Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with a chief complaint of progressive distance vision blur. Reports difficulty reading road signs, seeing the whiteboard, or watching television. Onset is gradual, with no associated eye pain, photophobia, or flashes/floaters. Current refractive correction is [insert power] or patient is currently uncorrected.
Clinical Examination Findings
Visual acuity (uncorrected): OD [X], OS [X]. Visual acuity (best corrected): OD [X], OS [X]. Refraction: [Spherical/Cylindrical power]. Slit lamp exam: Anterior segment quiet, cornea clear, anterior chamber deep and quiet. Fundus exam: Optic nerve head sharp, macula flat, peripheral retina intact without tears or detachments. Axial length: [X] mm.
Treatment Protocol
Prescribed corrective lenses (spectacles) with [Spherical/Cylindrical] power. Discussed options for contact lens fitting or refractive surgery (LASIK/PRK) if patient is a candidate. Advised annual comprehensive dilated eye exams to monitor for myopic maculopathy and retinal thinning.