Diagnosis and Plan Templates for Optometry and Ophthalmology
Diagnosis:
Healthy Eyes / No significant findings (Z01.00)
Refractive Error (e.g., Myopia [H52.11], Hyperopia [H52.01], Astigmatism [H52.2], Presbyopia [H52.4])
Plan:
Rx given to patient for eyeglasses constant wear + uv protection. single vision
Rx given to patient for eyeglasses constant wear + uv protection. bifocals or progressive addition lens.
Prescription provided to the patient for contact lenses: The patient was educated on the importance of maintaining an appropriate balance between wearing glasses and contact lenses. Additionally, patient education included advising against swimming in lakes while wearing contact lenses to prevent potential ocular infections.
For a first-time contact lens wearer, a contact lens examination was conducted. However, the patient needs to schedule a training session for the proper insertion and removal of contact lenses.
Annual eye examination recommended.
Follow-up visit for intraocular pressure assessment due to elevated intraocular pressure in one or both eyes above the normal baseline.
The patient was advised to use lenses with UV protection and a tint or photochromic option to prevent UV damage to the ocular adnexa.
Diagnosis:
Dry Eye Syndrome / Keratoconjunctivitis Sicca (H04.123)
Plan:
Artificial tears/lubricating eye drops 3-4 times a day ou. 1 gtt (e.g., Systane, Refresh)
Prescription for cyclosporine ophthalmic emulsion (e.g., Restasis)
Warm compresses and eyelid hygiene wash
Balanced Diet: Encourage the patient to maintain a balanced diet rich in Omega-3s, supplement or by consuming fatty fish like salmon, mackerel, and sardines.
Hydration and Eye Care: Recommend maintaining good hydration and following other dry eye management practices such as using artificial tears and practicing good eye hygiene.
Follow-up in 3 months for reassessment
Additional Diagnoses and Plans:
Demodex Dermatitis OU: Continue using lid scrubs OU eye lid cleansing.
Referral: If the chalazion persists or worsens, refer to ophthalmologist (MD) for possible excision.
Discussed surgery if needed we can refer opthalmologist, patient to consider.
Discussed surgery if needed we can refer opthalmologist, patient to consider.
Dermatochalasis LL: Discussed surgery if needed we can refer opthalmologist, patient to consider.
Pseudophakia : check up yearly
Diagnosis:
Bacterial Conjunctivitis (H10.021)
Viral Conjunctivitis (H10.13)
Allergic Conjunctivitis (H10.45)
Plan:
Bacterial: Antibiotic eye drops
Viral: Supportive care, cold compresses, lubricating drops
Allergic: Antihistamine/mast cell stabilizer drops
Patient education on hygiene to prevent spread
Follow-up if symptoms worsen or do not improve in 1 week
Diagnosis:
Glaucoma suspect
Primary Open-Angle Glaucoma (H40.11X0)
Angle-Closure Glaucoma (H40.21X0)
Plan:
Glaucoma Suspect, Risk (Optic Nerve):
Monitor and refer to an MD/OD for a comprehensive glaucoma evaluation, including optic coherence tomography (OCT), Heidelberg Retina Tomograph (HRT), gonioscopy, and pachymetry.
Refer to MD/ OD/ DO for Prescription for intraocular pressure-lowering medications (e.g., Timolol, Latanoprost)
Regular intraocular pressure monitoring
Visual field testing and optic nerve imaging (OCT)
Possible referral for glaucoma surgery (e.g., trabeculectomy) if needed
Pt under treatment by ophthalmologist or optometrist.
Follow-up every 3-6 months
5. Diabetic Retinopathy
Diagnosis:
pre-diabetic
Diabetic Retinopathy (Non-Proliferative [E11.329], Proliferative [E11.359])
Macular Edema (E11.351)
Plan:
Monitor blood sugar with pcp.
