DVBCQEY3 ;;ALB-CIOFO/ECF - EYE CONDITIONS QUESTIONNAIRE ; 6/15/2011
;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
;
TXT ;
;;
;; 6. Diplopia
;;
;; Does the Veteran have diplopia (double vision)?
;; ___ Yes ___ No
;; If yes, complete the following section:
;;
;; a. Provide etiology (such as traumatic injury, thyroid eye disease,
;; myasthenia gravis, etc.): __________________________________________________
;; b. The areas of diplopia must be documented on a Goldmann perimeter chart
;; that identifies the four major quadrants (upward, downward, left lateral and
;; right lateral) and the central field (20 degrees or less). Include the chart
;; with this Questionnaire.
;; Report the results from the Goldmann perimeter chart below:
;;
;; Indicate the areas where diplopia is present (the fields in which the
;; Veteran sees double using binocular vision):
;; ___ Central 20 degrees
;; ___ 21 to 30 degrees
;; ___ Down
;; ___ Lateral
;; ___ Up
;; ___ 31 to 40 degrees
;; ___ Down
;; ___ Lateral
;; ___ Up
;; ___ Greater than 40 degrees
;; ___ Down
;; ___ Lateral
;; ___ Up
;;^TOF^
;; c. Indicate frequency of the diplopia:
;; ___ Constant ___ Occasional
;; If occasional, indicate frequency of diplopia and most recent occurrence:
;; ____________________________________________________________________________
;;
;; d. Is the diplopia correctable with standard spectacle correction?
;; ___ Yes ___ No
;; If no, is the diplopia correctable with standard spectacle correction that
;; includes a special prismatic correction?
;; ___ Yes ___ No
;;
;; 7. Tonometry
;;
;; a. If tonometry was performed, provide results:
;; Right eye pressure: ___________ Left eye pressure: ___________
;;
;; b. Tonometry method used:
;; ___ Goldmann applanation
;; ___ Other, describe: _______________________________________________________
;;
;; 8. Slit lamp and external eye exam
;;
;; a. External exam/lids/lashes:
;; Right ___ Normal ___ Other, describe: ______________________________
;; Left ___ Normal ___ Other, describe: ______________________________
;; b. Conjunctiva/sclera:
;; Right ___ Normal ___ Other, describe: ______________________________
;; Left ___ Normal ___ Other, describe: ______________________________
;; c. Cornea:
;; Right ___ Normal ___ Other, describe: ______________________________
;; Left ___ Normal ___ Other, describe: ______________________________
;; d. Anterior chamber
;; Right ___ Normal ___ Other, describe: ______________________________
;; Left ___ Normal ___ Other, describe: ______________________________
;; e. Iris:
;; Right ___ Normal ___ Other, describe: ______________________________
;; Left ___ Normal ___ Other, describe: ______________________________
;; f. Lens:
;; Right ___ Normal ___ Other, describe: ______________________________
;; Left ___ Normal ___ Other, describe: ______________________________
;;^TOF^
;; 9. Internal eye exam (fundus)
;;
;; Fundus:
;; ___ Normal bilaterally
;; ___ Abnormal
;; If checked, complete the following section:
;; a. Optic disc:
;; Right ___ Normal ___ Other, describe: ______________________________
;; Left ___ Normal ___ Other, describe: ______________________________
;; b. Macula:
;; Right ___ Normal ___ Other, describe: ______________________________
;; Left ___ Normal ___ Other, describe: ______________________________
;; c. Vessels
;; Right ___ Normal ___ Other, describe: ______________________________
;; Left ___ Normal ___ Other, describe: ______________________________
;; d. Vitreous:
;; Right ___ Normal ___ Other, describe: ______________________________
;; Left ___ Normal ___ Other, describe: ______________________________
;; e. Periphery:
;; Right ___ Normal ___ Other, describe: ______________________________
;; Left ___ Normal ___ Other, describe: ______________________________
;;
;; 10. Visual fields
;;
;; Does the Veteran have a visual field defect (or a condition that may result
;; in visual field defect)?
;; ___ Yes ___ No
;; If yes, complete the following section:
;;
;; NOTE: For VA purposes, examiners must perform visual field testing using
;; either Goldmann kinetic perimetry or automated perimetry using Humphrey
;; Model 750, Octopus Model 101 or later versions of these perimetric devices
;; with simulated kinetic Goldmann testing capability. The results must be
;; recorded on a standard Goldmann chart providing at least 16 meridians 22 1/2
;; degrees apart for each eye and included with this Questionnaire.
