Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of POAG. Reports [stable/worsening] vision. Denies ocular pain, halos, or acute vision loss. Currently adherent to [medication name] QD/BID. No reported systemic side effects. Last IOP [value] mmHg.
Clinical Examination Findings
BCVA: [OD/OS]. IOP (Goldmann): [OD/OS] mmHg. Slit lamp: Cornea clear, AC deep and quiet, angles open (Shaffer grade [grade] 360 degrees). Fundus: C/D ratio [OD/OS], [thinning/notching] of neuroretinal rim, no disc hemorrhage. OCT-RNFL: [Average thickness] microns, [superior/inferior] thinning noted.
Treatment Protocol
Plan: Continue current IOP-lowering therapy. Target IOP: [value] mmHg. Discussed importance of strict adherence to topical regimen. Consider [SLT/iStent/Trabeculectomy] if target IOP is not achieved. Follow-up in [timeframe] with repeat VF and OCT.