Download Retinal Exam and Dilation Consent A dilated examination of the eye

Retinal Exam and Dilation Consent
A dilated examination of the eye and retina is an important part of ocular health testing. Drops are used
to widen the pupil and get a more complete view of the peripheral retina. It is then possible to evaluate
for the presence of retinal holes, tears, detachments, ocular melanomas, and circulatory changes in the
retina. These conditions can occur without symptoms and cause visual loss without early detection and
intervention.
It is important for patients who are diabetic, hypertensive, or have heart or thyroid conditions to have
dilated retina exams annually. Highly nearsighted patients and people who are not obtaining 20/20
vision, or have cataracts should have their eyes dilated as well. Patients with any family history of eye
disease or retinal detachments or who are seeing floating spots or flashing lights should have their
pupils dilated also.
There is no charge for this portion of the exam. It is covered by your vision plan and health insurance.
NOTE: Due to widening of the pupil, dilation may affect reading vision and some patients experience
near and distance vision blur, some light sensitivity (usually less than 4 hours, but may last till morning).
We will provide you with sunglasses. Most patients feel comfortable driving (with caution), but if you
would prefer to reschedule to bring a driver, please let us know.
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I would prefer to have my eyes dilated
I would like to reschedule my dilation to a later date
I choose not to have my eyes dilated and I release the Drs. of GNO Eyecare from any liability of
missed pathology by not having this test performed
GNO Eyecare is proud to provide our patients with cutting edge technology to uncover and diagnose
early changes from eye diseases. Below is a list of options to introduce you to these technologies. All
of these tests can be performed on patients of all ages.
Eye Photography
Our doctors recommend anterior and posterior photography of the eye every year as an integral part of
your examination. An anterior photo will be taken to assess inflammation from allergies, dry eye
syndrome, contact lens complications, cataracts, and eyelid pathology. A retinal photo will also be taken
and will capture the optic nerve, macula, and retinal arteries and veins. Our doctors will walk you
through these photographs and will be placed in your medical file and enables us to make important
comparisons if potential problems show themselves at a future examination.
We will be able to detect conditions such as:
Glaucoma
Macular Degeneration
Diabetes
High Blood Pressure
High Cholesterol
Ocular Melanomas
Autoimmune and other Systemic Disease
This test is not typically covered by vision insurance, however we will provide you with an itemized
bill as some insurance plans may reimburse you. The fee is $20 for all photos.
Visual Field Testing
The Visual Field Test measures the retinal function and sensitivity to light. It is a method of measuring an
individual's entire scope of vision, that is their central and peripheral (side) vision. Visual field testing
actually maps the visual fields of each eye individually. The visual field test is a subjective examination
and can assist in important early detections of many disorders such as:
Glaucoma
Diabetes
Retinal Detachment
Brain Tumors
Aneurysms
Our Doctors strongly recommend this quick, yet accurate exam for all patients, especially those who
have any of the following:
Headaches
Flashes of Light or Floaters
Over the age of 35
Heart Problems
Family Hx of Diabetes or High Blood Pressure
High Glasses Prescriptions Unexplained vision changes
Some medications for the tx of autoimmune diseases, cancers, blood pressure, and heart conditions
This test is not typically covered by vision insurance, however we will provide you with an itemized
bill as some insurance plans may reimburse you. The fee for The Visual field Test is $20.
Optical Coherence Tomography (OCT)
Optical coherence tomography (OCT) is a non-invasive imaging test that uses light waves to take crosssection pictures of your retina. This test is similar to an ultrasound and allows our doctors to view the
tissues and structures beneath the retina. This test is the gold standard for the detection, treatment,
and management of glaucoma, macular degeneration, optic nerve pathology, diabetic eye disease
among others.
This test is not typically covered by vision insurance, however we will provide you with an itemized
bill as some insurance plans may reimburse you. The fee for the ultrasound OCT is $20.
Please check all that apply
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I would like photos of my eye
($20)
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I would like the visual field test
($20)
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I would like the OCT Ultrasound
($20)
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I would like 2 above
($35)
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I would like all imaging
($45)
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I would like to skip all imaging at my exam today
Patient/Guardian Signature:
Date: