Cataract Evaluation & IOL Planning Note

Header Fields

Date: [Date of service]

Provider: [Rendering clinician name and credentials]

Location: [Clinic or facility name]

Visit Type: Cataract Evaluation & IOL Planning

Chief Complaint

[Patient-centered visual symptom and/or functional complaint in patient's own words] (If not stated, document: "Visit for cataract evaluation per referral.")

History of Present Illness

[Narrative paragraph beginning with chief complaint, including laterality throughout: visual symptoms (blur, glare, halos, starbursts, monocular diplopia/ghosting, decreased contrast, color changes), duration and progression, triggering contexts (night driving, bright light, screens, reading), prior interventions (updated glasses or contacts) and whether helpful, which eye is perceived worse] (Use OD/OS or Right/Left consistently. Do not infer unstated symptoms.)

[Functional impairment description with explicit activities affected and anchor statement for medical necessity] [Patient quote summarizing most significant limitation, especially driving] (Example: Patient states: "I stopped driving at night because headlights blind me.")

Refractive History and Visual Goals

• Current correction: [Glasses (distance / near / progressive) / Contact lenses / Readers / None]
• Prior monovision experience: [Contacts / LASIK / Natural / None] — [Tolerated well / Not tolerated / Unknown]
• Occupational and lifestyle demands: [Night driving frequency, computer use, near work requirements, outdoor activities]
• Patient-stated refractive goals (priority order): [Goal 1], [Goal 2], [Goal 3]
• Willingness to wear glasses post-op: [Distance / Near / Both / Prefers independence / Unknown]
• Willingness to accept halos/glare for reduced spectacle dependence: [Yes / No / Conditional / Unknown]
• Ocular dominance: [Dominant eye and method / Not tested]

(If goals are not finalized, document: "Refractive goals not finalized—counseling deferred pending testing/decision.")

Ocular History

• Prior ocular surgeries: OD: [Procedure and date / None] | OS: [Procedure and date / None]
• Ocular diagnoses: OD: [Diagnoses / None] | OS: [Diagnoses / None]
• Trauma history: OD: [Details / None] | OS: [Details / None]
• Dry eye/blepharitis: [Severity and current treatment / None]
• Retinal tears/detachment history: OD: [Details / None] | OS: [Details / None]

Relevant Medical History

• Anticoagulants/antiplatelets: [Medication name and indication / None]
• Alpha-1 antagonists and IFIS history: [Medication name / None] — [Prior IFIS: Yes / No / Unknown]
• Diabetes: [A1c and control status / Not applicable]
• Positioning limitations/tremor/cognitive concerns: [Details / None]
• Allergies relevant to perioperative care: [List / NKDA]

Examination

Visual Acuity

• OD: UCVA [acuity] | BCVA [acuity] | Near [acuity with add] | Refraction: [manifest or spectacle Rx]
• OS: UCVA [acuity] | BCVA [acuity] | Near [acuity with add] | Refraction: [manifest or spectacle Rx]

(Include near acuity and refraction only if relevant to planning. Mark Not obtained for elements not tested.)

Glare or Contrast Testing

(Include only when clinically indicated.)

Indication: [Symptom-based justification] — Method: [Device/test] — Results: OD: [Result] | OS: [Result]

Anterior Segment Examination

• OD:
  • Pupils: [Size, reactivity, RAPD if present] — Dilation: [Adequate / Poor / Expansion device anticipated]
  • Lids/ocular surface: [Findings affecting measurement reliability]
  • Cornea: [Surface, clarity, guttata, endothelium, scars]
  • Anterior chamber: [Depth, inflammation]
  • Iris: [Synechiae, pseudoexfoliation, pupil quality]
  • Lens: [Cataract type] — Grade: [Severity]
• OS:
  • Pupils: [Size, reactivity, RAPD if present] — Dilation: [Adequate / Poor / Expansion device anticipated]
  • Lids/ocular surface: [Findings affecting measurement reliability]
  • Cornea: [Surface, clarity, guttata, endothelium, scars]
  • Anterior chamber: [Depth, inflammation]
  • Iris: [Synechiae, pseudoexfoliation, pupil quality]
  • Lens: [Cataract type] — Grade: [Severity]

