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Routine: DVBCWEE4

DVBCWEE4.m

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  1. DVBCWEE4 ;ALB/RLC EYE EXAMINATION WKS TEXT - 1 ; 12 FEB 2007
  1.  ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
  1.  ;
  1.  ;
  1. TXT ;
  1.  ;;Narrative:  An eye examination must be conducted by a licensed optometrist
  1.  ;;or ophthalmologist.  Examinations for the evaluation of visual fields or
  1.  ;;muscle function will be conducted only when there is a medical indication.
  1.  ;;
  1.  ;;A.  Review of Medical Records:
  1.  ;;
  1.  ;;B.  Medical History (Subjective Complaints):
  1.  ;;
  1.  ;;    Comment on:
  1.  ;;
  1.  ;;    1.  General eye symptoms, pain, redness, swelling, discharge, watering, etc.
  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, side effects.
  1.  ;;    5.  For neoplasms, state date of diagnosis, benign or malignant, type
  1.  ;;        of treatment and last date of treatment.
  1.  ;;    6.  History of hospitalizations or surgery, dates and location if known,
  1.  ;;        reason or type of surgery.
  1.  ;;    7.  For trauma, type and date.
  1.  ;;    8.  For congestive or inflammatory glaucoma, duration and frequency of
  1.  ;;        attacks.
  1.  ;;
  1.  ;;C.  Physical Examination (Objective Findings):
  1.  ;;
  1.  ;;    Address each of the following, as applicable, and fully describe 
  1.  ;;    current findings:
  1.  ;;
  1.  ;;    1.  Visual Acuity:
  1.  ;;
  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 for distance and revised
  1.  ;;           Jaegar Standard or its equivalent for near.
  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.  ;;TOF
  1.  ;;               Right Eye                FAR            NEAR
  1.  ;;
  1.  ;;        RIGHT EYE     UNCORRECTED    __________      _________
  1.  ;;
  1.  ;;        RIGHT EYE     CORRECTED      __________      _________
  1.  ;;
  1.  ;;
  1.  ;;
  1.  ;;               Left Eye                 FAR            NEAR
  1.  ;;
  1.  ;;        LEFT EYE      UNCORRECTED    __________      _________
  1.  ;;
  1.  ;;        LEFT EYE      CORRECTED      __________      _________
  1.  ;;
  1.  ;;
  1.  ;;    2.  Diplopia:
  1.  ;;
  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 and provide the
  1.  ;;           Goldmann perimeter chart showing the actual areas of diplopia,
  1.  ;;           according to the format below.  Diplopia outside these areas
  1.  ;;           should also be reported even though it is not considered disabling
  1.  ;;           because it may be used in the evaluation of the underlying disease
  1.  ;;           or injury.
  1.  ;;
  1.  ;;                    Diplopia                      | Amount
  1.  ;;
  1.  ;;        Central 20 Degrees|      |                |
  1.  ;;        21 TO 30 Degrees  |      |                |
  1.  ;;                          | DOWN |                |
  1.  ;;                          |      | Right Lateral  |
  1.  ;;                          |      | Left Lateral   |
  1.  ;;                          |  UP  |                |
  1.  ;;                          |      | Right Lateral  |
  1.  ;;                          |      | Left Lateral   |
  1.  ;;        31 TO 40 Degrees  |      |                |
  1.  ;;                          | DOWN |                |
  1.  ;;                          |      | Right Lateral  |
  1.  ;;                          |      | Left Lateral   |
  1.  ;;                          |  UP  |                |
  1.  ;;                          |      | Right Lateral  |
  1.  ;;                          |      | Left Lateral   |
  1.  ;;
  1.  ;;TOF
  1.  ;;    3.  Visual Field Deficit:
  1.  ;;
  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, lacrimal duct) other than loss of visual acuity,
  1.  ;;        diplopia, or visual field defect.
  1.  ;;    5.  Enucleation.  Is prosthesis possible?
  1.  ;;    6.  Record results of any other examination findings including tonometry,
  1.  ;;        funduscopic, slit lamp.
  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.  ;;     1.  For nystagmus, provide type.
  1.  ;;
  1.  ;;
  1.  ;;
  1.  ;;Signature:                                   Date:
  1.  ;;END