to light.  Negative afferent pupillary defect.  Slit-lamp Examination - Lids, lashes, adnexa dermatochalasis OU.  Conjunctiva, cornea, and iris are clear.  The anterior chamber is clear and quiet.  Angles are 4 temporally.  Lens shows 1+ nuclear sclerosis and 2+ cortical cataract OD, 1+ nuclear sclerosis and cortical cataract OS.  Cup-to-disk is 0.7 and 0.6.  The posterior pole is clear.  Macula shows 1+ drusen and pigment irregularity OU, otherwise posterior pole is clear.  Peripheral retina shows choroidal nevus 2.5 disk diameters by 2.5 disk diameters, flat. The periphery is clear to past equator otherwise OU.

ASSESSMENT: 1) Myopia, astigmatism, and presbyopia.  2) Cataract. 3) Choroidal nevus OD, stable.  4) Dry age-related macular degeneration.  5) Large optic nerve head cup with reassuring intraocular pressures and history of normal visual fields.  No family history of glaucoma.

PLAN: 1) No change in prescription.  2) Continue antioxidant multivitamin with lutein daily.  Discussed benefits of dark, leafy, green vegetables and ultraviolet protection.  3) Return to the clinic in one year.

________, O.D./ht:____

__/08/____  Jane Doe    #00-00-00-8

SUBJECTIVE: Follow-up for keratitis OS.  Patient reports improvement in symptoms.  Compliance with TobraDex every two hours OS and Polysporin at bedtime.  She reports no redness or photophobia, mild irritation only.

OBJECTIVE: Anterior segment of the right eye is clear.  Left eye, 0.5 mm infiltrate superiorly is less dense today.  Epithelium is intact.  There is 1+ superficial punctate keratitis diffusely OS.  The anterior chamber is deep and quiet.

ASSESSMENT: 1) Resolving keratitis and secondary anterior uveitis.  2) Medicamentosa OS. 

PLAN: 1) Discontinue Polysporin ointment.  2) Taper TobraDex over the next three days and then discontinue.  Gradually restart contact lens wear and rebuild wearing time.  3) Return to the clinic in seven to ten days for comprehensive examination or follow-up sooner per symptoms.

____________, O.D./ht:___

__/22/_____  Jane Doe    #00-00-00

SUBJECTIVE: The patient is a 64-year-old female complaining of difficulties with near detail vision.  Current spectacles are one year old.  History of dry eyes and use of Artificial Tears p.r.n.  No complain of diplopia.  

OBJECTIVE: Patient is oriented times three and in a good

    mood.  Cover test shows to 6-8 right esotropia at distance. Extraocular motilities are smooth and full.  Visual fields are full to confrontation.  Pupils are equal, round, and reactive to light.  Negative afferent pupillary defect.  Slit-lamp Examination - Lids, lashes, adnexa, conjunctiva, cornea, and iris are clear.  The anterior chamber is clear and quiet.  Angles are 4 temporally.  Lens shows 1+ nuclear sclerosis and cortical changes OU.  Internal with dilation, cup-to-disk is 0.6 and 0.4.  The posterior pole shows subtle pigment irregularity with indirect illumination.  Macula is clear with no foveal light reflex present.  Periphery shows reticular pigment changes OU as before.

ASSESSMENT: 1) Dry eyes currently well-treated with Artificial Tears p.r.n.  2) Early cataract.  3) Retinal pigment epithelium changes of peripheral and posterior retina.  4) Hyperopia, astigmatism, and presbyopia, refractive status is stable.  5) Right esotropia with previous esophoria at distance, no complaints of diplopia. 

PLAN: 1) No change in prescription.  2) Continue Artificial Tears.  3) Recommend daily antioxidant multivitamin with lutein.  Discussed benefits of dark, leafy, green vegetables and ultraviolet protection.  4) Return to the clinic in one year for examination.

_________, O.D./ht:___

__/16/____  Jane Doe    #00-00-00-2

SUBJECTIVE: The patient is a 45-year-old female with history of conventional soft daily-wear contact lens use.  Patient reports unsatisfactory comfort with current lenses.  Current spectacles are satisfactory.  HISTORY and REVIEW OF SYSTEMS are updated in the chart.

OBJECTIVE: Cover test is orthophoric at distance.  Extraocular motilities are smooth and full.  Visual fields are full to confrontation.  Pupils are equal, round, and reactive to light. Negative afferent pupillary defect.  Slit-lamp Examination - Lids, lashes, conjunctiva, cornea, iris, and lens are all clear.  The anterior chamber is clear and quiet.  Angles are 4 temporally.  Internal with direct, cup-to-disk is 0.8 OU. The posterior pole and macula are clear with a positive foveal light reflex.  With Ciba-Focus monthly trial lenses - good centration, movement and lag OU.

ASSESSMENT: 1) Myopia, prepresbyopia.  2) Large optic nerve head cup with reassuring intraocular pressures and no family history of glaucoma.  3) Good contact lens fit, vision, and comfort with Ciba-Focus monthly lenses.

PLAN: 1) No change in spectacle prescription.  2) Sample of Opti-Free Express solutions given, gradually rebuild wearing time of contacts.  3) Return to the clinic in one week for contact lens check and dilation. 

_________, O.D./ht:___________

__/05/____  Jane Doe    #00-00-32-5

SUBJECTIVE: Four-month follow-up for intraocular pressure check. Patient takes glaucoma medications, Cosopt and Alphagan b.i.d. OU.  She reports compliance.  She reports also difficulty spacing drops out 10-15 minutes.  No vision changes reported.

OBJECTIVE: Pupils are equal, round, and reactive to light.  Negative afferent pupillary defect.  Slit-lamp Examination - Lids, lashes, adnexa dermatochalasis OU.  Conjunctiva, cornea, and iris are clear.  The anterior chamber is clear and quiet.  Cataract changes OU as before.  Four-mirror gonioscopy reveals scleral spur OU.  No transillumination defects of the iris. 

ASSESSMENT: 1) Chronic open-angle glaucoma.  2) Goal intraocular pressure of 21 not met with current therapy.

PLAN: 1) Continue Cosopt and Alphagan b.i.d. OU.  2) Discussed with patient importance of 10-20 minute separation between drops in the morning and in the evening.  Also recommended three minutes of lid closure after instillation.  3) Return to the clinic in one month for intraocular pressure check.

__________, O.D./ht:___

__/04/____  John Doe    #00-00-00-4

SUBJECTIVE: Contact lens check.  Patient reports mild vision complaint and dryness with left lens only.  

OBJECTIVE: Good centration and movement of lenses OU.  Lag is excessive OD in upgaze, acceptable OS.  Conjunctiva and cornea are clear and quiet OU.  With Acuvue toric trial lenses - good centration, movement and lag OU.  Visual acuity is 20/20 OU in the distance. 

ASSESSMENT: Patient is not satisfied with Bausch & Lomb Soflens 66 Toric comfort and vision.

PLAN: 1) Try Acuvue Toric.  2) Return to the clinic in one week.

_____________, O.D./ht:____

__/23/____  Jane Doe    #00-00-05-8

SUBJECTIVE: Contact lens check.  Patient reports good comfort and vision with Acuvue 2 lenses.  

OBJECTIVE: Good centration, movement and lag OU.  Conjunctiva and cornea are clear and quiet OU.

ASSESSMENT: Good contact lens fit, vision, and comfort.

PLAN: 1) Prescribe daily-wear two-week disposable.  2) Rebate given for near supply order here.  Provide copy for patient with order in the near future.  3) Return to the clinic in one year for examination.

____________, O.D./ht:__

__/09/____  Jane Doe    #00-00-00-0

(cc: Tom Jones, M.D., Hackensack Regional Office)

SUBJECTIVE: Two-month follow-up for branch retinal vein occlusion OS.  Patient is here today to rule out macular edema and neovascularization.  No symptoms of flashes or floaters reported.  Vision is stable.  Patient was seen by primary care physician one week ago.  No problems were found at that time per patient.  In the past patient has had hypertensive retinopathy and is currently on Coumadin. 