Intraocular Pressure

OD: [IOP mmHg] | OS: [IOP mmHg] — Method: [Applanation / Tonopen / iCare]

Dilated Fundus Examination

• OD: Optic nerve: [C/D ratio, appearance]; Macula: [Findings]; Vessels: [Findings]; Periphery: [Findings including tears/holes/lattice or normal]
• OS: Optic nerve: [C/D ratio, appearance]; Macula: [Findings]; Vessels: [Findings]; Periphery: [Findings including tears/holes/lattice or normal]

(If posterior view limited by cataract density, document limitation and plan for alternative evaluation.)

Diagnostic Testing

(Include only tests beyond routine comprehensive exam and biometry. Each test requires medical necessity justification.)

• [Test name]: Indication: [Medical necessity] — Results: [Key findings] — Impact: [Effect on surgical planning]

Biometry and IOL Calculation

Device: [Optical biometry / Ultrasound A-scan] — Date: [Date] — Quality: [Good / Fair / Poor] — Contact lens removed: [Duration / Not applicable]

Measurements

• OD: AL: [mm]; K1: [D @ axis]; K2: [D @ axis]; Corneal astigmatism: [D @ axis]; ACD: [mm]; LT: [mm]; WTW: [mm]
• OS: AL: [mm]; K1: [D @ axis]; K2: [D @ axis]; Corneal astigmatism: [D @ axis]; ACD: [mm]; LT: [mm]; WTW: [mm]

(Mark Pending if biometry incomplete or unreliable; document next steps.)

IOL Calculation

• OD:
  • Formula: [Barrett / Haigis / Holladay / Hoffer Q / Post-refractive] (Rationale for formula choice if non-standard: [Reason])
  • IOL options: [Model/Power → Predicted SE], [Model/Power → Predicted SE]
  • Discrepancy reconciliation: [If methods disagree, describe resolution and final rationale]
• OS:
  • Formula: [Barrett / Haigis / Holladay / Hoffer Q / Post-refractive] (Rationale for formula choice if non-standard: [Reason])
  • IOL options: [Model/Power → Predicted SE], [Model/Power → Predicted SE]
  • Discrepancy reconciliation: [If methods disagree, describe resolution and final rationale]

Astigmatism Plan

• OD: Astigmatism: [Magnitude, regular / irregular] — Plan: [No treatment with glasses / Toric IOL at axis / Corneal relaxing incisions] — Patient counseled that residual astigmatism may persist.
• OS: Astigmatism: [Magnitude, regular / irregular] — Plan: [No treatment with glasses / Toric IOL at axis / Corneal relaxing incisions] — Patient counseled that residual astigmatism may persist.

Assessment

Cataract Assessment

• OD: [Cataract type] — Visually significant: [Yes / No] based on: [Symptom correlation], [Objective findings], [Cataract severity]. (If cataract not primary driver of symptoms, state alternative explanation.)
• OS: [Cataract type] — Visually significant: [Yes / No] based on: [Symptom correlation], [Objective findings], [Cataract severity]. (If cataract not primary driver of symptoms, state alternative explanation.)

Ocular Comorbidities Affecting Prognosis or IOL Selection

• [Condition]: [Supporting findings] — Impact on outcome: [Expected effect] — IOL implications: [Selection guidance] — Expectations discussed: [Yes / No]

(Add one entry per relevant condition. Omit section if no significant comorbidities.)

