TEMPLATE Patient admission into the long-term treatment for wet AMD (811702e4-06c3-421e-855f-a29aec3bb348)

TEMPLATE ID811702e4-06c3-421e-855f-a29aec3bb348
ConceptPatient admission into the long-term treatment for wet AMD
DescriptionTo determine an appropriate treatment for patients diagnosed with wet AMD.
PurposeTo determine an appropriate treatment for patients diagnosed with wet AMD.
References
Authorsname: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2015-10-20
Other Details Languagename: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2015-10-20
OtherDetails Language Independent{MetaDataSet:Sample Set =MetaDataSet:Sample Set , Copyright=Copyright, Owner=Owner, Speciality=Speciality}
KeywordsAMD; anti-VEGF; Intravitreal injection
Language useden
Citeable Identifier1013.26.111
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.encounter.v1, otherContributors=jose.andonegui.navarro@cfnavarra.es; Luis Serrano, Universidad Pública de Navarra (UPNA), lserrano@unavarra.es; Jesús D. Trigo, Universidad Pública de Navarra (UPNA), jesusdaniel.trigo@unavarra.es, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1], code=at0000, itemType=COMPOSITION, level=0, text=Encounter, description=Interaction, contact or care event between a subject of care and healthcare provider(s)., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0], code=at0000, itemType=SECTION, level=1, text=Patients background, description=Clinical information needed from a patient to give context to the responsible physician before register him within a specific service., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-EVALUATION.reason_for_encounter.v1], code=at0000, itemType=EVALUATION, level=2, text=Reason for encounter, description=The reason for initiation of any healthcare encounter or contact by the individual who is the subject of care., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-EVALUATION.reason_for_encounter.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-EVALUATION.reason_for_encounter.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Contact type, description=Identification of the type, or administrative category, of healthcare sought or required by the subject of care., comment=Coding of the 'Contact type' with a terminology is desirable, where possible. Examples include: pre-employment medical, routine antenatal visit, women's health check, pre-operative assessment, or annual medical check-up., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Routine ophthalmology consultation
  • Routine primary care review
  • Eye complication identified at the hospital emergency department
  • Specialised consultation at retinologist's office
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'Chief complaint' may be used as a valid synonym for 'Presenting problem' in templates., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1], code=at0000, itemType=OBSERVATION, level=2, text=Story/History, description=The subjective clinical history of the subject of care as recorded directly by the subject, or reported to a clinician by the subject or a carer., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], 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itemType=ELEMENT, level=6, text=Story, description=Narrative description of the story or clinical history for the subject of care., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v1], code=at0000, itemType=CLUSTER, level=6, text=Symptom/Sign, description=Reported observation of a physical or mental disturbance in an individual., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=7, text=Symptom/Sign name, description=The name of the reported symptom or sign., comment=Symptom name should be coded with a terminology, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=7, text=Description, description=Narrative description about the reported symptom or sign., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[at0151], code=at0151, itemType=ELEMENT, level=7, text=Body site, description=Simple body site where the symptom or sign was reported., comment=Occurrences of this data element are set to 0..* to allow multiple body sites to be separated out in a template if desired. This allows for representation of clinical scenarios where a symptom or sign needs to be recorded in multiple locations or identifying both the originating and distal site in pain radiation, but where all of the other attributes such as impact and duration are identical. If the requirements for recording the body site are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the Detailed anatomical location' SLOT in this archetype. If the anatomical location is included in the Symptom name via precoordinated codes, this data element becomes redundant. If the anatomical location is recorded using the 'Structured body site' SLOT, then use of this data element is not allowed - record only the simple 'Body site' OR 'Structured body site', but not both., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[openEHR-EHR-CLUSTER.anatomical_location.v1], code=at0000, itemType=CLUSTER, level=7, text=Anatomical location, description=A physical site on or within the human body., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=8, text=Body site name, description=Identification of a single physical site either on, or within, the human body., comment=This data element is the only mandated data point in this archetype and should be used as the primary data point to record an anatomical location with a commonly used name. It is strongly recommended that 'Body site name' be recorded as specifically as is anatomically possible. For example: record 'upper eyelid' rather than recording 'eyelid' with 'upper' as a qualifier; 'fifth rib' rather than 'rib' with a numeric qualifier. Use the other data elements for laterality, aspect, region and anatomical line to provide more detail. This data element should be coded with a terminology capable of triggering decision support, where possible - an appropriate termset for use here could comprise individual concepts or a list of precoordinated terms. Free text should be used only if there is no appropriate terminology available., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0065], code=at0065, itemType=ELEMENT, level=8, text=Specific site, description=Additional detail using a specific region or a point on, or within, the identified body site., comment=Use to increase precision of identification of the body site, if required. For example, the upper right quadrant or McBurney's point on the abdominal wall or interphalangeal joint of the great toe. If the 'Body site name' data element uses pre-coordinated terms that include the specific site, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.story.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.symptom_sign.v1]/items[openEHR-EHR-CLUSTER.anatomical_location.v1]/items[at0002], code=at0002, itemType=ELEMENT, level=8, text=Laterality, description=The side of the body on which the identified body site is located., comment=If the identified body site has no laterality, this data element should not have a value. If the 'Body site name' data element uses pre-coordinated terms that include laterality, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left  [Left side of the body.]