;;
;; If additional testing is necessary to evaluate visual fields, it must be
;; conducted using either a tangent screen or a 30-degree threshold visual
;; field with the Goldmann III stimulus size. The examination report must then
;; include the tracing of either the tangent screen or of the 30-degree
;; threshold visual field with the Goldmann III stimulus size.
;;^TOF^
;; a. Was visual field testing performed?
;; ___ Yes ___ No
;; Results:
;; ___ Using Goldmann's equivalent III/4e target
;; ___ Using Goldmann's equivalent IV/4e target (used for aphakic individuals
;; not well adapted to contact lens correction or pseudophakic individuals
;; not well adapted to intraocular lens implant)
;; ___ Other, describe: _______________________________________________________
;;
;; b. Does the Veteran have contraction of a visual field?
;; ___ Yes ___ No
;; If yes, include Goldmann chart with this Questionnaire.
;;
;; c. Does the Veteran have loss of a visual field?
;; ___ Yes ___ No
;; If yes, check all that apply and indicate eye affected:
;;
;; ___ Homonymous hemianopsia ___ Right ___ Left ___ Both
;; ___ Loss of temporal half of visual field ___ Right ___ Left ___ Both
;; ___ Loss of nasal half of visual field ___ Right ___ Left ___ Both
;; ___ Loss of inferior half of visual field ___ Right ___ Left ___ Both
;; ___ Loss of superior half of visual field ___ Right ___ Left ___ Both
;; ___ Other, specify: _____________________________________________________
;; ___ Right ___ Left ___ Both
;;
;; d. Does the Veteran have a scotoma?
;; ___ Yes ___ No
;; If yes, check all that apply and indicate eye affected:
;; ___ Scotoma affecting at least 1/4 of the visual field
;; ___ Right ___ Left ___ Both
;; ___ Centrally located scotoma
;; ___ Right ___ Left ___ Both
;;
;; e. Does the Veteran have legal (statutory) blindness (visual field diameter
;; of 20 degrees or less in the better eye, even if the corrected visual
;; acuity is 20/20) based upon visual field loss?
;; ___ Yes ___ No
;;^TOF^
;; SECTION IV: Eye conditions
;;
;; 1. Conditions
;;
;; Does the Veteran have any of the following eye conditions?
;; ___ Yes ___ No
;; If no, proceed to Section V.
;; If yes, check all that apply:
;; ___ Anatomical loss of eyelids,
;; brows, lashes (If checked, complete # 2 below)
;; ___ Lacrimal gland and lid
;; disorders (other than
;; ptosis or anatomic loss) (If checked, complete # 3 below)
;; ___ Ptosis, for either or both
;; eyelids (If checked, complete # 4 below)
;; ___ Conjunctivitis and other
;; conjunctival conditions (If checked, complete # 5 below)
;; ___ Corneal conditions (If checked, complete # 6 below)
;; ___ Cataract and other lens
;; conditions (If checked, complete # 7 below)
;; ___ Inflammatory eye conditions
;; and/or injuries (If checked, complete # 8 below)
;; ___ Glaucoma (If checked, complete # 9 below)
;; ___ Optic neuropathy and other
;; disc conditions (If checked, complete # 10 below)
;; ___ Retinal conditions (If checked, complete # 11 below)
;; ___ Neurologic eye conditions (If checked, complete # 12 below)
;; ___ Tumors and neoplasms (If checked, complete # 13 below)
;; ___ Other eye conditions (If checked, complete # 14 below)
;;
;; For each checked answer, complete the appropriate section (2-14) below:
;;
;; 2. Anatomical loss of eyelids, brows, lashes
;;
;; a. Indicate condition and side affected (check all that apply):
;; ___ Partial or complete loss of eyelid
;; Side affected: ___ Right ___ Left ___ Both
;; ___ Complete loss of eyebrows
;; Side affected: ___ Right ___ Left ___ Both
;; ___ Complete loss of eyelashes
;; Side affected: ___ Right ___ Left ___ Both
;;
;; b. Is the Veteran's decrease in visual acuity or other visual impairment,
;; if present, attributable to eyelid loss?