Tight blood sugar control (coordinate with primary care physician)
Refer to specialist for probable need of Anti-VEGF injections (e.g., Avastin, Eylea)
Refer for Laser photocoagulation therapy
Refer for Regular fundus photography and OCT imaging
Follow-up every 3-6 months
6. Age-Related Macular Degeneration (AMD)
Diagnosis:
Dry AMD (H35.31)
Wet AMD (H35.32)
Plan:
Dry AMD: AREDS2 supplements, lifestyle modifications (e.g., diet rich in leafy greens) refer to Retina specialist.
Based on the Age-Related Eye Disease Study 2 (AREDS2), the following supplement regimen is recommended for managing dry AMD:
- Vitamin C: 500 mg
- Vitamin E: 400 IU
- Lutein: 10 mg
- Zeaxanthin: 2 mg
- Zinc: 80 mg (or 25 mg in some formulations)
- Copper: 2 mg (included to prevent copper deficiency anemia from high zinc intake)
Lifestyle Modifications
Dietary Recommendations:
- Leafy Green Vegetables: Incorporate a diet rich in leafy greens such as spinach, kale, and collard greens, which are high in lutein and zeaxanthin.
- Fruits and Vegetables: Consume a variety of colorful fruits and vegetables rich in antioxidants.
- Fish: Eat fish high in omega-3 fatty acids (such as salmon, mackerel, sardines) at least twice a week.
- Nuts and Seeds: Include nuts and seeds which are good sources of healthy fats and vitamin E.
- Whole Grains: Prefer whole grains over refined grains to maintain overall health and reduce inflammation.
Lifestyle Habits:
- Quit Smoking: Smoking is a major risk factor for AMD. Seek support to quit smoking if necessary.
- Exercise Regularly: Engage in regular physical activity to maintain cardiovascular health and overall well-being.
- Maintain a Healthy Weight: Aim for a healthy weight through a balanced diet and regular exercise to reduce the risk of AMD progression.
- Sun Protection: Wear sunglasses that block UV and blue light to protect your eyes from harmful rays.
- Control Blood Pressure and Cholesterol: Monitor and manage blood pressure and cholesterol levels through diet, exercise, and medications as prescribed.
Referral to a Retina Specialist
Referral:
- Schedule a referral to a retina specialist for a comprehensive evaluation and management plan.
- To perform diagnostic tests such as optical coherence tomography (OCT) and fundus photography to monitor the condition and its progression.
- Follow-up appointments as recommended by the retina specialist to closely monitor AMD and adjust treatment as necessary.
Wet AMD: refer to refer to Retina specialist r/o need for Anti-VEGF injections (e.g., Lucentis, ect.
Regular monitoring with and fundus photography
Refer to specialist for Low vision aids if needed
Follow-up every 1-3 months for AMD, 6-12 months for AMD
7. Cataracts
Diagnosis:
Cataracts (Nuclear Sclerotic [H25.11], Cortical [H25.12], Posterior Subcapsular [H25.13])
Plan:
Observation and monitoring of visual acuity. UV protection
Refer to specialist rule out need for cataract surgery, patient to consider.
Prescription for updated glasses if needed UV protection
Discuss cataract surgery options and timing, patient to consider.
Referral to ophthalmic surgeon for evaluation
Follow-up every 6-12 months
8. Retinal Detachment
Diagnosis:
Retinal Detachment (H33.01)
Retinal Tear (H33.331)
Plan:
Immediate referral to retinal specialist.
Patient education on signs and symptoms of retinal detachment
Refer to specialist for Post-operative follow-up as per retinal specialist's protocol
9. Uveitis
Diagnosis:
Anterior Uveitis (H20.00)
Intermediate/Post. Uveitis (H30.20)
Plan:
Prescription for corticosteroid eye drops (e.g., Prednisolone acetate)
Cycloplegic drops for pain relief (e.g., Atropine)
Systemic immunosuppressive therapy if needed (coordinate with rheumatologist)
Regular follow-up to monitor inflammation and intraocular pressure
10. Amblyopia
Diagnosis:
Amblyopia (Strabismic [H53.03], Refractive [H53.02], Deprivation [H53.01])
Plan:
Prescription for corrective lenses
Occlusion therapy (patching the stronger eye)
Atropine drops in the stronger eye
Vision therapy exercises
Follow-up every 3-6 months
Optometry Treatment Plans for Various Corneal Conditions
ICD-10 Code: H18.829 (Corneal Dellen, unspecified eye)
Symptoms:
- Typically asymptomatic
- Occasional foreign-body sensation
- Irritation
Signs:
- Oval-shaped corneal thinning adjacent to raised corneal and/or limbal lesions
- Fluorescein pooling within the dellen
Pathophysiology/Diagnosis:
- Focal dehydration of the corneal stroma, often near pterygium or filtering bleb
Treatment Plan:
- Hydration:
- Frequent use of artificial tears or lubricating ointments to keep the cornea hydrated.