  • Right  [Right side of the body.]
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  • New  [A new episode of the symptom or sign - either the first ever occurrence or a reoccurrence where the previous episode had completely resolved.]
  • Ongoing  [This symptom or sign is ongoing, effectively a single, continuous episode.]
  • Indeterminate  [It is not possible to determine if this occurrence of the symptom or sign is new or ongoing.]
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  • Worsening  [The severity of the symptom or sign has worsened overall during this episode.]
  • Unchanged  [The severity of the symptom or sign has not changed overall during this episode.]
  • Improving  [The severity of the symptom or sign has improved overall during this episode.]
  • Resolved  [The severity of the symptom or sign has resolved.]
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This generally represents a broad category of applied refraction. Specific refraction details can be described using 'Refractive Correction'., comment=Details of the exact correction applied, or where multiple corrections should be captured via 'Refractive Correction'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Pinhole visual acuity  [The test is performed with pinhole refraction applied.]
    • Usual corrected visual acuity  [The test is performed with the patient's usual refractive correction i.e spectacles or contact lenses.]
    • Best corrected visual acuity  [The test is performed with the patient's optimal refractive correction.]
    • Unaided visual acuity  [The test was performed without visual aid.]
  •  Text
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  • Left eye  [The test result refers to the visual acuity of the left eye only.]
  • Right eye  [The test result refers to the visual acuity of the right eye only.]
  • Both eyes simultaneously  [Both eyes were examined simultaneously.]
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  •  Coded Text
    • Not performed  [The visual acuity test was never performed.]
    • Not completed  [The visual acuity test was started but could not be completed.]
  •  Text
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  • Ratio
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  • Ratio
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  • Unitary
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  • 1: NPL - No perception of light  [The subject has no perception of light.]
  • 2: PL - Perception of light  [The subject can perceive light.]
  • 3: HM - Hand movement  [The subject can perceive hand movement.]
  • 4: CF - Count fingers  [The subject can count fingers.]
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Assumed value: 0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0010], code=at0010, itemType=ELEMENT, level=7, text=Derived Score, description=Visual acuity expressed as an integer score which is calculated from one or more of the other result notation formats. The original notation should be captured using 'Derived Score Original Notation' format'., comment=Details of the algorithm used and original result format may be recorded under 'Derived Score Methodology'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=>=0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0053]/items[at0066], code=at0066, itemType=ELEMENT, level=7, text=Interpretation, description=The test result expressed as a qualitative term, normally coded., comment=Example: 'Visual Acuity 20/20' or 'Jaeger 'J2' score'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0054], code=at0054, itemType=ELEMENT, level=6, text=Overall Interpretation, description=A term, commonly coded, expressing an overall interpretation of the visual acuity test., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/data[at0003]/items[at0040], code=at0040, itemType=ELEMENT, level=6, text=Comment, description=Any additional narrative comment about the visual acuity test., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/state[at0041], code=at0041, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=5, text=State, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/state[at0041]/items[at0112], code=at0112, itemType=ELEMENT, level=6, text=Confounding Factors, description=Patient circumstances which affect interpretation of the result. Often termed 'reliability' in opthalmological documentation., comment=Examples: 'Patient was confused', 'Low light conditions'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.visual_acuity.v1]/data[at0001]/events[at0134]/state[at0041]/items[at0042], code=at0042, itemType=ELEMENT, level=6, text=Refractive Correction, description=The specific type(s) of refractive correction applied when measuring visual acuity., comment=Examples: 'No correction : unaided', 'Pinhole'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Spectacles  [The subject's vision was corrected by spectacles.]
