Optometry Dry Eye Follow-Up Note

Date: [Date] Patient: [Patient Name] DOB: [DOB] Clinician: [Clinician Name]

Visit Type: Dry Eye Follow-Up Primary Diagnosis: [Primary dry eye diagnosis] Last Dry Eye Visit: [Date of prior dry eye visit]

(Omit any section not documented in the encounter. Do not infer adherence or response without explicit patient report or objective data. For commonly expected ocular surface metrics intentionally skipped, state "not performed.")

Chief Concern

[Reason for today's visit] (Limit to 1–2 lines; for protocol follow-up use: "Follow-up for response to [therapy] started [date]")

Interval History

(Anchor to the last dry eye visit. Include only changes since last visit.)

• Symptom trajectory: [improved / unchanged / worse] since [last visit date]; [specific symptoms and functional impacts]; [timing patterns or triggers if relevant]
• Patient-reported outcome: [OSDI / DEQ-5 / SPEED] [current score] (prior: [score/date]) (Include only if measured this visit)
• Adherence and tolerance:
  • Artificial tears: [type], [actual vs prescribed frequency], [tolerance]
  • Lid hygiene/warm compresses: [method and frequency actually performed], [tolerance]
  • Prescription drops: [medication], [dose/frequency], [duration], [tolerance/adverse effects]
  • In-office therapies since last visit: [type/date], [patient-reported response]
  • Contact lens wear: [modality/wear time], [tolerance] (if applicable)
• New relevant context since last visit: [new systemic medications, autoimmune symptoms, ocular surgery, or other relevant changes] (Include only if changed)

Objective

(Structure by eye with today-versus-prior comparisons when available. Use compact notation.)

Ocular Surface Metrics

• OD: TBUT ([method]): [seconds] (prior: [value]); Staining ([dye], [scale]): [score/location] (prior: [score]); Tear volume: [value]; Meibomian glands: [expressibility/quality]
• OS: TBUT ([method]): [seconds] (prior: [value]); Staining ([dye], [scale]): [score/location] (prior: [score]); Tear volume: [value]; Meibomian glands: [expressibility/quality]

Visual Acuity / IOP (Include if clinically indicated, especially with steroid use)

• VA: OD [acuity], OS [acuity]; IOP ([method]): OD [mmHg], OS [mmHg]

External/Adnexa

• OD: [lid position, blink completeness, lid margin findings, meibomian orifice status]
• OS: [lid position, blink completeness, lid margin findings, meibomian orifice status]

Slit Lamp Exam

• OD: Tear film [quality]; Conjunctiva [injection/staining]; Cornea [findings with staining score]; [AC/Lens if relevant]
• OS: Tear film [quality]; Conjunctiva [injection/staining]; Cornea [findings with staining score]; [AC/Lens if relevant]

Ancillary tests / In-office procedures today (Include only if performed)

• [Procedure/test]: [indication]; Result: [result]; Influence on plan: [brief statement]

Assessment

(Problem-oriented, ordered by clinical importance. For each: include subtype when known, status since last visit, supporting evidence, and identified drivers. Do not add diagnoses without objective basis.)

[Problem 1]: [Diagnosis with subtype]

[improved / stable / worse] since last visit. Supporting evidence: [key symptoms and objective metrics]. Drivers: [contributors such as meibomian dysfunction, allergy, exposure, medication effects].

[Problem 2]: [Diagnosis]

(Include additional problems only if discussed)

[Status and supporting evidence]

Plan

(Organize by problem. Specify continue/start/stop/change with dose, frequency, duration, and rationale. Include safety monitoring for steroids or immunomodulators.)

[Problem 1]

• Continue: [therapy, dose/frequency] – [rationale based on response]
• Start: [therapy, dose/frequency/duration] – [indication]; Safety monitoring: [IOP check/labs if applicable]
• Stop/Change: [therapy] – [reason: lack of efficacy / intolerance / adverse effect]
• Escalation criteria: [thresholds for advanced therapy or referral]

[Problem 2]

• [Continue/start/stop/change as above]

Maintenance Regimen

• Daily: [lubrication schedule, lid hygiene, warm compress routine]
• Flares: [rescue measures and maximum frequency]
• Environmental/behavioral: [humidification, screen breaks, other measures]

Follow-up: [Timeframe] for [purpose]. Return sooner for: pain, photophobia, decreased vision, unilateral redness, or other concerning changes.

Clinician Signature: [Name, credentials, date/time]