- Bandage Contact Lens:
- Consider using a bandage contact lens to promote healing and protect the cornea.
- Environmental Modification:
- Avoid dry or windy environments to prevent further dehydration.
- Follow-up:
- Monitor regularly for any changes or complications.
Diagnostic and Treatment Plan for Exposure Keratopathy
ICD-10 Code: H16.223 (Exposure keratopathy, bilateral)
Epidemiology/History:
- Ask about Bell's palsy, eyelid surgery, cerebrovascular accident, multiple sclerosis, herpes simplex/zoster, thyroid eye disease, nocturnal lagophthalmos, floppy eyelid syndrome.
Symptoms:
- Redness
- Foreign body sensation
- Burning, worse in the morning
Signs:
- Mild SPK to ulceration
- SPK in the inferior 1/3 or interpalpebral region
- Decreased corneal sensitivity
Pathophysiology/Diagnosis:
- Abnormal or incomplete lid closure
Treatment Plan:
- Lubrication:
- Use artificial tears during the day and lubricating ointment at night.
- Eyelid Taping:
- Tape the eyelids closed at night or use a moisture chamber.
- Medical Management:
- Treat underlying conditions such as thyroid disease or Bell's palsy.
- Surgical Options:
- In severe cases, consider surgical options like tarsorrhaphy or eyelid weight implants.
- Follow-up:
- Regular monitoring for any progression or complications.
Diagnostic and Treatment Plan for Filamentary Keratopathy
ICD-10 Code: H16.239 (Filamentary keratitis, unspecified eye)
Epidemiology/History:
- History of dry eye, superior limbic keratoconjunctivitis, Sjogren's syndrome, neurotrophic keratopathy.
Symptoms:
- Pain
- Red eye
- Foreign-body sensation
- Photophobia
Signs:
- Irregular strands of epithelial cells present in mucous form on the epithelium
Pathophysiology/Diagnosis:
- Chronic inflammation of the cornea
Treatment Plan:
- Lubrication:
- Frequent use of preservative-free artificial tears.
- Mechanical Removal:
- Carefully remove filaments using forceps under slit-lamp guidance.
- Anti-inflammatory Drops:
- Use topical steroids or cyclosporine to reduce inflammation.
- Mucolytic Agents:
- Consider acetylcysteine drops to dissolve mucus.
- Follow-up:
- Frequent follow-ups to monitor for recurrence.
Diagnostic and Treatment Plan for Superficial Punctate Keratitis (SPK)
ICD-10 Code: H16.149 (Superficial punctate keratitis, unspecified eye)
Symptoms:
- Pain
- Photophobia
- Red eye
- Foreign-body sensation
Signs:
- Dot epithelial defects that stain with fluorescein
Pathophysiology/Diagnosis:
- Common causes include dry eye syndrome, drug toxicity, exposure keratopathy, contact lens disorders, trichiasis
Treatment Plan:
- Lubrication:
- Frequent use of artificial tears.
- Medication Adjustment:
- Discontinue or change any causative medications.
- Protective Measures:
- Use protective eyewear to prevent further exposure.
- Anti-inflammatory Drops:
- Use mild topical steroids or cyclosporine if inflammation is significant.
- Follow-up:
- Monitor regularly for improvement or complications.
