Ophthalmology Patient Letter
Created by
Richard Wood
Specialty
Ophthalmologist
Last edited
10/20/2026
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About this template
A concise structure for ophthalmology correspondence documenting eye-specific visual acuity, intraocular pressure, diagnoses, clinical findings, assessment, management, and follow-up. It supports clear communication of encounter details to the patient.
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Arthur Pendelton 14/05/1948 — St Thomas' Hospital ophthalmology clinic visit
Dear Mr Arthur Pendelton,
Visual Acuity
Right eye: 6/9 Left eye: 6/18, PH 6/9
Intraocular Pressure
Right eye: 22 mmHg Left eye: 24 mmHg
Diagnosis
- Bilateral Primary Open-Angle Glaucoma (POAG)
- Left Nuclear Sclerotic Cataract
- Bilateral Dry Age-Related Macular Degeneration (AMD)
- Meibomian Gland Dysfunction (MGD)
Slit-lamp exam today showed bilateral lid margin telangiectasia and capped meibomian glands. Corneas clear, AC deep and quiet OU. Lens examination revealed mild NS cataract OD and moderate NS cataract OS reducing VA. Dilated fundoscopy showed CDR 0.7 OD and 0.8 OS with inferior neuroretinal rim thinning OS. Maculae demonstrated hard drusen and mild RPE mottling OU, no subretinal fluid or haemorrhage. OCT RNFL confirmed inferior thinning OS, stable compared to baseline. Humphrey VF 24-2 reliable, showing early superior arcuate defect OS and full field OD.
Your glaucoma pressures are slightly elevated today, and there is a moderate cataract in the left eye accounting for the recent blurriness. The dry macular changes remain stable with no signs of wet conversion.
We will switch your evening drops to latanoprost / timolol (Fixapost®) 50 mcg/5 mg/mL 1 drop OU nocte to improve IOP control. Start sodium hyaluronate (Hylo-Forte®) 0.2% 1 drop OU QID PRN and perform daily warm compresses for lid hygiene. We have added you to the waiting list for left phacoemulsification and IOL insertion; pre-assessment will contact you with a date.
We will review you in the glaucoma clinic in 4 months with repeat VF and OCT, or sooner following your cataract surgery. Please attend Eye Casualty immediately if you experience sudden loss of vision, severe ocular pain, or new distortion in your central vision.
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