Optometrist's Note

Date of Examination: 1 November 2024 - Issued prescription for glasses OD Sphere -2.50, Cylinder -0.75, Axis 180, Distance Prism 0, VA 6/6, Near Add +1.50, Near Prism 0, Near VA N5, OS Sphere -2.75, Cylinder -1.00, Axis 10, Distance Prism 0, VA 6/6, Near Add +1.50, Near Prism 0, Near VA N5 - Dispensing recommendations Dispensing recommendations discussed including progressives with anti-reflective coating, 1.67 high-index lens material. - Treatments: Advised lubricating eye drops (Hylo-Fresh) three times daily for mild dry eye symptoms. - Follow-Up: Routine follow-up in 12 months, or sooner if symptoms worsen or vision changes. - Patient Education: Provided information on proper contact lens hygiene, discussed symptoms of presbyopia, and recommended annual eye examinations. - Referrals: No referrals made at this time. -Current Glasses OD: -2.00 / -0.50 x 170, OS: -2.25 / -0.75 x 5. Information obtained from previous records and focimetry. Subjective: - Chief Complaint: Patient reports blurred vision for both distance and near, particularly struggling with reading small print and driving at night. Also notes occasional eye strain. - History of Present Illness: Symptoms have been gradually worsening over the past 6 months. No sudden changes, pain, or flashes/floaters. Eye strain is worse after prolonged computer use. - Past Ocular History: History of myopia since childhood, corrected with spectacles. No history of ocular surgeries, trauma, or significant eye conditions. Diagnosed with mild dry eye 2 years ago, managed with over-the-counter drops. - Medical History: Diagnosed with controlled hypertension, managed with daily medication. No history of diabetes or other systemic conditions affecting ocular health. - Medication History: Lisinopril 10mg daily for hypertension. Uses occasional artificial tears for dry eye. No ocular specific medications. - Allergies: Penicillin (rash). No known ocular medication allergies. - Family Ocular History: Mother has glaucoma. Father has presbyopia and cataracts. - Social History: Non-smoker, rarely consumes alcohol. Works as an accountant, spending 8+ hours daily on a computer. Enjoys reading in free time. - Other information Patient expressed concern about developing glaucoma due to maternal history. Objective: - Vision: Unaided visual acuity OD: 6/24, OS: 6/30 - Pinhole Vision: Pinhole visual acuity OD: 6/12, OS: 6/15 - Visual Acuity: Visual acuity with current glasses OD: 6/9, OS: 6/12 - Retinoscopy: OD: -2.50 / -0.75 x 180, OS: -2.75 / -1.00 x 10 - Intraocular Pressure: Goldmann applanation tonometry: OD 16 mmHg, OS 17 mmHg. Within normal limits. Anterior Segment: - Lids and lashes: OU: Clear, no discharge or inflammation. - Cornea: OU: Clear, no staining or infiltrates. - Anterior Chamber: OU: Deep and quiet. No cells or flare. - Pupil Reactions: OU: Pupils equal, round, and reactive to light and accommodation (PERRLA). -Media: OU: Clear vitreous, no significant floaters or Shafer’s sign. -Lens: OU: Early nuclear sclerosis noted, consistent with age-related changes, no significant opacification affecting vision. Posterior Segment: - Macula: OU: Healthy macula, flat, no drusen or oedema. - Peripheral retina: OU: Attached, no tears, holes, or detachments noted. - Optic Discs: OU: Pink and healthy, C/D ratio 0.3, sharp margins. No notching or haemorrhage. - Retinal Vessels: OU: Normal calibre and tortuosity, A/V ratio 2:3. No signs of retinopathy. Fundus examination performed with direct and indirect ophthalmoscopy after dilation with Tropicamide 1%. - Additional Tests: No additional tests performed today. Assessment: - Binocular Refraction: Orthophoric at distance and near, good motility, no suppression detected. - Foveal Suppression: No foveal suppression noted. - Refraction Notes: Subjective refraction yielded improved acuity and comfort compared to current correction. Patient reports clear vision with new prescription. - Myopia (H52.1), Presbyopia (H52.4), Mild Dry Eye Syndrome (H04.12), Early Age-Related Cataract (H25.0) - Differential: Glaucoma (ruled out by normal IOP and healthy optic discs), Diabetic Retinopathy (ruled out by medical history and fundus exam).