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Routine: DVBCWEE6

DVBCWEE6.m

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  1. DVBCWEE6 ;ALB/RLC EYE EXAMINATION WKS TEXT - 1 ; 12 FEB 2007
  1.  ;;2.7;AMIE;**138**;Apr 10, 1995;Build 6
  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.  ;;of disease or injury that may be associated with visual field defect or
  1.  ;;impaired muscle function.  Unless medically contraindicated, the fundus must
  1.  ;;be examined with the claimant's pupils dilated.  The examiner must identify
  1.  ;;the disease, injury, or other pathologic process responsible for any visual
  1.  ;;impairment found.
  1.  ;;
  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.  Visual symptoms, including distorted or enlarged image, glare,
  1.  ;;        blurring, haloes, floaters, photophobia, etc.
  1.  ;;    3.  Current ophthalmologic treatment, side effects.  State whether
  1.  ;;        continuous medication is required.
  1.  ;;    4.  For neoplasms, state date of diagnosis, exact diagnosis, whether
  1.  ;;        benign or malignant, types and dates of treatment, and date of last
  1.  ;;        treatment.
  1.  ;;    5.  History of hospitalization or surgery, dates and location if known,
  1.  ;;        reason or type of surgery.
  1.  ;;    6.  For trauma, type of injury, cause, eye injured, and date.
  1.  ;;    7.  Report any incapacitating episodes due to eye diseases such as
  1.  ;;        angle-closure glaucoma, choroidopathy (including uveitis, iritis,
  1.  ;;        cyclitis, and choroiditis), keratopathy, scleritis, retinopathy or
  1.  ;;        maculopathy, intraocular hemorrhage, detachment of retina, or unhealed
  1.  ;;        eye injury.  List each incapacitating episode, if any, during the past
  1.  ;;        12-month period, its duration in days, and the cause of the episode
  1.  ;;        of incapacitation.  Note:  An incapacitating episode is a period of
  1.  ;;        acute symptoms severe enough to require bed rest and treatment by a
  1.  ;;        physician or other healthcare provider.
  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.  ;;        a. Examination of visual acuity must include the central
  1.  ;;           uncorrected and its equivalent corrected visual acuity for distance
  1.  ;;           and near vision using Snellen's test type or its equivalent.
  1.  ;;           Evaluate central visual acuity on the basis of corrected distance
  1.  ;;           vision with central fixation, even if a central scotoma is present.
  1.  ;;           Examine each eye independently and record the refractive information
  1.  ;;           indicated below.
  1.  ;;        b. Use Snellen's test type or its equivalent for distance and revised
  1.  ;;           Jaegar Standard or its equivalent for near.
  1.  ;;        c. Provided that he or she customarily wears contact lenses, determine
  1.  ;;           the visual acuity of any individual affected by a corneal disorder
  1.  ;;           that results in severe irregular astigmatism (including keratoconus)
  1.  ;;           that can be improved more by contact lenses than by eyeglass lenses,
  1.  ;;           as corrected by contact lenses.
  1.  ;;        d. For visual acuity worse than 5/200 in either or both eyes, report
  1.  ;;           the distance in feet/inches (or meters/centimeters) from the face at
  1.  ;;           which the veteran can count fingers/detect hand motion/read the
  1.  ;;           largest line on the chart.  If the veteran cannot detect hand
  1.  ;;           motion or count fingers at any distance, state whether he or she has
  1.  ;;           light perception.
  1.  ;;        e. Does the lens required to correct distance vision in the poorer eye
  1.  ;;           differ by more than three diopters from the lens required to correct
  1.  ;;           distance vision in the better eye?  If so, explain the reason for
  1.  ;;           the difference.
  1.  ;;        f. Is there a difference equal to two or more scheduled steps or lines
  1.  ;;           of visual acuity between near and distance corrected vision for
  1.  ;;           either eye, with the near vision being worse?  If so, include at
  1.  ;;           least two recordings of near and distance corrected vision and an
  1.  ;;           explanation of the reason for the difference.
  1.  ;;
  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.  Muscle function examination:
  1.  ;;        a. Use a Goldmann perimeter chart that identifies the four major
  1.  ;;           quadrants (upward, downward, left and right lateral) and the
  1.  ;;           central field (20 degrees or less) and chart the areas of diplopia.
