Sample Patient | 67F | MRN 001234 | Last exam 03/18/26
Sample Patient R | 78F | MRN 004417 | Last exam 05/12/26 Retina specialist view
Today: IOP check per 03/26 plan
Dx: POAG OU moderate (target mid-teens OU); pseudophakia OU; MGD OU
OD: above target last 2 visits as SLT effect wanes
OS: stable on current regimen
Surgery/Procedures: CE/PCIOL OD 04/21, OS 05/21; SLT OD 05/24
Meds: latanoprost 0.005% QHS OU
Allergies/Intolerances: sulfa (hives)
Failed/stopped tx: Rocklatan OU — hyperemia, d/c 01/26
Standing decisions: timolol avoided — asthma (06/22)
Open items: OCT RNFL + VF 24-2 ordered 03/26, not yet done
67F with moderate POAG OU here for IOP check per the 03/26 plan; OD has run above target the last two visits as her 05/24 SLT effect wanes, while OS remains stable (target mid-teens OU). Pseudophakic OU (CE/PCIOL 2021). On latanoprost QHS OU; Rocklatan was d/c 01/26 for hyperemia, and timolol is avoided given asthma. Sulfa allergy. MGD OU. Today: IOP check — OD control and the OCT/VF ordered 03/26 but not yet done are the open items.
IOP ck per 03/26 plan. POAG OU mod — above target OD ×2 visits as SLT waned, OS stable (tgt mid-teens); CE/PCIOL OU ’21, SLT OD 05/24; latanoprost QHS OU; Rocklatan d/c 01/26 (hyperemia); sulfa allergy; timolol avoided (asthma); MGD OU; OCT/VF ordered 03/26 not done.
Today: IVV OD due — T&E q12 per 05/26 plan; extend to q14 only if dry (q14 failed 03/25)
Dx: nAMD OD (type 1 CNV) — dry ×5 visits on IVV q12; iAMD OS (large drusen, no CNV)
OD: CST 254 µm, no IRF/SRF; VA 20/40
OS: no exudation; Amsler stable; VA 20/25
Anti-VEGF OD: 24 inj — IVA ×3 (01–03/23) → IVE ×8 (04/23–01/24) → IVV ×13 (02/24–present)
Tx failures: IVA — persistent SRF after 3 monthly; IVE — SRF recurred at q8 (09/23), persistent at q6
T&E: max tolerated interval q12; q14 → SRF recurrence (03/25)
Procedures: CE/PCIOL OU 2019
Meds: AREDS2 PO daily
Allergies: povidone-iodine — chlorhexidine prep
Open items: OCT OS due 06/26
Illustrative example — fictional patient.