;; ___ Yes ___ No ___ There is no decrease in visual acuity or other
;; visual impairment
;; If no, explain: ____________________________________________________________
;;^TOF^
;; c. If present, does eyelid loss cause scarring or disfigurement?
;; ___ Yes ___ No
;; If yes, complete Section IV, Scarring and disfigurement.
;;
;; 3. Lacrimal gland and lid conditions
;;
;; Indicate the Veteran's condition(s) and side affected (check all that apply):
;; ___ Ectropion Side affected: ___ Right ___ Left ___ Both
;; ___ Entropion Side affected: ___ Right ___ Left ___ Both
;; ___ Lagophthalmos Side affected: ___ Right ___ Left ___ Both
;; ___ Disorder of the lacrimal apparatus (epiphora, dacryocystitis, etc.)
;; If checked, specify condition: _________________________________________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; c. If present, does lacrimal or lid condition cause scarring or
;; disfigurement?
;; ___ Yes ___ No
;; If yes, complete Section IV, Scarring and disfigurement.
;;
;; 4. Ptosis
;;
;; a. If ptosis is present, indicate side affected:
;; ___ Right ___ Left ___ Both
;;
;; b. Is the Veteran's decrease in visual acuity or other visual impairment,
;; if present, attributable to ptosis?
;; ___ Yes ___ No ___ There is no decrease in visual acuity or other visual
;; impairment
;; If no, explain: ____________________________________________________________
;;
;; c. Does the ptosis cause disfigurement?
;; ___ Yes ___ No
;; If yes, complete Section IV, Scarring and disfigurement.
;;
;; 5. Conjunctivitis and other conjunctival conditions
;;
;; a. Indicate type of conjunctivitis, activity, and side affected (check
;; all that apply):
;; ___ Trachomatous:
;; ___ Active Eye affected: ___ Right ___ Left ___ Both
;; ___ Inactive Eye affected: ___ Right ___ Left ___ Both
;; ___ Nontrachomatous:
;; ___ Active Eye affected: ___ Right ___ Left ___ Both
;; ___ Inactive Eye affected: ___ Right ___ Left ___ Both
;;^TOF^
;; b. Indicate the Veteran's other conjunctival conditions, if any (check
;; all that apply):
;; ___ Pinguecula Eye affected: ___ Right ___ Left ___ Both
;; ___ Symblepharon Eye affected: ___ Right ___ Left ___ Both
;; ___ Other, describe: _______________________________________________________
;; Eye affected: ___ Right ___ Left ___ Both
;;
;; c. Is the Veteran's decrease in visual acuity or other visual impairment, if
;; present, attributable to any of the eye conditions checked above in this
;; section?
;; ___ Yes ___ No ___ There is no decrease in visual acuity or other visual
;; impairment
;; If no, explain: ____________________________________________________________
;;
;; d. Does any eye condition identified in this section cause scarring or
;; disfigurement?
;; ___ Yes ___ No
;; If yes, complete Section IV, Scarring and disfigurement.
;;
;; 6. Corneal conditions
;;
;; a. Has the Veteran had a corneal transplant?
;; ___ Yes ___ No
;; If yes, indicate side of transplant: ___ Right ___ Left ___ Both
;; Indicate residuals (check all that apply):
;; ___ Pain Eye affected: ___ Right ___ Left ___ Both
;; ___ Photophobia Eye affected: ___ Right ___ Left ___ Both
;; ___ Glare sensitivity Eye affected: ___ Right ___ Left ___ Both
;; ___ Other, describe: _______________________________________________________
;; Eye affected: ___ Right ___ Left ___ Both
;;
;; b. Does the Veteran have keratoconus?
;; ___ Yes ___ No
;; If yes, indicate eye affected: ___ Right ___ Left ___ Both
;;
;; c. Does the Veteran have a pterygium?
;; ___ Yes ___ No
;; If yes, indicate eye affected: ___ Right ___ Left ___ Both
;;
;; d. Does the Veteran have another corneal condition that may result in an
;; irregular cornea?
;; (For example, pellucid marginal degeneration, irregular astigmatism from
;; corneal scar, post-laser refractive surgery, acne rosacea keratopathy, etc.)
;; ___ Yes ___ No
;; If yes, specify corneal condition: _________________________________________
;; Eye affected: ___ Right ___ Left ___ Both
;;^TOF^
;; e. Is the Veteran's decrease in visual acuity or other visual impairment, if
;; present, attributable to keratoconus or another corneal condition, if
;; present?
