Refractive Patient Note

Dr. Eleanor Vance, Consultant Ophthalmologist Professional registration number: 1234567 Patient Name: Sarah Jenkins Date of Birth: 15/05/1988 Medical Record Number: SJ88155 Date of Consultation: 01/11/2024 Reason for Visit: Ms. Jenkins presented with a primary complaint of progressively worsening blurry vision in both eyes, more pronounced at night and when reading. She was referred by her GP, Dr. Alex Smith, for evaluation of potential refractive error and suitability for refractive surgery. Background: Ms. Jenkins reports a 6-month history of declining visual clarity. Initially, she noticed difficulty reading small print and signs at a distance. Over the past 3 months, these symptoms have intensified, leading to headaches and eye strain, particularly after prolonged screen use. She has not tried any previous interventions or treatments for this specific issue, beyond over-the-counter reading glasses which provide minimal relief. Ocular History: No previous ocular diagnoses, surgeries, trauma, or treatments reported for either eye. Medical History: Ms. Jenkins has a history of seasonal allergies well-controlled with over-the-counter antihistamines. No other relevant systemic medical conditions, surgeries, or hospitalisations. Medications: * Loratadine 10mg, once daily (as needed for allergies) * Multivitamin, once daily Allergies: * Penicillin (rash) * Codeine (nausea) Ophthalmic Examination: Visual Acuity: * Right Eye (OD): Uncorrected Visual Acuity (UCVA) 6/24, Best Corrected Visual Acuity (BCVA) 6/6 with -2.50 sphere * Left Eye (OS): UCVA 6/30, BCVA 6/6 with -3.00 sphere Refraction: Right eye refraction values: -2.50 / -0.25 x 180 Left eye refraction values: -3.00 / -0.50 x 5 Intraocular Pressure: * Right Eye (OD): 16 mmHg (Goldmann Applanation Tonometry) * Left Eye (OS): 15 mmHg (Goldmann Applanation Tonometry) Examination: Lids and lashes: Clear, no abnormalities. Conjunctiva: White and quiet. Sclera: White. Cornea: Clear, no opacities or oedema. Anterior chamber: Deep and clear. Iris: Normal configuration, reactive pupils. Lens: Clear, no cataracts. Optic nerve: Pink, sharp margins, cup-to-disc ratio 0.3 in both eyes. Macula: Flat, no drusen or oedema. Retina: Attached, no tears or detachments observed in periphery for both eyes. Summary: Ms. Jenkins presents with symptomatic myopia and mild astigmatism in both eyes, consistent with her refractive error measurements. There are no other ocular pathologies identified. She is a suitable candidate for further discussion regarding refractive surgery options given her desire for reduced spectacle dependence. Recommendation: * Discuss potential for laser refractive surgery (e.g., LASIK or PRK) as a long-term solution for myopia and astigmatism. * Provide information on benefits, risks, and post-operative care. * Schedule a follow-up appointment for further detailed counselling and pre-operative assessments, including corneal topography and pachymetry. * Continue current medications as prescribed. Risks: Potential risks of refractive surgery, including dry eyes, glare, halos, under- or over-correction, infection, and vision loss (rare), were discussed with the patient. The importance of understanding these risks and making an informed decision was emphasised. Dr. Eleanor Vance Consultant Ophthalmologist City Eye Clinic