Surgical Risk Factors

• Poor dilation / IFIS risk: [Present / Absent] — [Details]
• Pseudoexfoliation / zonular weakness: [Present / Absent] — [Details]
• Prior ocular surgery: [Type and laterality / None]
• Corneal or endothelial compromise: [Present / Absent] — [Details]
• Dense/brunescent lens or posterior polar cataract: [Present / Absent]
• Anticoagulation: [Medication and plan / None]
• Cooperation/positioning limitations: [Present / Absent] — [Details]

Plan

Right Eye (OD)

• Recommendation: [Observe / Optimize ocular surface then reassess / Proceed with cataract surgery] — Medical necessity: [Functional impairment statement linking symptoms to visual limitations not correctable by glasses]. Expected benefit: [Anticipated functional improvement].
• IOL Strategy: Target refraction: [Plano / Mild myopia / Monovision near target] — IOL type: [Monofocal / Toric monofocal / EDOF / Multifocal] — Rationale: [Clinical reasoning]
  • Counseling: [Distance prioritized; reading glasses required. / Monovision planned; adaptation and depth perception discussed. / Halos, glare, and variable night vision satisfaction discussed.]
  • Premium options: [Discussed and accepted / Discussed and declined / Not discussed]
• IOL Selection: [Model, Power, Incision location, Toric axis if applicable] (If not finalized: Pending [repeat biometry / ocular surface treatment / additional calculations].)
• Surgical Details: Phacoemulsification with PCIOL — Anesthesia: [Topical / MAC / Retrobulbar] — Special requirements: [Pupil expansion / CTR / Trypan blue / None]

Left Eye (OS)

• Recommendation: [Observe / Optimize ocular surface then reassess / Proceed with cataract surgery] — Medical necessity: [Functional impairment statement linking symptoms to visual limitations not correctable by glasses]. Expected benefit: [Anticipated functional improvement].
• IOL Strategy: Target refraction: [Plano / Mild myopia / Monovision near target] — IOL type: [Monofocal / Toric monofocal / EDOF / Multifocal] — Rationale: [Clinical reasoning]
  • Counseling: [Distance prioritized; reading glasses required. / Monovision planned; adaptation and depth perception discussed. / Halos, glare, and variable night vision satisfaction discussed.]
  • Premium options: [Discussed and accepted / Discussed and declined / Not discussed]
• IOL Selection: [Model, Power, Incision location, Toric axis if applicable] (If not finalized: Pending [repeat biometry / ocular surface treatment / additional calculations].)
• Surgical Details: Phacoemulsification with PCIOL — Anesthesia: [Topical / MAC / Retrobulbar] — Special requirements: [Pupil expansion / CTR / Trypan blue / None]

Bilateral Surgery Timing

[Sequential surgery planned with interval / Second eye pending first eye outcome / Not applicable—unilateral surgery only]

Perioperative Management

• Ocular surface optimization: [Treatment plan and timeline / Not needed]
• Anticoagulation management: [Continue / Hold / Coordinate with prescriber]
• Alpha-1 antagonist/IFIS counseling: [Discussed / Not applicable]

Informed Consent

[Narrative summary documenting consent discussion including diagnosis, indication, nature of cataract surgery with IOL implantation, and patient's decision]

• Alternatives reviewed: [Observation / Glasses / Contact lenses / Different IOL strategies]
• Material risks discussed: [Infection, bleeding, inflammation, corneal edema, posterior capsule rupture, retinal detachment, CME, refractive surprise, glare/halos, anesthesia risks] (Tailor to patient-specific factors.)
• Patient questions addressed: [Yes / No]
• Decision: [Proceed / Defer / Considering]
• Consent form: [Signed and filed / To be obtained at pre-op visit]

(If patient is only considering surgery, document: "Counseling provided; formal consent to be obtained if patient elects surgery.")

Financial Counseling

(Include only if premium or noncovered services discussed; omit entirely for routine monofocal cases.)

• Upgrade selected: [Toric / EDOF / Multifocal / LRI]
• Covered vs. noncovered explained: [Yes]
• Patient acknowledges out-of-pocket cost and no guarantee of spectacle independence: [Yes]
• Financial documentation: [Waiver signed and filed]

(If premium options discussed but declined, document: "Premium IOL options discussed and declined; proceeding with standard monofocal.")

Orders and Follow-up

• Testing ordered: [Test and indication / None]
• Surgery scheduling: [Scheduled for date / Pending authorization / Patient to decide]
• Co-management: [Arrangement details / None]
• Follow-up: [Next appointment] — Instructions: [Interim guidance]