Documenting an ophthalmology list
Operation notes, day-one reviews with the drop schedule, and letters to the referring optometrist and the GP.
Day one after cataract surgery
Day one, right phaco and IOL, uncomplicated. 21.5 dioptre lens in the bag.
Unaided 6/9 right. IOP 17. Cornea clear, wound sealed, Seidel negative. AC 1+ cells, IOL centred.
Pred Forte four times a day for a week, then taper weekly over three weeks. Chloramphenicol four times a day for one week.
No rubbing, shield at night for a week. Left eye listed for 3 November. Refraction with her optometrist at four weeks.
Procedure
R phacoemulsification + IOL (21.5 D, in the bag), uncomplicated.
Examination
VA R 6/9 unaided. IOP 17. Cornea clear. Wound sealed, Seidel negative. AC 1+ cells. IOL centred.
Drops
- Prednisolone acetate 1% QID for 1 week, then taper weekly over 3 weeks
- Chloramphenicol 0.5% QID for 1 week
Plan
- No eye rubbing; shield at night for 1 week
- L eye listed 3 November
- Refraction with optometrist at 4 weeks
Letters
- Letter to the referring optometrist
- The lens power, the day-one acuity, the drop schedule and the date for refraction.
- Letter to the GP
- A short copy of the same, with the second eye date.
- Operation note
- Dictated on the list: anaesthesia, lens and power, complications and the post-operative drops.
