Ophthalmic surgery outcomes are measured across a timeline that begins months before the knife goes in and continues for years after. A cataract extraction looks straightforward until the post-operative IOP spike at day three that nobody saw coming — except it was in the pre-operative exam, flagged by a family history of glaucoma that was buried in a field someone had to scroll past to reach the surgery schedule. The clinical record that loses that detail loses the continuity of care.
Pre-Operative Assessment
EOM, Cover Tests, and Pupil Exam are the strabismus and neuro-ophthalmic baseline fields. For cataract surgery, these determine whether an alignment procedure needs to be co-staged. For retinal surgery, pupil response is the pre-operative neurological baseline that post-operative changes are measured against. Cover tests at the screening exam that reveal a latent exotropia change the surgical plan for a patient presenting with a primary complaint of cataract — the surgically induced change in image magnification will unmask the deviation.
OD and OS with VA, VA Near, and IOP for each eye are the refraction and pressure entries. The Previous prescription field captures the pre-surgical optical correction, which is essential for calculating the target refraction for IOL power selection and for establishing the refractive outcome at post-operative follow-up visits. An IOP logged at the pre-operative assessment that's 18 mmHg in the right eye and 22 mmHg in the left is not a normal finding to carry into a vitrectomy without a note.
Medical History, Family history, and Allergy are the systemic risk fields. Random Blood Sugar at the pre-assessment visit, combined with the medication list and Allergy field, determines whether the surgical risk profile for a diabetic patient is acceptable or whether an HbA1c is required before proceeding. Documenting this at intake rather than at pre-admission is what prevents the day-before-surgery conversation where a borderline RBS shows up for the first time in the record.
The Six-Stage Follow-Up Architecture
The post-operative monitoring structure — 1st Date through 6th Follow Up — each carries a complete SOAP entry: Subjective, Objective, Assessment, and Plan, plus individual BP, HR, and RBS readings, a radiological description field, and an image attachment. This isn't redundancy; it's the longitudinal clinical record that an ophthalmologist reviewing a patient eighteen months post-vitrectomy needs to understand what happened at each stage.
Subjective captures the patient's reported symptoms at that visit: visual improvement, photopsia, floaters, pain, distortion. Objective captures the clinical examination findings: IOP, VA, fundal appearance, media clarity. Assessment is the clinical interpretation. Plan is the management decision for the period until the next follow-up. The assessment at the second follow-up directly conditions the plan for the third — without the full chain, the decision rationale for any individual management step is opaque.
BP, HR, and RBS at each post-operative visit catch the systemic changes that affect wound healing, retinal vascular perfusion, and medication tolerance. A RBS at the third follow-up that's significantly higher than at the first is a signal that the diabetic patient's glycaemic control has deteriorated in the post-operative period — a clinical finding that affects both the surgical outcome prognosis and the patient's ongoing management.
Surgery Picture and the follow-up picture fields at each stage create the visual record that supplements the text findings. Fundal photography or anterior segment slit-lamp images taken at each follow-up are the objective baseline for detecting progressive changes that clinical description alone might miss.
Rating closes the record with an outcome assessment — the surgeon's or clinic's evaluation of the final result. Combined with the complete clinical timeline, it creates the audit data for surgical outcomes review.