;; ___ Yes ___ No ___ There is no decrease in visual acuity or other
;; visual impairment
;; If yes, specify corneal condition responsible for visual impairment
;; ___________________________________________________________________________.
;; If no, explain: ____________________________________________________________
;;
;; f. Does any eye condition identified in this section cause scarring or
;; disfigurement?
;; ___ Yes ___ No
;; If yes, complete Section IV, Scarring and disfigurement.
;;
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQEY3 14444 printed Apr 09, 2024@20:50:22 Page 2
DVBCQEY3 ;;ALB-CIOFO/ECF - EYE CONDITIONS QUESTIONNAIRE ; 6/15/2011
+1 ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
+2 ;
TXT ;
+1 ;;
+2 ;; 6. Diplopia
+3 ;;
+4 ;; Does the Veteran have diplopia (double vision)?
+5 ;; ___ Yes ___ No
+6 ;; If yes, complete the following section:
+7 ;;
+8 ;; a. Provide etiology (such as traumatic injury, thyroid eye disease,
+9 ;; myasthenia gravis, etc.): __________________________________________________
+10 ;; b. The areas of diplopia must be documented on a Goldmann perimeter chart
+11 ;; that identifies the four major quadrants (upward, downward, left lateral and
+12 ;; right lateral) and the central field (20 degrees or less). Include the chart
+13 ;; with this Questionnaire.
+14 ;; Report the results from the Goldmann perimeter chart below:
+15 ;;
+16 ;; Indicate the areas where diplopia is present (the fields in which the
+17 ;; Veteran sees double using binocular vision):
+18 ;; ___ Central 20 degrees
+19 ;; ___ 21 to 30 degrees
+20 ;; ___ Down
+21 ;; ___ Lateral
+22 ;; ___ Up
+23 ;; ___ 31 to 40 degrees
+24 ;; ___ Down
+25 ;; ___ Lateral
+26 ;; ___ Up
+27 ;; ___ Greater than 40 degrees
+28 ;; ___ Down
+29 ;; ___ Lateral
+30 ;; ___ Up
+31 ;;^TOF^
+32 ;; c. Indicate frequency of the diplopia:
+33 ;; ___ Constant ___ Occasional
+34 ;; If occasional, indicate frequency of diplopia and most recent occurrence:
+35 ;; ____________________________________________________________________________
+36 ;;
+37 ;; d. Is the diplopia correctable with standard spectacle correction?
+38 ;; ___ Yes ___ No
+39 ;; If no, is the diplopia correctable with standard spectacle correction that
+40 ;; includes a special prismatic correction?
+41 ;; ___ Yes ___ No
+42 ;;
+43 ;; 7. Tonometry
+44 ;;
+45 ;; a. If tonometry was performed, provide results:
+46 ;; Right eye pressure: ___________ Left eye pressure: ___________
+47 ;;
+48 ;; b. Tonometry method used:
+49 ;; ___ Goldmann applanation
+50 ;; ___ Other, describe: _______________________________________________________
+51 ;;
+52 ;; 8. Slit lamp and external eye exam
+53 ;;
+54 ;; a. External exam/lids/lashes:
+55 ;; Right ___ Normal ___ Other, describe: ______________________________
+56 ;; Left ___ Normal ___ Other, describe: ______________________________
+57 ;; b. Conjunctiva/sclera:
+58 ;; Right ___ Normal ___ Other, describe: ______________________________
+59 ;; Left ___ Normal ___ Other, describe: ______________________________
+60 ;; c. Cornea:
+61 ;; Right ___ Normal ___ Other, describe: ______________________________
+62 ;; Left ___ Normal ___ Other, describe: ______________________________
+63 ;; d. Anterior chamber
+64 ;; Right ___ Normal ___ Other, describe: ______________________________
+65 ;; Left ___ Normal ___ Other, describe: ______________________________
+66 ;; e. Iris:
+67 ;; Right ___ Normal ___ Other, describe: ______________________________
+68 ;; Left ___ Normal ___ Other, describe: ______________________________
+69 ;; f. Lens:
+70 ;; Right ___ Normal ___ Other, describe: ______________________________
+71 ;; Left ___ Normal ___ Other, describe: ______________________________
+72 ;;^TOF^
+73 ;; 9. Internal eye exam (fundus)
+74 ;;
+75 ;; Fundus:
+76 ;; ___ Normal bilaterally