  • Contact lenses  [The subject's vision was corrected by contact lenses.]
  • Pinhole  [The subject's vision was corrected by use of a pinhole.]
  • Autorefraction  [The subject's vision was corrected by autorefraction.]
  • Retinoscopy  [The subject's vision was corrected by retinoscopy.]
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Units:
  • ft
  • m
  • cm
  • in
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  • logMar chart  [A logMar chart was used to measure distance visual acuity.]
  • Snellen chart  [A Snellen chart was used to measure distance visual acuity.]
  • ETDRS chart  [An ETDRS chart was used to measure distance visual acuity.]
  • Picture chart  [A picture chart was used to measure distance visual acuity.]
  • Reduced logMar  [A Reduced logMar chart was used to measure near visual acuity.]
  • Reduced Snellen  [A Reduced Snellen chart was used to measure near visual acuity.]
  • Faculty of Ophthalmologists 'N' Score  [Faculty of Ophthalmologists 'N' Score chart was used to measure near visual acuity.]
  • Jaeger 'J' Score  [A Jaeger 'J' Score chart was used to measure near visual acuity.]
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  • Letter  [A letter optotype was used to measure distance visual acuity.]
  • Orientation  [An orientation optotype was used to measure distance visual acuity.]
  • Picture  [A picture optotype was used to measure distance visual acuity.]
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  • Single letter  [A single letter algorithm was used to derive the visual acuity score.]
  • Whole line  [A whole line algorithm was used to derive the visual acuity score.]
  • Last line single letter  [A last line single letter algorithm was used to derive the visual acuity score.]
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  • US Snellen  [The distance test result, recorded as Snellen visual acuity expressed in feet, where 20/20 is regarded as normal.]
  • Metric Snellen  [The distance test result, recorded in Snellen format expressed in metres, where 6/6 is regarded as normal.]
  • Decimal Snellen  [The distance test result,recorded as Sn ellen visual acuity expressed as a decimal ratio, where 1.0 is regarded as normal.]
  • ETDRS Letters  [Visual acuity expressed using ETDRS Letters format, with a value of 100 regarded as normal.]
  • Low Vision Score  [Graded scale used when patient has low levels of visual acuity.]
  • logMar  [The test result, recorded as logMar visual acuity, where a value of 0 is regarded as normal.]
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  • Left eye  [The left eye was examined.]
  • Right eye  [The right eye was examined.]
