H52.13Myopia, bilateralPrimaryH52.23Astigmatism, bilateralH04.123Dry eye syndrome, bilateralE11.3219Type 2 DM without diabetic retinopathy, unspecified92004Ophthalmological exam new patient comprehensive$18592015Determination of refractive state$45PMHx
Type 2 Diabetes (well-controlled, A1C 6.8), Hypertension (controlled with lisinopril)
Medications
Lisinopril 10 mg daily, Metformin 500 mg BID, Refresh Tears PRN
Family History
Mother: glaucoma. Father: type 2 diabetes.
Social History
Software engineer. Non-smoker. Occasional alcohol. Exercise 3x/week.
Chief Complaint
Annual comprehensive eye exam. Patient reports mild dry eye symptoms, worse in the afternoon. No new visual complaints.
Jennifer is a 48-year-old female presenting for her annual comprehensive eye examination. She reports increased dry eye symptoms over the past 3 months, particularly in the afternoons and with prolonged screen use. She works 8+ hours/day at a computer. Denies pain, discharge, flashes, or floaters. Last exam 1 year ago with no significant changes noted.
Assessment
1. Myopia, bilateral (H52.13) 2. Astigmatism, bilateral (H52.23) 3. Dry eye syndrome, bilateral (H04.123) 4. DM type 2 without diabetic retinopathy (E11.3219) 5. Hypertensive retinopathy, not present
Plan
1. Updated spectacle Rx — Rx given today 2. Contact lens Rx provided (same as glasses minus 0.25 DS) 3. Dry eye: warm compresses BID, omega-3 supplements, Refresh Tears PRN. Increase artificial tears to QID if inadequate relief in 6 weeks. 4. Diabetic eye exam: no retinopathy detected. Annual follow-up in 12 months. 5. Return PRN or in 12 months for annual exam.
| Eye | Sph | Cyl | Axis | Add |
|---|---|---|---|---|
| OD | -2.25 | -0.75 | 90 | +1.5 |
| OS | -2.75 | -0.50 | 85 | +1.5 |
Progressive lenses recommended
| Eye | Brand | Sph | BC | Dia |
|---|---|---|---|---|
| OD | Acuvue Oasys | -2.00 | 8.4 | 14 |
| OS | Acuvue Oasys | -2.50 | 8.4 | 14 |
Reduce glasses Rx by -0.25 DS
| Eye | Sph | Cyl | Axis | Add |
|---|---|---|---|---|
| OD | -2.25 | -0.75 | 090 | — |
| OS | -2.75 | -0.50 | 085 | — |
Encounter Record
Created: Tue, May 5, 2026
Signed by Dr. Johnson at 9:12 AM