Established patient returns to the eye clinic for complete exam/OCT/photos to
monitor macular degeneration.
CC: Patient states that vision is stable OU since his last eye exam. Patient has
intermittent double vision that has been going on for years when not wearing
glasses and has improved since cataract surgery. Now the double vision is hardly
ever noticeable. Patient denies any eye pain or irritation, and is not using any
drops on a regular basis.
Diabetic Review
- Year diagnosed: N/A; pre-diabetic
- Management: diet controlled
- Most recent blood sugar per patient: unknown
- Most recent HA1c: 6.0% (06/2019)
The patient was last seen on 04/15/19 with Dr. Veres for a VF/DFE.
The patient's last complete exam was on 10/15/18 with Dr. Windham.
OCULAR MEDS:
1. AREDS2 BID PO
-no refill/renewal needed today
The patient is being followed for:
1. NIDDM without retinopathy OU; (-)Clinically significant macular edema OU
2. Hypertension without ocular complications OU
3. Pseudophakia OU
4. Refractive error OU; presbyopia OU
5. Intermediate non-exudative age-related macular degeneration OU; worsening OU
6. Low risk glaucoma suspect secondary to asymmetric cupping OU; stable OU
7. Intermittent alternating exotropia OU; improved symptoms since cataract
surgery
REVIEW OF SYSTEMS
[-]Constitutional
[-]ENT
[+]Cardiovascular: HTN, hyperlipidemia
[+]Respiratory: Chronic obstructive lung disease
[-]Gastrointestinal
[+]Genitourinary: History of malignant neoplasm of prostate, ED
Calculus of Kidney, prostate cancer
[+]Musculoskeletal degenerative joint disease
[-]Integumentary
[-]Neurologic
[-]Psychiatric
[+]Endocrine prediabetes
[-]Hematologic/Lymph:
[-]Autoimmune/Allergic
PAST OCULAR HX:
[-]Trauma:
[+]Surgery: CE OU 07/2019 at Columbus VA
[+]Strabismus: lazy eye OS since childhood
[-]Glaucoma:
FAM. OC HX:
[-]Glaucoma
[-]Macular Degeneration
[-]Blindness
[-]Retinal Detachment
PSHX:
[-]Tobacco
[-]ETOH
Current Medications Reviewed
Allergies - Patient has answered NKA
ORIENTATION: Time/Person/Place
MOOD AND AFFECT: Appropriate
CURRENT SPECTACLE RX: 10/2018 (pre-cataract surgery OU)
OD: +4.00 -2.00 X 103 2.5 BI 0.75 BU
OS: +3.75 -1.00 X 105 3.5 BI 0.50 BD
ADD: +2.50
VISUAL ACUITY: without correction in phoropter
DIST
OD 20/30-2
OS 20/20-2
COVER TEST (without correction):D: 15 IAXT
COVER TEST (with correction): N: 25 IAXT
EOM AND HIRSCHBERG ALIGNMENT: Smooth and full w/o Diplopia/Pain;
No apparent tropia OD/OS
CONFRONTATION VISUAL FIELDS: Full to finger counting OU
AMSLER GRID: Normal OU
PUPILS: Equal round and reactive to light; (-)RAPD
REFRACTION AND BEST VISUAL ACUITY:
OD: -0.25 -0.50 x 090 20/20-2
OS: plano -0.25 x 093 20/20-2
ADD: +2.50
SLIT LAMP EXAM:
Lids/Lashes/Ocular Adnexa: lash debris OU
Sclera/Conjunctiva: Clear and quiet OU
Cornea (epithelium, stroma, endothelium, tear film): arcus OU, EBMD OU
Anterior Chamber: Deep/no cells or flare OU
Iris: Flat and intact, no rubeosis OU
TONOMETRY:
OD: 14
OS: 14
TIME: 9:32
DILATION:
1 GTT Tropicamide (1.0%) OU
1 GTT Phenylephrine (2.5%) OU
INTERNAL (90D, 20D BIO):
LENS (anterior/posterior capsule, cortex, nucleus)
OD: PCIOL; centered; small vertical crack just temp to fixation
OS: PCIOL; centered
VITREOUS:
OD: Syneresis
OS: Syneresis
NERVE:
OD: 0.35/0.35 cup/disc ratio (horiz/vert)
Normal Color/Margins
OS: 0.40/0.40 cup/disc ratio (horiz/vert)
Normal Color/Margins
MACULA:
OD: No blood, fluid or exudates, scattered intermediate and small hard drusen
with pigment clumping/mottling, scattered soft drusen
OS: No blood, fluid or exudates, scattered intermediate and small hard drusen
with pigment clumping/mottling, scattered soft drusen
BLOOD VESSELS:
OD: Normal course and caliber
OS: Normal course and caliber
PERIPHERY:
OD: No holes, tears or detachments
OS: No holes, tears or detachments
ADDITIONAL TESTS:
OCT RNFL
OD: SS: 8/10; 75um avg thickness, borderline thinning superiorly
OS: SS: 9/10; 74um avg thickness, borderline thinning superior temporal
quadrant
- stable OD/OS to baseline in 2013 per GPA
OCT MAC
OD: SS: 10/10; 232um CT; normal foveal contour, intact RPE (-)IRF/SRF/VMT
OS: SS: 10/10; 230um CT; normal foveal contour, intact RPE (-)IRF/SRF/VMT,
irregluar RPE
- stable OD/OS to scan 10/2018
FUNDUS PHOTOGRAPHY
OD: few small hard drusen and intermediate drusen, few soft drusen;
stable cupping, pigment mottling
OS: few small hard drusen and intermediate drusen, few soft drusen;
stable cupping, pigment mottling
- worsening OD/OS to 10/2018
ASSESSMENT:
1. NIDDM without retinopathy OU; (-)Clinically significant macular edema OU
2. Hypertension without ocular complications OU
3. Pseudophakia OU
4. Refractive error OU; presbyopia OU
5. Intermediate non-exudative age-related macular degeneration OU; worsening OU
6. Low risk glaucoma suspect secondary to asymmetric cupping OU; stable OU
a. IOP today: 14/14 OD/OS normal, untreated OU
b. OCT RNFL 9/2019: stable without progression per GPA OU.
c. Photos 9/2019: Stable cupping OU
d. Visual Field 01/2017: normal OU
e. Gonioscopy 01/2017: open to CB 360 OU
f. Pachymetry 01/2017: 508/520 OS/OS
7. Intermittent alternating exotropia OU; improved symptoms since cataract
surgery
PLAN:
1. Patient educated on findings, benefits of tight glucose control, modifiable
risk factors, and the importance of continued follow with primary care
physician; monitor at complete.
2. Encouraged good blood pressure control; monitor at complete.
3. Educated patient on good status; monitor at complete.
4. Continue with OTC readers if needed; monitor at complete.
5. Patient education on findings, the benefits/risks of lifestyle modifications
and appropriate antioxidant therapy for risk reduction; Rx'ed AREDS2 BID PO
every day; continue amsler grid: RTC STAT with changes; otherwise, monitor
with DFE in 6 months.
6. Discussed stability; no treatement indicated; monitor with VF in 6 months.
7. Continue without prism at this time; advised to RTC should diplopia re-occur;
otherwise monitor at complete.
RTC 04/2020 DFE/24-2 HVF
RTC 09/2020 Complete/OCT/photos