Ophthalmology Cataract Template (Optom use only)

This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.

Optometry Referral Details

Date of Referral: [Date]

Priority: [Routine]

Patient history and details: [Text]

Patient symptomatic:

Cataract Information

Lifestyle affected:

Wants Surgery:

Cataract leaflet given:

AMD present:

Yes
No
Don’t know

Ocular examination – External/Internal

Comment right eye: [Text]

Comment left eye: [Text]

Tonometry (value between 0-50mmHg)

Applanation:

Yes
No
Not possible

Right: [Text]

Left: [Text]

Relative afferenct pupilary defect:

Fields affected:

Last eye test

Date of test: [Date]

Right acuity:

6/4.5
6/5
6/6
6/9
6/12
6/18
6/24
6/36
6/60
3/60
1/60
CF
HM
P of L
No P of L

Left acuity:

6/4.5
6/5
6/6
6/9
6/12
6/18
6/24
6/36
6/60
3/60
1/60
CF
HM
P of L
No P of L

Refraction Details

Right Vision

R Sph: +/-

R Cyl: +/-

R Sph: [Between 0 – 25]

R Cyl: [Between 0 – 15]

R Axis: [Between 0 – 180]

R VA:

6/4.5
6/5
6/6
6/9
6/12
6/18
6/24
6/36
6/60
3/60
1/60
CF
HM
P of L
No P of L

R PH VA:

6/4.5
6/5
6/6
6/9
6/12
6/18
6/24
6/36
6/60

R Add: [Between 1 – 4]

R NVA:

N4.5
N5
N6
N8
N9
N10
N12
N14
N18
N24
N36
N48
NIL

Left Vision

L Sph: +/-

L Cyl: +/-

L Sph: [Between 0 – 25]

L Cyl: [Between 0 – 15]

L Axis: [Between 0 – 180]

L VA:

6/4.5
6/5
6/6
6/9
6/12
6/18
6/24
6/36
6/60
3/60
1/60
CF
HM
P of L
No P of L

L PH VA:

6/4.5
6/5
6/6
6/9
6/12
6/18
6/24
6/36
6/60

L Add: [Between 1 – 4]

L NVA:

N4.5
N5
N6
N8
N9
N10
N12
N14
N18
N24
N36
N48
NIL

Ophthalmology Cataract Guideline