OCT Interpretation Report (Optic Nerve/RNFL)

Patient: [name, DOB or MRN]   Date Performed: [date]   Eye(s): [OD / OS / OU]

Protocol(s): [e.g., Peripapillary RNFL, Macular GCIPL]   Device: [device/model]   Ordering Clinician: [name]   Interpreting Clinician: [name]

Indication

[Primary indication and clinical question—include glaucoma stage or suspect status, purpose of study (baseline / progression evaluation / post-intervention / functional correlation), and any relevant confounders such as high myopia or macular pathology if known]

Quality Assessment

OD: Signal strength [value]; centration [adequate / decentered]; artifacts [none / describe]; segmentation [acceptable / errors noted]. Reliability: [Good / Fair / Poor] (If Poor, state findings limited and recommend repeat. If Fair, specify affected findings.)

OS: Signal strength [value]; centration [adequate / decentered]; artifacts [none / describe]; segmentation [acceptable / errors noted]. Reliability: [Good / Fair / Poor] (If Poor, state findings limited and recommend repeat. If Fair, specify affected findings.)

Findings

OD:

• RNFL: Global average [value µm]; quadrant summary [S/I/N/T values]; [anatomical pattern description with clock-hour localization if thinning present] (Describe pattern rather than relying solely on color-classification.)
• GCC/GCIPL: [Average and minimum thickness; hemifield/sector pattern] (If not performed, state "Not performed." Do not imply normal.)
• ONH metrics: [Include if available and clinically used; qualify if unreliable] (Optional—omit if not routinely reported.)

OS:

• RNFL: Global average [value µm]; quadrant summary [S/I/N/T values]; [anatomical pattern description with clock-hour localization if thinning present]
• GCC/GCIPL: [Average and minimum thickness; hemifield/sector pattern]
• ONH metrics: [Include if available and clinically used; qualify if unreliable]

Comparison & Progression

OD: Prior comparison: [date(s) / No prior OCT—establishes baseline]. Method: [event-based / trend-based / qualitative]. Conclusion: [No evidence of progression / Possible progression / Likely progression / Progression confirmed] (Downgrade certainty if quality reduced. Note if RNFL near floor limits detection.)

OS: Prior comparison: [date(s) / No prior OCT—establishes baseline]. Method: [event-based / trend-based / qualitative]. Conclusion: [No evidence of progression / Possible progression / Likely progression / Progression confirmed]

Impression

OD (Reliability: [Good / Fair / Poor]): [Key abnormality pattern, consistency with glaucoma vs alternative diagnosis if relevant, stability/progression conclusion]

OS (Reliability: [Good / Fair / Poor]): [Key abnormality pattern, consistency with glaucoma vs alternative diagnosis if relevant, stability/progression conclusion]

Management Impact

• Treatment: [No change / escalate therapy / laser discussion / surgical evaluation]
• Monitoring: [Repeat OCT and functional testing interval]
• IOP target: [Adjustment if applicable] (If OCT unreliable, emphasize repeat testing over escalation.)

Signature: [name/credentials]   Date/Time Signed: [date/time]