  1.  ;;           Include the plotted chart with the examination report.  Indicate on
  1.  ;;           the chart whether or not diplopia is present in the following areas:
  1.  ;;
  1.  ;;           Central 20 degrees
  1.  ;;           21 to 30 degrees
  1.  ;;                    Down
  1.  ;;                    Left lateral
  1.  ;;                    Right lateral
  1.  ;;                    Up
  1.  ;;           31 to 40 degrees
  1.  ;;                    Down
  1.  ;;                    Left lateral
  1.  ;;                    Right lateral
  1.  ;;                    Up
  1.  ;;
  1.  ;;        b. State whether diplopia occurs occasionally or more than
  1.  ;;           occasionally.
  1.  ;;        c. State whether or not diplopia is correctable with spectacles.
  1.  ;;
  1.  ;;    NOTE: Procedure for using Goldmann perimeter to assess diplopia field.
  1.  ;;    1) Both eyes are open and the device is centered between the eyes.
  1.  ;;    2) The patient's attention is directed towards a III/4e target while both
  1.  ;;    eyes are open and fixating on the target.
  1.  ;;    3) The patient maintains attention to the target while it is moved.  Areas
  1.  ;;    of diplopia are identified on the VF paper.
  1.  ;;
  1.  ;;    3. Visual Field Examination:
  1.  ;;       a. Use either Goldmann kinetic perimetry or automated perimetry using
  1.  ;;          Humphrey Model 750, Octopus Model 101, or later versions of these
  1.  ;;          perimetric devices with simulated kinetic Goldmann testing
  1.  ;;          capability.
  1.  ;;       b. For phakic (normal) individuals, as well as for pseudophakic or
  1.  ;;          aphakic individuals who are well adapted to intraocular lens implant
  1.  ;;          or contact lens correction, visual field examinations must be 
  1.  ;;          conducted using a standard target size and luminance, which is
  1.  ;;          Goldmann's equivalent III/4e.
  1.  ;;       c. For aphakic individuals not well adapted to contact lens correction
  1.  ;;          or pseudophakic individuals not well adapted to intraocular lens
  1.  ;;          implant, visual field examinations must be conducted using Goldmann's
  1.  ;;          equivalent IV/4e.
  1.  ;;       d. In all cases, record the results on a standard Goldmann chart, and
  1.  ;;          include the Goldmann chart with the examination report.  Chart at
  1.  ;;          least 16 meridians 22 1/2 degrees apart for each eye and indicate
  1.  ;;          the Goldmann equivalent used.
  1.  ;;       e. If additional testing is necessary to evaluate visual fields,
  1.  ;;          conduct the additional testing using either a tangent screen or a
  1.  ;;          30-degree threshold visual field with the Goldmann III stimulus size.
  1.  ;;          Include the tracing of either the tangent screen or of the 30-degree
  1.  ;;          threshold visual field with the Goldmann III stimulus size in the
  1.  ;;          examination report.
  1.  ;;       f. Plot all scotomas carefully in order to allow measurements to be made
  1.  ;;          for adjustments in the calculation of visual field defects.
  1.  ;;
  1.  ;;    4. Provide 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. If there is enucleation, can a prosthesis be worn? 
  1.  ;;    6. If nystagmus is present, state whether it is the central type.
  1.  ;;    7. Has a lens been removed?  If so, state whether an intraocular lens
  1.  ;;       replacement (implant) is present.
  1.  ;;    8. If chronic conjunctivitis is present, is it active (with objective
  1.  ;;       findings, such as red, thick conjunctivae, mucous secretion, etc.) or
  1.  ;;       inactive?
  1.  ;;    9. Report results of tonometry.
  1.  ;;   10. Report results of slit lamp biomicroscopic examination.
  1.  ;;   11. For ocular funduscopic retinal examination, report any abnormality of
  1.  ;;       optic nerve, vessels, macula, etc.
  1.  ;;   12. Report any other abnormalities noted.
  1.  ;;
  1.  ;;D.  Diagnostic and Clinical Tests:  (Other than for visual acuity, 
  1.  ;;    diplopia, and visual fields, as described above.)
  1.  ;;    1. Include results of all diagnostic and clinical tests conducted in the 
  1.  ;;       examination report.
  1.  ;;
  1.  ;;E.  Diagnosis:
  1.  ;;
  1.  ;;    1.  Describe the effects of the condition(s) on the veteran's usual
  1.  ;;        occupation and daily activities.
  1.  ;;
  1.  ;;
  1.  ;;
  1.  ;;Signature:                                   Date:
  1.  ;;END