Ophthalmology — Comprehensive Eye Examination Template

Visit Information

Date: [Date]
Visit type: New patient / Established / Comprehensive annual
Referring physician: [Name] / Self-referred
Reason for visit: [Chief complaint]

Chief Complaint

[Primary visual concern]
Duration: [X] days/weeks/months/years
Eye(s) affected: Right / Left / Both
Current status: Stable / Worsening / Fluctuating

History of Present Illness

For Visual Changes

Type: Decreased vision / Blurred vision / Distorted vision / Double vision / Floaters / Flashes
Onset: Sudden / Gradual
Constant / Intermittent
Distance / Near / Both
Associated: Pain / Redness / Discharge / Photophobia / Halos
Impact on activities: [Driving, reading, etc.]

For Eye Pain

Location: Ocular / Periorbital / Retrobulbar
Character: Sharp / Dull / Pressure / Foreign body sensation
Severity: [X]/10
Timing: Constant / Intermittent / Movement-related
Associated: Vision change / Redness / Discharge / Photophobia / Nausea

For Red Eye

Duration: [X] days
Discharge: None / Watery / Mucoid / Purulent
Itching: Yes / No
Pain: Yes / No
Vision change: Yes / No
Contact lens wear: Yes / No — [Type, wear schedule, hygiene]
Recent URI: Yes / No
Exposure: [Sick contacts, allergens, chemicals]

For Flashes/Floaters

Onset: Sudden / Gradual
Quantity: [Number of floaters, frequency of flashes]
Pattern: [Description]
Location in field: [Central, peripheral, specific quadrant]
Associated: Curtain/shadow / Vision loss / Trauma
Risk factors: Myopia / Prior eye surgery / Family history RD

Ocular History

Past Eye Problems

Refractive error: None / Myopia / Hyperopia / Astigmatism / Presbyopia
Glaucoma: No / Yes — Type: [X], Duration: [X]
Cataracts: No / Yes — [Status]
Macular degeneration: No / Yes — Type: [Dry/wet], [R/L]
Diabetic retinopathy: No / Yes — [Stage]
Retinal detachment: No / Yes — [Date, treatment, eye]
Dry eye: No / Yes — [Severity, treatment]
Uveitis: No / Yes — [Type, etiology]
Strabismus/amblyopia: No / Yes — [History]
Other: [List]

Prior Eye Surgery

Procedure	Eye	Date	Surgeon
Cataract/IOL	[R/L]	[Date]	[Name]
LASIK/PRK	[R/L]	[Date]
Glaucoma surgery	[R/L]	[Date]
Retinal surgery	[R/L]	[Date]
Other

Eye Medications

Current eye drops:

Medication	Eye	Frequency	Duration
[Drug]	[R/L/OU]	[X times/day]	[X]

Compliance: Good / Fair / Poor
Side effects: None / [List]

Glasses/Contact Lenses

Glasses: No / Yes — Age: [X] years
Contact lenses: No / Yes

• Type: Soft / RGP / Hybrid / Scleral
• Wear schedule: Daily disposable / Extended / [X]
• Hours/day: [X]
• Last replaced: [Date]

Medical History

Diabetes: No / Yes — Duration: [X] years, A1c: [X]%
Hypertension: No / Yes
Autoimmune/inflammatory: No / Yes — [Type]
Thyroid disease: No / Yes — [Graves, hypothyroid]
Connective tissue: No / Yes — [RA, lupus, sarcoid]
Neurologic: No / Yes — [MS, myasthenia, stroke]
Cancer: No / Yes — [Type — relevance to eye]

Medications

[Current systemic medications — note those with ocular effects]
Hydroxychloroquine: No / Yes — Duration: [X] years, dose: [X] mg
Steroids: No / Yes — [Route, duration]
Anticoagulants: No / Yes — [Type]
Tamoxifen: No / Yes
Amiodarone: No / Yes
Other: [List]

Allergies

[Drug allergies, especially to eye drops]
Sulfa: No / Yes
Latex: No / Yes
Contrast: No / Yes

Family History

Glaucoma: No / Yes — [Relationship]
Macular degeneration: No / Yes — [Relationship]
Cataracts: No / Yes — [Relationship]
Retinal detachment: No / Yes — [Relationship]
Blindness: No / Yes — [Relationship, cause]

Social History

Tobacco: Current / Former / Never — Pack-years: [X]
Alcohol: [Quantity]
Occupation: [Visual demands, exposures]
Driving: Yes / No — [Restrictions]
Eye protection use: [Sports, work]

Physical Examination

Visual Acuity

	Right Eye (OD)	Left Eye (OS)
Distance uncorrected	[20/X]	[20/X]
Distance with glasses	[20/X]	[20/X]
Distance pinhole	[20/X]	[20/X]
Near uncorrected	[J#]	[J#]
Near with glasses	[J#]	[J#]

Refraction (if performed)

	OD	OS
Sphere	[+/-X.XX]	[+/-X.XX]
Cylinder	[+/-X.XX]	[+/-X.XX]
Axis	[X]°	[X]°
Add	[+X.XX]	[+X.XX]
Best corrected VA	[20/X]	[20/X]

Cycloplegic: No / Yes — [Method]

Pupils

	OD	OS
Size (light)	[X] mm	[X] mm
Size (dark)	[X] mm	[X] mm
Shape	Round / [Irregular]	Round / [Irregular]
Reaction	Brisk / Sluggish / Fixed	Brisk / Sluggish / Fixed

RAPD: None / Present [OD/OS]

Extraocular Motility

Versions: Full / [Limitation — specify direction, eye]
Ductions: Full / [Limitation]
Alignment: Orthophoric / [Tropia/phoria — type, magnitude]
Cover test: [Results]
Diplopia: None / [Description]

Confrontation Visual Fields

OD: Full / [Defect — type, location]
OS: Full / [Defect — type, location]

Intraocular Pressure

Method: Goldmann / Tonopen / iCare / NCT
Time: [X:XX AM/PM]

	OD	OS
IOP	[X] mmHg	[X] mmHg

CCT (if measured): OD [X] μm, OS [X] μm

External Examination

Lids/Lashes:

Finding	OD	OS
Position	Normal / [Ptosis, entropion, ectropion]	[Findings]
Lashes	Normal / [Trichiasis, madarosis]	[Findings]
Meibomian glands	Normal / [Plugging, atrophy]	[Findings]
Lesions	None / [Description]	[Findings]

Lacrimal:

Puncta: Patent / [Stenotic]
TBUT: [X] seconds (normal >10)
Schirmer's: [X] mm/5 min (if performed)

Conjunctiva:

Finding	OD	OS
Injection	None / [Diffuse, sectoral, ciliary]	[Findings]
Discharge	None / [Watery, mucoid, purulent]	[Findings]
Chemosis	Absent / Present	[Findings]
Follicles/papillae	None / [Location]	[Findings]
Lesions	None / [Description]	[Findings]

Slit Lamp Examination

Cornea:

Finding	OD	OS
Clarity	Clear / [Edema, opacity]	[Findings]
Epithelium	Intact / [SPK, erosion, ulcer]	[Findings]
Stroma	Clear / [Infiltrate, scar, dystrophy]	[Findings]
Endothelium	Normal / [Guttae, cell loss]	[Findings]
Arcus	None / Present	[Findings]
KP	None / [Fine, mutton fat]	[Findings]
Fluorescein	Negative / [Staining pattern]	[Findings]

Anterior Chamber:

Finding	OD	OS
Depth	Normal / Shallow / Deep	[Findings]
Cell	0 / [1+ to 4+]	[Findings]
Flare	0 / [1+ to 4+]	[Findings]
Hypopyon	None / [Height]	[Findings]
Hyphema	None / [Extent]	[Findings]

Iris:

Finding	OD	OS
Color	[Brown, blue, etc.]	[Color]
Pattern	Normal / [Atrophy, synechiae]	[Findings]
NVI	None / Present	[Findings]
Surgical	[Iridotomy, iridectomy]	[Findings]

Lens:

Finding	OD	OS
Status	Phakic / Pseudophakic / Aphakic	[Status]
Position	Centered / [Subluxed]	[Findings]
Clarity	Clear / Cataract: [NS/Cortical/PSC grade]	[Findings]
IOL	[Type if known]	[Type]

Gonioscopy (if indicated)

Method: [4-mirror, Goldmann, Zeiss]

Quadrant	OD	OS
Superior	[Grade 0-4, Shaffer]	[Grade]
Inferior	[Grade]	[Grade]
Nasal	[Grade]	[Grade]
Temporal	[Grade]	[Grade]

PAS: None / [Location, extent]
NVA: None / Present
Pigment: [Grade]
Angle recession: None / [Extent]

Dilated Fundus Examination

Dilation: [Tropicamide 1%, Phenylephrine 2.5%] at [Time]

Vitreous:

Finding	OD	OS
Clarity	Clear / [Haze, cells]	[Findings]
PVD	Absent / Present / Partial	[Status]
Hemorrhage	None / [Location]	[Findings]

Optic Nerve:

Finding	OD	OS
C/D ratio	[0.X]	[0.X]
Rim	Healthy / [Thinning — location]	[Findings]
Color	Pink / Pale	[Findings]
Margins	Sharp / [Blurred]	[Findings]
NVD	None / Present	[Findings]
Hemorrhage	None / [Location]	[Findings]
RNFL	Intact / [Defect]	[Findings]

Macula:

Finding	OD	OS
Foveal reflex	Present / Absent	[Findings]
Drusen	None / [Few/many, hard/soft]	[Findings]
RPE changes	None / [Description]	[Findings]
Edema	None / [CME, DME]	[Findings]
CNV/scarring	None / [Description]	[Findings]
ERM	None / Present	[Findings]
Hemorrhage	None / [Description]	[Findings]

Vessels:

Finding	OD	OS
A/V ratio	[Normal/narrow]	[Findings]
Crossing changes	None / [AV nicking]	[Findings]
NVE	None / [Location]	[Findings]
Hemorrhages	None / [Dot/blot, flame]	[Findings]
Cotton wool	None / [Location]	[Findings]
Exudates	None / [Location]	[Findings]

Peripheral Retina:

Finding	OD	OS
Lattice	None / [Location]	[Findings]
Holes/tears	None / [Location]	[Findings]
Detachment	None / [Location, extent]	[Findings]
Other	[Description]	[Description]

Diagnostic Testing

OCT (if performed)

Macula OCT:

• OD: [Normal / CME / ERM / Drusen / CNV / etc.]
• OS: [Findings]
• Central foveal thickness: OD [X] μm, OS [X] μm

RNFL OCT:

• OD: Average [X] μm — [Normal / Borderline / Abnormal]
• OS: Average [X] μm — [Normal / Borderline / Abnormal]
• Pattern: [Global thinning / Focal defect — location]

Visual Fields (if performed)

Test: [HVF 24-2, 10-2, Goldmann]
Reliability: OD [Fixation, FP, FN] / OS [Reliability]
OD: [Normal / Defect — type, location]
OS: [Normal / Defect — type, location]
MD: OD [X] dB, OS [X] dB
Progression: Stable / [Worsening — rate]

Other Testing

Fundus photos: [Obtained/reviewed]
Fluorescein angiography: [Findings]
ICG angiography: [Findings]
Pachymetry: OD [X] μm, OS [X] μm
A/B scan ultrasound: [Findings]
Topography/tomography: [Findings]

Assessment

1) [Primary diagnosis] — [OD/OS/OU]
Severity: [Mild/moderate/severe]
Stability: [Stable/progressing]
2) [Secondary diagnoses]
3) [Refractive status]

Plan

Medical Treatment

• [ ] Continue current eye drops
• [ ] Start: [Medication, dosing, eye]
• [ ] Change: [Medication adjustment]
• [ ] Discontinue: [Medication]
• [ ] Artificial tears: [Type, frequency]

Procedures

• [ ] No procedures indicated
• [ ] Laser: [Type — LPI, SLT, PRP, focal, YAG]
• [ ] Injection: [Anti-VEGF, steroid — drug, eye]
• [ ] Minor procedure: [Chalazion, punctal plugs, etc.]

Surgical Planning

• [ ] No surgery indicated
• [ ] Cataract surgery discussed — [Scheduled / To schedule]
• [ ] Glaucoma surgery discussed
• [ ] Retinal surgery referral
• [ ] Oculoplastic referral

New Glasses/Contacts

• [ ] Glasses prescription given
• [ ] Contact lens fitting
• [ ] Refraction needed at follow-up
• [ ] Low vision referral

Additional Testing

• [ ] OCT
• [ ] Visual fields
• [ ] Fundus photography
• [ ] Fluorescein angiography
• [ ] B-scan ultrasound
• [ ] ERG/VEP
• [ ] Other: [Specify]

Referrals

• [ ] Retina specialist
• [ ] Glaucoma specialist
• [ ] Cornea specialist
• [ ] Oculoplastics
• [ ] Neuro-ophthalmology
• [ ] Pediatric ophthalmology
• [ ] Low vision services
• [ ] PCP for systemic workup

Patient Education

• Diagnosis explained
• Treatment rationale
• Medication instructions
• Signs of emergency (RD symptoms, acute vision loss, pain)
• Driving restrictions (if applicable)

Follow-up

Return: [X] weeks/months

• For: [Exam, testing, treatment response]
• Sooner if: [Vision change, pain, floaters/flashes]

Communication

Report sent to: [Referring physician, PCP]
Surgery scheduling: [If applicable]