Ophthalmological Letter Sample Report #1
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,