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description=Details about image quality related to ease of visualization of structures on eye fundus, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.fundoscopic_examination.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0136]/items[at0051]/items[at0057]/items[at0059], code=at0059, itemType=ELEMENT, level=9, text=Quality, description=Levels quantifying the quality of each acquisition, based in the ease to visualize the structures on the eye fundus, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, 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  • 1: Quality inadequate for any diagnostic purpose  [*]
  • 2: Unable to exclude all emergent findings  [*]
  • 3: Only able to exclude emergent findings  [*]
  • 4: Quality not ideal, but is possible to exclude subtle findings  [*]
  • 5: Ideal quality  [*]
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  • Direct  [Study performed by direct ophthalmoscopy]
  • Indirect  [Study of eye fundus by indirect ophthalmoscopy method]
  • Contact lens biomicroscopy  [Eye fundus viewing through biomicroscopy lens in contact to patient's eye surface]
  • Non-contact lens biomicroscopy  [Eye fundus viewing through biomicroscopy lens without contact to patient's eye surface]
  • Mydriatic retinography  [Observation of retina through funduscopic images acquired by previous dilatation of patient's pupils]
  • Non-mydriatic retinography  [Observation of retina through funduscopic images acquired without previous dilatation of patient's pupils]
  • Angiography  [Observation of the eye fundus using a fluorescent dye inyected to emphasize the blood vessels in the eye retina]
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  • 30º  [30º angle used for small pupil (SP) capture (for patients with pupil diameter <3.3mm)]
  • 45º  [45º angle used to acquire eye fundus of normal pupils]
  • 60º  [60º angle used to acquire eye fundus in some DR screening studies]
  • 100º  [Wide angle acquisition]
  • 200º  [Ultra-wide angle acquisition]
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  • Study field 1  [*]
  • Study field 2  [*]
  • Study field 3  [*]
  • Study field 4  [*]
  • Study field 5  [*]
  • Study field 6  [*]
  • Study field 7  [*]
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  • Mosaic  [Mosaic obtained from combining every peripheral acquisitions and the center one]
  • Central  [Image centered on the macula]
  • Nasal  [Image centered on the optic nerve or papila]
  • Temporal  [Image centered on the temporal quadrant of the retina]
  • Superior  [Image centered on the superior half of the retina]
  • Inferior  [Image centered on the inferior half of the retina]
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  • Left eye  [The left eye was examined.]
  • Right eye  [The right eye was examined.]
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  • RF  [Red-free imaging.]
  • IR  [Infrared reflectance imaging.]
  • AF  [BluePeak blue laser autofluorescence imaging.]
  • FA  [Fluorescein Angiography.]
  • ICGA  [Indocyanine green angiography.]
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  • OCT overview  [Details about slice/s of the retina regarding its/their position in the reference image.]
  • Retina exam  [Study of a slice of the retina and measurement of its thickness profile.]
  • Retina change  [Measurement of the thickness profile for each slice of retina in study and comparison of thickness progression in time during a follow-up.]
  • 3D view  [Study of a 3D recontruction of the retina.]
  • Thickness map exam  [Thickness study over the image of reference for multi-frame acquisition.]
  • Thickness map change  [Thickness progression study between several images of reference using different multi-frame acquisitions taken along time.]
  • RNFL thickness exam  [Measurement of thickness for retinal nerve fiber layer and comparison regarding the values from an age-adjusted normative database.]
  • RNFL thickness change  [Measurement of thickness for retinal nerve fiber layer and comparison regarding other measures obtained during a follow-up process.]
  • RNFL thickness trend  [Trend study for the evolution of retinal nerve fiber layer thickness.]
  • Asymmetry analysis  [Study of difference in thickness comparing: values in different eyes (OD-OS), and superior-inferior hemispheres of the same eye.]
  • RNFL & asymmetry analysis  [Study centered in retinal nerve fiber layer thickness and asymmetry of the retina.]
  • Posterior pole assessment  [Study centered in thickness around the optic nerve and macula.]
  • Other  [Other type of report.]
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  • Reference image  [The image of the retina used to indicate the position of OCT slices.]
  • Single OCT scan  [Report including a specific OCT scan.]
  • OCT volume scan  [A 3D reconstruction of eye structure using several OCT frames.]
  • Retinal thickness profile  [Graph showing the thickness of retina for a specific OCT scan.]
  • Retinal thickness map  [Coloured map showing the thickness of retina over the reference image.]
  • RNFL thickness profile  [Graph representing the thickness of the retinal nerve fiber layer around the optic nerve.]
  • RNFL thickness map  [Retinal nerve fiber layer thickness profile measured, compared to normal thickness values for different sections around the optic nerve.]
  • Thickness profile change  [Graph showing the thickness of retina from a specific OCT slice and compares them to values obtained in different acquisitions during a follow-up.]
  • Thickness map change  [Retinal thickness map obtained from the comparison of thickness values obtained in different acquisitions during a follow-up.]
  • Periapillary RNFL thickness classification  [Classification of total thickness measured for different sections around the papilla according to an age-adjusted normative database.]
  • Retinal average thickness  [Average thickness values in sections of retina located close to the macula.]
