Ophthalmology — Cataract Evaluation Template

Visit Information

Date: [Date]
Visit type: Cataract evaluation / Pre-op / Post-op [Day X]
Surgical eye: Right / Left / Both (staged)

Chief Complaint

[Primary visual concern]
Duration: [X] months/years
Impact on daily activities: [Driving, reading, glare, etc.]

Visual Function Assessment

Functional Impairment

Activities affected:

• [ ] Driving (day)
• [ ] Driving (night)
• [ ] Reading
• [ ] Computer/screens
• [ ] Television
• [ ] Hobbies: [Specific activities]
• [ ] Work duties: [Specific tasks]
• [ ] Activities of daily living

Glare symptoms: None / Mild / Moderate / Severe

• Triggers: [Sunlight, oncoming headlights, indoor lighting]

Halos: None / Present
Monocular diplopia: None / Present
Quality of life impact: Mild / Moderate / Significant

• Falls or near-falls due to vision: No / Yes

Visual Requirements

Occupation: [Current work, visual demands]
Driving status: Active driver / Non-driver

• License requirements: [X]

Hobbies with visual demands: [List]
Refractive goals: [Distance, near, intermediate, monovision]

Ocular History

Cataract History

Onset: [Gradual]
Duration: [X] months/years
Prior cataract evaluation: None / [Date, surgeon]
Surgical decision: First time considering / Previously declined

Prior Eye Surgery

Procedure	Eye	Date	Outcome
[LASIK/PRK]	[R/L]	[Date]	[VA achieved]
[Other]

Other Eye Conditions

Glaucoma: No / Yes — [Type, IOP control, medications, surgery]
Macular degeneration: No / Yes — [Type, status]
Diabetic retinopathy: No / Yes — [Stage, treatment]
Corneal disease: No / Yes — [Type — affects IOL calculation]
Dry eye: No / Yes — [Severity]
Amblyopia: No / Yes — [Eye]
Strabismus: No / Yes — [Type]
Uveitis: No / Yes — [History]
Retinal detachment: No / Yes — [Eye, treatment]
Other: [List]

Eye Medications

[Current eye drops]

Medical History

Diabetes: No / Yes — A1c: [X]%, Duration: [X] years
Hypertension: No / Yes — [Controlled]
Anticoagulation: No / Yes — [Drug, INR if applicable]
Alpha-blocker use: No / Yes — [Drug — Flomax syndrome risk]
Prostate medications: [List]
Immunosuppression: No / Yes — [Reason]
Bleeding disorders: No / Yes
Anesthesia history: [Prior surgeries, complications]

Medications

[Relevant medications]
Alpha-blockers: [Tamsulosin, alfuzosin, etc.] — Duration: [X]
Anticoagulants: [List]
Steroids: [Route, duration]

Allergies

[Drug allergies — especially antibiotics, eye drops, anesthesia]
Latex: No / Yes
Iodine/Betadine: No / Yes

Physical Examination

Visual Acuity

	Right Eye (OD)	Left Eye (OS)
Uncorrected distance	[20/X]	[20/X]
Best corrected distance	[20/X]	[20/X]
Pinhole	[20/X]	[20/X]
Near (corrected)	[J#]	[J#]
Potential acuity (PAM/interferometry)	[20/X]	[20/X]

Glare testing: OD [20/X], OS [20/X]

Refraction

	OD	OS
Sphere	[+/-X.XX]	[+/-X.XX]
Cylinder	[+/-X.XX]	[+/-X.XX]
Axis	[X]°	[X]°
Add	[+X.XX]	[+X.XX]
SE	[X]	[X]

Prior refractive surgery: No / Yes — [LASIK/PRK, date]

Pupils

Size: OD [X] mm, OS [X] mm (mesopic)
Reaction: OD [Brisk/Sluggish], OS [Brisk/Sluggish]
RAPD: None / Present [Eye]

Intraocular Pressure

OD: [X] mmHg
OS: [X] mmHg
Method: [Goldmann/Tonopen]

Slit Lamp Examination

Cornea:

Finding	OD	OS
Clarity	Clear / [Guttae, scarring]	[Findings]
Endothelial cell count	[X] cells/mm²	[X] cells/mm²
Fuchs' dystrophy	No / Yes [Grade]	[Status]
Prior refractive	No / [LASIK flap, PRK haze]	[Findings]
Arcus	None / Present	[Findings]

Anterior Chamber:

Depth: Normal / Shallow
Van Herick: [Grade]
Angle: Open / Narrow

Iris:

IFIS risk: Low / Moderate / High

• Alpha-blocker use: [X]

Synechiae: None / [Description]
Pseudoexfoliation: No / Yes

Lens:

Cataract	OD	OS
Nuclear sclerosis	Grade [0-4]	Grade [0-4]
Cortical	Grade [0-4]	Grade [0-4]
Posterior subcapsular	Grade [0-4]	Grade [0-4]
Brunescence	None / [Grade]	[Grade]
White cataract	No / Yes	No / Yes

Zonular integrity: Intact / [Concern — PXF, trauma]
Subluxation: None / [Degree]

Dilated Fundus Examination

Optic Nerve:

C/D ratio: OD [0.X], OS [0.X]
Rim: Healthy / [Glaucomatous changes]

Macula:

Finding	OD	OS
Foveal reflex	Present / Absent	[Status]
Drusen	None / [Grade]	[Findings]
ERM	None / Present	[Findings]
CME	None / Present	[Findings]
Other	[Description]	[Description]

Peripheral Retina:

Lattice/holes: None / [Location]
Other: [Findings]

Diagnostic Testing

Biometry

Device: [IOLMaster 700, Lenstar, etc.]

