| 
               Indication 
  
  
  • • •
  
 | 
          
            
               Indication comment 
  
  
  
  
 | 
          
          
| 
               OD 
  
  
  • • •
  
 | 
          
            
               OD comment 
  
  
  
  
 | 
          
          
| 
               OS 
  
  
  • • •
  
 | 
          
            
               OS comment 
  
  
  
  
 | 
          
          
| 
               Diagnosis 
  
  
  • • •
  
 | 
          
            
               Diag/Assess Comment 
  
  
  
  
 | 
          
          
| 
               Impact on decision 
  
  
  
  
 | 
          
            
               | 
          
          
