Sample Transcribed Reports:

Ophthalmology . . . Page 3


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  Edited Sample Report

Thank you for referring this woman for ocular review. I had seen her July ** with what appeared to be very dry eyes. Schirmer testing confirmed that and she was complaining of frequent subconjunctival hemorrhages in the left eye and the occasional sharp, stabbing pain in both eyes. At the time, I suggested Tear Gel and Artificial Tears.She called September ** saying that the Tear Gel made fluid happen in the left eye and I asked to recheck her.

What she described was a huge cyst from the Tear Gel in the left eye and further irritation which has stopped since she has stopped the Tear Gel and is slowly improving. Examination showed the cystic change with chemosis in the infranasal conjunctiva in the left eye. There was a slight yellowing of the conjunctiva bilaterally inferiorly but no real salmon patch changes. The exophthalmometry readings were symmetric and normal.

Diagnosis: Left conjunctival chemosis.

I could not see any orbital abnormality of note with no engorged vessels of the conjunctiva or the fundus. I'm sure that this is the area that Mrs. * was looking at and that it has not, in fact, been caused by the Tear Gel but that the Tear Gel may have irritated the conjunctiva. I have asked for an ultrasound of the orbit and will consider biopsy of the conjunctiva if the problem does not resolve. There is a possibility of vascular congestion or lymphoproliferative disease presenting like this but this is not the lymphoproliferative material itself seen here and I would like further imaging before pursuing any other diagnostic maneuvers.

  Edited Sample Report

Thank you for sending this fellow back for examination. He underwent resection of a glioma in 1992 with irradiation and chemotherapy. He is now on pituitary replacement treatment. He has had one episode of shingles in the past which were right facial in nature. His last checkup at the Cancer Agency was unremarkable.

He has been noticing discomfort in the left eye with bright light for the past week.

Exam showed best acuity of 20/20 in the right eye and the left eye. There was no anterior chamber cell or reaction.There was a left pterygium with no evidence of corneal staining. The intraocular pressures and the fundi, undilated,were unremarkable.

Diagnosis: No evidence of corneal epithelial disease or intraocular inflammatory disease.

I have placed * on Naphcon-A to try to get the pterygium to settle. He may be having some discomfort simply based on dryness adjacent to the pterygium. I have asked for a Goldmann visual field to document results of his previous therapy which, apparently, did affect some of his visual cortex. I will also dilate his pupil at the next visit.

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  Edited Sample Report

Thank you for sending this ***-year-old who complains of being blinded by light at about 6:30 in the morning while driving. It does not matter whether she's wearing or not wearing her contact lenses, the same symptom occurs. She does wear a soft, nondisposable contact. She is also finding her eyes somewhat uncomfortable by the end of the day. She is using an appropriate contact lens cleaning and care system.

Medical History: Well.

Ocular History: Unremarkable.

Family History: Mother with glaucoma treated by drops.

Meds: None.

Allergies: None.

Exam shows best acuity of 20/15 in both eyes with a myopic mildly astigmatic refraction. The slit lamp exam shows large follicular conjunctivitis inferiorly in both eyes and some perilimbal redness. The intraocular pressures and the fundi were unremarkable.

Diagnosis: Follicular conjunctivitis.

I have sent the patient for conjunctival scraping and culture including microtrach prior to instituting any treatment. I believe treating the conjunctiva appropriately may relieve her symptoms.

  Edited Sample Report

Thank you for sending this ***-year-old clerk and student nurse who has noted a mark in the medial portion of her right eye that has been present for several years. Her mother has seen it and they have not noticed any particular change in size. There is no accompanying irritation.

This patient was born in Canton and her parents are both of Chinese origin. She is a soft tissue contact lens wearer.

Medical History: Unremarkable.

Family History: Unremarkable.

Meds: Birth control pill.

Allergies: None known.

With her current contact lenses here vision is only 20/40. This can be improved to 20/20 with an over refraction.The lesion in the right plica is obviously a nevus with cysts and normal structures contained in it. There is also bilateral large inferior follicular conjunctivitis. There rest of the ocular exam is unremarkable.

Impressions: 1) Right conjunctival nevus.
                     2) Follicular conjunctivitis.

I have sent her for photographs of the lesion and for cultures including a microtrach of the conjunctiva. I will review her after the culture results are in. The plica conjunctival nevus does not require any treatment but I should look at it periodically to make sure it does not undergo any degeneration. I have reassured the patient that this is a benign.

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