> ## Documentation Index > Fetch the complete documentation index at: https://mintlify.com/appertafoundation/openeyes/llms.txt > Use this file to discover all available pages before exploring further. # OphCiExamination Module > Comprehensive clinical examination recording in OpenEyes # OphCiExamination - Clinical Examination The **OphCiExamination** module is the most comprehensive and frequently used module in OpenEyes. It provides a flexible framework for recording complete ophthalmic examinations with 59+ specialized element types covering all aspects of eye care. ## Overview OphCiExamination is designed to support all ophthalmic subspecialties with configurable workflows. Elements can be enabled or disabled based on the clinic type, and the initial set of elements displayed can be customized for each subspecialty. The module is implemented as a namespaced Yii module: `\OEModule\OphCiExamination\OphCiExaminationModule` ## Core Examination Elements ### History & Presenting Complaint Free-text recording of patient history and presenting complaint Systematic recording of ocular and systemic comorbidities Comprehensive allergy recording with severity grading Initial triage assessment and vital signs ### Vision Assessment #### Visual Acuity The visual acuity element supports both simple and complex recording modes: **Simple Mode:** * Quick entry for routine clinic use * Single reading per eye * Common correction types **Complex Mode:** * Multiple readings per eye * Detailed correction specification (unaided, pinhole, glasses, contact lens) * Different notation systems (Snellen, LogMAR, ETDRS) * Method recording (standard chart, near chart, CF, HM, PL, NPL) **Near Visual Acuity:** * Separate element for near vision testing * Jaeger and other near notation support * Reading distance recording ```php theme={null} // Visual acuity configuration Element_OphCiExamination_VisualAcuity Element_OphCiExamination_NearVisualAcuity ``` #### Refraction Comprehensive refraction recording with: * Sphere, cylinder, axis for both eyes * Addition for presbyopia * Subjective and objective refraction * Cycloplegic refraction support ### Intraocular Pressure Records intraocular pressure with: * Multiple measurement methods (applanation, non-contact, iCare, Perkins, etc.) * Time of measurement * Multiple readings per eye * Statistical analysis of readings * Automatic flagging of abnormal values ### Anterior Segment Examination Detailed slit-lamp examination findings using EyeDraw integration for graphical documentation Records pupil size, reactivity, and abnormalities (RAPD, irregular pupils, etc.) Documents dilating drops administered including drug, time, and side effects Specific corneal findings including thickness, clarity, and pathology ### Posterior Segment Examination **Posterior Pole:** * Detailed posterior segment findings * EyeDraw integration for retinal diagrams * Macula assessment * Vascular changes **Optic Disc:** * Cup-to-disc ratio * Disc appearance and color * Neuroretinal rim assessment * Optic disc photos integration **Diabetic Retinopathy Grading:** * Standardized DR severity scale * Retinopathy level (none, background, pre-proliferative, proliferative) * Maculopathy assessment * Clinical Significance of Macular Edema (CSMO) * Photo grade comparison **DR Retinopathy & Maculopathy:** * Separate detailed elements for diabetic eye disease * Retinopathy features (microaneurysms, hemorrhages, exudates, neovascularization) * Maculopathy classification ### Imaging & Investigations Optical coherence tomography results and interpretation Detailed slit lamp biomicroscopy findings Fundus photography and findings Corneal endothelial cell counts and morphology ### Specialist Examination Elements #### Glaucoma * **Glaucoma Risk**: Automated risk stratification * **Optic Disc**: Detailed disc assessment for glaucoma * **Gonioscopy**: Angle assessment and grading * **Van Herick**: Anterior chamber depth estimation * **IOP Graph**: Longitudinal IOP tracking #### Cataract * **Anterior Segment - CCT**: Central corneal thickness measurement * **Cataract Surgical Management**: Pre-operative assessment and planning * **PCR Risk**: Posterior capsule rupture risk calculation * **Biometry Integration**: Links to biometry measurements #### Medical Retina * **DR Grading**: Diabetic retinopathy assessment * **Maculopathy**: Macular pathology documentation * **OCT**: Retinal imaging and measurements * **Injection Management**: Anti-VEGF treatment planning #### Corneal * **Cornea**: Detailed corneal examination * **Anterior Segment - CCT**: Pachymetry * **Specular Microscopy**: Endothelial assessment * **CXL History**: Corneal cross-linking history * **CXL Outcome**: Cross-linking treatment outcomes #### Strabismus & Pediatrics * **Cover Test**: Ocular alignment assessment * **Nine Positions**: Motility examination in diagnostic positions * **Convergence & Accommodation**: Near point testing * **Stereo Acuity**: Depth perception testing * **Colour Vision**: Color blindness testing (Ishihara, etc.) * **Red Reflex**: Pediatric screening ### Clinical Decision Support Automated posterior capsule rupture risk calculation for cataract surgery Risk stratification for glaucoma progression A\&E red flag identification for urgent conditions Safeguarding concerns documentation ### Management & Outcomes #### Diagnoses Structured diagnosis recording with: * Principal and secondary diagnoses * ICD-10 coding * Laterality (right, left, bilateral) * Date of diagnosis #### Management Planning **Current Management Plan:** * Active management strategies * Treatment goals * Monitoring frequency **Cataract Surgical Management:** * Surgical suitability assessment * Patient expectations * Biometry requirements * IOL selection guidance **Overall Management Plan:** * Comprehensive treatment strategy * Follow-up planning * Multi-disciplinary coordination #### Clinic Outcomes Defines the next steps in patient care: * Follow-up booking (interval and location) * Discharge from service * Community optometry follow-up * Patient advice ### Additional Elements **Clinical Procedures:** * In-clinic minor procedures * Procedure documentation **Drug Administration:** * Medications given during examination * Dosage and route recording **Observations:** * Blood pressure * Pulse * Temperature * Other vital signs **Communication Preferences:** * Patient contact preferences * Language needs * Information sharing consent **Contacts:** * GP details * Next of kin * Social services involvement **Risks:** * Clinical risk factors * Falls risk * VTE assessment **Post-Op Complications:** * Surgical complication recording * Severity grading * Management documentation **Pain:** * Pain assessment scales * Location and characteristics **Comments & Conclusion:** * Free-text clinical notes * Summary of findings **Optom Comments:** * Optometrist-specific notes * Recommendations for ophthalmologist ## Examination Workflow ### Creating an Examination 1. **Select Patient**: Navigate to patient record 2. **Create Event**: Click "Add Examination" 3. **Add Elements**: Use the element adder to select relevant examination components 4. **Record Data**: Complete each element with clinical findings 5. **Review**: Check completeness and accuracy 6. **Save**: Finalize the examination The initial set of elements displayed is configurable per subspecialty, reducing clicks for routine examinations. ### Element Adder Dialog The examination uses a sophisticated adder dialog system: * Quick search for elements * Recently used elements highlighted * Subspecialty-specific element grouping * Add multiple elements at once ### EyeDraw Integration Many elements integrate with the **EyeDraw** canvas for graphical documentation: * Anterior segment diagrams * Fundus drawings * Surgical procedure illustrations * Standardized iconography ```php theme={null} // EyeDraw is a required dependency 'dependencies' => [ 'Eyedraw' ], ``` ## Configuration ### Module Registration ```php theme={null} 'OphCiExamination' => array( 'class' => '\OEModule\OphCiExamination\OphCiExaminationModule', ), ``` ### Element Configuration Configure which elements are available per subspecialty through the admin interface or system settings: * Enable/disable elements globally * Set default elements for each subspecialty * Configure mandatory vs optional elements * Set element display order ### Visual Acuity Settings Configure default recording mode: * Simple vs complex mode preference * Default notation system * Default correction type ### DR Grading Image Optionally provide a reference image for DR grading: ```bash theme={null} # Copy DR grading reference image cp drgrading.jpg protected/modules/OphCiExamination/assets/img/ # Expected dimensions: 452 x 699 pixels ``` ## Development Guidelines The OphCiExamination module follows modern development practices: ### Use of Traits Common functionality is abstracted into reusable PHP traits: * `HasCorrectionType`: For visual acuity corrections * `HasWithHeadPosture`: For orthoptic measurements * `HasRelationOptions`: For enumerated options ### Widget-Based Architecture Business logic is managed in widgets and models, not templates: * Element rendering logic in widget classes * Data validation in models * Minimal PHP in view templates ### Testing Comprehensive testing approach: * **PHP Unit Tests**: Model and business logic (TDD encouraged) * **Katalon Tests**: End-to-end functional testing * **JavaScript**: Element controller testing ### Naming Conventions * Use `ClassName::class` instead of string literals * Descriptive method names * Public methods first, then protected, then private ## Clinical Use Cases **Typical Elements:** * History * Visual Acuity * IOP * Anterior Segment * Gonioscopy * Optic Disc * Glaucoma Risk * Management Plan * Clinic Outcome **Typical Elements:** * History * Visual Acuity * Refraction * Anterior Segment * Cataract Surgical Management * PCR Risk * Biometry (linked module) * Posterior Pole * Management Plan **Typical Elements:** * History * Visual Acuity * IOP * Anterior Segment * Posterior Pole * DR Grading (for diabetic patients) * OCT * Maculopathy * Injection Management * Clinic Outcome **Typical Elements:** * History * Visual Acuity (age-appropriate) * Colour Vision * Cover Test * Nine Positions * Stereo Acuity * Refraction * Anterior Segment * Posterior Pole * Diagnoses * Management Plan ## Integration Points ### Other Modules OphCiExamination integrates with: * **OphInBiometry**: Links biometry measurements for cataract management * **OphDrPrescription**: Treatment plan generates prescription requirements * **OphTrOperationbooking**: Surgical management triggers operation booking * **OphCoCorrespondence**: Examination findings populate letter templates ### External Systems Supports integration with: * Imaging devices (OCT, fundus cameras) * IOP measurement devices * Visual field analyzers * Hospital PAS/EPR systems ## Best Practices Use structured elements rather than free text where possible for better data quality and reporting Include all relevant elements even if findings are normal - negative findings are clinically important Always record formal diagnoses using the Diagnoses element for accurate coding Complete the Clinic Outcome element to ensure appropriate follow-up is scheduled ## Further Reading Return to modules overview Examination recording workflows Element models and APIs