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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
• • •
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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
• • •
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Pupil OD
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Pupil OS
• • •
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Pupil OS
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Afferent Pupilary Defect
• • •
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Afferent Pupillary Defect
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IOP OD
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IOP OS
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IOP OS
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IOP OD
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Slit Lamp Exam
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Anterior Segment Normal OD
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Anterior Segment Normal OS
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Eyelid/lacrimal gland/adnexa OD
• • •
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Eyelid/lacrimal gland/adnexa OS
• • •
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Conjunctiva/Sclera OD
• • •
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Conjunctiva/Sclera OS
• • •
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Cornea OD
• • •
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Cornea OS
• • •
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Iris OD
• • •
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Iris OS
• • •
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Anterior Chamber OD
• • •
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Anterior Chamber OS
• • •
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Lens OD
• • •
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Lens OS
• • •
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Anterior Segment Drawing OD
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Anterior Segment Drawing OS
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Dilated Fundus Exam
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Posterior Segment Normal OU
|
Dilated exam deferred
|
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Optic Nerve OD
• • •
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Optic Nerve OS
• • •
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Cup to Disc Ratio OD
• • •
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Cup to Disc Ratio OS
• • •
|
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Macula OD
• • •
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Macula OS
• • •
|
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Vessels OD
• • •
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Vessels OS
• • •
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Periphery OD
• • •
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Periphery OS
• • •
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Vitreous OD
• • •
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Vitreous OS
• • •
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Retina OD
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Retina OS
|
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External Exam
|
|
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Eyebrow - Right
• • •
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Eyebrow - Right
|
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Eyebrow - Left
• • •
|
Eyebrow - Left
|
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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
• • •
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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
• • •
|
|
VSD RUL
|
VSD LUL
|
|
Lagophthalmos OD
|
Lagophthalmos OS
|
|
Epiphora evaluation
|
|
|
Lacrimal Evaluation for Epiphora
|
|
|
Normal RLL
|
Normal LLL
|
|
Findings: RLL Puncta
|
Assessment
|
|
Findings: LLL Puncta
|
Assessment
|
|
Nasal Endoscopy performed
|
|
|
Findings:
|
|
|
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
|
