DVBCWEE4 ;ALB/RLC EYE EXAMINATION WKS TEXT - 1 ; 12 FEB 2007
;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
;
;
TXT ;
;;Narrative: An eye examination must be conducted by a licensed optometrist
;;or ophthalmologist. Examinations for the evaluation of visual fields or
;;muscle function will be conducted only when there is a medical indication.
;;
;;A. Review of Medical Records:
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;;
;; 1. General eye symptoms, pain, redness, swelling, discharge, watering, etc.
;; 2. Duration and frequency of periods of incapacitation, and rest
;; requirements.
;; 3. Visual symptoms, including distorted or enlarged image, etc.
;; 4. Current ophthalmologic treatment, side effects.
;; 5. For neoplasms, state date of diagnosis, benign or malignant, type
;; of treatment and last date of treatment.
;; 6. History of hospitalizations or surgery, dates and location if known,
;; reason or type of surgery.
;; 7. For trauma, type and date.
;; 8. For congestive or inflammatory glaucoma, duration and frequency of
;; attacks.
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following, as applicable, and fully describe
;; current findings:
;;
;; 1. Visual Acuity:
;;
;; a. Examine each eye independently and record the refractive
;; information indicated below.
;; b. Use conventional lenses for correction unless the patient
;; has keratoconus, is well adapted to contact lenses and wishes
;; to wear them, and contact lenses result in best corrected
;; visual acuity.
;; c. Use Snellen's test type or its equivalent for distance and revised
;; Jaegar Standard or its equivalent for near.
;; d. Carry out an examination with the pupils dilated unless
;; contraindicated, and record the ophthalmic findings.
;; e. For visual acuity worse than 5/200 in either or both eyes,
;; report the distance in feet/inches (or meters/centimeters)
;; from the face at which the veteran can count fingers/detect
;; hand motion/read the largest line on the chart. If the
;; veteran cannot detect hand motion or count fingers at any
;; distance, state whether he or she has light perception.
;; f. If keratoconus is present, state whether contact lenses
;; are required or adequate correction is possible by other means.
;;TOF
;; Right Eye FAR NEAR
;;
;; RIGHT EYE UNCORRECTED __________ _________
;;
;; RIGHT EYE CORRECTED __________ _________
;;
;;
;;
;; Left Eye FAR NEAR
;;
;; LEFT EYE UNCORRECTED __________ _________
;;
;; LEFT EYE CORRECTED __________ _________
;;
;;
;; 2. Diplopia:
;;
;; a. Perform the measurement of muscle function using a
;; Goldmann Perimeter Chart and chart the areas in which diplopia
;; exists. Include the chart as part of the examination report
;; to be sent to the regional office.
;; b. If diplopia is present, state whether it is constant or
;; intermittent, whether it is present at all distances or only
;; for near or distant vision, and whether it is correctable by
;; use of lenses or prisms.
;; c. If diplopia is constant and not correctable, indicate which
;; of the sectors of the visual field are affected and provide the
;; Goldmann perimeter chart showing the actual areas of diplopia,
;; according to the format below. Diplopia outside these areas
;; should also be reported even though it is not considered disabling
;; because it may be used in the evaluation of the underlying disease
;; or injury.
;;
;; Diplopia | Amount
;;
;; Central 20 Degrees| | |
;; 21 TO 30 Degrees | | |
;; | DOWN | |
;; | | Right Lateral |
;; | | Left Lateral |
;; | UP | |
;; | | Right Lateral |
;; | | Left Lateral |
;; 31 TO 40 Degrees | | |
;; | DOWN | |
;; | | Right Lateral |
;; | | Left Lateral |
;; | UP | |
;; | | Right Lateral |
;; | | Left Lateral |
;;
;;TOF
;; 3. Visual Field Deficit:
;;
;; a. Chart any visual field defect using a Goldmann Perimeter
;; Chart and include the chart as part of the examination report
;; to be sent to the regional office.
;; b. For an aphakic eye which cannot be fitted with contact
;; lenses or intra-ocular implant, use the IV/4e test object.
