Reviewed April 11, 2024
Have you noticed how the ophthalmic community seems to talk in code? PT w/? IOP f/u VF OU. And sometimes we even make-up our own abbreviations system.
I once audited Evaluation and Management (E&M) chart notes and found that the technician would frequently use “BE.” I was confused as to what this could possibly mean. Then it was explained to me, BE = both eyes. It was a few days later that I also learned that BE in the medical world actually stands for barium enema!
To avoid confusion or even embarrassing mistakes, here are some of the most commonly used appropriate abbreviations. Use them to standardize documentation in the medical record.
When you are audited, the nurse reviewer will know exactly what you are referencing. And you might consider submitting this list along with your chart notes for easier interpretation.
a.c. - Before meals ante cibum
AAG - Acute angle closure glaucoma
ABN – Advanced Beneficiary Notice
AC - Anterior chamber
ACC - Accommodative
ACG - Angle closure glaucoma
ACIOL - Anterior chamber IOL
ACT - Alternate cover test
AFGE - Air fluid gas exchange
AL - Axial length
ALK - Automated lamellar keratoplasty
ALT - Argon laser trabeculoplasty
AMD/ARMD - Age-related macular degeneration
APCT - Alternate prism + cover test
APD - Afferent pupillary defect
Appl - Applanation tension
ASC - Ambulatory surgical center
AT - Applanation tension
ATR - Against-the-rule astigmatism
BAT – Brightness Acuity Test
BCC – Basal Cell Carcinoma
BCVA – Best Corrected Visual Acuity
BDR - Background diabetic retinopathy
b.i.d. - Twice a day bis in die
BIO – Binocular Indirect Ophthalmoscopy
BRAO - Branch Retinal Artery Occlusion
BRVO - Branch Retinal Vein Occlusion
BSC, BSCL - Bandage Soft Contact Lens
C + S - Culture and sensitivity
C/D - Cup-to-disc ratio
CA - Corneal abrasion
CACG - Chronic angle closure glaucoma
CAIRS - Corneal Allogenic Intrastromal Ring Segments
cC - With correction
CC - Chief Complaint
CE/IOL - Cataract Extraction with Intraocular Lens Implant
CF - Count Fingers
CL - Contact Lens
C/O - Complains of
COAG - Chronic Open Angle Glaucoma
CRVO - Central Retinal Vein Occlusion
CS - Cortical Spokes
CVF - Confrontation Visual Field
D - Diopter
D + N - Distance and near
D&V - Ductions and versions
DALK - Deep Anterior Lamellar Keratoplasty
*D/C - Discontinue
DCR - Dacryocystorhinostomy
DD - Disc Diameter
DES - Dry Eye Syndrome
DLEK - Deep Lamellar Endothelial Keratoplasty
DM - Diabetes Mellitus
DME - Diabetic Macular Edema
DOB - Date of Birth
DOS - Date of Service
DR - Diabetic Retinopathy
DSAEK - Descemet Stripping Automated Endothelial Keratoplasty
DSEK - Descemet Stripping Endothelial Keratoplasty
DVA - Distance Visual Acuity
DWEK - Descemetorhexis Without Endothelial Keratoplasty
DX - Diagnosis
DZ - Disease
EBMD - Epithelial Basement Membrane Dystrophy
EBV - Epstein-Barr Virus
ECC - Endothelial Cell Count
ECCE - Extracapsular Cataract Extraction
ECG - Electrocardiogram
ECP - Endoscopic Cyclophotocoagulation
ED - Emergency Department
EKC - Epidemic Keratoconjunctivitis
EKG - Electrocardiogram
EL - Endolaser
ELM - External Limiting Membrane
EMD - Exudative Macular Degeneration
EOM - Extraocular Muscles
ERM - Epiretinal Membrane
ESRD - End Stage Renal Disease
ET - Esotropia
E(T) - Intermittent Esotropia
EUA - Exam Under Anesthesia
F + F - Fix and follow
f/u - Follow-up
FA - Fluorescein angiography
FB - Foreign body
FH - Family history
FLR - Foveal Light Reflex
