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Ophthalmologic Examination Documentation Report (Retinal Eye Screening)

Published: August 9, 2026Updated: August 16, 2026

This report documents the results of a visual examination of your retina, which is part of an eye screening to check for early signs of eye health or disease.

Quick summary

["Your retinal screening helps detect potential vision or health issues early."]

Medically reviewed by WellAlly Editorial TeamLast reviewed August 16, 2026Editorial policy

Key facts at a glance

LOINC
103592-2
Short code
Retinal eye screen rpt Doc
Synonyms
Retinal eye screen rpt Doc
Category
chemistry
Sample
serum
Container
Red-top tube (SST)
Units
N/A
Ref low
0.8
Ref high
1.2
Critical range
— – 5 N/A
Fasting
false
Population
adult
Sex
all
Age range
18–65 years
CPT
85610
SNOMED
396252006
Specimen volume
5 mL
Stability
Room temperature: 4h, Refrigerated: 24h, Frozen: 7d
Hemolysis max
500
Lipemia max
1000
Icterus max
500
TAT
4–24 hours
Order
routine

What Is a Retinal Eye Screening?

A retinal eye screening involves a dilated eye exam where your doctor uses special lighting and a tool called an ophthalmoscope to examine the retina—the light-sensitive tissue at the back of your eye. This helps assess blood vessels, the optic nerve, and other structures for signs of disease, such as diabetic retinopathy, glaucoma, or macular degeneration.

Why Might You Need This Test?

Eye screenings are often recommended for people with risk factors like diabetes, high blood pressure, or a family history of eye diseases. They may also be part of routine check-ups for older adults or those with symptoms like blurred vision or frequent headaches.

What Happens During the Screening?

Before the exam, your doctor will dilate your pupils with eye drops to allow a full view of your retina. You may experience temporary blurred vision afterward. The exam itself is quick and painless, focusing on identifying any abnormalities in retinal blood flow, nerve health, or other structures.

What Does the Report Document?

The report captures visual findings, such as the condition of blood vessels, the optic disc (where the optic nerve enters the eye), and any signs of swelling, lesions, or other irregularities. It may also note the presence of fluid buildup or other indicators of potential eye conditions.

Reference range

INR: 0.8-1.2 (warfarin: 2.0-3.0)N/A

Specimen: serum

Inform your healthcare provider if you are taking blood thinners. No special preparation required.

Clinical interpretation

How abnormal results are interpreted and what conditions they suggest.

Clinical Significance

Frequently asked questions

How soon can I expect results?
Results from a retinal eye screening are typically reviewed by your healthcare provider during or shortly after the exam. If abnormalities are found, they may recommend further testing or follow-up visits to monitor or treat the condition.
What if my screening shows no issues?
If your screening is normal, your doctor may schedule regular follow-ups to ensure ongoing eye health, especially if you have risk factors for eye diseases. Regular check-ups help catch problems early when they’re easier to treat.
Will I need to prepare for this test?
No special preparation is needed. However, if you wear contact lenses, your doctor may advise removing them before the exam. Avoid bright lights or screens before the appointment to help your pupils dilate fully.
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This information is for educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment.

Medical Disclaimer

This content is for general informational and educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the guidance of a qualified healthcare provider with any questions you have about a medical condition, and never disregard professional medical advice or delay seeking it because of something you read here.

If you think you may have a medical emergency, call your local emergency number or go to the nearest emergency department immediately.

Medically reviewed by WellAlly Editorial Team Last reviewed August 16, 2026. · Read our editorial policy