Re: First Name Last Name
Date of Exam: MM/DD/YYYY

Dear Dr. XX:

I had the pleasure of seeing (XX) for retinal evaluation on MM/DD/YYYY. She is a pleasant (XX)-year-old who was poked in the eye 1 week ago. Several days after getting poked in the eye, she started noticing flashes and floaters. You had referred her for evaluation and management.

Clinical Findings:
Visual acuity, uncorrected, is 20/25 OU.

Intraocular pressure is 14 mmHg OU.

Anterior segment examination is unremarkable. There are no obvious puncture sites.

Dilated funduscopic examination of the right eye reveals macula, vessels, and periphery. There is no PVD or peripheral retinal pathology.

Examination of the left eye reveals a complete PVD. There are no events of any peripheral retinal pathology on careful scleral depression. The macula and vessels are within normal limits.

Assessment and Plan:
Acute posterior vitreous detachment, left eye. I do not see any evidence of any puncture sites related to the needle stick. I also do not see any evidence of any retinal tears, holes or detachments. We did review signs and symptoms of retinal tears and detachment, and I have asked her to call me immediately if she does notice any changes. I have asked her to return in 2 weeks for close followup.

Thank you very much for allowing me to share in the care of this very pleasant patient. Please feel free to call me at your convenience for any questions.

Sincerely,

Ophthalmological Letter Sample Report #2

Re: First Name Last Name
Date of Exam: MM/DD/YYYY

Dear Dr. XX:

I had the pleasure of seeing Mr. (XX) on followup today on MM/DD/YYYY. He is a pleasant (XX)-year-old with a history of retinal tear, status post laser in the past. He reports stable vision. He is still noticing floaters.

Clinical Findings:
Visual acuity with correction is 20/70, pinhole 20/60 OD, 20/40 OS.

Intraocular pressure is 20 mmHg OD, 19 mmHg OS.

Anterior segment examination reveals 1-2+ NS, OU.

Dilated funduscopic examination reveals peripheral laser retinopexy OU. There are no new retinal tears, holes or detachments.

Assessment and Plan:
Retinal tear, status post laser retinopexy in the past, both eyes. I do not see any evidence of any new retinal tears, holes or detachments. We did review signs and symptoms of these, and I have asked him to call me immediately if he does notice any changes. I have asked him to return in 1 year for followup.

Sincerely,

Ophthalmological Letter Sample Report #3

Re: First Name Last Name
Date of Exam: MM/DD/YYYY

Dear Dr. XX:

I had the pleasure of seeing Ms. (XX) in followup today on MM/DD/YYYY. She is a pleasant (XX)-year-old with a history of moderate dry macular degeneration. She reports some slight blurring of vision at near.

Clinical Findings:
Visual acuity, uncorrected, is 20/30-2 OD, 20/50 pinhole, 20/40 OS.

Intraocular pressure is 19 mmHg OU.

Anterior segment examination reveals 2+ NS, OD and a PCIOL OS.

Dilated funduscopic examination reveals macular drusen, OU. There is a large drusenoid pigment epithelial detachment in the left eye. There is no evidence of any macular edema, hemorrhage or subretinal fluid.

Assessment and Plan:
Moderate dry macular degeneration, both eyes, with drusenoid pigment epithelial detachment, left eye. Ms. (XX) appears stable from a retinal standpoint. I do not see any evidence of choroidal neovascularization, macular edema or hemorrhage. We did review signs and symptoms of these, and she does know to call immediately if she does have any distortion or vision changes. I have asked her to return in 6 months for a followup but to contact me immediately with any changes.

Sincerely,

Ophthalmological Letter Sample Report #4

Re: First Name Last Name
Date of Exam: MM/DD/YYYY

Dear Dr. XX:

I had the pleasure of seeing Mr. (XX) for retinal consultation on MM/DD/YYYY. He is a pleasant (XX)-year-old who has been noting floaters in his left eye for the last month. You had referred him for evaluation and management.

Clinical Findings:
Visual acuity with correction is 20/25 OD, 20/30 OS.

Intraocular pressure is 16 mmHg OD, 14 mmHg OS.

