September 1, 2001 |
Patient: |
11-year-old Asian/white male |
Chief complaint: |
no visual or asthenopic complaints; wants overnight corneal reshaping contact lenses |
History: |
no important personal or family ocular or systemic health history
no medications or allergies to medications |
Uncorrected VA: |
OD: 20/600 |
OS: 20/400 |
Sim k: |
OD: 46.75/45.37 @ 024 clear mires |
OS: 46.00/45.12 @ 168 clear mires |
Manifest refraction: |
OD: –5.00 –0.25 X 061 20/20 |
OS: –4.00 –0.50 X 137 20/20 |
Slit lamp: |
OU: lids and lashes clean, cornea clear, conjunctiva healthy, anterior chamber deep, quiet |
Contact lens trial: |
OD: 84-550-36-10.0 |
OS: 83-550-35-10.0 |
CL fit: |
OU: good centration, 4.0 mm touch, good edge lift |
Assessment: |
1) Good fit with contact lenses |
Plan: |
1) Order contact lenses and return for dispense |
|
OD: 84-550-36-10.0 |
OS: 83-550-35-10.0 |
September 20, 2001 |
Visit: |
1 day am |
Wearing time: |
9.5 hours, wearing contact lenses now |
Wearing: |
OD: 84-550-36-10.0 |
OS: 83-550-35-10.0 |
Chief complaint: |
no visual or asthenopic complaints |
Uncorrected VA: |
OD: 20/63 |
OS: 20/58 |
Slit lamp: |
OU: grade 2 central punctate stain |
CL fit: |
OD: superior nasal centration, 4.5 mm touch, good edge lift |
OS: slight nasal centration, 4.5 mm touch, good edge lift |
Assessment: |
1) Central stain |
Plan: |
1) Monitor pm |
September 20, 2001 |
Visit: |
1 day pm |
Wearing: |
OD: 84-550-36-10.0 |
OS: 83-550-35-10.0 |
Chief complaint: |
poor vision even with glasses until a few minutes ago |
Uncorrected VA: |
OD: 20/63 |
OS: 20/138 |
Slit lamp: |
OU: no stain |
Assessment: |
1) No stain |
Plan: |
1) Return 1 week |
September 29, 2001 |
Visit: |
1 week pm |
Wearing: |
OD: 84-550-36-10.0 |
OS: 83-550-35-10.0 |
Chief complaint: |
no visual or asthenopic complaints |
Uncorrected VA: |
OD: 20/26 |
OS: 20/25 |
Manifest refraction: |
OD: +0.75 –1.25 X 035 20/25+ |
OS: +1.25 –1.50 X 135 20/20+ |
Slit lamp: |
OU: no stain |
Topography: |
OU: slight nasal decentration |
Assessment: |
1) lens may be too shallow |
Plan: |
1) increase RZD OD; return one week |
October 4, 2001 |
Visit: |
2 week pm |
Wearing: |
OD: 84-550-36-10.0 |
OS: 83-550-35-10.0 |
Chief complaint: |
no visual or asthenopic complaints |
Uncorrected VA: |
OD: 20/26 |
OS: 20/25 |
Manifest refraction: |
OD: +0.25 –1.50 X 140 20/15– |
OS: +0.75 –1.50 X 140 20/15– |
Slit lamp: |
OU: no stain |
Topography: |
OU: slight nasal decentration |
Assessment: |
1) lenses may be too shallow |
Plan: |
1) dispensed new lens OD, compare results between eyes two weeks |
October 17, 2001 |
Visit: |
1 month pm |
Wearing: |
OD: 84-575-36-10.0 |
OS: 83-550-35-10.0 |
Chief complaint: |
no visual or asthenopic complaints |
Uncorrected VA: |
OD: 20/20 |
OS: 20/15 |
Manifest refraction: |
OD: plano –0.25 X 055 20/20+ |
OS: plano –0.25 X 165 20/15– |
Slit lamp: |
OU: no stain |
Topography: |
OU: small, well-centered treatment zone |
Assessment: |
1) stable refractive error throughout the day |
Plan: |
1) return two months |
December 13, 2001 |
Visit: |
1 month pm |
Wearing: |
OD: 84-575-36-10.0 |
OS: 83-550-35-10.0 |
Chief complaint: |
no visual or asthenopic complaints |
Uncorrected VA: |
OD: 20/21 |
OS: 20/19 |
Manifest refraction: |
OD: +0.25 –0.75 X 045 20/20+ |
OS: +0.75 –1.25 X 125 20/15 |
Slit lamp: |
OU: no stain |
Topography: |
OU: small, well-centered treatment zone |
Assessment: |
1) contact lens OS too shallow |
Plan: |
1) order 83-575-35-10.0 OS and mail to patient; return 3 months/prn |
March 17, 2002 |
Visit: |
1 month pm |
Wearing: |
OD: 84-575-36-10.0 |
OS: 83-575-35-10.0 |
Chief complaint: |
no visual or asthenopic complaints |
Uncorrected VA: |
OD: 20/19 |
OS: 20/17 |
Manifest refraction: |
OD: plano –0.75 X 045 20/15 |
