• Ophthalmic Abbreviations 101

    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
    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 - Age-related macular degeneration
    APCT - Alternate prism + cover test
    APD - Afferent pupillary defect
    Appl - Applanation tension
    ARMD - Age related macular degeneration
    ASC - Ambulatory surgical center
    AT - Applanation tension
    ATR - Against-the-rule astigmatism
    BDR - Background diabetic retinopathy
    b.i.d. - Twice a day bis in die
    C + S - Culture and sensitivity
    C/D - Cup-to-disc ratio
    CA - Corneal abrasion
    CACG - Chronic angle closure glaucoma
    D - Diopter
    D + N - Distance and near
    D&V - Ductions and versions
    F + F - Fix and follow
    f/u - Follow-up
    FA - Fluorescein angiography
    FB - Foreign body
    FH - Family history
    FTFC - Full to finger counting
    FTG - Full-time glasses
    FTP - Full-time patch
    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
    ICCE - Intracapsular cataract extraction
    ICG - Indocyanine green angiography
    IOL - Intraocular lens
    IOP - Intraocular pressure
    J  J1  J2 - Jaeger notation/size of type for near vision
    JODM - Juvenile onset diabetes mellitus
    KCS - Keratoconjunctivitis sicca
    K-reading - Measurement of corneal curvature with a keratometer
    LASIK - Laser in situ keratomileusis
    LD - Lattice degeneration
    LL - Lower lid
    LLL - Left lower lid
    LLR - Left lateral rectus
    LMR - Left medial rectus
    LP - Light perception
    LP+P - Light perception and projection
    LT - Left
    MG - Myasthenia gravis
    MI - Myocardial infarction; heart attack
    MR - Manifest refraction
    MS - Multiple sclerosis
    N - Near
    N + V - Nausea and vomiting
    n.p.o. - Nothing by mouth nil per Os
    NI - No improvement
    NKA - No known allergies
    NKDA - No known drug allergies
    NI - Normal
    NLD - Nasolacrimal duct
    NLP - No light perception
    NML - Normal
    NPDR - Non-proliferative diabetic retinopathy
    NR - Non-reactive
    NS - Nuclear sclerosis
    NVM - Neovascular membrane
    OAG - Open angle glaucoma
    OHT - Ocular hypertensive
    OD - right eye oculus dexter
    OS - Left eye oculus sinister
    OU - Both eyes oculus uterque
    p.c. - After meals
    p.o. - By mouth
    p.p. - After eating
    PACT - Prism + alternate cover test
    PAM - Potential acuity meter
    PC - Posterior capsule
    PCIOL - Posterior chamber IOL
    PD - Prism diopter
    PDR - Proliferative diabetic retinopathy
    ph - Pin hole
    PI - Peripheral iridectomy/iridotomy
    PK - Penetrating keratoplasty
    pl - Plano lens
    PMH - Past medical history
    PMMA - Polymethylmethacrylate
    p/o - Postoperatively
    POAG - Primary open angle glaucoma
    PPL - Pars plana lensectomy
    PPV - Pars plana vitrectomy
    PRK - Photorefractive keratectomy
    PRP - Pan retinal photocoagulation
    PSC - Posterior subcapsular cataract
    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
    RA - Rheumatoid arthritis
    RAPD - Relative afferent papillary defect
    RD - Retinal detachment
    REF - Refraction
    REM - Rapid eye movement
    RET - Retinoscopy
    RGP - Rigid gas permeable
    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
    R&R - Recess and resect
    RSO - Right superior oblique
    RSR - Right superior rectus
    RT - Right eye
    RTC - Return to clinic
    RUL - Right upper eyelid
    RX - Treatment – glasses, medicine, etc
    RXT - Right exotropia
    SCC - Squamous cell carcinoma
    SCL - Soft contact lens
    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 - Symptoms
    T - Tension
    TA - Tension by applanation
    TBT - Tear break-up time
    TM - Trabecular meshwork
    Trab - Trabeculectomy
    TRD - Traction retinal detachment
    Tx - Treatment
    ung - Ointment
    VA - Visual acuity
    VF - Visual field
    Vit - Vitreous
    x - Exophoria at distance
    XT - Exotropia at distance
    YAG - Yttrium-aluminum-garnet laser

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    About the author: This article has been adapted from the January 2006 issue of Techniques. It was written by Academy Coding Executive Sue Vicchrilli, COT, OCS.