- 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 Jan 18, 2025@02:47:27 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