This document contains the results of an orthoptic evaluation for an unnamed patient. It includes information about the patient's chief complaints, medical history, visual acuity and refraction tests. The orthoptic evaluation section details the results of tests measuring stereopsis, eye movement, phoria, vergence ranges, accommodative response and facility. The impression and advice sections summarize the examiner's findings and recommendations.

1. Date:
Time: WORK-UP DONE BY:
Patient Details:
1. Name Age / Sex:
2. Occupation Reg. No.:
History:
3. Main Complaints:
4. Hours of near work / Computer use and related details:
5. Associated Symptoms:
6. General health and medication details
7. REFRACTION
PGP OD:
OS:
VISUAL ACUITY OD:
OS:
RETINOSCOPY OD:
OS:
ACCEPTANCE OD:
OS:
Orthoptics Evaluation

2. 8.ORTHOPTIC EVALUATION
STEREOPSIS (NEAR)
W4DT D N
EOM OD
OS
COVER TEST OD
OS
MADDOXROD:
(HORIZONTAL)
OD
OS
PBCT OD
OS
AC/A ratio
Gradient AC/A ratio
NPC (ACCOMODATIVE TARGET) SUBJECTIVE cm OBJECTIVE cm
NPC (WITH RED FILTER) SUBJECTIVE cm OBJECTIVE cm
Qualitative comments: Recedes / doesn’t recede on repeated testing
NPA OD cm OS cm OU cm
AA OD cm OS cm OU cm
Hofstetter’s Minimum (AA)
MEM Retinoscopy OD DS OS DS
NRA DS
PRA DS
FUSIONAL VERGENCE
AMPLITUDES (STEP VERGENCE)
COMMENTS
BLUR BREAK RECOVERY
NFV D
N
PFV D
N
Reduced PFV (D/N) Reduced NFV (D/N) / Both
Reduced / BOTH NORMAL

3. VERGENCE FACILITY (15 BO / 5 BI) CPM
COMMENTS -Equally clears BO / BI
-Difficulty clearing BO /BI / Both
ACCOMMODATIVE FACILITY
(+/- 2.00 ; +/- 1.50 ; +/- 1.00 DS)
OD CPM
OS CPM
OU CPM
COMMENTS -Equally clears Plus / Minus lenses
-Difficulty clearing Plus / Minus / Both
BVA FINDINGS -CISS (PASS / FAIL)
-FUSIONAL RANGES (FAILS BI / FAILS
BO / PASS BI / PASS BO)
-ACCOMMODATIVE FACILITY(PASS /
FAIL)
-W4DT (FUSION / SUPPRESSION /
DIPLOPIA)
-VERGENCE FACILITY (PASS / FAIL)
IMPRESSION:
ADVICE:
FOLLOW - UP