Anterior Segment

The front structures of the eye, including the lids, lashes, conjunctiva, cornea, iris, anterior chamber, lens, sclera, and orbit.

• Lids

Assessment of eyelid position, structure, and health.

• Lashes

Evaluation of eyelash cleanliness, alignment, and presence of debris or infection.

• Lens

Refers to the crystalline lens inside the eye.

• • Clear indicates no cataract or opacity.
• Iris

The colored part of the eye controlling pupil size.

• • Flat & Intact indicates normal structure.
• Cornea

The clear front surface of the eye responsible for focusing light.

• Conjunctiva

The thin membrane covering the sclera and inner eyelids.

• AC (Anterior Chamber)

The space between the cornea and iris.

• • Deep & Quiet indicates normal depth and no inflammation.
• Angles

Refers to the drainage angle of the eye.

• • Open suggests low risk for angle-closure glaucoma.
• Tears

Assessment of tear quality and quantity.

• Lacrimal System

System responsible for tear production and drainage.

• Van Herick Method

A slit-lamp technique used to estimate anterior chamber depth.

• Sclera

The white outer layer of the eye.

• • White indicates normal appearance.
• Orbit

The bony socket surrounding the eye.

• • No lesions, no asymmetry indicates normal findings.
• WNL (Within Normal Limits)

Indicates findings are considered clinically normal.

Posterior Segment

The back structures of the eye, including the vitreous, retina, macula, blood vessels, and optic nerve.

• Vitreous

The clear gel filling the eye.

• • Clear indicates no floaters or hemorrhage.
• CD Ratio VH (Cup-to-Disc Ratio Vertical/Horizontal)

Measurement of the optic nerve cup compared to the disc.
Used to assess glaucoma risk.

• Rim

The neural tissue surrounding the optic cup.

• • Pink, healthy indicates good optic nerve health.
• Color

Refers to optic disc color.

• Disc Margin

Edges of the optic nerve head.

• • Sharp, distinct indicates normal appearance.
• Depth

Depth of the optic cup.

• Lamina

Refers to the lamina cribrosa of the optic nerve.

• • Not visible is commonly normal.
• Macula

The central retina responsible for sharp vision.

• • Flat, clear, PFR indicates normal macular reflex.
• Posterior Pole

Central area of the retina including macula and optic nerve.

• Vessels

Assessment of retinal blood vessels.

• AV (Artery-Vein Ratio)

Ratio of retinal artery width to vein width (e.g., 2/3).

• Crossing

Evaluation of artery-vein crossings.

• Course

Path of retinal blood vessels.

• Reflex

Light reflex from retinal vessels.

• Periphery

Outer retina.

• • No breaks, no tears indicates retinal stability

Additional Testing / Imaging

• Automated Visual Field

Test that measures peripheral vision.

Options Explained:

• • 10-2 / 24-2 / 30-2 / 120 – Different visual field testing patterns
  • Esterman – Functional field test, often for driving
  • Not Done – Test not performed

Retinal Photos

Color photographs of the retina used for documentation and monitoring.

OCT Macula

Optical Coherence Tomography of the Macula
Evaluates macular thickness and structure.

OCT Disc

Optical Coherence Tomography of the Optic Disc
Analyzes optic nerve and RNFL thickness, commonly for glaucoma.

Entrance Test

IOP (Intraocular Pressure)

The pressure of fluid inside the eye.

• • OD – Right eye
  • OS – Left eye

Drops

Eye drops used before IOP measurement.

• • Alcaine – Anesthetic
  • NaFl – Fluorescein dye

IOP Type

Method used to measure IOP.

• • NCT – Non-Contact Tonometry

IOP Time

Time at which IOP was recorded.

Stereo

Assessment of depth perception.

EOMs (Extraocular Movements)

Evaluation of eye muscle movement.

• • Full OU indicates normal movement in both eyes.

Pupils

Evaluation of pupil size and reaction to light.

• • ERRL (–) APD OU indicates normal pupillary response.

CVF (Confrontation Visual Fields)

Basic screening of peripheral vision.

Cover Test / Phoria

Evaluates eye alignment at distance and near.

Phoria / Vertical

Measurement of latent eye misalignment.

Color Vision

Color Test

Assessment of color perception.

Right Score / Left Score

Number of correct responses.

Lensometry / Habitual Prescription

SPH (Sphere)

Indicates degree of nearsightedness or farsightedness.

CYL (Cylinder)

Amount of astigmatism.

AXIS

Orientation of astigmatism correction (0–180 degrees).

ADD (Add Power)

Additional plus power for near vision, typically for presbyopia.

Prism Required

Indicates whether prism correction is needed.

H Prism (Horizontal Prism)

Prism correction for left-right eye misalignment.

H Base

Direction of horizontal prism (Base In / Base Out).

V Prism (Vertical Prism)

Prism correction for up-down eye misalignment.

V Base

Direction of vertical prism (Base Up / Base Down).

Visual Acuity (VA)

VA Uncorrected

Vision measured without glasses or contact lenses.

VA Corrected

Vision measured with correction.

FAR (6m)

Distance visual acuity.

NEAR (40 cm)

Near visual acuity.

OD / OS / OU

• • OD – Right eye

  • OS – Left eye

  • OU – Both eyes

CC (Chief Complaint)

The primary reason the patient is visiting for an eye examination.

IOP (Intraocular Pressure)

The pressure of fluid inside the eye.

• • OD – Right eye
  • OS – Left eye

Drops

Eye drops used before IOP measurement.

• • Alcaine – Anesthetic
  • NaFl – Fluorescein dye

IOP Type

Method used to measure IOP.

• • NCT – Non-Contact Tonometry

IOP Time

Time at which IOP was recorded.