Eye

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

Narrative: An eye examination must be conducted by a licensed optometrist or ophthalmologist. Examinations for the evaluation of visual fields or muscle function will be conducted only when there is a medical indication.

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. General eye symptoms, pain, redness, swelling, discharge, watering, etc.
2. Duration and frequency of periods of incapacitation, and rest requirements.
3. Visual symptoms, including distorted or enlarged image, etc.
4. Current ophthalmologic treatment, side effects.
5. For neoplasms, state date of diagnosis, diagnosis, benign or malignant, type of treatment and last date of treatment.
6. History of hospitalization or surgery, dates and location if known, reason or type of surgery.
7. For trauma, type and date.
8. For congestive or inflammatory glaucoma, duration and frequency of attacks.

C. Physical Examination (Objective Findings):

Address each of the following, as applicable, and fully describe current findings:

1. Visual Acuity:

1. Examine each eye independently and record the refractive information indicated below.
2. Use conventional lenses for correction unless the patient has keratoconus, is well adapted to contact lenses and wishes to wear them, and contact lenses result in best corrected visual acuity. In that case, use contact lenses to determine best corrected visual acuity.
3. Use Snellen's test type or its equivalent for distance and revised Jaegar Standard or its equivalent for near.
4. Carry out an examination with the pupils dilated unless contraindicated, and record the ophthalmic findings.
5. For visual acuity worse than 5/200 in either or both eyes, report the distance in feet/inches (or meters/centimeters) from the face at which the veteran can count fingers/detect hand motion/read the largest line on the chart. If the veteran cannot detect hand motion or count fingers at any distance, state whether he or she has light perception.
6. If keratoconus is present, state whether contact lenses are required or adequate correction is possible by other means.

Right Eye		FAR	NEAR
Right Eye	Uncorrected
RIGHT EYE	CORRECTED

Left Eye		FAR	NEAR
LEFT EYE	Uncorrected
LEFT EYE	CORRECTED

2. Diplopia:

1. Perform the measurement of muscle function using a Goldmann Perimeter Chart and chart the areas in which diplopia exists. Include the chart as part of the examination report to be sent to the regional office.
2. If diplopia is present, state whether it is constant or intermittent, whether it is present at all distances or only for near or distant vision, and whether it is correctable by use of lenses or prisms.
3. If diplopia is constant and not correctable, indicate which sectors of the visual field are affected and provide the Goldmann perimeter chart showing the actual areas of diplopia, according to the format below. Diplopia outside these areas should also be reported even though it is not considered disabling because it may be used in the evaluation of the underlying disease or injury.

Diplopia			Amount
Central 20 Degrees
21 TO 30 Degrees
	DOWN
		Right Lateral
		Left Lateral
	UP
		Right Lateral
		Left Lateral
31 TO 40 Degrees
	DOWN
		Right Lateral
		Left Lateral
	UP
		Right Lateral
		Left Lateral

3. Visual Field Deficit:

1. Chart any visual field defect using a Goldmann Perimeter Chart and include the chart as part of the examination report to be sent to the regional office.
2. For an aphakic eye which cannot be fitted with contact lenses or intra-ocular implant, use the IV/4e test object. For all other cases, use the III/4e test object.
3. If the examiner determines that charting with other test objects is indicated, those test results should be reported on a separate chart. All charts, along with an explanation of the need for using a different test object and an explanation of any discrepancies in results, should be included as part of the examination report.
4. All scotomas should be plotted carefully in order to allow measurements to be made for adjustments in the calculation of visual field defects.

4. Details of eye disease or injury (including eyebrows, eyelashes, eyelids, lacrimal duct) other than loss of visual acuity, diplopia, or visual field defect.

5. Enucleation, Is prosthesis possible?

6. Record results of any other examination findings including tonometry, funduscopic, slit lamp.

D. Diagnostic and Clinical Tests: (Other than for visual acuity, diplopia, and visual fields, as described above.)

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. For nystagmus, provide type.