Anterior segment examination is unremarkable.

Dilated funduscopic examination of the right eye reveals normal macula, vessels, and periphery.

Examination of the left eye reveals a complete PVD. There are 2 small horseshoe-shaped tears inferonasally and 1 small horseshoe-shaped tear superotemporally. There is a pigmented tear temporally. There is no significant subretinal fluid.

Assessment and Plan:
Acute posterior vitreous detachment with retinal tears, left eye. We discussed treatment options, and I recommended proceeding with laser retinopexy to the tears. This will be scheduled for him first thing tomorrow morning. We will monitor him closely post laser.

Sincerely,

Ophthalmological Letter Sample Report #5

Re: First Name Last Name
Date of Exam: MM/DD/YYYY

Dear Dr. XX:

I had the pleasure of seeing Ms. (XX) in followup today. She is a pleasant (XX)-year-old with a history of a branch retinal vein occlusion in the left eye. She reports stable vision.

Of note, she was switched from Combigan to Travatan recently.

Clinical Findings:
Visual acuity with correction is 20/40 OD, 20/30 OS.

Intraocular pressure is 14 mmHg OU.

Anterior segment examination reveals 1+ NS, OU.

Dilated funduscopic examination reveals a cup-to-disc ratio of 0.8 OU. In the right eye, the macula, vessels, and periphery are within normal limits. In the left eye, there are intraretinal hemorrhages and telangiectasias in the superotemporal macula. There is no macular edema or neovascularization.

Fluorescein angiography did reveal areas of capillary nonperfusion but no significant macular edema or neovascularization.

Assessment:
1. Branch retinal vein occlusion, left eye.
2. Retinal ischemia, left eye.

Plan:
Ms. (XX) is stable from a retinal standpoint. I do not see any evidence of any macular edema or neovascularization. We did discuss that Travatan does have a small risk of macular edema, so we will monitor for this. I have asked her to return in 6 months or sooner if symptoms warrant.

Sincerely,

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PREOPERATIVE DIAGNOSIS: Band keratopathy, right eye.

POSTOPERATIVE DIAGNOSIS: Band keratopathy, right eye.

PROCEDURE PERFORMED: EDTA chelation of right eye.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: Monitored anesthesia care and topical.

COMPLICATIONS: None.

BLOOD LOSS: None.

SPECIMENS: None.

INDICATIONS FOR PROCEDURE: This is a (XX)-year-old Hispanic female with progressive visual loss in her right eye secondary to band keratopathy.

DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was brought back to the operating room in the supine position. A drop of tetracaine was placed in the right eye. The right eye was prepped and draped in the usual sterile fashion for a procedure of the right eye.

A lid speculum was then placed in the right eye. A crescent blade was then used to remove the epithelium over the band keratopathy in the right eye. A 3 mL syringe with a polishing tip was then used with EDTA to polish and gently remove the band keratopathy. EDTA was used in a concentration of 4:1. Then, 4 mL of EDTA and 16 mL of sterile preservative-free BSS were mixed prior to the procedure. The EDTA with polishing was used until all of the band keratopathy was removed. The area was inspected and found to be in good condition with mild corneal edema and epithelial basement membrane irregularly from the band keratopathy.

The area was then rinsed thoroughly with BSS. A drop of Vigamox and Voltaren were placed in the eye. The lid speculum was removed. An 8.4 Night & Day bandage contact lens was placed in the eye. The area was cleaned, and an eye shield was placed over the eye. The patient left the operating room in good condition.

The patient was instructed to return the following day for a postoperative check in the eye clinic. She was given her three drops, including Pred Forte, Vigamox, and Voltaren and instructed to use them four times a day.

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OBJECTIVE:  Visual acuity, uncorrected, is 20/30-2 OD, 20/50 pinhole, 20/40 OS. Intraocular pressure is 19 mmHg OU. Anterior segment examination shows 2+ NS, OD and a PCIOL OS. Dilated funduscopic examination reveals macular drusen, OU. There is a large drusenoid pigment epithelial detachment in the left eye. There is no evidence of any macular edema, hemorrhage or subretinal fluid.

