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Routine: DVBCWEE1

DVBCWEE1.m

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  1. DVBCWEE1 ;ALB/CMM EYE EXAMINATION WKS TEXT - 1 ; 6 MARCH 1997
  1.  ;;2.7;AMIE;**12**;Apr 10, 1995
  1.  ;
  1.  ;
  1. TXT ;
  1.  ;;A.  Review of Medical Records:
  1.  ;;
  1.  ;;B.  Medical History (Subjective Complaints):
  1.  ;;
  1.  ;;    Comment on:
  1.  ;;    1.  Pain.
  1.  ;;    2.  Duration and frequency of periods of incapacitation, and rest
  1.  ;;    requirements.
  1.  ;;    3.  Visual symptoms, including distorted or enlarged image, etc.
  1.  ;;    4.  Current ophthalmologic treatment.
  1.  ;;    5.  For malignant neoplasms, state type of treatment and last date.
  1.  ;;    If treatment is current, describe.
  1.  ;;
  1.  ;;C.  Physical Examination (Objective Findings):
  1.  ;;
  1.  ;;    Address each of the following, as applicable, and fully describe 
  1.  ;;    current findings:
  1.  ;;    1.  Visual Acuity:
  1.  ;;        a.  Examine each eye independently and record the refractive 
  1.  ;;        information indicated below.
  1.  ;;        b.  Use conventional lenses for correction unless the patient
  1.  ;;        has keratoconus, is well adapted to contact lenses and wishes
  1.  ;;        to wear them, and contact lenses result in best corrected 
  1.  ;;        visual acuity.
  1.  ;;        c.  Use Snellen's test type or its equivalent.
  1.  ;;        d.  Carry out an examination with the pupils dilated unless 
  1.  ;;        contraindicated, and record the ophthalmic findings.
  1.  ;;        e.  For visual acuity worse than 5/200 in either or both eyes,
  1.  ;;        report the distance in feet/inches (or meters/centimeters) 
  1.  ;;        from the face at which the veteran can count fingers/detect 
  1.  ;;        hand motion/read the largest line on the chart.  If the 
  1.  ;;        veteran cannot detect hand motion or count fingers at any
  1.  ;;        distance, state whether he or she has light perception.
  1.  ;;        f.  If keratoconus is present, state whether contact lenses 
  1.  ;;        are required or adequate correction is possible by other means.
  1.  ;;
  1.  ;;
  1.  ;;                                       NEAR           FAR
  1.  ;;
  1.  ;;        RIGHT EYE     UNCORRECTED    __________      _________
  1.  ;;
  1.  ;;        RIGHT EYE     CORRECTED      __________      _________
  1.  ;;
  1.  ;;
  1.  ;;
  1.  ;;                                        NEAR          FAR
  1.  ;;
  1.  ;;        LEFT EYE      UNCORRECTED    __________      _________
  1.  ;;
  1.  ;;        LEFT EYE      CORRECTED      __________      _________
  1.  ;;
  1.  ;;
  1.  ;;    2.  Diplopia:
  1.  ;;        a.  Perform the measurement of muscle function using a 
  1.  ;;        Goldmann Perimeter Chart and chart the areas in which diplopia
  1.  ;;        exists.  Include the chart as part of the examination report 
  1.  ;;        to be sent to the regional office.
  1.  ;;        b.  If diplopia is present, state whether it is constant or 
  1.  ;;        intermittent, whether it is present at all distances or only 
  1.  ;;        for near or distant vision, and whether it is correctable by 
  1.  ;;        use of lenses or prisms.
  1.  ;;        c.  If diplopia is constant and not correctable, indicate 
  1.  ;;        which sectors of the visual field are affected and provide 
  1.  ;;        the Goldmann perimeter chart showing the actual areas of 
  1.  ;;        diplopia, according to the format below.  Diplopia outside
  1.  ;;        these areas should also be reported even though it is not
  1.  ;;        considered disabling because it may be used in the evaluation
  1.  ;;        of the underlying disease or injury.
  1.  ;;
  1.  ;;               CENTRAL 20 DEGREES          _________
  1.  ;;
  1.  ;;               21 TO 30 DEGREES
  1.  ;;                     DOWN
  1.  ;;                           RIGHT LATERAL   _________
  1.  ;;
  1.  ;;                           LEFT LATERAL    _________
  1.  ;;
  1.  ;;                     UP
  1.  ;;                           RIGHT LATERAL   _________
  1.  ;;
  1.  ;;                           LEFT LATERAL    _________
  1.  ;;
  1.  ;;               31 TO 40 DEGREES
  1.  ;;                     DOWN
  1.  ;;                           RIGHT LATERAL   _________
  1.  ;;
  1.  ;;                           LEFT LATERAL    _________
  1.  ;;
  1.  ;;                     UP
  1.  ;;                           RIGHT LATERAL   _________
  1.  ;;
  1.  ;;                           LEFT LATERAL    _________
  1.  ;;
  1.  ;;
  1.  ;;    3.  Visual Field Deficit:
  1.  ;;         a.  Chart any visual field defect using a Goldmann Perimeter
  1.  ;;         Chart and include the chart as part of the examination report
  1.  ;;         to be sent to the regional office.
  1.  ;;         b.  For an aphakic eye which cannot be fitted with contact 
  1.  ;;         lenses or intra-ocular implant, use the IV/4e test object.  
  1.  ;;         For all other cases, use the III/4e test object.
  1.  ;;         c.  If the examiner determines that charting with other test 
  1.  ;;         objects is indicated, those test results should be reported 
  1.  ;;         on a separate chart.  All charts, along with an explanation 
  1.  ;;         of the need for using a different test object and an 
  1.  ;;         explanation of any discrepancies in results, should be 
  1.  ;;         included as part of the examination report.
  1.  ;;         d.  All scotomas should be plotted carefully in order to 
  1.  ;;         allow measurements to be made for adjustments in the 
  1.  ;;         calculation of visual field defects.
  1.  ;;     4.  Details of eye disease or injury (including eyebrows, 
  1.  ;;     eyelashes, eyelids) other than loss of visual acuity, diplopia, 
  1.  ;;     or visual field defect:
  1.  ;;
  1.  ;;D.   Diagnostic and Clinical Tests:  (Other than for visual acuity, 
  1.  ;;diplopia, and visual fields, as described above.)
  1.  ;;
  1.  ;;     1.  Include results of all diagnostic and clinical tests 
  1.  ;;     conducted in the examination report.
  1.  ;;
  1.  ;;E.  Diagnosis:
  1.  ;;
  1.  ;;Signature:                                   Date:
  1.  ;;END