Examination: OD OS

VAsc: CSM1 CSM1

Pupils: Irregular, peaked 6 → 4 no APD

CVF: not documented not documented

EOM: Intact Intact

Tpalp: Deferred Soft

External: WNL (no glass FB seen) WNL

SLE:
LL: WNL WNL
C/S: trace diffuse hyperemia white and quiet
K: 3 mm K lac at 8 o’clock clear
AC: flat deep and quiet
I: peaked, small amount to wound round, reactive
L: clear clear

DFE:
Media: deferred clear, no VH
Discs: deferred 0.3, sharp margins
Macula: deferred foveal reflex
Vessels: deferred WNL
Periphery: deferred flat, no heme