Measurement	OD	OS
Axial length	[X.XX] mm	[X.XX] mm
K1	[X.XX] D @ [X]°	[X.XX] D @ [X]°
K2	[X.XX] D @ [X]°	[X.XX] D @ [X]°
Avg K	[X.XX] D	[X.XX] D
Astigmatism	[X.XX] D @ [X]°	[X.XX] D @ [X]°
ACD	[X.XX] mm	[X.XX] mm
WTW	[X.XX] mm	[X.XX] mm
LT	[X.XX] mm	[X.XX] mm

IOL calculation formula: [Barrett, SRK/T, Holladay, Hill-RBF]
Post-refractive formula: [If applicable — Barrett True-K, ASCRS calculator]

Topography/Tomography

Device: [Pentacam, Orbscan, Atlas]
Regular astigmatism: Yes / Irregular
Keratoconus: No / Suspect / Yes
Post-LASIK: No / Yes — [Pattern]
HOAs: [Normal / Elevated]

OCT Macula

OD: [Normal / ERM / CME / Drusen / AMD features]
OS: [Findings]
Central foveal thickness: OD [X] μm, OS [X] μm
Cataract affecting image quality: Yes / No

Visual Potential Testing (if indicated)

PAM: OD [20/X], OS [20/X]
Interferometry: OD [20/X], OS [20/X]
Limitation: [Cataract density affecting test]

Surgical Planning

Operative Eye

Eye to operate: Right / Left
Second eye planned: No / Yes — [Timing]

IOL Selection

Target Refraction:

Distance: [Plano / -0.50 / etc.]
Near/intermediate target: [If monovision or multifocal]
Patient preference: Both eyes distance / Monovision / Extended depth

IOL Type:

[ ] Monofocal
[ ] Monofocal toric
[ ] Extended depth of focus (EDOF)
[ ] EDOF toric
[ ] Multifocal
[ ] Multifocal toric
Specific IOL: [Model, power]

IOL Calculation:

Formula	IOL Power	Predicted Refraction
[Barrett]	[X.X] D	[+/-X.XX]
[SRK/T]	[X.X] D	[+/-X.XX]
[Holladay]	[X.X] D	[+/-X.XX]

Selected power: [X.X] D
Target: [Plano, -0.50, etc.]

Toric Calculations (if applicable):

Corneal astigmatism: [X.XX] D @ [X]°
IOL cylinder: [X.X] D
Axis placement: [X]°
Predicted residual: [X.XX] D

Surgical Approach

Incision location: [Temporal, superior, on-axis]
Incision size: [X.X] mm
Femtosecond laser: No / Yes
LRIs planned: No / Yes — [Location, length]
Capsular tension ring: Not planned / Planned — [Reason]
Iris hooks: Not planned / Planned — [Reason]

Anesthesia

Planned: Topical / MAC with topical / Retrobulbar / Peribulbar / General
Patient preference/needs: [Anxiety, cooperation concerns]

Risk Factors

Risk Factor	Status	Consideration
IFIS risk	[Low/Mod/High]	[Malyugin ring, hooks, epinephrine]
Zonular weakness	[No/Yes]	[CTR, slow phaco]
Shallow AC	[No/Yes]	[Viscoelastic, technique]
Small pupil	[No/Yes]	[Dilation, hooks, Malyugin]
Dense cataract	[No/Yes]	[Technique modification]
PXF	[No/Yes]	[CTR consideration]
Fuchs'	[No/Yes]	[DMEK consideration]
High myope	[No/Yes]	[RD counseling]
Only eye	[No/Yes]	[Enhanced consent]

Assessment

1) Cataract [OD/OS/OU] — [Grade, type]
Visual significance: Yes
Functional impairment: [Documented activities]
2) [Co-existing conditions affecting surgery/outcome]
3) Surgical candidacy: Good / [Concerns]

Informed Consent Discussion

Risks Discussed

• [ ] Infection (endophthalmitis)
• [ ] Bleeding
• [ ] Retinal detachment
• [ ] Cystoid macular edema
• [ ] Need for glasses after surgery
• [ ] IOL dislocation
• [ ] Posterior capsule opacification (YAG)
• [ ] Refractive surprise
• [ ] Dysphotopsia (if premium IOL)
• [ ] Loss of vision (rare)
• [ ] Risks specific to this patient: [X]

Patient Understanding

Questions answered: Yes
Patient/family understanding: Good
Written consent: Signed / To be signed day of surgery

Premium IOL Discussion (if applicable)

Options reviewed: [Toric, multifocal, EDOF]
Out-of-pocket cost: Discussed — [Amount]
Realistic expectations set: Yes

• Spectacle independence: [Realistic likelihood]
• Potential for dysphotopsia: Discussed

Plan

Pre-Operative Orders

• [ ] Medical clearance: [Required / Not required]
• [ ] Anticoagulation: Continue / Hold — [Instructions]
• [ ] Alpha-blocker: Continue / Hold
• [ ] Pre-op eye drops: [Regimen]
• [ ] NPO instructions
• [ ] Arrival time
• [ ] Driver arranged

Surgery Scheduled

Date: [X]
Time: [X]
Location: [Facility]
Surgeon: [Name]
Eye: [OD/OS]
IOL: [Model, power]

Post-Op Planning

Day 1 visit: [Date]
Standard post-op regimen: [Drops]
Work/activity restrictions: [X]

Follow-up

Pre-op: [Date if needed]
Day 1 post-op: [Date]
Week 1: [Date]
Month 1: [Date] — Refraction

Communication

Report to PCP: [Sent/pending]
Surgery scheduled with: [Scheduler]
Patient instructions given: Yes