ASSESSMENT AND PLAN:  Moderate dry macular degeneration, both eyes, with drusenoid pigment epithelial detachment, left eye. The patient appears stable from a retinal standpoint. We do not see any evidence of choroidal neovascularization, macular edema or hemorrhage. We did review signs and symptoms of these, and she does know to call immediately if she does have any distortion or vision changes. We have asked her to return in six months for a followup.

Ophthalmology SOAP Note Sample #2

SUBJECTIVE:  The patient is a pleasant (XX)-year-old who has experienced blurry vision in both eyes, left eye greater than the right eye, for the last several months. Her past ocular history is significant for dry macular degeneration and history of cataract surgeries in both eyes. The patient has also been treated for ocular hypertension.

OBJECTIVE:  On examination, the patient’s vision is 20/40 in the right eye and 20/30 in the left eye. Anterior segment examination reveals posterior chamber intraocular lenses in both eyes. Intraocular pressures are 20 in each eye. Fundus examination of the right eye shows the retina to be attached 360 degrees without any tears or holes. There are drusen in the macula. There is a small pocket of subretinal fluid temporal to the optic disc, not involving the fovea. There is no cystoid macular edema present. There is no retinal hemorrhage or lipid exudation present. Fundus examination of the left eye shows the retina to be attached 360 degrees without any tears or holes. There is a flat choroidal nevus inferotemporally. There are RPE changes and drusen in the macula and temporal to the optic disc. There are two distinct pockets of subretinal fluid, one involving the inferior macula and the other one in a juxtapapillary position involving the superonasal portion of the macula. There is no retinal hemorrhage present. There is no cystoid macular edema or lipid exudation present. Fluorescein angiography reveals focal areas of leakage in both eyes consistent with central serous retinopathy. ICG videoangiography shows enlarged and hyperpermeable choroidal vessels in both eyes consistent with central serous retinopathy. There is no tuft of neovascularization noted per ICG angiography.

ASSESSMENT AND PLAN:  The patient has pockets of subretinal fluid with pinpoint areas of leakage in both eyes and ICG angiographic pattern consistent with central serous retinopathy. The patient informed us that she is taking Advair for her asthma. Steroid products have been associated with CSR. We asked her to follow up with her primary care physician in order to see whether she could be on a nonsteroidal medicine. We plan to see her back in one month for reevaluation.

Ophthalmology SOAP Note Sample #3

SUBJECTIVE:  The patient is a pleasant (XX)-year-old who was noted to have choroidal nevus in her right eye and is here today for further evaluation. She has not experienced loss of vision or distortion.

OBJECTIVE:  On examination, her vision is 20/20 in both eyes. Pressures are 15 in each eye. Fundus examination of the right eye reveals an approximately 1 mm flat choroidal nevus temporal to the optic disc. There is no orange pigment or subretinal fluid present. Fundus examination of the left eye shows the retina to be attached 360 degrees without any tears or holes.

ASSESSMENT AND PLAN:  The patient has a flat choroidal nevus in her right eye. We reassured her that we do not see any high-risk features. At this point, we recommend annual monitoring. Baseline fundus photographs were obtained today.

Ophthalmology SOAP Note Sample #4

SUBJECTIVE:  The patient was seen for followup examination. We have been following this patient for epiretinal membrane in his left eye and retinal microaneurysms and hemorrhages in both eyes. We initiated systemic workup, including hemoglobin A1c. The patient’s hemoglobin A1c level came back borderline high. The patient states that his vision has been stable.

OBJECTIVE:  On examination, the patient’s vision is 20/60 in the right eye and 20/40 in the left eye. Anterior segment examination reveals posterior chamber intraocular lenses in both eyes. The intraocular pressures are 16 in each eye. Fundus examination showed scattered microaneurysms and intraretinal hemorrhages. There is a stable epiretinal membrane in the left eye. OCT examination showed epiretinal membrane with mild macular edema in the left eye.

ASSESSMENT AND PLAN:
1.  Retinal microaneurysms and hemorrhages: The patient’s hemoglobin A1c was borderline high. We asked him to follow up with his primary care physician to be evaluated further for diabetes. We plan to see him back in three months for reevaluation.
2.  Epiretinal membranes in the left eye: This appears to be stable. We asked him to continue Acular eye drops three times a day in that eye.