;; For all other cases, use the III/4e test object.
;; c. If the examiner determines that charting with other test
;; objects is indicated, those test results should be reported
;; on a separate chart. All charts, along with an explanation
;; of the need for using a different test object and an
;; explanation of any discrepancies in results, should be
;; included as part of the examination report.
;; d. All scotomas should be plotted carefully in order to
;; allow measurements to be made for adjustments in the
;; calculation of visual field defects.
;;
;; 4. Details of eye disease or injury (including eyebrows,
;; eyelashes, eyelids, lacrimal duct) other than loss of visual acuity,
;; diplopia, or visual field defect.
;; 5. Enucleation. Is prosthesis possible?
;; 6. Record results of any other examination findings including tonometry,
;; funduscopic, slit lamp.
;;
;;D. Diagnostic and Clinical Tests: (Other than for visual acuity,
;; diplopia, and visual fields, as described above.)
;;
;; 1. Include results of all diagnostic and clinical tests
;; conducted in the examination report.
;;
;;E. Diagnosis:
;;
;; 1. For nystagmus, provide type.
;;
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWEE4 6903 printed Apr 09, 2024@20:51:49 Page 2
DVBCWEE4 ;ALB/RLC EYE EXAMINATION WKS TEXT - 1 ; 12 FEB 2007
+1 ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
+2 ;
+3 ;
TXT ;
+1 ;;Narrative: An eye examination must be conducted by a licensed optometrist
+2 ;;or ophthalmologist. Examinations for the evaluation of visual fields or
+3 ;;muscle function will be conducted only when there is a medical indication.
+4 ;;
+5 ;;A. Review of Medical Records:
+6 ;;
+7 ;;B. Medical History (Subjective Complaints):
+8 ;;
+9 ;; Comment on:
+10 ;;
+11 ;; 1. General eye symptoms, pain, redness, swelling, discharge, watering, etc.
+12 ;; 2. Duration and frequency of periods of incapacitation, and rest
+13 ;; requirements.
+14 ;; 3. Visual symptoms, including distorted or enlarged image, etc.
+15 ;; 4. Current ophthalmologic treatment, side effects.
+16 ;; 5. For neoplasms, state date of diagnosis, benign or malignant, type
+17 ;; of treatment and last date of treatment.
+18 ;; 6. History of hospitalizations or surgery, dates and location if known,
+19 ;; reason or type of surgery.
+20 ;; 7. For trauma, type and date.
+21 ;; 8. For congestive or inflammatory glaucoma, duration and frequency of
+22 ;; attacks.
+23 ;;
+24 ;;C. Physical Examination (Objective Findings):
+25 ;;
+26 ;; Address each of the following, as applicable, and fully describe
+27 ;; current findings:
+28 ;;
+29 ;; 1. Visual Acuity:
+30 ;;
+31 ;; a. Examine each eye independently and record the refractive
+32 ;; information indicated below.
+33 ;; b. Use conventional lenses for correction unless the patient
+34 ;; has keratoconus, is well adapted to contact lenses and wishes
+35 ;; to wear them, and contact lenses result in best corrected
+36 ;; visual acuity.
+37 ;; c. Use Snellen's test type or its equivalent for distance and revised
+38 ;; Jaegar Standard or its equivalent for near.
+39 ;; d. Carry out an examination with the pupils dilated unless
+40 ;; contraindicated, and record the ophthalmic findings.
+41 ;; e. For visual acuity worse than 5/200 in either or both eyes,
+42 ;; report the distance in feet/inches (or meters/centimeters)
+43 ;; from the face at which the veteran can count fingers/detect
+44 ;; hand motion/read the largest line on the chart. If the
+45 ;; veteran cannot detect hand motion or count fingers at any
+46 ;; distance, state whether he or she has light perception.
+47 ;; f. If keratoconus is present, state whether contact lenses
+48 ;; are required or adequate correction is possible by other means.
