BE Virtual
BE F2F
URC
Post Inj
MOCT
RETINA
Cataract
post injection
Diagnosis
Eye(s):
Right Eye
Left Eye
Both Eyes
Systemic
Diagnosis:
Select Diagnosis
Wet AMD
Dry AMD
GA
Disciform
DMO
BRVO
CRVO
PDR
Severe NPDR
Steroid Response
NVG
POAG
Ocular HTN
NTG
Glaucoma Suspect
PACS
PAC
PACG
CACG
PXF Glaucoma
Secondary Glaucoma
Mixed Glaucoma
Trabeculectomy
Cyclodiode Laser
SLT
Failed Trabeculectomy
MicroPulse Diode Laser
YAG PI
Phaco + MIGS
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Previous Treatments
Number of Previous Treatments / Injections:
Select Treatment:
Eylea
Faricimab
Lucentis
Ongavia
Ozurdex
Iluvien
PRP
Sect PRP
Focal Laser
Diagnosis2:
Wet AMD
CRVO
BRVO
DMO
Myopic
Dry AMD
Eye:
Right Eye
Left Eye
Gap:
4/52
6/52
8/52
10/52
12/52
14/52
16/52
Add
Treatment
Eye(s):
Right Eye
Left Eye
Both Eyes
Oral
Treatment Option:
Select Treatment Option
G Monopost
G Cosopt
G Cosopt
G Fixapost
G Trusopt BD
G Trusopt TDS
G Alphagan BD
G Alphagan TDS
G Thealoz
G Cationorm
G Hyloforte
G VisuXL
OC Hylonight
VisuXL gel
G Xailin Night
Tab Acetazolamide BD
Tab Acetazolamide TDS
Tab Acetazolamide QDS
Add Treatment
Findings
Vision
Right Eye: 6/
Left Eye: 6/
Intraocular Pressure
Right Eye:
Left Eye:
Impression
Persistent IRF BE
RE Dry but VA Worse
LE dry but worse VA
RE Persistent SRF
LE Persistent SRF
RE Resolution of SRF
LE Resolution of SRF
RE Reduction of SRF
LE Reduction of SRF
Hyper reflective spots
Dry Macula BE
Plan
Monitor
Rev 6m
T&E Ext
T&E Reduce
Custom Plan 5
Custom Plan 6
Custom Plan 7
Custom Plan 8
Custom Plan 9
Custom Plan 10
Management Plan
Number of Injections:
Treatment:
Eylea
Faricimab
Lucentis
Ongavia
Ozurdex
Iluvien
PRP
Sect PRP
Focal Laser
Eye:
Right Eye
Left Eye
Diagnosis:
Wet AMD
CRVO
BRVO
Myopic
Dry AMD
Gap between treatments:
4/52
6/52
8/52
10/52
12/52
14/52
16/52
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Title:
Mr
Mrs
Ms
Miss
Gender:
Gentleman
Lady
Patient's Name:
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Letter:
