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Subjective
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How long eyelids/eyebrows been drooping?
• • •
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Comments
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Review of Symptoms
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Comments
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Exam
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Visual Acuity OD
• • •
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Visual Acuity OD
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Visual Acuity OS
• • •
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Visual Acuity OS
|
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Pinhole OD
• • •
|
Pinhole OD
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Pinhole OS
• • •
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Pinhole OS
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|
Motility OD
• • •
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Moility OD
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Motility OS
• • •
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Motility OS
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|
Confrontation Visual Field OD
• • •
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Confrontation Visual Field OD
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|
Confrontational Visual Field OS
• • •
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Confrontation Visual Field OS
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|
Pupil OD
• • •
|
Pupil OD
|
|
Pupil OS
• • •
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Pupil OS
|
|
Afferent Pupilary Defect
• • •
|
Afferent Pupillary Defect
|
|
IOP OD
|
IOP OS
|
|
IOP OS
|
IOP OD
|
|
Slit Lamp Exam
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|
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Anterior Segment Normal OD
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Anterior Segment Normal OS
|
|
Eyelid/lacrimal gland/adnexa OD
• • •
|
Eyelid/lacrimal gland/adnexa OS
• • •
|
|
Conjunctiva/Sclera OD
• • •
|
Conjunctiva/Sclera OS
• • •
|
|
Cornea OD
• • •
|
Cornea OS
• • •
|
|
Iris OD
• • •
|
Iris OS
• • •
|
|
Anterior Chamber OD
• • •
|
Anterior Chamber OS
• • •
|
|
Lens OD
• • •
|
Lens OS
• • •
|
|
Anterior Segment Drawing OD
|
Anterior Segment Drawing OS
|
|
Dilated Fundus Exam
|
|
|
Posterior Segment Normal OU
|
Dilated exam deferred
|
|
Optic Nerve OD
• • •
|
Optic Nerve OS
• • •
|
|
Cup to Disc Ratio OD
• • •
|
Cup to Disc Ratio OS
• • •
|
|
Macula OD
• • •
|
Macula OS
• • •
|
|
Vessels OD
• • •
|
Vessels OS
• • •
|
|
Periphery OD
• • •
|
Periphery OS
• • •
|
|
Vitreous OD
• • •
|
Vitreous OS
• • •
|
|
Retina OD
|
Retina OS
|
|
External Exam
|
|
|
Eyebrow - Right
• • •
|
Eyebrow - Right
|
|
Eyebrow - Left
• • •
|
Eyebrow - Left
|
|
Upper Eyelid Skin - Right
• • •
|
Upper Eyelid - Right
|
|
Upper Eyelid Skin - Left
• • •
|
Upper Eyelid - Left
|
|
Upper Eyelid Height - Right
• • •
|
Upper Eyelid - Right
|
|
Upper Eyelid Height - Left
• • •
|
Upper Eyelid - Left
|
|
Lower Eyelid - Right
• • •
|
Lower Eyelid - Right
|
|
Lower Eyelid - Left
• • •
|
Lower Eyelid - Left
|
|
Forehead - Right
• • •
|
Forehead - Right
|
|
Forehead - Left
• • •
|
Forehead - Left
|
|
Cheek - Right
• • •
|
Cheek - Right
|
|
Cheek - Left
• • •
|
Cheek - Left
|
|
Nose
• • •
|
Nose
|
|
Peri-oral - Right
• • •
|
Peri-oral - Right
|
|
Per-ioral - Left
• • •
|
Peri-oral - Left
|
|
Chin
• • •
|
Chin
|
|
Neck
• • •
|
Neck
|
|
Eyelid measurements
|
|
|
Marginal Reflex Distance - Right
• • •
|
Marginal Reflex Distance - Left
• • •
|
|
Levator Function - Right
• • •
|
Levator Function - Left
• • •
|
|
Assessment
|
|
|
Diagnosis
|
|
|
Brow Ptosis
• • •
|
Brow Ptosis
|
|
Dermatochalasis Upper Eyelids
• • •
|
Dermatochalasis Upper Eyelids
|
|
Myogenic Ptosis
• • •
|
Myogenic Ptosis
|
|
Lower Eyelids
• • •
|
Lower Eyelids
|
|
Neck/Face
• • •
|
Neck/Face
|
|
Plan
|
|
|
Recommendation
• • •
|
Recommendation Continued
• • •
|
|
Further Recomendations
• • •
|
Comments
|