+77 ;; ___ Abnormal
+78 ;; If checked, complete the following section:
+79 ;; a. Optic disc:
+80 ;; Right ___ Normal ___ Other, describe: ______________________________
+81 ;; Left ___ Normal ___ Other, describe: ______________________________
+82 ;; b. Macula:
+83 ;; Right ___ Normal ___ Other, describe: ______________________________
+84 ;; Left ___ Normal ___ Other, describe: ______________________________
+85 ;; c. Vessels
+86 ;; Right ___ Normal ___ Other, describe: ______________________________
+87 ;; Left ___ Normal ___ Other, describe: ______________________________
+88 ;; d. Vitreous:
+89 ;; Right ___ Normal ___ Other, describe: ______________________________
+90 ;; Left ___ Normal ___ Other, describe: ______________________________
+91 ;; e. Periphery:
+92 ;; Right ___ Normal ___ Other, describe: ______________________________
+93 ;; Left ___ Normal ___ Other, describe: ______________________________
+94 ;;
+95 ;; 10. Visual fields
+96 ;;
+97 ;; Does the Veteran have a visual field defect (or a condition that may result
+98 ;; in visual field defect)?
+99 ;; ___ Yes ___ No
+100 ;; If yes, complete the following section:
+101 ;;
+102 ;; NOTE: For VA purposes, examiners must perform visual field testing using
+103 ;; either Goldmann kinetic perimetry or automated perimetry using Humphrey
+104 ;; Model 750, Octopus Model 101 or later versions of these perimetric devices
+105 ;; with simulated kinetic Goldmann testing capability. The results must be
+106 ;; recorded on a standard Goldmann chart providing at least 16 meridians 22 1/2
+107 ;; degrees apart for each eye and included with this Questionnaire.
+108 ;;
+109 ;; If additional testing is necessary to evaluate visual fields, it must be
+110 ;; conducted using either a tangent screen or a 30-degree threshold visual
+111 ;; field with the Goldmann III stimulus size. The examination report must then
+112 ;; include the tracing of either the tangent screen or of the 30-degree
+113 ;; threshold visual field with the Goldmann III stimulus size.
+114 ;;^TOF^
+115 ;; a. Was visual field testing performed?
+116 ;; ___ Yes ___ No
+117 ;; Results:
+118 ;; ___ Using Goldmann's equivalent III/4e target
+119 ;; ___ Using Goldmann's equivalent IV/4e target (used for aphakic individuals
+120 ;; not well adapted to contact lens correction or pseudophakic individuals
+121 ;; not well adapted to intraocular lens implant)
+122 ;; ___ Other, describe: _______________________________________________________
+123 ;;
+124 ;; b. Does the Veteran have contraction of a visual field?
+125 ;; ___ Yes ___ No
+126 ;; If yes, include Goldmann chart with this Questionnaire.
+127 ;;
+128 ;; c. Does the Veteran have loss of a visual field?
+129 ;; ___ Yes ___ No
+130 ;; If yes, check all that apply and indicate eye affected:
+131 ;;
+132 ;; ___ Homonymous hemianopsia ___ Right ___ Left ___ Both
+133 ;; ___ Loss of temporal half of visual field ___ Right ___ Left ___ Both
+134 ;; ___ Loss of nasal half of visual field ___ Right ___ Left ___ Both
+135 ;; ___ Loss of inferior half of visual field ___ Right ___ Left ___ Both
+136 ;; ___ Loss of superior half of visual field ___ Right ___ Left ___ Both
+137 ;; ___ Other, specify: _____________________________________________________
+138 ;; ___ Right ___ Left ___ Both
+139 ;;
+140 ;; d. Does the Veteran have a scotoma?
+141 ;; ___ Yes ___ No
+142 ;; If yes, check all that apply and indicate eye affected:
+143 ;; ___ Scotoma affecting at least 1/4 of the visual field
+144 ;; ___ Right ___ Left ___ Both
+145 ;; ___ Centrally located scotoma
+146 ;; ___ Right ___ Left ___ Both
+147 ;;
+148 ;; e. Does the Veteran have legal (statutory) blindness (visual field diameter
+149 ;; of 20 degrees or less in the better eye, even if the corrected visual
+150 ;; acuity is 20/20) based upon visual field loss?
+151 ;; ___ Yes ___ No
+152 ;;^TOF^
+153 ;; SECTION IV: Eye conditions
+154 ;;
+155 ;; 1. Conditions
+156 ;;
+157 ;; Does the Veteran have any of the following eye conditions?
+158 ;; ___ Yes ___ No
+159 ;; If no, proceed to Section V.
+160 ;; If yes, check all that apply:
+161 ;; ___ Anatomical loss of eyelids,
+162 ;; brows, lashes (If checked, complete # 2 below)
+163 ;; ___ Lacrimal gland and lid
+164 ;; disorders (other than
+165 ;; ptosis or anatomic loss) (If checked, complete # 3 below)
+166 ;; ___ Ptosis, for either or both
+167 ;; eyelids (If checked, complete # 4 below)
+168 ;; ___ Conjunctivitis and other
+169 ;; conjunctival conditions (If checked, complete # 5 below)
+170 ;; ___ Corneal conditions (If checked, complete # 6 below)
+171 ;; ___ Cataract and other lens
+172 ;; conditions (If checked, complete # 7 below)
+173 ;; ___ Inflammatory eye conditions
+174 ;; and/or injuries (If checked, complete # 8 below)
+175 ;; ___ Glaucoma (If checked, complete # 9 below)
+176 ;; ___ Optic neuropathy and other
+177 ;; disc conditions (If checked, complete # 10 below)
+178 ;; ___ Retinal conditions (If checked, complete # 11 below)
+179 ;; ___ Neurologic eye conditions (If checked, complete # 12 below)
+180 ;; ___ Tumors and neoplasms (If checked, complete # 13 below)
+181 ;; ___ Other eye conditions (If checked, complete # 14 below)
+182 ;;
+183 ;; For each checked answer, complete the appropriate section (2-14) below:
+184 ;;
+185 ;; 2. Anatomical loss of eyelids, brows, lashes
+186 ;;
+187 ;; a. Indicate condition and side affected (check all that apply):
+188 ;; ___ Partial or complete loss of eyelid
+189 ;; Side affected: ___ Right ___ Left ___ Both
+190 ;; ___ Complete loss of eyebrows
+191 ;; Side affected: ___ Right ___ Left ___ Both
+192 ;; ___ Complete loss of eyelashes
+193 ;; Side affected: ___ Right ___ Left ___ Both
+194 ;;
+195 ;; b. Is the Veteran's decrease in visual acuity or other visual impairment,
+196 ;; if present, attributable to eyelid loss?
+197 ;; ___ Yes ___ No ___ There is no decrease in visual acuity or other
+198 ;; visual impairment
+199 ;; If no, explain: ____________________________________________________________
+200 ;;^TOF^
+201 ;; c. If present, does eyelid loss cause scarring or disfigurement?
+202 ;; ___ Yes ___ No
+203 ;; If yes, complete Section IV, Scarring and disfigurement.
+204 ;;
+205 ;; 3. Lacrimal gland and lid conditions
+206 ;;
+207 ;; Indicate the Veteran's condition(s) and side affected (check all that apply):
+208 ;; ___ Ectropion Side affected: ___ Right ___ Left ___ Both
+209 ;; ___ Entropion Side affected: ___ Right ___ Left ___ Both
+210 ;; ___ Lagophthalmos Side affected: ___ Right ___ Left ___ Both
+211 ;; ___ Disorder of the lacrimal apparatus (epiphora, dacryocystitis, etc.)
+212 ;; If checked, specify condition: _________________________________________
+213 ;; Side affected: ___ Right ___ Left ___ Both
+214 ;;
+215 ;; c. If present, does lacrimal or lid condition cause scarring or
+216 ;; disfigurement?
+217 ;; ___ Yes ___ No
+218 ;; If yes, complete Section IV, Scarring and disfigurement.
+219 ;;
+220 ;; 4. Ptosis
+221 ;;
+222 ;; a. If ptosis is present, indicate side affected:
+223 ;; ___ Right ___ Left ___ Both
+224 ;;
+225 ;; b. Is the Veteran's decrease in visual acuity or other visual impairment,
+226 ;; if present, attributable to ptosis?