FOB - Frequency of Blinking
FP - Fundus Photos
FTFC - Full to finger counting
FTG - Full-time glasses
FTO – Full-time Occlusion
FTP - Full-time patch
Fx – Fracture
GCA - Giant Cell Arteritis
GCL - Ganglion Cell Layer
GFE - Gas-fluid Exchange
GO - Graves’ Orbitopathy
GP - Gas permeable
GPC - Giant papillary conjunctivitis
GVF - Goldmann visual field
H - Hyperphoria
H + P - History and physical
*h.s. - At bedtime hora somni
h/o - History of
HA - Headache
HBP - High Blood Pressure
HCL - Hard Contact Lens
HM - Hand Motions
HS - Herpes Simplex
HVF - Humphrey Visual Field
HZ - Herpes Zoster
HZO - Herpes Zoster Ophthalmicus
ICCE - Intracapsular cataract extraction
ICE - Iridocorneal Endothelial Syndrome
ICG - Indocyanine green angiography
ICL - Intraocular Contact Lens
ICR - Intrastromal Corneal Ring
IK - Interstitial Keratitis
ILM - Internal Limiting Membrane
IO - Inferior Oblique
ION - Ischemic Optic Neuropathy
IOL - Intraocular lens
IOP - Intraocular pressure
IRMA - Intraretinal Microvascular Abnormality
IV - Intravenous
J J1 J2 - Jaeger notation/size of type for near vision
JOAG - Juvenile Onset Open-angle Glaucoma
JODM - Juvenile onset diabetes mellitus
JRA - Juvenile Rheumatoid Arthritis
KC - Keratoconus
KCS - Keratoconjunctivitis sicca
K-reading - Measurement of corneal curvature with a keratometer
LASIK - Laser in situ keratomileusis
LD - Lattice degeneration
LF - Levator Function
LI - Laser Iridotomy
LK – Left Keratotomy
LL - Lower lid
LLL - Left lower lid
LLR - Left lateral rectus
LMR - Left medial rectus
LP - Light perception
LP+P - Light perception and projection
LPI - Laser Peripheral Iridotomy
LT - Left
LUL - Left Upper Lid
MG - Myasthenia gravis
MGD - Meibomian Gland Dysfunction
MH - Macular Hole
MI - Myocardial infarction; heart attack
MMC - Mitomycin C
MP - Membrane Peel/Peeling
MR - Manifest refraction
MRD - Marginal Reflex Distance
MS - Multiple sclerosis
MVA - Motor Vehicle Accident
N - Near
N/A - Not Applicable
N + V - Nausea and vomiting
n.p.o. - Nothing by mouth nil per Os
NdYAG - Neodymium Yiitirum-aluminum Garnet Laser
NEMD - Nonexudative Macular Degeneration
NFL- Nerve Fiber Layer
NI - No improvement
NKA - No known allergies
NKDA - No known drug allergies
NLD - Nasolacrimal duct
NLDO - Nasolacrimal Duct Obstruction
NLP - No light perception
NL/ NML - Normal
NPDR - Non-proliferative diabetic retinopathy
NR - Non-reactive
NS - Nuclear sclerosis
NTG - Normal-tension Glaucoma
NV - Neovascularization
NVA - Neovascularization of the Angle
NVD - Neovascularization at the Disc
NVE - Neovascularization Elsewhere
NVG - Neovascular Glaucoma
NVI - Neovascularization of the Iris
NVM - Neovascular membrane
OAG - Open angle glaucoma
OCP - Ocular Cicatricial Pemphigoid
OGR - Open Globe Repair
OHT - Ocular hypertensive
*OD - right eye oculus dexter
OKN - Optikinetic Nystagmus
ON - Optic Nerve
OPT - Ocular Photodynamic Therapy
*OS - Left eye oculus sinister
*OU - Both eyes oculus uterque
p.c. - After meals
p.o. - By mouth
p.p. - After eating
PACG - Primary Angle-closure Glaucoma
PACT - Prism + alternate cover test
PAM - Potential acuity meter
PC - Posterior capsule
PC - Posterior Chamber
PCIOL - Posterior chamber IOL
PCO - Posterior Capsule Opacity
PD - Prism diopter
PDR - Proliferative diabetic retinopathy
PDT - Photodynamic Therapy (with verteporfin)
PED - Pigment Epithelial Detachment
PEE - Punctate Epithelial Erosion
PERRLA - Pupils Equal, Round and Reactive to Light and Accommodation
ph - Pin hole
