Chief Complaint: Blurry vision OU
Onset: Gradual over the last 6 months.
Location: OU
Severity: mild
Duration: 6 months to a year.
Relieving Factors: Glasses help but need updating.
Patient Ocular History: Last eye exam 3 years prior. Patient received bifocal glasses.
Family Ocular History: (-) Glaucoma.
Patient Medical History:
- DM type 2 for 8 years. Blood sugar levels and HbA1c unknown.
- Hypertension for 2 years.
- Last Physical exam 1 year prior. Patient reported normal results and good health.
Review of Systems: Within normal limits
Clinical Findings: BCVA: 20/40 OD, 20/25 OS
Pupils: WNL (-) APD
Conf Fields: Full to finger counting OU
IOP: 17mmHg OD, 16mmHg OS.
Slit Lamp: Anterior segment is clear and WNL, (-) NVI. Lens was clear.
Dilated Fundus Exam: See Photos below
OD |
OS |
See the comments for assessment and plan