Patient returns to the eye clinic for complete exam CC: Patient currently has broken glasses and complains of blurred vision without the glasses on. Patient complains of itchy eyes and allergies as well and said she is allergic to everything outside.... The patient was last seen Nov 24, 2014 by Dr. Wilhelm for complete/OCT/photos The patient is being followed for: 1. Mild glaucoma suspect OU due to borderline RNFL and previous VF defects 2. Pseudophakia OU 3. Trace epiretinal membrane OU 4. Hypertension without angiopathy OU 5. Hyperopia OS, astigmatism OU, presbyopia OU OCULAR HX: Pain/Discomfort Scale 1/10: 0 [-] Trauma: [+] Surgery: cataract surgery OU 2008 - Eye specialists in Chilli. [-] Strabismus: [-] Glaucoma: [-] Flashes: [+] Floaters: since surgery, occasional, stable, OU [-] Diplopia: Other: ocular migraine FAM. OC HX: unknown [-]Glaucoma [-]Blindness [-]Retinal Detachment [-]Macular Degeneration Other: MED HX: (-)DM (+)HTN: on meds (+)Hyperlipidemia: on meds (-)CVA (-)Cancer (-)Hepatic (-)Renal (-)Cardiovascular (-)Respiratory (+)Neurological: bipolar disorder, migraines (-)Genitourinary (+)Hemotologic: patient reports running anemic on blood counts (+)Endocrine: hypothyroid (-)Musculoskeletal (-)Autoimmune (+)Gastrointestinal: GERD PSHX: (-)Smoke (-)ETOH Current Medications Reviewed Blood Pressure - 136/86 (11/30/2015 19:23) Jan 16, 2015@11:43:36 BLOOD HBA1C 5.6 % 4.5 - 6.0 Allergies - INFLUENZA, TRAMADOL CURRENT SPECTACLE RX: OD: plano -0.75 x 158 OS: +1.25 -1.00 x 175 ADD: +2.50 VISUAL ACUITY: With Correction DIST OD 20/20 OS 20/20 PUPILS: PERRL: Yes APD: [-] CONFRONTATOINS: FULL TO FINGER COUNTING OU EOMS: Full and smooth OU, no pain or diplopia OU REFRACTION AND BEST VISUAL ACUITY: OD: plano -0.50 x 158 20/20 OS: +1.50 -1.00 x 175 20/20 ADD: +2.50 20/20 Patient prefers [+]Pal [+]UV400 [+]Scratch coating SLIT LAMP EXAM: Lids/Lashes: clear OU Sclera/Conjunctiva: trace papillae OU Cornea: CE scars OU; thin tear film OU; no staining, TBUT WNL OU ANTERIOR CHAMBER: OD: Deep/Dark/Quiet OS: Deep/Dark/Quiet IRIS: OD: Flat and Intact, No Rubeosis OS: Flat and Intact, No Rubeosis TONOMETRY: OD: 15 OS: 15 TIME: 10:09 am DILATION: 1 GTT Tropicamide (1.0%) OU 1 GTT Phenylephrine (2.5%) OU INTERNAL (78, 20D BIO): LENS: OD: PCIOL OS: PCIOL VITREOUS: OD: clear OS: clear NERVE: OD: 0.30/0.30 hor/vert, healthy rim tissue OHN Size determined by 78D size x 1.1 [+]Small vertical optic disc diameter ~1.3 mm Rim Evaluation [+]ISNT Retinal nerve fiber layer. [-]wedge-shaped arcuate dark areas emanating from the optic disc greater than an arteriole wide. Parapapillary Atrophy [+]Zone Alpha PPA Optic disc hemorrhage [-]Drance OS: 0.35/0.35 hor/vert, malinserted, nasal drusen, healthy rim tissue OHN Size determined by 78D size x 1.1 [+]Small vertical optic disc diameter ~1.3 mm Rim Evaluation [+]ISNT Retinal nerve fiber layer. [?]wedge-shaped arcuate dark areas emanating from the optic disc greater than an arteriole wide - possible defect superior nasal Parapapillary Atrophy [+]Zone Alpha PPA Optic disc hemorrhage [-]Drance MACULA: OD: no blood, fluid or exudates; trace ERM; trace perifoveal drusen OS: no blood, fluid or exudates; trace ERM; trace perifoveal drusen BLOOD VESSELS: OD: normal course and caliber OS: normal course and caliber PERIPHERY: OD: No holes, tears or detachments OS: No holes, tears or detachments; choroidal pigment changes superotemporal ADDITIONAL TESTS: (+) OCT: RNFL Thickness Average Analysis Report OD: avg thickness = 84; borderline superior thinning OS: avg thickness = 82; borderline superior thinning -Impression: stable to 11/2014 scans OU ASSESSMENT: 1. Mild glaucoma suspect OU due to borderline RNFL and previous VF defects -low risk suspect a. IOP 12/1/15: 15/15, untreated OU b. OCT 12/1/15: borderline thinning OD, OS but stable OU to 2014 c. Optos 11/24/14: stable cupping OU d. visual field 06/25/14: no glaucomatous defects OU e. gonioscopy 06/25/14: open angles 360 OU f. pachymetry 09/21/12: 563/555: slight thicker than average CCT OD>OS g. GDx 06/25/14: NFI= 30/24: superior thinning OD, WNL OS; stable OU to 03/28/13 2. Pseudophakia OU 3. Trace epiretinal membrane OU 4. Hypertension without angiopathy OU 5. Hyperopia OS, astigmatism OU, presbyopia OU 6. Allergic conjunctivitis OU - complaints of itching PLAN: 1. Educated patient on findings from today's exam. OCT RNFL findings are stable at this time. No treatment indicated at this time but will ontinue to monitor superior rim OD for progressive/glaucomatous like changes. Monitor as follows: a. IOP 05/2016 b. repeat OCT 12/2016 complete exam c. repeat photos 12/2016 complete exam d. repeat visual field 05/2016 e. repeat gonioscopy 05/2016 f. repeat pachymetry PRN g. repeat GDx 05/2016 2. Monitor at complete exam 12/2016 3. Very mild ERM. Monitor with amsler grid returning with any changes. Monitor at complete exam 12/2016 4. Encouraged good blood pressure control; monitor complete exam/photos 12/2016 5. Sent Rx to optical shop. Monitor 12/2016. 6. Educated patient on findings today and prescribed ketotifen BID OU. Monitor at VF visit 5/2016. RTC 5/2016 visual field testing