Dry Eye Disease Evaluation Note

Date/Time: [Encounter date and time]

Provider: [Clinician name and credentials]

Location: [Clinic/site]

Visit Type: [New / Established / Pre-op Optimization / Reassessment]

Referral Source: [Referring clinician/service] (Only include if applicable)

Records Reviewed: [Outside records reviewed with source, dates, and pertinent findings] (Only include if outside records were actually reviewed)

Chief Complaint

[Patient's primary concern in their own words, including laterality (OD/OS/OU)]

History of Present Illness

[Narrative covering symptom onset, duration, and course (intermittent vs persistent; progressive vs stable); primary symptom descriptors (dryness, burning, foreign body sensation, tearing, photophobia, fluctuating vision); diurnal pattern; functional impact (screen tolerance, reading, driving, contact lens wear); key triggers (screen time, low humidity, airflow, travel, CPAP); relieving factors; and prior/current dry eye treatments with response and adherence. Include contact lens history if the patient is a wearer. If the patient is a poor historian, state this and document the information source.] (Write 2–6 sentences)

Symptom Score

Instrument: [OSDI-6 / OSDI / DEQ-5 / SPEED / SANDE / Not administered] Score: [Numeric score with severity band if applicable] Date administered: [Date] (If a validated questionnaire was not administered, document the reason and provide a clinician-estimated severity [mild/moderate/severe] with brief context)

Contributing Factors

[Environmental/behavioral factors (screen time, humidity, airflow exposure, CPAP use); medication contributors (systemic medications associated with dryness, chronic preserved topical drops, recent topical steroids/antibiotics); relevant medical history (autoimmune disease, Sjögren's, thyroid disease, rosacea, diabetes, prior ocular surgeries affecting surface); contact lens wear details if applicable] (Use brief notation. If systemic review was not performed today, explicitly state "Systemic review not performed today" rather than implying negative findings)

Past Ocular History

[Prior refractive or cataract surgery; glaucoma; herpetic eye disease; recurrent corneal erosion; contact lens complications; eyelid procedures; prior DED interventions (punctal plugs, thermal pulsation, IPL)] (Include only relevant history)

Allergies

[Medication allergies with reaction type; known preservative sensitivities]

Current Medications

Ocular: [Name, eye (OD/OS/OU), frequency; preserved vs preservative-free if known; include OTC/artificial tears if used]

Systemic: [Name; dose if relevant to DED or ocular surface]

Objective Examination

(Document OD and OS separately throughout. If an element was not assessed, state "Not assessed" with reason rather than leaving blank)

Visual Acuity and IOP

Visual Acuity (corrected): OD: [VA] OS: [VA] (Note if fluctuating vision complaint correlates with findings)

IOP: OD: [mmHg] OS: [mmHg] Method: [Method]

External and Lid Examination

• Blink: [Complete/incomplete; reduced rate if observed]
• Lid position/closure: [Findings]
• Lashes/lash line: [Collarettes, debris, Demodex suspicion]
• Lid margin: [Telangiectasia, irregularity, frothing]

Meibomian Gland Assessment

(Required. If gland expression was not performed, state the reason)

• Orifices: [Capped/plugged/pouting]
• Expressibility: [Gentle digital pressure / Standardized evaluator] OD: [Grade or description] OS: [Grade or description]
• Meibum quality: OD: [Clear/cloudy/turbid/inspissated] OS: [Clear/cloudy/turbid/inspissated]
• Meibography: [Performed / Not performed] (If performed: device; dropout OD [None/mild/moderate/severe], OS [None/mild/moderate/severe])

Tear Film and Ocular Surface

• Tear meniscus height: OD: [Qualitative or measured] OS: [Qualitative or measured]
• Tear debris/foam: [Present/absent]
• Conjunctiva: [Hyperemia, conjunctivochalasis, papillae; distribution]
• Cornea: [Findings]
• Tear breakup: Method: [NIBUT / Fluorescein TBUT] OD: [seconds] OS: [seconds]

Ocular Surface Staining

(If staining was not performed, state the reason)

