From the Guidelines
A comprehensive eye exam documentation should include chief complaint, history, visual acuity measurements, refraction results, external examination findings, pupil assessment, extraocular muscle function, confrontation visual fields, slit lamp examination, intraocular pressure readings, and dilated fundus examination results. Begin with the patient's demographic information and reason for visit. Document visual acuity for each eye (e.g., "OD: 20/40, OS: 20/30") and refraction data showing sphere, cylinder, and axis measurements, as recommended by the refractive errors preferred practice pattern 1. Note external findings including lid position and lashes. Record pupil size, shape, and reactivity, along with extraocular movements in all gazes. Document anterior segment findings including cornea clarity, anterior chamber depth, iris appearance, and lens status. Include intraocular pressure values (e.g., "OD: 16 mmHg, OS: 18 mmHg"), which is preferably measured using a contact applanation method, such as a Goldmann tonometer 1. For the posterior segment, document optic nerve appearance with cup-to-disc ratio, macula status, vessel characteristics, and peripheral retina findings. This structured documentation ensures comprehensive care and facilitates follow-up by clearly tracking changes in ocular health over time, as emphasized in the comprehensive adult medical eye evaluation preferred practice pattern 1.
Some key points to consider when documenting a comprehensive eye exam include:
- Visual acuity with current correction at distance and near, with refraction when indicated 1
- External examination, including eyelid position and character, lashes, lacrimal apparatus and tear function, globe position, and pertinent facial features 1
- Pupillary function, including size and response to light, and relative afferent pupillary defect 1
- Ocular alignment and motility, including cover/uncover test, alternate cover test, ductions and versions 1
- Slit-lamp biomicroscopic examination, including eyelid margins and lashes, tear film, conjunctiva, sclera, cornea, anterior chamber, and assessment of central and peripheral anterior chamber depth, iris, lens, and anterior vitreous 1
- Intraocular pressure measurement, preferably using a contact applanation method, such as a Goldmann tonometer 1
- Fundus examination, including mid and posterior vitreous, retina, vasculature, and optic nerve 1
From the Research
Eye Exam Documentation
There are no research papers to assist in answering this question as the provided studies focus on the comparison of prostaglandin analogues and their efficacy in treating glaucoma and ocular hypertension, rather than eye exam documentation.
- The studies 2, 3, 4, 5, 6 discuss the treatment of glaucoma and ocular hypertension using prostaglandin analogues, but do not provide information on eye exam documentation.
- These studies compare the efficacy and tolerability of different prostaglandin analogues, such as latanoprost, bimatoprost, and travoprost, but do not address the documentation of eye exams.
- The results of these studies may be useful for ophthalmologists in determining the optimal treatment for patients with glaucoma or ocular hypertension, but do not provide guidance on eye exam documentation.