PI - Peripheral iridectomy/iridotomy
PION - Posterior Ischemic Optic Neuropathy
PK - Penetrating keratoplasty
pl - Plano lens
PMH - Past medical history
PMMA - Polymethylmethacrylate
p/o - Postoperatively
POAG - Primary open angle glaucoma
POS - Place of Service
PPA - Peripapillary Atrophy
PPL - Pars plana lensectomy
PPV - Pars plana vitrectomy
PRK - Photorefractive keratectomy
PRP - Pan retinal photocoagulation
PSC - Posterior subcapsular cataract
PT - Patient
PTO - Part time Occlusion
PVD - Posterior Vitreous Detachment
PVR - Proliferative Vitreoretinopathy
PXF - Pseudoexfoliation
PXG - Pseudoexfoliation Glaucoma
PXS - Pseudoexfoliation Syndrome
q.a.m. - Every day before noon
*q.d. - Every day
q.h. - Every hour
*q.h.s. - At bedtime
q.i.d. - 4 times a day
q.n. - Every night
*q.o.d. - Every other day
q.p.m. - Every day after noon
R/O - Rule out
RA - Rheumatoid arthritis
RAPD - Relative afferent papillary defect
R/B/A -Risks/Benefits/Alternatives
RCE - Recurrent Corneal Erosion
RD - Retinal detachment
REF - Refraction
REM - Rapid eye movement
RET - Retinoscopy
RGP - Rigid gas permeable
RHT - Right Hypertropia
RIO - Right inferior oblique
RIR - Right inferior rectus
RK - Radial keratotomy
RLL - Right lower lid
RLR - Right lateral rectus
RMR - Right medial rectus
ROP - Retinopathy of prematurity
ROS - Review of systems
RP - Retinitis pigmentosa
RPE - Retinal Pigment Epithelium
R/R - Round and Reactive pupil
R&R - Recess and resect
RSO - Right superior oblique
RSR - Right superior rectus
RT - Right eye
RTC - Return to clinic
RUL - Right upper eyelid
RVO - Retinal Vein Occlusion
RX - Treatment – glasses, medicine, etc
RXT - Right exotropia
S/P - Status post
SB - Scleral Buckle
sC - without correction
SCC - Squamous cell carcinoma
SCL - Soft contact lens
SLE - Systemic Lupus Erythematosus
SLK - Superior Limbic Keratoconjunctivitis
SLT - Selective Laser Trabeculoplasty
SNF - Skilled Nursing Facility
SO - Silicone Oil
SO - Superior oblique
SOB - Short of breath
SCODI - Scanning computerized ophthalmic diagnostic imaging
SPH - Sphere
SPK - Superficial punctate keratitis
SR - Superior rectus
SRNV - Subretinal neovascular membrane
stat. - Immediately
*Sub.q. - Subcutaneous under the skin
Sx – Surgery
Sx - Symptoms
T - Tension
TA - Tension by applanation
TASS - Toxic Anterior Segment Syndrome
TB - Tuberculosis
TBT - Tear break-up time
TID - Three times a day
TM - Trabecular meshwork
TORCH - Toxoplasmosis, Rubella, Cytomegalovirus, Herpes
TP - Tonopen
Trab - Trabeculectomy
TRD - Traction retinal detachment
TRO - Thyroid Related Orbitopathy
Tx - Treatment
UGH - Uveitis-Glaucoma-Hyphema Syndrome
UL - Upper Lid
UME - Uveitic Macular Edema
ung - Ointment
URI - Upper Respiratory Infection
UV - Ultraviolet
VA - Visual acuity
VEGF - Vascular Endothelial Growth Factor
VF - Visual field
VH - Vitreous Hemorrhage
Vit - Vitreous
VMA - Vitreomacular Adhesion
VMT - Vitreomacular Traction
VZV - Varicella Zoster Virus
W4D - Worth 4-dot Test
x - Exophoria at distance
XT - Exotropia at distance
X(T) - Intermittent Exotropia
YAG - Yttrium-aluminum-garnet laser
y/o - Years Old
YTD - Year-to-Date
Note: Abbreviations marked with an asterisk (*) have been cited by Institute for Safe Medication Practices (ISMP) as frequently misinterpreted and involved in harmful medication errors. ISMP recommends alternative documentation.
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This list is adapted from Fundamentals of Ophthalmic Coding.