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 of disease or injury that may be associated with visual field defect or impaired muscle function. Unless medically contraindicated, the fundus must be examined with the claimant's pupils dilated. The examiner must identify the disease, injury, or other pathologic process responsible for any visual impairment found.

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. General eye symptoms, pain, redness, swelling, discharge, watering, etc.
2. Visual symptoms, including distorted or enlarged image, glare, blurring, haloes, floaters, photophobia, etc.
3. Current ophthalmic treatment, side effects. State whether continuous medication is required.
4. For neoplasms, state date of diagnosis, exact diagnosis, whether benign or malignant, types and dates of treatment, and date of last treatment.
5. History of hospitalization or surgery, dates and location if known, reason or type of surgery.
6. History of hospitalization or surgery, dates and location if known, reason or type of surgery.
7. For trauma, type of injury, cause, eye injured, and date.
8. Report any incapacitating episodes due to eye diseases such as angle-closure glaucoma, choroidopathy (including uveitis, iritis, cyclitis, and choroiditis), keratopathy, scleritis, retinopathy or maculopathy, intraocular hemorrhage, detachment of retina, or unhealed eye injury. List each incapacitating episode, if any, during the past 12-month period, its duration in days, and the cause of the episode of incapacitation. Note: An incapacitating episode is a period of acute symptoms severe enough to require bed rest and treatment by a physician or other healthcare provider.

C. Physical Examination (Objective Findings):

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

1. Visual Acuity:

1. Examination of visual acuity must include the central uncorrected and its equivalent corrected visual acuity for distance and near vision using Snellen's test type or its equivalent. Evaluate central visual acuity on the basis of corrected distance vision with central fixation, even if a central scotoma is present. Examine each eye independently and record the refractive information indicated below.
2. Use Snellen's test type or its equivalent for distance and revised Jaegar Standard or its equivalent for near.
3. Provided that he or she customarily wears contact lenses, determine the visual acuity of any individual affected by a corneal disorder that results in severe irregular astigmatism (including keratoconus) that can be improved more by contact lenses than by eyeglass lenses, as corrected by contact lenses.
4. 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.
5. Does the lens required to correct distance vision in the poorer eye differ by more than three diopters from the lens required to correct distance vision in the better eye? If so, explain the reason for the difference.
6. Is there a difference equal to two or more scheduled steps or lines of visual acuity between near and distance corrected vision for either eye, with the near vision being worse? If so, include at least two recordings of near and distance corrected vision and an explanation of the reason for the difference.

Right Eye		FAR	NEAR
Right Eye	Uncorrected
RIGHT EYE	CORRECTED

Left Eye		FAR	NEAR
LEFT EYE	Uncorrected
LEFT EYE	CORRECTED

2. Muscle function examination:

1. Use a Goldmann perimeter chart that identifies the four major quadrants (upward, downward, left and right lateral) and the central field (20 degrees or less) and chart the areas of diplopia. Include the plotted chart with the examination report. Indicate on the chart whether or not diplopia is present in the following areas:
   
   Central 20 degrees
   21 to 30 degrees
       Down
       Left lateral
       Right lateral
       Up
   31 to 40 degrees
       Down
       Left lateral
       Right lateral
       Up
   
   
2. State whether diplopia occurs occasionally or more than occasionally.
3. State whether or not diplopia is correctable with spectacles.

NOTE: Procedure for using Goldmann perimeter to assess diplopia field.

1. Both eyes are open and the device is centered between the eyes.
2. The patient's attention is directed towards a III/4e target while both eyes are open and fixating on the target.
3. The patient maintains attention to the target while it is moved. Areas of diplopia are identified on the VF paper.

3. Visual Field Examination:

1. Use either Goldmann kinetic perimetry or automated perimetry using Humphrey Model 750, Octopus Model 101, or later versions of these perimetric devices with simulated kinetic Goldmann testing capability.
2. For phakic (normal) individuals, as well as for pseudophakic or aphakic individuals who are well adapted to intraocular lens implant or contact lens correction, visual field examinations must be conducted using a standard target size and luminance, which is Goldmann's equivalent III/4e.
3. For aphakic individuals not well adapted to contact lens correction or pseudophakic individuals not well adapted to intraocular lens implant, visual field examinations must be conducted using Goldmann's equivalent IV/4e.
4. In all cases, record the results on a standard Goldmann chart, and include the Goldmann chart with the examination report. Chart at least 16 meridians 22½ degrees apart for each eye and indicate the Goldmann equivalent used.
5. If additional testing is necessary to evaluate visual fields, conduct the additional testing using either a tangent screen or a 30-degree threshold visual field with the Goldmann III stimulus size. Include the tracing of either the tangent screen or of the 30-degree threshold visual field with the Goldmann III stimulus size in the examination report.
6. Plot all scotomas carefully in order to allow measurements to be made for adjustments in the calculation of visual field defects.

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

5. If there is an enucleation, can a prosthesis be worn?

6. If nystagmus is present, state whether it is the central type.

7. Has a lens been removed? If so, state whether an intraocular lens replacement (implant) is present.

8. If chronic conjunctivitis is present, is it active (with objective findings, such as red, thick conjunctivae, mucous secretion, etc.) or inactive?

9. Report results of tonometry.

10. Report results of slit lamp biomicroscopic examination.

11. For ocular funduscopic retinal examination, report any abnormality of optic nerve, vessels, macula, etc.

12. Report any other abnormalities noted.

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. Describe the effects of the condition(s) on the veteran's usual occupation and daily activities.