OCT Interpretation Report (Macula/Retina)

Patient: [Patient name and identifiers per local policy]

Study Date: [Date of image acquisition]

Interpretation Date: [Date of this report]

Laterality: [OD / OS / OU]

Ordering Clinician: [Name / Self-ordered as treating clinician]

Interpreting Clinician: [Name and credentials]

Indication

[Reason for OCT, working diagnosis, and current treatment status if applicable]. (1–2 sentences establishing medical necessity for serial imaging.)

Image Quality

[Overall quality rating]. Signal strength: [value / not available].

• [Limiting factors, if any] (e.g., motion artifact, media opacity, segmentation errors, off-center capture)
• [Interpretability statement] ([Adequate for assessment / Limited: unable to reliably assess [structure/region] due to [reason]])

Findings

OD: (If not imaged, state "Not imaged" and omit bullets.)

• Central subfield thickness: [value µm] (State "Unreliable due to segmentation errors" if applicable.)
• Intraretinal fluid: [present / absent] (If present: [foveal / extrafoveal], [trace / mild / moderate / severe].)
• Subretinal fluid: [present / absent] (If present: location and extent.)
• PED: [present / absent] (If present: [serous / fibrovascular / drusenoid / hemorrhagic], size/distribution.)
• Vitreomacular interface: [ERM / VMT / PVD status / macular hole staging, as applicable]
• Outer retina: Ellipsoid zone and RPE [intact / focal disruption / atrophy] (Specify distribution if abnormal.)
• [Other pertinent findings] (Include only if present.)

OS: (If not imaged, state "Not imaged" and omit bullets.)

• Central subfield thickness: [value µm] (State "Unreliable due to segmentation errors" if applicable.)
• Intraretinal fluid: [present / absent] (If present: [foveal / extrafoveal], [trace / mild / moderate / severe].)
• Subretinal fluid: [present / absent] (If present: location and extent.)
• PED: [present / absent] (If present: [serous / fibrovascular / drusenoid / hemorrhagic], size/distribution.)
• Vitreomacular interface: [ERM / VMT / PVD status / macular hole staging, as applicable]
• Outer retina: Ellipsoid zone and RPE [intact / focal disruption / atrophy] (Specify distribution if abnormal.)
• [Other pertinent findings] (Include only if present.)

(Document pertinent negatives only when image quality supports confident exclusion.)

Impression

OD: [Key findings and fluid status summary]. Compared to [prior OCT date]: [stable / improved / worsened]. (State "No prior OCT available for comparison" if none. Lead with quality limitations if applicable.)

OS: [Key findings and fluid status summary]. Compared to [prior OCT date]: [stable / improved / worsened]. (State "No prior OCT available for comparison" if none. Lead with quality limitations if applicable.)

Plan

• [Treatment decision]: [Proceed with / Defer] [therapy] ([brief rationale linked to OCT findings])
• Follow-up: [interval] (Note if adjusted based on current findings.)
• [Additional testing or referral if indicated] (e.g., FA, OCTA, retina surgical evaluation)

I personally reviewed and interpreted the OCT images listed above.

[Interpreting clinician name], [Credentials]

Signature: ________________________________

Date/Time: [Date and time of signature]

Communication

(Include only if urgent or unexpected findings were communicated outside routine workflow.)

[Finding communicated] conveyed to [recipient name/role] on [date/time] via [phone / secure message / in-person].