  • Asymmetry OD-OS  [Asymmetry map comparing thickness values from different eyes in the same locations.]
  • Hemisphere asymmetry  [Asymmetry map comparing thickness at superior and inferior hemispheres in retina.]
  • RNFL thickness trend  [Graph that represents the evolution along time of the thickness in retinal nerve fiber layer.]
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in mm., comment=Matches to DICOM (0022,0030) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/state[at0003]/items[at0125], code=at0125, itemType=ELEMENT, level=6, text=Horizontal field of view, description=The horizontal field of view in degrees., comment=Matches to DICOM (0022,000C) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=Units: deg, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/state[at0003]/items[at0130], code=at0130, itemType=CLUSTER, level=6, text=Contrast/Bolus, description=Information about the contrast agents administered prior to or during the acquisition., comment=Matches to DICOM (0018,0012) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/state[at0003]/items[at0130]/items[at0131], code=at0131, itemType=ELEMENT, level=7, text=Contrast/bolus agent, description=Identification of the contrast agent., comment=Matches to DICOM (0018,0012) attribute. Values permitted are defined by DICOM standard (PS 3.16) inside the table with Context ID 4200 (Ophthalmic Imaging Agent)., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Fluorescein  [Corresponds to DICOM Code value C-B02CC.]
  • Indocyanine green  [Corresponds to DICOM Code value C-B0156.]
  • Rose Bengal  [Corresponds to DICOM Code value C-B0295.]
  • Trypan blue  [Corresponds to DICOM Code value C-22853.]
  • Methylene blue  [Corresponds to DICOM Code value C-B02C5.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/state[at0003]/items[at0130]/items[at0132], code=at0132, itemType=ELEMENT, level=7, text=Contrast/bolus volume, description=Volume injected in milliliters of diluted contrast agent., comment=Matches to DICOM (0018,1041) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 ml, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/data[at0001]/events[at0002]/state[at0003]/items[at0130]/items[at0133], code=at0133, itemType=ELEMENT, level=7, text=Contrast/bolus volume ingredient concentration, description=Milligrams of active ingredient per milliliter of (diluted) agent., comment=Matches to DICOM (0018,1049) attribute., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 mg/ml, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.patients_background.v0]/items[openEHR-EHR-OBSERVATION.ophthalmic_tomography_examination.v0]/protocol[at0004], code=at0004, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0], code=at0000, itemType=SECTION, level=1, text=Clinical decision, description=Defines the process of making a decision about the diagnosis of a specific disease., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=SECTION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1], code=at0000, itemType=EVALUATION, level=2, text=Clinical Synopsis, description=Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.clinical_synopsis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Synopsis, description=The summary, assessment, conclusions or evaluation of the clinical findings., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1], code=at0000, itemType=EVALUATION, level=2, text=Problem/Diagnosis, description=Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual., comment=Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Problem/Diagnosis name, description=Identification of the problem or diagnosis, by name., comment=Coding of the name of the problem or diagnosis with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=Clinical description, description=Narrative description about the problem or diagnosis., comment=Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0012], code=at0012, itemType=ELEMENT, level=4, text=Body site, description=Identification of a simple body site for the location of the problem or diagnosis., comment=Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[at0077], code=at0077, itemType=ELEMENT, level=4, text=Date/time of onset, description=Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed., comment=Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_amd.v0], code=at0000, itemType=CLUSTER, level=4, text=Classification of age related macular degeneration, description=Classifies the condition and argues the diagnostic decision for age-related macular degeneration., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_amd.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=5, text=AMD classification, description=Clinical grade determined for age-related macular degeneration., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • No AMD  [No or a few (<5) small drusen (<63 micrometres in diameter).]
  • Early AMD  [Many small drusen or a few intermediate-sized (63-124 micrometres in diameter) drusen, or macular pigmentary changes.]
  • Intermediate AMD  [Extensive intermediate drusen or at least one large (≥125 micrometres) drusen, or geographic atrophy not involving the foveal centre.]
  • Dry advanced AMD atrophic  [Geographic atrophy involving the foveal centre.]