Ophthalmology SOAP Note Sample #5

SUBJECTIVE:  The patient was seen for followup examination. The patient has been followed for proliferative diabetic retinopathy and epiretinal membrane. The patient states that her blood sugar is under good control, and she has not noted any loss of vision.

OBJECTIVE:  On examination, the patient’s vision was 20/25 in the right eye and 20/30 in the left eye. Intraocular pressures were 16 in the right and 17 in the left. There was no neovascularization of iris. Fundus examination showed PRP laser in both eyes. There was no clinically significant macular edema present. There was epiretinal membrane present in both eyes. OCT examination of the right eye showed no macular edema. OCT examination of the left eye showed less macular edema.

ASSESSMENT AND PLAN:  We reassured the patient that she is stable from a retinal standpoint. We asked her to stop Acular eye drops in her right eye and continue Acular in her left eye once a day. We also asked her to continue good control of her blood sugar levels.

Ophthalmology SOAP Note Sample #6

SUBJECTIVE:  The patient was seen for followup examination. We have been following him for nonproliferative diabetic retinopathy. He states that his blood sugar is under good control and has not experienced loss of vision.

OBJECTIVE:  On examination, the patient’s vision is 20/20 in both eyes. Anterior segment examination is unremarkable. Fundus examination shows scattered dot-blot hemorrhages and microaneurysms in both eyes. There is no clinically significant macular edema in both eyes. There is no neovascularization process present in either eye. OCT examination confirms a lack of macular edema in both eyes. Fluorescein angiography shows microaneurysms with minimal leakage without any neovascularization process in either eye.

ASSESSMENT AND PLAN:  The patient has mild to moderate nonproliferative diabetic retinopathy. We asked him to continue good control of his blood sugar and pressure levels. We will continue regular monitoring.

Ophthalmology SOAP Note Sample #7

SUBJECTIVE:  The patient was seen for followup examination. We have been following her for epiretinal membrane in her right eye and extramacular drusen in both eyes. She states that her vision has been stable.

OBJECTIVE:  On examination, the patient’s vision is 20/25 in the right eye and 20/20 in the left eye. Anterior segment examination shows age-appropriate nuclear sclerotic changes in both eyes. Intraocular pressures are 16 in each eye. Fundus examination shows the retina to be attached 360 degrees without any tears or holes. There are peripheral and extramacular drusen in both eyes. There is no subretinal fluid or hemorrhage present. There is a mild and a stable epiretinal membrane in the right eye. OCT examination shows no subretinal fluid or macular edema in both eyes. There is a stable epiretinal membrane in the right eye.

ASSESSMENT AND PLAN:  The patient is very stable from a retinal standpoint. We reassured her of these findings. At this point, we recommend annual monitoring.

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PREOPERATIVE DIAGNOSIS:  Cyst of iris and ciliary body, right eye, rule out neoplastic component.

POSTOPERATIVE DIAGNOSIS:  Cyst of iris and ciliary body, right eye, rule out neoplastic component.

OPERATION PERFORMED:
1.  Aspiration of iridociliary cyst, right eye.
2.  Transscleral cryotherapy of partially collapsed cyst of iris and ciliary body, right eye.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and was positioned on the operating table. Cardiac and blood pressure monitoring devices were applied. General inhalational anesthesia was induced without complications. The patient was prepped and draped in the usual fashion for a procedure of the right eye.

A lid speculum was inserted between the lids of the eye to expose the eye. A curved conjunctival incision was created from a position at the limbus in the 9 o’clock meridian, curving toward the fornix in the superotemporal quadrant and returning to the limbus in the 12 o’clock meridian. The subconjunctival connective tissues were dissected from this conjunctival incision toward the limbus in the superotemporal quadrant until the entire limbal region had been uncovered. Transcorneal transillumination was then performed to cast a glow on the sclera corresponding to transillumination defects in the eye wall caused by the iris cyst. The position of the cyst was marked on the sclera with a sterile marking pen.

