Ophthalmology Postoperative Follow-up Note (Retina/Vitreoretinal)

Date: [Date]

Provider: [Provider name and credentials]

Location: [Clinic/Facility]

Visit Type: Postoperative follow-up (retina/vitreoretinal)

Post-op Interval: [POD / POW / POM] #[Number]

Operated Eye: [OD / OS]

Surgical Context

Procedure: [Procedure performed]; Indication: [Pre-op diagnosis]; Date of Surgery: [Date]; Tamponade: [Gas type with estimated fill / Silicone oil / None]; Lens Status: [Phakic / Pseudophakic / Aphakic]; Current Requirements: [Positioning, shield use, activity restrictions]

(If surgical details unavailable, state "per op note" or "per patient report—records requested" and label uncertainty. Maintain consistent laterality notation throughout.)

Subjective

Reason for Visit: [One-line purpose of visit]

[Interval history since surgery] (Include symptom trajectory [improved / unchanged / worsened], complication screen responses actually elicited [pain, vision changes, flashes/floaters, redness/discharge, trauma/strain], drop adherence and barriers, positioning compliance if applicable, and relevant events [ER visits, anesthesia exposure, altitude/flight]. Do not document negatives for items not asked. Note if history is unreliable and alternate source used.)

Objective

VA: [Operated eye acuity with method] (Note if gas bubble limits assessment.)

IOP: [Value and method] (If not obtained, state "not assessed—[reason]—[plan]")

Anterior Segment: [Pertinent findings: lids, conjunctiva, cornea, AC cell/flare, lens/IOL, wound/sclerotomy sites]

Posterior Segment: [Media clarity, vitreous status with gas/oil fill estimate if applicable, optic nerve, macula, peripheral retina attachment 360°, status of breaks/laser/buckle]

Imaging: [OCT, fundus photos, B-scan with clinical interpretation] (Include only studies performed with interpretation, not studies ordered.)

(For VA, IOP, and retinal attachment status, never leave blank—use "not assessed—[reason]—[plan]" if not obtained. Include fellow eye only if examined, with clear laterality.)

Assessment

1. [Primary postoperative status: post-op interval, procedure, retinal status, gas/oil fill if applicable]
2. [Complications or concerns in descending urgency: IOP, inflammation, wound issues] (Include only if present.)
3. [Fellow-eye issues] (Include only if addressed at this visit; clearly separate with laterality.)

(Number problems in descending clinical urgency. Omit unused problem lines.)

Plan

Problem 1: [Management for primary postoperative status]

• Medications: [Drops with eye, dose, frequency, taper schedule; note starts/stops/changes]
• Positioning: [Position, hours/day, duration, sleeping instructions, rationale] (If op details uncertain, provide conservative interim guidance with urgent follow-up.)
• Precautions: [Gas warnings: no flying/altitude until absorbed, no nitrous oxide, avoid supine / Silicone oil precautions / Activity restrictions: shield, lifting, water]
• Return precautions: [Document counseling for: worsening pain, decreased vision, increasing redness/discharge, new flashes/floaters, curtain/shadow, severe headache/nausea/vomiting; note if written instructions provided]
• Follow-up: [Timeframe and planned testing]

Problem 2: [Management] (Include only if applicable; document refusal and counseling if intervention declined.)

(Ensure all plans specify laterality where applicable.)