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Routine: DVBCWEE2

DVBCWEE2.m

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  1. DVBCWEE2 ;ALB/CMM EYE EXAMINATION WKS TEXT - 1 ; 6 MARCH 1997
  1.  ;;2.7;AMIE;**76*;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.  ;;                                        FAR            NEAR
  1.  ;;
  1.  ;;        RIGHT EYE     UNCORRECTED    __________      _________
  1.  ;;
  1.  ;;        RIGHT EYE     CORRECTED      __________      _________
  1.  ;;
  1.  ;;
  1.  ;;
  1.  ;;                                        FAR            NEAR
  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 which 
  1.  ;;         of the sectors of the visual field are affected: 
  1.  ;;         central 20 degrees; 
  1.  ;;         21 to 30 degrees: Upward; Downward; Right Lateral; Left Lateral
  1.  ;;         31 to 40 degrees: Upward; Downward; Right Lateral; Left Lateral  
  1.  ;; 
  1.  ;;         On the Goldmann perimeter chart, chart the actual areas of all
  1.  ;;         diplopia, even when the diplopia is not within the sectors listed
  1.  ;;         above. Provide the Goldmann perimeter chart with your examination
  1.  ;;         report. 
  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.  ;;
  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