Using a 27 gauge needle attached to an aspirating syringe, the sclera was punctured near the posterior margin of the cyst, and the tip of the needle was directed into the central aspect of the cyst under direct visualization. The cyst was slowly aspirated until no additional fluid could be removed. The needle was withdrawn. The aspirate was submitted to pathology for cytopathologic study. Transscleral cryotherapy was then performed to the entire region of the iris cyst as marked on the sclera, including the portion that extended into the peripheral iris. The treatment was repeated as a double freeze-thaw cycle at every site, and multiple overlapping sites were treated until the entire lesion had been double frozen.

The conjunctiva was then re-placed in its normal position. It was secured with a running suture of 7-0 Vicryl. The lid speculum was removed. Bacitracin/polymyxin ointment was applied to the surface of the eye. The lids were patched with a sterile eye pad dressing. The patient tolerated the procedure well. He was transferred to postanesthesia recovery in satisfactory condition.

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PREOPERATIVE DIAGNOSES:
1.  Right eye corneoscleral laceration.
2.  Uveal prolapse, right eye.
3.  Vitreous prolapse, anterior chamber, right eye.
4.  Traumatic cataract, right eye.

POSTOPERATIVE DIAGNOSES:
1.  Right eye corneoscleral laceration.
2.  Uveal prolapse, right eye.
3.  Vitreous prolapse, anterior chamber, right eye.
4.  Traumatic cataract, right eye.

OPERATIONS PERFORMED:
1.  Repair of complex corneoscleral laceration, right eye.
2.  Resection of prolapsed uveal tissue, right eye.
3.  Anterior vitrectomy for vitreous prolapse, right eye.
4.  Injection of intracameral antibiotics, right eye.
5.  Partial aspiration of traumatic cataract, right eye.

SURGEON:  John Doe, MD

ANESTHESIA:  General anesthesia.

ANESTHESIOLOGIST:  Jane Doe, MD

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  None.

COUNTS:  Needle and sponge counts were correct at the end of the case.

DISPOSITION:  The patient will be admitted for observation and postoperative care.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old female who presented with a complex corneoscleral laceration to the right eye. The patient’s preoperative vision measured at count fingers at 1 foot in the right eye. The patient’s preoperative examination disclosed flat anterior chamber with vitreous prolapse and a traumatic cataract. The patient elected to undergo operative repair of the right eye penetrating ocular injury.

DESCRIPTION OF OPERATION:  The patient was brought to the main operative room, where the operative eye was marked. The patient was brought to the operating room and placed in the supine position. EKG leads were placed. Intravenous sedation was administered. General anesthesia was induced without complication. The ocular surface and periorbital skin of the operative eye were disinfected and draped in the standard fashion for eye surgery. A lid speculum was placed. A time-out was called. Additional topical anesthesia was placed on the ocular surface of the operative eye.

Viscoelastic was injected into the anterior chamber with complex corneoscleral laceration. The 9-0 nylon was used to approximate the limbus. Interrupted 10-0 nylon sutures were used to repair the complex corneal laceration.

Next, Westcott scissors were used to create an inferior peritomy. Full extent of the scleral laceration was visualized. Interrupted 9-0 nylon sutures were used to close the scleral aspect of the laceration. Uveal prolapse was seen through the inferior scleral laceration. Uvea was repositioned and uvea that could not be repositioned was resected.

Next, two paracenteses were made at the 9 o’clock and 3 o’clock positions. An anterior vitrectomy was performed for vitreous prolapse. A traumatic cataract was visualized in the anterior chamber, and the traumatic cataract was partially aspirated with a 27-gauge cannula.

Next, intracameral clindamycin, vancomycin, and ceftriaxone antibiotic were administered. The chamber was filled with balanced salt solution. A physiologic pressure was achieved. The paracenteses were sutured with 10-0 nylon suture. All suture knots were buried.

The wounds were checked and were felt to be watertight. The anterior chamber was deep. The intraocular pressure was satisfactory. The lid speculum was removed. Gentamicin ointment was placed on the operative eye followed by sterile patch and shield.

The patient tolerated the procedure well and was taken to the recovery area in good condition. The surgeon performed the entire procedure.

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