+227 ;; ___ Yes ___ No ___ There is no decrease in visual acuity or other visual
+228 ;; impairment
+229 ;; If no, explain: ____________________________________________________________
+230 ;;
+231 ;; c. Does the ptosis cause disfigurement?
+232 ;; ___ Yes ___ No
+233 ;; If yes, complete Section IV, Scarring and disfigurement.
+234 ;;
+235 ;; 5. Conjunctivitis and other conjunctival conditions
+236 ;;
+237 ;; a. Indicate type of conjunctivitis, activity, and side affected (check
+238 ;; all that apply):
+239 ;; ___ Trachomatous:
+240 ;; ___ Active Eye affected: ___ Right ___ Left ___ Both
+241 ;; ___ Inactive Eye affected: ___ Right ___ Left ___ Both
+242 ;; ___ Nontrachomatous:
+243 ;; ___ Active Eye affected: ___ Right ___ Left ___ Both
+244 ;; ___ Inactive Eye affected: ___ Right ___ Left ___ Both
+245 ;;^TOF^
+246 ;; b. Indicate the Veteran's other conjunctival conditions, if any (check
+247 ;; all that apply):
+248 ;; ___ Pinguecula Eye affected: ___ Right ___ Left ___ Both
+249 ;; ___ Symblepharon Eye affected: ___ Right ___ Left ___ Both
+250 ;; ___ Other, describe: _______________________________________________________
+251 ;; Eye affected: ___ Right ___ Left ___ Both
+252 ;;
+253 ;; c. Is the Veteran's decrease in visual acuity or other visual impairment, if
+254 ;; present, attributable to any of the eye conditions checked above in this
+255 ;; section?
+256 ;; ___ Yes ___ No ___ There is no decrease in visual acuity or other visual
+257 ;; impairment
+258 ;; If no, explain: ____________________________________________________________
+259 ;;
+260 ;; d. Does any eye condition identified in this section cause scarring or
+261 ;; disfigurement?
+262 ;; ___ Yes ___ No
+263 ;; If yes, complete Section IV, Scarring and disfigurement.
+264 ;;
+265 ;; 6. Corneal conditions
+266 ;;
+267 ;; a. Has the Veteran had a corneal transplant?
+268 ;; ___ Yes ___ No
+269 ;; If yes, indicate side of transplant: ___ Right ___ Left ___ Both
+270 ;; Indicate residuals (check all that apply):
+271 ;; ___ Pain Eye affected: ___ Right ___ Left ___ Both
+272 ;; ___ Photophobia Eye affected: ___ Right ___ Left ___ Both
+273 ;; ___ Glare sensitivity Eye affected: ___ Right ___ Left ___ Both
+274 ;; ___ Other, describe: _______________________________________________________
+275 ;; Eye affected: ___ Right ___ Left ___ Both
+276 ;;
+277 ;; b. Does the Veteran have keratoconus?
+278 ;; ___ Yes ___ No
+279 ;; If yes, indicate eye affected: ___ Right ___ Left ___ Both
+280 ;;
+281 ;; c. Does the Veteran have a pterygium?
+282 ;; ___ Yes ___ No
+283 ;; If yes, indicate eye affected: ___ Right ___ Left ___ Both
+284 ;;
+285 ;; d. Does the Veteran have another corneal condition that may result in an
+286 ;; irregular cornea?
+287 ;; (For example, pellucid marginal degeneration, irregular astigmatism from
+288 ;; corneal scar, post-laser refractive surgery, acne rosacea keratopathy, etc.)
+289 ;; ___ Yes ___ No
+290 ;; If yes, specify corneal condition: _________________________________________
+291 ;; Eye affected: ___ Right ___ Left ___ Both
+292 ;;^TOF^
+293 ;; e. Is the Veteran's decrease in visual acuity or other visual impairment, if
+294 ;; present, attributable to keratoconus or another corneal condition, if
+295 ;; present?
+296 ;; ___ Yes ___ No ___ There is no decrease in visual acuity or other
+297 ;; visual impairment
+298 ;; If yes, specify corneal condition responsible for visual impairment
+299 ;; ___________________________________________________________________________.
+300 ;; If no, explain: ____________________________________________________________
+301 ;;
+302 ;; f. Does any eye condition identified in this section cause scarring or
+303 ;; disfigurement?
+304 ;; ___ Yes ___ No
+305 ;; If yes, complete Section IV, Scarring and disfigurement.
+306 ;;
+307 QUIT