OBJECTIVE: Cover test is orthophoric at distance.  Extraocular motilities are smooth and full.  Visual fields are full to confrontation.  Pupils are equal, round, and reactive to light. Negative afferent pupillary defect.  Slit-lamp Examination - Lids, lashes, adnexa, conjunctiva, cornea, and iris are clear. The anterior chamber is deep and quiet.  Lens shows 2+ nuclear sclerosis and 1+ cortical cataract OU.  Posterior vitreous detachment bilaterally.  The periphery is clear to past equator OU.  The posterior pole of the right eye is clear.  Left eye shows cotton-wool spots forming in area of large retinal hemorrhage superior to optic nerve head.  There is no neovascularization.  Macula is flat and nonedematous OU with mild pigment changes consistent with previous examinations.

ASSESSMENT: Branch retinal vein occlusion OS.

PLAN: 1) Follow-up here p.r.n. if vision changes are noted OS.  2) Reviewed symptoms of retinal detachment.  3) Return to the clinic in two months for examination with dilation.

__________, O.D./ht:___

__/__/____  Jane Doe    #00-00-31-7

SUBJECTIVE: The patient is a 21-year-old female wanting new glasses. History of successful contact lens wear.  Patient reports noncompliance with regular monthly replacements.  Patient is unsure of age of current contact lens pair.  HISTORY and REVIEW OF SYSTEMS are updated in the chart.

OBJECTIVE: Cover test is orthophoric at distance and 6 exophoria at near. Extraocular motilities are smooth and full.  Visual fields are full to confrontation.  Pupils are equal, round, and reactive to light.  Negative afferent pupillary defect. Slit-lamp Examination - Lids, lashes, adnexa, conjunctiva, cornea, iris, and lens are all clear.  The anterior chamber is clear and quiet.  Angles are 4 temporally.  1 mm of limbal neovascularization superiorly OD as before.  Good centration, movement and lag OU of contacts.  3+ deposits OD and 1+ OS. Internal with dilation, cup-to-disk is 0.7 x 0.6 in the vertical OD, 0.7 x 0.5 in the vertical OS.  The posterior pole and macula are clear with a positive foveal light reflex.  The periphery is clear to past equator OU.

ASSESSMENT: 1) High myopia and astigmatism.  2) Poor compliance with monthly replacement of contacts.  Good fit with current lenses.  3) Corneal neovascularization OD, stable.

PLAN: 1) Subjective prescription given.  2) Contact lens parameters updated.  Stressed to patient importance of daily-wear one-month replacement, recommending Opti-Free Express solutions.  3) Return to the clinic in two years for examination or follow-up sooner per symptoms.

_________, O.D./ht:___

__/__/______  Jim Doe    #0-0-0-6

SUBJECTIVE: three-week follow-up for posterior vitreous detachment.  Patient reports less noticeable symptoms regarding flashes and floaters.  No vision changes reported.

OBJECTIVE: Pupils are equal, round, and reactive to light.  Negative afferent pupillary defect.  Visual fields are full to confrontation.  Slit-lamp Examination - Lids, lashes, adnexa, conjunctiva, cornea, iris, and lens are all clear.  The anterior chamber is clear and quiet.  Angles are 4 temporally.  Anterior vitreous is clear OU.  Internal with dilation, disk, macula, and vessels are clear OU.  Posterior vitreous detachment OS. Media clear OD.  The periphery is clear to past equator OU. No holes, breaks, or tears.

ASSESSMENT: Posterior vitreous detachment, stable for three weeks.

PLAN: 1) Reviewed symptoms of retinal detachment.  2) Return to the clinic in three months for dilation. 

____________, O.D./ht:___

__/__/____  Janey Doe  #00-00-02-0

SUBJECTIVE: Contact lens check and dilation.  Patient reports satisfactory comfort and vision with Acuvue 2 lens OD and Bausch & Lomb Soflens 66 Toric lens OS.  Patient reports adaptation to comfort with current lenses.

OBJECTIVE: Good centration, movement and lag OU, 20^o malorientation OS.  Conjunctiva and cornea are clear and quiet OU.  Internal with dilation, cup-to-disk is 0.4 and 0.5.  The posterior pole and macula are clear with a positive foveal light reflex.  The periphery is clear to past equator OU.

ASSESSMENT: 1) Good contact lens fit, vision, and comfort.  2) Ocular health no apparent pathology. 

PLAN: 1) Prescribe daily-wear two-week disposable, parameters in chart.  20^o malorientation figured into prescription of left lens.  2) Return to the clinic in one year for examination.

__________, O.D./ht:___