• Dyes used: [Fluorescein / Lissamine green]
• Grading scale: [Oxford / NEI / Other]
• Corneal staining: OD: [Grade and distribution] OS: [Grade and distribution]
• Conjunctival/lid margin staining: OD: [Grade and distribution] OS: [Grade and distribution]
• Lid wiper epitheliopathy: [Assessed/not assessed; grade if assessed]
• Clinical interpretation: [Pattern significance, e.g., inferior interpalpebral staining consistent with evaporative component]

Ancillary Testing

(For each test performed, document value with units, device/method, and OD/OS results. If not performed, state "Not performed" with reason. Note if noninvasive testing was completed prior to drop instillation)

• Tear osmolarity: OD: [mOsm/L] OS: [mOsm/L] Inter-eye difference: [mOsm/L] Device: [Device]
• Schirmer I: [With / Without] anesthesia; OD: [mm/5 min] OS: [mm/5 min]
• Inflammatory marker (MMP-9): OD: [Positive/Negative] OS: [Positive/Negative]
• Other testing: [Interferometry, lipid layer thickness, other as performed]

Assessment

Diagnosis: [Dry eye disease confirmed / Dry eye disease suspected / Symptoms present without objective homeostasis disruption] — [ICD-appropriate terminology: keratoconjunctivitis sicca, meibomian gland dysfunction, exposure keratopathy, other as applicable]

Subtype/Etiologic Driver: [Evaporative / Aqueous-deficient / Mixed] — Dominant drivers: [Lipid deficiency/MGD, aqueous deficiency, lid/blink dysfunction, inflammation, neurosensory factors] (List contributing diagnoses separately if present: MGD, Demodex blepharitis, allergic conjunctivitis, medication toxicity, exposure keratopathy)

Severity: [Mild / Moderate / Severe / Stage 1–4] — Anchored to: [Symptom score, TBUT/NIBUT, staining grade; note complications if present: filaments, epithelial defects, contact lens intolerance]

Findings–Symptom Concordance: [Concordant / Discordant] (If discordant, document implications such as neurosensory component or subclinical inflammation)

Differential Considerations: [Allergic conjunctivitis, recurrent erosion, HSV keratitis, neuropathic pain, medicamentosa, other] (Include when symptoms are atypical, unilateral, or disproportionate to signs; may omit for straightforward cases)

Plan

Education: [Discussion of chronic/relapsing nature and identified dominant drivers; expectations for staged therapy; drop technique and eyelid hygiene reviewed]

Foundational Measures

• Environment: [Humidity optimization, reduce airflow exposure, scheduled screen breaks]
• Lubrication: [Preservative-free artificial tears regimen and frequency; nighttime gel/ointment if indicated]
• Lid hygiene/warm compresses: [Method, duration, frequency]

Targeted Therapy

• MGD/evaporative: [Optimized heat therapy; in-office procedures (thermal pulsation, IPL, manual expression) with indication; oral omega-3 or doxycycline/azithromycin if indicated] (Include only therapies recommended)
• Aqueous deficiency: [Punctal occlusion consideration with contraindication screening; secretagogues if used]
• Inflammation: [Topical cyclosporine/lifitegrast with start date, dosing, expected onset; topical corticosteroid bridge with explicit duration, taper plan, and IOP monitoring schedule]
• Other contributors: [Demodex treatment, allergy management, contact lens modifications, rosacea management] (Include only if applicable)

Monitoring Targets

[Symptom score (same instrument) target; TBUT/NIBUT goal; staining grade reduction target; meibum quality improvement; other relevant metrics]

Referrals/Workup

[Autoimmune/Sjögren's evaluation with rationale and labs/rheumatology referral if indicated; oculoplastics for lid malposition; other specialty referrals as needed] (Include only if referral is being made)

Follow-up

Interval: [4–12 weeks based on severity and treatments initiated]

Return precautions: [Worsening pain, decreased vision, photophobia, severe unilateral redness]

Procedures Performed

(Include this section only if a procedure was performed during the visit)

• Procedure: [Name and laterality]
• Indication: [Clinical indication]
• Consent: [Informed consent obtained]
• Device/technique: [Details]
• Complications: [None / Describe]
• Post-procedure instructions: [Instructions, medications, restrictions]

(Do not infer symptom denial, adherence, or negative exam findings not documented in the encounter. For clinically important elements not assessed, document "Not assessed" with reason. If the patient declines recommended testing or treatment, document the discussion, risks explained, and alternative plan)