Optometry Consultation Note

Optometry Consultation Note History and Symptoms Reason for visit: Routine eye examination and concern regarding occasional blurry vision, especially at night. History: * Myopia diagnosed at age 12, corrected with glasses. * No history of eye injuries or surgeries. * Occasional dry eyes, managed with over-the-counter lubricating drops. Symptoms: * Intermittent blurry vision, worse in low light. * Mild eye strain after prolonged computer use. * No pain, redness, or discharge. General health: Patient reports good general health. No known systemic conditions such as diabetes or hypertension. Previous ocular history: * Annual eye exams since age 12. * No history of glaucoma, cataracts, or retinal detachment. Family ocular history: * Mother has presbyopia. * Father has myopia. Medication: * Multivitamin once daily. * Artificial tears as needed. Allergies: * Penicillin (rash). Smoker: No Driver: Yes Occupation: Graphic Designer Supplementary Tests Pupil size: R: 3mm L: 3mm Pachymetry: R: 540 microns L: 538 microns Stereopsis: 40 seconds of arc Pupillary reflexes: PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation) Colour vision: Normal (Ishihara plates) Visual fields: Full to confrontation Amsler grid: No distortion reported External Examination Lids/lashes: Clear, no redness or discharge. Tear film: Stable, mild reduced tear break-up time. Cornea: R: Clear L: Clear Conjunctiva: Clear and white, no injection. Anterior chamber: Deep and clear bilaterally. Iris: R: Blue, flat, good pupillary margin L: Blue, flat, good pupillary margin General notes: R: No abnormalities noted L: No abnormalities noted Internal Examination Method: Direct and indirect ophthalmoscopy Dilation: Tropicamide 1% OU Media: R: Clear L: Clear Vitreous: R: Clear, no PVD L: Clear, no PVD Optic disc: R: Pink, distinct margins, CD ratio 0.3 L: Pink, distinct margins, CD ratio 0.3 Vessels: R: Normal calibre, no haemorrhages or exudates L: Normal calibre, no haemorrhages or exudates General notes: Retina appears healthy in all quadrants, no peripheral retinal degenerations or tears observed. Pressures: Today: OD: 14 mmHg, OS: 15 mmHg at 14:30 (Goldmann Applanation Tonometry) Advice / Plan Assessment: Myopia with mild astigmatism, stable. Presbyopia onset. Mild dry eye syndrome. Spectacles: Recommend new spectacle prescription for distance vision with progressive addition lenses to address presbyopia and reduce eye strain during near tasks. Patient advised to wear glasses for driving and computer work. Management Plan: 1. Prescribe new spectacle correction: OD -3.00 DS / -0.50 Cyl x 180, OS -3.25 DS / -0.25 Cyl x 175. Add +1.00 OU. 2. Recommend continued use of artificial tears for dry eye symptoms. 3. Advise regular breaks during screen time (20-20-20 rule). 4. Discuss importance of good lighting for reading and near work. Recall Interval: 1 November 2025