The CE provider will describe and discuss, as appropriate:
a. Best corrected visual acuity for each eye, and the lens correction for each eye
(manifest refraction, correction of own lenses is not sufficient for "best corrected");
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1. If there is a loss of visual acuity, document the cause of the loss.
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2. If the vision loss is due to a cortical visual disorder, it must be confirmed by
documenting the cause of the brain lesion.
b. Examination of pupils, external examination, and extraocular motions;
c. Visual field -- confrontation visual fields;
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1. If confrontation fields are not normal, or if there is a history of glaucoma or
other conditions resulting in visual field loss, visual fields are needed;
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2. Confrontation fields are acceptable evidence that the fields are normal. Restricted
fields must be confirmed either by acceptable automated static threshold perimetry,
measuring the central 24 to 30 degrees of the visual field performed on an acceptable
perimeter (acceptable tests include the Humphrey Field Analyzer (HFA) 30-2, Octopus
32, Octopus 30-2, and HFA 24-2); or an acceptable manual or automated kinetic perimetry
(for example, Goldmann perimetry);
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3. Include a printout of any visual field testing (perimetry) results; and
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4. If there is a loss of visual fields, document the cause of the loss.
d. Intraocular pressure for each eye;
e. Slit lamp examination: include detailed description of the cornea and lens;
f. Fundus examination: include detailed description of the discs, vessels, maculae,
and peripheral retina; and
g. Describe any observed visual behaviors, such as the ability to navigate in the
office, reaching for items handed to them, using a cellphone in the waiting room,
etc.