+49 ;;TOF
+50 ;; Right Eye FAR NEAR
+51 ;;
+52 ;; RIGHT EYE UNCORRECTED __________ _________
+53 ;;
+54 ;; RIGHT EYE CORRECTED __________ _________
+55 ;;
+56 ;;
+57 ;;
+58 ;; Left Eye FAR NEAR
+59 ;;
+60 ;; LEFT EYE UNCORRECTED __________ _________
+61 ;;
+62 ;; LEFT EYE CORRECTED __________ _________
+63 ;;
+64 ;;
+65 ;; 2. Diplopia:
+66 ;;
+67 ;; a. Perform the measurement of muscle function using a
+68 ;; Goldmann Perimeter Chart and chart the areas in which diplopia
+69 ;; exists. Include the chart as part of the examination report
+70 ;; to be sent to the regional office.
+71 ;; b. If diplopia is present, state whether it is constant or
+72 ;; intermittent, whether it is present at all distances or only
+73 ;; for near or distant vision, and whether it is correctable by
+74 ;; use of lenses or prisms.
+75 ;; c. If diplopia is constant and not correctable, indicate which
+76 ;; of the sectors of the visual field are affected and provide the
+77 ;; Goldmann perimeter chart showing the actual areas of diplopia,
+78 ;; according to the format below. Diplopia outside these areas
+79 ;; should also be reported even though it is not considered disabling
+80 ;; because it may be used in the evaluation of the underlying disease
+81 ;; or injury.
+82 ;;
+83 ;; Diplopia | Amount
+84 ;;
+85 ;; Central 20 Degrees| | |
+86 ;; 21 TO 30 Degrees | | |
+87 ;; | DOWN | |
+88 ;; | | Right Lateral |
+89 ;; | | Left Lateral |
+90 ;; | UP | |
+91 ;; | | Right Lateral |
+92 ;; | | Left Lateral |
+93 ;; 31 TO 40 Degrees | | |
+94 ;; | DOWN | |
+95 ;; | | Right Lateral |
+96 ;; | | Left Lateral |
+97 ;; | UP | |
+98 ;; | | Right Lateral |
+99 ;; | | Left Lateral |
+100 ;;
+101 ;;TOF
+102 ;; 3. Visual Field Deficit:
+103 ;;
+104 ;; a. Chart any visual field defect using a Goldmann Perimeter
+105 ;; Chart and include the chart as part of the examination report
+106 ;; to be sent to the regional office.
+107 ;; b. For an aphakic eye which cannot be fitted with contact
+108 ;; lenses or intra-ocular implant, use the IV/4e test object.
+109 ;; For all other cases, use the III/4e test object.
+110 ;; c. If the examiner determines that charting with other test
+111 ;; objects is indicated, those test results should be reported
+112 ;; on a separate chart. All charts, along with an explanation
+113 ;; of the need for using a different test object and an
+114 ;; explanation of any discrepancies in results, should be
+115 ;; included as part of the examination report.
+116 ;; d. All scotomas should be plotted carefully in order to
+117 ;; allow measurements to be made for adjustments in the
+118 ;; calculation of visual field defects.
+119 ;;
+120 ;; 4. Details of eye disease or injury (including eyebrows,
+121 ;; eyelashes, eyelids, lacrimal duct) other than loss of visual acuity,
+122 ;; diplopia, or visual field defect.
+123 ;; 5. Enucleation. Is prosthesis possible?
+124 ;; 6. Record results of any other examination findings including tonometry,
+125 ;; funduscopic, slit lamp.
+126 ;;
+127 ;;D. Diagnostic and Clinical Tests: (Other than for visual acuity,
+128 ;; diplopia, and visual fields, as described above.)
+129 ;;
+130 ;; 1. Include results of all diagnostic and clinical tests
+131 ;; conducted in the examination report.
+132 ;;
+133 ;;E. Diagnosis:
+134 ;;
+135 ;; 1. For nystagmus, provide type.
+136 ;;
+137 ;;
+138 ;;
+139 ;;Signature: Date:
+140 ;;END
