Eye Examination Record

Eye Examination Record Patient Information Name: Sarah Jenkins NHS Number: 123 456 7890 Address: 12 Orchard Lane, Bristol, BS1 5YZ Tel: 07700 900333 Email: sarah.jenkins@example.com GP: Dr. Eleanor Vance Present at Examination: Patient only Alternative Contact: Mr. David Jenkins, Husband, 07700 900444 NHS Sight Test Eligibility Reason for Test: Patient has a family history of glaucoma and is over 60 years old. Domiciliary Eligibility Reason Reason: Patient is unable to leave home unaccompanied due to severe mobility impairment following a stroke. History & Symptoms Patient reports gradually worsening blurred vision in both eyes over the past 6 months, particularly when reading. Experiences occasional headaches, mainly in the evenings. Denies flashes, floaters, or pain. Reports difficulty with night driving. General Health Controlled hypertension (diagnosed 5 years ago). History of mild osteoarthritis. Non-smoker, rarely drinks alcohol. No known allergies. Medications Lisinopril 10mg OD for hypertension. Ocular History Last eye examination 2 years ago, reported good vision. No history of ocular surgery, trauma, or infections. Wears reading glasses purchased over-the-counter. Family History Mother diagnosed with glaucoma at age 70. Father had cataracts removed in his 80s. Maternal grandfather had macular degeneration. Hobbies/Tasks Enjoys reading, knitting, and watching television. Previously enjoyed gardening but finds it difficult now due to vision and mobility issues. Requires clear vision for daily tasks around the home. Current Prescription & Visual Acuity Current Spectacles (Reading, ~2 yrs old): R: +2.00 DS L: +2.00 DS Distance VA with current specs: R: 6/12, L: 6/18 Near VA with current specs: N8 at 35cm, struggling with small print. Pupils PERRLA, direct and consensual reflexes brisk. No anisocoria. RAPD: Negative. Retinoscopy R: +0.75 / -0.25 x 180 L: +1.00 / -0.50 x 5 PD: 62mm Subjective Refraction R: +0.75 / -0.25 x 180 (6/6) L: +1.00 / -0.50 x 5 (6/7.5) Add: +2.50 DS (N5 at 35cm) Tonometry Method: Icare tonometer R: 16 mmHg L: 17 mmHg Time: 14:30 Drops Used: Proxymetacaine 0.5% (prior to tonometry), Tropicamide 1% (for dilation) Batch No: PX12345, TR67890 Expiry: 11/2025, 03/2026 OMB/Motility Full range of extraocular movements. Orthophoric at distance and near. No nystagmus. Cover test negative for phoria/tropia. Stereopsis reduced (600 arc seconds). External Examination Lids/Lashes: Mild blepharitis noted bilaterally, few misdirected lashes. No ptosis or lagophthalmos. Conj/Sclera: Clear and white, no injection or pterygium. Anterior Segment Cornea: Clear, no opacities or staining. AC: Deep and clear, no cells or flare. Lens: Nuclear sclerosis grade 2+ bilaterally, no cortical or posterior subcapsular changes. Ophthalmoscopy Media: Clear, mild nuclear sclerosis noted. Fundus: Healthy appearance bilaterally. Vessels: Normal calibre and tortuosity, no haemorrhages or exudates. Macula: Clear, no drusen or signs of macular oedema. Disc: Pink and healthy, C/D ratio R: 0.4, L: 0.4, symmetrical, good neuro-retinal rim. No peripapillary atrophy. Dilation: Yes Visual Fields R: Full to confrontation L: Full to confrontation Final Prescription R: +0.75 / -0.25 x 180 Add +2.50 (DVA: 6/6, NVA: N5) L: +1.00 / -0.50 x 5 Add +2.50 (DVA: 6/7.5, NVA: N5) Comment Patient has early cataracts affecting visual acuity, particularly at near. Refraction shows a slight hyperopic shift. Mild blepharitis managed with lid hygiene. Intraocular pressures are within normal limits. Family history of glaucoma noted, will monitor closely. Action 1. Advised patient new distance and reading spectacles based on subjective refraction. 2. Recommended warm compresses and lid hygiene for blepharitis. 3. Discussed early cataract development and advised regular monitoring. 4. Provided information on glaucoma due to family history and importance of regular check-ups. 5. Eligible for NHS GOS3 voucher. Recall Advised for routine eye examination in 12 months, or sooner if symptoms worsen. Type of Examination NHS GOS1 Declaration I declare that I have personally carried out the sight test detailed above on 1 November 2024 and that in my professional opinion the test was necessary. I also declare that to the best of my knowledge and belief the patient meets the eligibility criteria for an NHS sight test. Optometrist Name: Dr. Thomas Kelly GOC Number: 012345