Diagnostic and Treatment Plan for Thygeson's Superficial Punctate Keratitis
ICD-10 Code: H16.239 (Thygeson's superficial punctate keratitis, unspecified eye)
Epidemiology/History:
- Rare, most common in the 2nd-3rd decade
Symptoms:
- Foreign-body sensation
- Tearing
Signs:
- Gray-white, elevated corneal epithelial opacities
- Rarely stain with fluorescein
Pathophysiology/Diagnosis:
- Unknown etiology, possibly viral
Treatment Plan:
- Lubrication:
- Use artificial tears to alleviate symptoms.
- Mild Steroids:
- Use mild topical steroids during flare-ups.
- Bandage Contact Lens:
- Consider for severe cases to provide relief.
- Follow-up:
- Regular follow-ups to monitor for exacerbations or remissions.
Diagnostic and Treatment Plan for Neurotrophic Keratopathy
ICD-10 Code: H16.219 (Neurotrophic keratopathy, unspecified eye)
Epidemiology/History:
- History of stroke, previous herpes infections, diabetes
Symptoms:
- Redness
- Tearing
- Decreased vision
- Foreign body sensation
Signs:
- SPK with perilimbal injection
- Sterile inferior oval ulcer without significant inflammation
Pathophysiology/Diagnosis:
- CN V neuropathy leads to desensitization and delayed corneal healing
Treatment Plan:
- Lubrication:
- Use preservative-free artificial tears and lubricating ointment.
- Prophylactic Antibiotics:
- To prevent secondary infections.
- Bandage Contact Lens:
- For corneal protection and to promote healing.
- Neurotrophic Factors:
- Consider cenegermin (recombinant human nerve growth factor) for severe cases.
- Follow-up:
- Close monitoring to prevent complications such as corneal ulceration.
Diagnostic and Treatment Plan for Recurrent Corneal Erosion
ICD-10 Code: H18.839 (Recurrent erosion of cornea, unspecified eye)
Epidemiology/History:
- Previous superficial trauma or corneal dystrophies
Symptoms:
- Recurrent acute pain, often in the morning
- Lacrimation
- Photophobia
- Blurred vision
Signs:
- Corneal abrasion that stains with fluorescein
Pathophysiology/Diagnosis:
- Poor adhesion between the basement membrane and underlying tissue
Treatment Plan:
- Lubrication:
- Use artificial tears during the day and lubricating ointment at night.
- Hypertonic Saline:
- Use hypertonic saline drops or ointment to reduce epithelial edema.
- Bandage Contact Lens:
- Consider for patients with frequent recurrences.
- Surgical Options:
- For persistent cases, consider anterior stromal puncture or phototherapeutic keratectomy (PTK).
- Follow-up:
- Regular follow-ups to monitor healing and prevent recurrence.
Diagnostic and Treatment Plan for Thermal/Ultraviolet Keratopathy
ICD-10 Code: H16.139 (Thermal/Ultraviolet keratopathy, unspecified eye)
Epidemiology/History:
- History of welding or using a sunlamp without protective eyewear
Symptoms:
- Ocular pain
- Photophobia
- Blurred vision
Signs:
- Confluent SPK within the interpalpebral region of the cornea
Pathophysiology/Diagnosis:
- UV light-induced damage to the corneal epithelium
Treatment Plan:
- Lubrication:
- Frequent use of artificial tears.
- Cycloplegics:
- Use cycloplegic drops to reduce pain and photophobia.
- Oral Analgesics:
- Protective Measures:
- Advise on the use of UV-protective eyewear.
- Follow-up:
- Monitor for improvement and ensure there are no secondary infections.
Diagnostic and Treatment Plan for Dry Eye Disease (Evaporative Dry Eye, Keratoconjunctivitis Sicca)
ICD-10 Code: H04.123 (Dry eye syndrome, bilateral)
Epidemiology/History:
- Common with aging, more in women. Associated with medications, collagen vascular disorders, environmental factors.
Symptoms:
- Burning
- Dryness
- Tearing
- Itching
- Increased blinking
- Photophobia
- Contact lens intolerance
Signs:
- Thin tear meniscus
- Decreased Schirmer findings
- Decreased TBUT
- Conjunctival injection
- Corneal filaments
