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Anatomy  •  Exam  •  Refraction  •  Gonioscopy  •  Alignment  •  External
Diagnosis/Findings  •  Tests  •  Procedures/Lasers Etc.  •  Others

ANATOMY
OU both eyes
OD right eye
OS left eye
IO inferior oblique
SO superior oblique
MR medial rectus
SR superior rectus
LR lateral rectus
IR inferior
CB ciliary body

EXAM
Va visual acuity
cc with refractive correction
sc without refractive correction
PH pinhole visual acuity
PHNI pinhole no improvement
NI no improvement
CF @ XX ft counts fingers (specify distance)
HM @ XX ft hand motion (specify distance)
LP light perception
LP c projection light perception with projection
LP s projection light perception without projection
NLP no light perception
CSM central, steady, maintained
F+F fixes and follows
BCVA best corrected visual acuity

REFRACTION
WRx wearing Rx (currently worn eyeglass/contact lens prescription)
ARx autorefraction
MRx manifest refraction
CRx cycloplegic refraction
NRx near refraction
Add amount of plus reading power (for bifocal/progressives)
R retinoscopy
Rc cycloplegic retinoscopy
Sph sphere
Cyl cylinder
Ax axis
[+/- number sphere] + [number cylinder] x [0-180 axis]
PD Pupillary distance or prism diopter
Δ prism diopter

GONIOSCOPY
CBB ciliary body band
SS scleral spur
TM trabecular meshwork
SL Schwalbe’s line
PAS peripheral anterior synechiae
NVA neovascularization of the angle
EOM extraocular muscles/movement

ALIGNMENT
E esophoria
ET esotropia
E(T) intermittent esotropia
X exophoria
XT exotropia
X(T) intermittent exotropia
HT hypertropia
HoT hypotropia

EXTERNAL
MRD1 margin to reflex distance 1
MRD2 margin to reflex distance 2
LF levator function
PF palpebral fissure
Lag lid lag
APD, RAPD afferent papillary defect, relative afferent papillary defect APD by reverse testing/consensual response
CVF confrontation visual fields
IOP intraocular pressure
T tonometry
Ta applanation (Goldmann) tonometry
Tp pneumotonometer
CCT/Pachy central corneal thickness/pachymetry
SLE slit lamp exam
L/L lids/lashes
C/S conjunctiva/sclera
K cornea
A/C or AC anterior chamber
K deep and quiet
C/F cell/flare (graded 1+ to 4+)
I iris
R/R round/reactive
PS posterior synechiae (designate location/clock hours)
NVI neovascularization of the iris
L lens
ACIOL anterior chamber intraocular lens
PCIOL posterior chamber
AV anterior vitreous
DFE dilated fundus exam
UDFE undilated fundus exam
C/D cup/disc ratio
D/M/V/P disc/macula/vessels/periphery
RPE retinal pigment epithelium

DIAGNOSIS/FINDINGS
Lids
MGD meibomian gland dysfunction
MGP meibomian gland plugging
   
Cornea
PEE punctate epithelial erosion
PEK punctate epithelial keratopathy/keratitis
SPK superficial punctate keratopathy/keratitis
SLK superior limbic keratoconjunctivitis
BK band keratopathy
ED epithelial defect
DF Descemet’s fold
KP keratic precipitate
PK penetrating keratoplasty
EKC epidemic keratoconjunctivitis
KCS keratoconjunctivitis sicca
PBK pseudophakic bullous keratopathy
IK interstitial keratitis
KC or KCN keratoconus
   
Glaucoma
POAG/OAG primary open angle glaucoma/open angle glaucoma
COAG chronic open angle glaucoma
JOAG juvenile open angle glaucoma
SOAG secondary open angle glaucoma
NVG neovascular glaucoma
ACG angle closure glaucoma
NTG/LTG normal/low tension glaucoma
OHT ocular hypertension
UGH uveitis glaucoma hyphema syndrome
PXF pseudoexfoliation
   
