OBJECTIVE

VA
OD 20/40-2 cc 20/40+1 ph 20/40 J16 cc J10
OS 20/20 J16 cc J10
(-) matting, (-) discharge, (-) collarettes 2-(-) papilla, (-) follicle, (-) ins
pissated glands
Full EOM
(-) diplopia, (-) pain on movement, (-) nystagmus
VH4, (-) cells and flare IOL in place
VH4, (-) cells and flare IOL in place
Fundoscopy
Good ROR, CDR 0.3, AVR 2:3, (-) exudates, (-) hemorrhage + ring. + Watzke Allen
TBUT
OD sec 3 3 3
OS sec 4 4 4
IOP
OD mmHg 16
OS mmHg 16
ASSESSMENT
Psedophakia Ou; DTS OU; Macular Hole OD; ERM OS; Mild NPDR OU; Focal VMT OD
PLAN
For Retina Referral on Tuesday Start Systane Ultra eye drops 1 drop to both eyes
4 xa day and as needed Follow up on Tueday AM 8AM Ophtha Office with companion