OS: +0.25 –0.50 X 155 20/15 |
Slit lamp: |
OU: no stain |
Topography: |
OU: small, well-centered treatment zone |
Assessment: |
1) stable vision OU |
Plan: |
1) return 6 months/prn |
September 1, 2001 |
Patient: |
12-year-old Asian female |
Chief complaint: |
no visual or asthenopic complaints; wants overnight corneal reshaping contact lenses |
History: |
no important personal or family ocular or systemic health history
no medications or allergies to medications |
Uncorrected VA: |
OD: 20/30 |
OS: 20/30 |
Sim k: |
OD: 42.12/43.37 @ 094 clear mires |
OS: 42.25/43.37 @ 104 clear mires |
Manifest refraction: |
OD: –0.50 DS 20/15 |
OS: –0.50 DS 20/15 |
Slit lamp: |
OU: lids and lashes clean, cornea clear, conjunctiva healthy, anterior chamber deep, quiet |
Contact lens trial: |
OD: 82-500-33-10.5 |
OS: 82-500-33-10.5 |
CL fit: |
OU: good centration, 4.0 mm touch, good edge lift |
Assessment: |
1) Good fit with contact lenses |
Plan: |
1) Order contact lenses and return for dispense |
|
OD: 82-500-33-10.5 |
OS: 82-500-33-10.5 |
September 20, 2001 |
Visit: |
1 day am |
Wearing time: |
10.0 hours, wearing contact lenses now |
Wearing: |
OD: 82-500-33-10.5 |
OS: 82-500-33-10.5 |
Chief complaint: |
contact lenses feel "tickly" all the time |
Uncorrected VA: |
OD: 20/15 |
OS: 20/17 |
Manifest refraction |
OD: +0.25 –0.25 X 045 20/15 |
OS: plano 20/15– |
Slit lamp: |
OU: no stain |
CL fit: |
OD: good centration, 5.0 mm touch, good edge lift |
OS: good centration, 5.0 mm touch, good edge lift |
Assessment: |
1) good vision |
Plan: |
1) monitor 1 week pm |
September 29, 2001 |
Visit: |
1 week pm |
Wearing: |
OD: 82-500-33-10.5 |
OS: 82-500-33-10.5 |
Chief complaint: |
no visual or asthenopic complaints |
Uncorrected VA: |
OD: 20/17 |
OS: 20/15 |
Manifest refraction |
OD: +0.50 DS 20/15– |
OS: +0.75 DS 20/15– |
Slit lamp: |
OU: no stain OD; trace temporal foreign body stain OS |
Topography: |
OU: temporal decentration |
Assessment: |
1) good vision OU |
Plan: |
1) return one week |
October 13, 2001 |
Visit: |
2 week pm |
Wearing: |
OD: 82-525-33-10.5 |
OS: 82-525-33-10.5 |
Chief complaint: |
no visual or asthenopic complaints |
Uncorrected VA: |
OD: 20/16 |
OS: 20/25 |
Manifest refraction |
OD: +1.25 –0.75 X 035 20/15– |
OS: +0.25 –0.75 X 155 20/20+ |
Slit lamp: |
OU: no stain |
Topography: |
OU: slight central island |
Assessment: |
1) lenses may be too shallow |
Plan: |
1) order 82-525-33-10.5 OU and mail; begin wearing new contact lenses when receive and return 2 weeks |
October 17, 2001 |
Visit: |
1 month pm |
Wearing: |
OD: 82-525-33-10.5 |
OS: 82-525-33-10.5 |
Chief complaint: |
no visual or asthenopic complaints |
Uncorrected VA: |
OD: 20/20 |
OS: 20/19 |
Manifest refraction |
OD: +1.00 –0.25 X 065 20/20+ |
OS: +1.25 DS 20/15– |
Slit lamp: |
OU: no stain |
Topography: |
OU: nasal decentration |
Assessment: |
1) still too shallow |
Plan: |
1) order 82-550-33-10.5 OU and mail; return 2 months/prn |
December 15, 2001 |
Visit: |
3 month pm |
Wearing: |
OD: 82-550-33-10.5 |
OS: 82-550-33-10.5 |
Chief complaint: |
no visual or asthenopic complaints |
Uncorrected VA: |
OD: 20/16 |
OS: 20/19 |
Manifest refraction |
OD: +0.50 DS 20/15 |
OS: plano –0.50 X 070 20/15 |
Slit lamp: |
OU: no stain |
Topography: |
OU: temporal decentration OD, irregular OS |
Assessment: |
1) good, stable vision |
Plan: |
1) return 3 months/prn |
March 30, 2002 |
Visit: |
1 month pm |
Wearing: |
OD: 82-550-33-10.5 |
OS: 82-550-33-10.5 |
Chief complaint: |
no visual or asthenopic complaints |
Uncorrected VA: |
OD: 20/18 |
OS: 20/18 |
Manifest refraction |
OD: +0.50 –0.50 X 165 20/15 |
OS: +0.25 –0.50 X 005 20/15 |
Slit lamp: |
OU: no stain |
Topography: |
OU: temporal treatment zone |
Assessment: |
1) stable vision OU |
Plan: |
1) return 6 months/prn |
