NHS GOS Sight Test

Optometrist - Issued prescription for glasses * OD: Sphere -2.50, Cylinder -0.75, Axis 180, Distance Prism 0, Visual Acuity 6/6 * OS: Sphere -2.75, Cylinder -0.50, Axis 175, Distance Prism 0, Visual Acuity 6/6 * Near Add: +1.50 OU * Near Prism: 0 OU * Near Visual Acuity: N5 OU - Dispensing recommendations * Spectacles recommended: Yes, prescription is stable. Patient requires varifocals for distance and near correction, with high index lenses due to prescription strength. - Sight test type: * 16-59 years – All patients: 2 years - NHS Early Retest Code: * Not applicable; routine recall. - Treatments: * None mentioned. - Follow-Up: * Routine recall in 2 years for a full sight test. Return sooner if any new symptoms or vision changes occur. - Patient Education: * Advised on the benefits of varifocal lenses for seamless vision transition. Discussed the importance of regular eye examinations, especially with a family history of glaucoma. Provided information on proper lens care. - Referrals: * None at this time. - Current Glasses * OD: Sphere -2.25, Cylinder -0.50, Axis 170, Distance Prism 0, Visual Acuity 6/9 * OS: Sphere -2.50, Cylinder -0.50, Axis 175, Distance Prism 0, Visual Acuity 6/9 * Near Add: +1.25 OU * Near Prism: 0 OU * Near Visual Acuity: N8 OU Subjective: - Chief Complaint: * Patient reports slightly blurred distance vision and increasing difficulty reading small print, especially in the evenings, for the past 6 months. - History of Present Illness: * Onset was gradual, approximately 6 months ago. Symptoms have steadily worsened, leading to occasional headaches after prolonged reading. No sudden vision loss or pain reported. - Past Ocular History: * No history of eye diseases or surgeries. Wears glasses for distance and has done so since age 25. First experience with presbyopia symptoms. - Medical History: * Generally healthy. Diagnosed with well-controlled hypertension 5 years ago. No other significant systemic conditions. - Medication History: * Lisinopril 10mg once daily for hypertension. No ocular medications. - Allergies: * Penicillin (rash). - Family Ocular History: * Mother had glaucoma (diagnosed in her 60s). Father wore glasses for presbyopia. - Family Medical History: * Father had type 2 diabetes. Mother has hypertension. - Social History: * Non-smoker. Consumes alcohol socially (1-2 units per week). Works as an accountant, spending significant time on a computer. Enjoys gardening and reading. Objective: - Vision: * Unaided Visual Acuity: OD 6/18, OS 6/24 - Pinhole Vision: * Pinhole Visual Acuity: OD 6/9, OS 6/12 - Visual Acuity: * With current glasses: OD 6/9, OS 6/9 - Retinoscopy: * OD: -2.50 / -0.75 x 180 * OS: -2.75 / -0.50 x 175 - Intraocular Pressure: * Measurement method: Goldmann Applanation Tonometry * OD: 16 mmHg (Normal) * OS: 17 mmHg (Normal) Anterior Segment: - Lids and lashes: * OU: Clear, no signs of inflammation or lesions. - Cornea: * OU: Clear, no opacities or staining noted. - Anterior Chamber: * OU: Deep and quiet. No cells or flare. - Pupil Reactions: * OU: Pupils equal, round, reactive to light and accommodation. No RAPD. - Media: * OU: Clear vitreous. - Lens: * OU: Clear, no cataracts observed. Posterior Segment: - Macula: * OU: Flat, good foveal reflex. No drusen or oedema. - Peripheral retina: * OU: Attached, no tears, holes, or degenerations observed. - Optic Discs: * OU: Pink and healthy, distinct margins. C/D ratio 0.3, 0.3. No signs of cupping or nerve fibre layer loss. - Retinal Vessels: * OU: Normal calibre and tortuosity. Artery-to-vein ratio 2:3. No signs of retinopathy. * Fundus examination performed via direct and indirect ophthalmoscopy following dilation with Tropicamide 1%. - Additional Tests: * None performed during this visit. Assessment: - Binocular Refraction: * Orthophoric at distance and near. Good fusional reserves. No suppression. - Foveal Suppression: * No foveal suppression detected. - Refraction Notes: * Refraction refined from current spectacle correction, showing a slight increase in myopia and a new addition for presbyopia. Binocular balancing achieved excellent visual comfort. - Myopia (H47.1) - Presbyopia (H52.4) - No significant differential diagnoses based on current findings.