Established patient returns to the eye clinic for DFE/OCT/VF 24-2 to monitor intermediate AMD and 
glaucoma suspicion OU

CC: Patient reports eye fatigue when reading and occasional blurry vision. Patient denies any eye 
pain, irritation, dryness, flashes, floaters, or diplopia and is using the following meds as indicated below:

Ocular Medications:
- ARED2 BID - good compliance

Diabetic Review
- Year diagnosed: prediabetic
- Management: diet
- Most recent blood sugar per patient: unknown
- Most recent HA1c: 6.1%, 12/2019

The patient was last seen/complete 09/2019 Dr. Haberthy

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
6. Low risk glaucoma suspect secondary to asymmetric cupping 
   OU
7. Intermittent alternating exotropia OU

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

Uncorrected VAs: 
OD: 20/20-2
OS: 20/25-2

EOM and Hirschberg Alignment: Smooth and full w/o 
                              Diplopia/Pain; no apparent 
                              tropia OD/OS
CONFRONTATION VIS FIELDS: FULL TO FINGER COUNTING OD/OS
AMSLER GRID: Normal OD/OS
PUPILS: PERRL: Yes; (-)APD

SLIT LAMP EXAM: 
Lids/Lashes/Ocular Adnexa: tr debris OU
Sclera/Conjunctiva: Clear and quiet OU
Cornea (epithelium, stroma, endothelium, tear film): arcus OU; mild EBMD OU central round ant stromal scar OS
Anterior Chamber: Deep/no cells or flare OU
Iris: Flat and intact, no rubeosis OU

TONOMETRY: 
OD: 14
OS: 15
TIME: 0935

DILATION: 
1 GTT Tropicamide (1.0%) OU 
1 GTT Phenylephrine (2.5%) OU 
TIME: 0935

INTERNAL (78/90, 20D BIO):

LENS (anterior/posterior capsule, cortex, nucleus)
OD: PCIOL, centered, small vertical crack temp to fixation
OS: PCIOL, centered, clear

VITREOUS: 
OD: Syneresis
OS: Syneresis

NERVE: 
OD: 0.30/0.30 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 small/intermediate 
    drusen, couple large drusen with mottling
OS: No blood, fluid or exudates, scattered small/intermediate 
    drusen, few large drusen temp with mottling

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 MAC
OD: SS: 8/10; 226um CT; normal foveal contour, scattered 
    drusen, intact RPE (-)IRF/SRF/VMT
OS: SS: 8/10; 226um CT; normal foveal contour, scattered 
    drusen, temp confluent drusen, intact RPE (-)IRF/SRF/VMT

- stable OD/OS to 09/2019; moderate progression OD, mild progression OS to 08/2013 baseline

FUNDUS PHOTOGRAPHY
OD: macular degeneration as described above
OS: macular degeneration as described above
- stable OD/OS to 09/2019 photos

VISUAL FIELD 24-2
OD: Reliability - poor 20% FP; 0% FN; 0/0 FL; excessive false 
    positives
MD: 1.76 PSD: 1.44
Pattern of defect: no defects present, pattern deviation worse 
than total deviation

Repeatability: No repeatable defects, stable to baseline 2013

OS: Reliability - good 0% FP; 0% FN; 0/0 FL 
MD: 1.03 PSD: 1.51
Pattern of defect: no defects present, pattern deviation worse 
than total deviation

Repeatability: No repeatable defects, stable to baseline 2013

ASSESSMENT: 
1. Hypertension without ocular complications OU - stable
2. Pseudophakia OU - stable
3. Intermediate non-exudative age-related macular degeneration 
   OU - stable OU
4. Low risk glaucoma suspect secondary to asymmetric cupping 
   OU - stable
        a. IOP today: 14/15 OD/OS; untreated OU
        b. OCT RNFL 9/2019: stable to 2013 per GPA
        c. Photos 03/2020: Stable cupping OU
        d. Visual Field 03/2020: clear OU, stable to baseline 
           2013
        e. Gonioscopy 01/2017: open to CB 360 OU
        f. Pachymetry 01/2017: 508/520 OS/OS
5. Dry eye syndrome OU - new

PLAN:
1. Patient educated; Encouraged good blood pressure control; 
   monitor at complete.
2. Educated patient; monitor at complete.
3. Patient education on findings, the benefits/risks of 
   lifestyle modifications and appropriate antioxidant therapy 
   for risk reduction. Continue AREDS2 BID. Continue 
   monitoring amsler grid and RTC ASAP with changes seen, 
   otherwise monitor complete.
4. Patient educated; Stressed importance of continued follow 
   up to monitor for progression. No treatment warranted due 
   to stability since 2013. Monitor complete. Repeat special 
   testing as clinically indicated.
5. Patient educated; Encouraged OTC ATs TID OU. Monitor 
   complete.

RTC 09/2020 Complete/OCT/photos