Lens
ACC anterior cortical changes/cataract
NS nuclear sclerosis
PCC posterior cortical changes
PSC posterior subcapsular cataract
PCO posterior capsular opacity (post-cataract patients)
   
Retina
CWS cotton wool spot
DBH dot blot heme (hemorrhage)
BRVO branch retinal vein occlusion
CRVO central retinal vein occlusion
BRAO branch retinal artery occlusion
CRAO central retinal artery occlusion
BDR background diabetic retinopathy
NPDR non-proliferative diabetic retinopathy
PDR proliferative diabetic retinopathy
PVD posterior vitreous detachment
NVD neovascularization of the disc
NVE neovascularization elsewhere
CSME clinically significant macular edema (for diabetes)
CME cystoid macular edema
IRMA intraretinal microvascular anomalies
ERM epiretinal membrane
RD retinal detachment
TRD tractional detachment
VMT vitreomacular traction
VH vitreous hemorrhage
IRMA intraretinal microvascular anomalies
AMD/ARMD age-related macular degeneration
CNV choroidal neovascularization
SRNV subretinal neovascularization
CNVM choroidal neovascular membrane
SRNVM subretinal neovascular membrane
POHS presumed ocular histoplasmosis
CSCR central serous chorioretinopathy
RP retinitis pigmentosa
   
Nerve/Neuro
PPA peripapillary atrophy
ION ischemic optic neuropathy
AION anterior ischemic optic neuropathy
PION posterior ischemic optic neuropathy
NAION nonarteritic ischemic optic neuropathy
TON traumatic optic neuropathy
MG myasthenia gravis
MS multiple sclerosis
LHON Leber’s hereditary optic neuropathy
LCA Leber’s congenital amaurosis
GCA Giant cell arteritis
PXE pseudoxanthoma elasticum

TESTS
VF Visual field
HVF Humphrey visual field (usually 30-2; need to specify if 10-2 or red target, etc)
GVF Goldmann visual field
FANG fluorescein angiography
OCT optical coherence tomography
OCT NFL OCT of nerve fiber layer (optic nerve evaluation)
ERG electroretinogram
EOG electrooculogram

PROCEDURES/LASERS ETC.
CE cataract extraction
ECCE extracapsular cataract extraction
ICCE intracapsular cataract extraction
Phaco phacoemulsification
Phaco/ACIOL or Phaco/PCIOL phaco with anterior chamber intraocular lens or posterior chamber intraocular lens
   
Cornea
PKP penetrating keratoplasty
LASIK laser in situ keratomileusis, also laser-assisted in situ keratomileusis
LASEK laser epithelial keratomileusis
PRK photorefractive keratectomy
DALK deep anterior lamellar keratoplasty
DLK diffuse lamellar keratitis
   
Glaucoma
ALT argon laser trabeculoplasty
SLT selective laser trabeculoplasty
LI/LPI laser iridotomy/laser peripheral iridotomy
CPC cyclophotocoagulation
Trab trabeculectomy
Cryo cryotherapy
AVx anterior vitrectomy
   
Retina
PRP pan-retinal photocoagulation
Focal focal laser photocoagulation
PDT photodynamic therapy
PPV/Vx  pars plana vitrectomy/vitrectomy
MP/Mx membrane peel/membranectomy
SB  scleral buckle
   
Drops/Meds Dilators (red top)
M1 Mydriacyl (tropicamide) 1%
N2.5/N10 Neo-Synephrine (phenylephrine) 2.5% or 10%
CM Cyclomydril (for peds patients)
C1 Cyclogyl (cyclopentolate) 1%
HA homatropine
A1% atropine 1%
AT, PFAT artificial tears, preservative-free artificial tears
WC/LS warm compresses/lid scrubs

OTHERS
CL/SCL/HCL contact lens/ soft contact lens/ Hard contact lens
   
 
© 2008 Bryan Kim, MD. University of Illinois at Chicago