  • Exudative or wet AMD  [Choroidal neovascularisation or evidence for neovascular maculopathy (subretinal haemorrhage, serous retinal or retinal pigment epithelium detachments, lipid exudates, or fibrovascular scar).]
  • Ungradable  [Patient ungradable due to the low quality of acquisitions or uncertainty of the evaluator.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_amd.v0]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Diagnostic criteria, description=Clinical findings supporting the diagnose or grading., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Small drusen  [Drusen < 63 µm in diameter.]
  • Intermediate drusen  [Drusen 63-124 µm in diameter.]
  • Numerous intermediate drusen  [More than x drusen 63-124 µm in diameter.]
  • Large drusen  [Drusen ≥125 µm in diameter.]
  • Geographic atrophy  [A sharply demarcated, usually round or oval, area of atrophy of the RPE not involving the center of the fovea.]
  • Geographic atrophy involving foveal center  [Geographic atrophy of the RPE involving the foveal center.]
  • Choroidal neovascularization (CNV)  [Pathologic angiogenesis originating from the choroidal vasculature that extends through a defect in Bruch's membrane.]
  • Serous or hemorragic detachment  [Serous or hemorragic detachment of the neourosensory retina or RPE.]
  • Retinal hard exudates  [Hard exudates resulting from chronic intravascular leakage.]
  • Fibrovascular proliferation  [Subretinal and sub-RPE fibrovascular proliferation.]
  • Disciform scar (subretinal fibrosis)  [Subretinal fibrovascular tissue that usually becomes more fibrous within a few years and that is often the end result of CNV.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_amd.v0]/items[at0022], code=at0022, itemType=ELEMENT, level=5, text=Clinical findings, description=Overall findings on the patient considered in the diagnostic classification., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=termset: ac0001, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/data[at0001]/items[openEHR-EHR-CLUSTER.classification_amd.v0]/items[at0003], code=at0003, itemType=ELEMENT, level=5, text=Comments, description=Additional comments that clarify the diagnostic decision made., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.problem_diagnosis.v1]/protocol[at0032], code=at0032, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0], code=at0000, itemType=EVALUATION, level=2, text=Contraindication, description=Identification of a treatment, test or procedure which should not be provided to the subject of care, for clinical reasons., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Contraindication, description=Identification of a contraindication to a treatment, test or procedure, including a class of medications or vaccines., comment=Coding of the identified 'Contraindication' with a terminology is desirable, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0]/data[at0001]/items[at0003], code=at0003, itemType=ELEMENT, level=4, text=Rationale, description=Description of evidence or rationale for the contraindication., comment=Please note: an optional URI link to evidence within the health record is also permitted using Reference Model attributes. As this URI link may not be accessible from a message or by receiving clinical system it is desirable that a narrative description of the rationale should be explicitly stated., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Very low VA (below 0.1 in first clinical encounter)
  • Healed lesions (Identified signs of previous treatments)
  • Multimorbidity (Coexistence of additional alterations on the retina)
  • Reaction to anti-VEGF (Suspicion of hypersensitivity to agents used in intravitreal injections)
  • No response to treatment (VA decreased below 0.1 three consecutive reviews)
  • Morphologic deterioration of the lesion
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0]/protocol[at0006], code=at0006, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0]/protocol[at0006]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Last updated, description=The date this contraindication was last updated., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.contraindication.v0]/protocol[at0006]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=Review date, description=Date when due for review by a clinician., comment=In some circumstances, contraindications are not intended to be indefinite or lifelong, and this contraindication should be reconsidered in the context of changing clinical circumstances. For example: if a family member is no longer taking immunosuppressive therapy, then live vaccines could safely be administered to the subject of care again and the contraindication is effectively obsolete., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.recommendation.v1], code=at0000, itemType=EVALUATION, level=2, text=Recommendation on the treatment of AMD, description=A suggestion, advice or proposal for clinical management., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVALUATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.recommendation.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.encounter.v1]/content[openEHR-EHR-SECTION.clinical_decision.v0]/items[openEHR-EHR-EVALUATION.recommendation.v1]/data[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=4, text=Recommendation, description=Narrative description of the recommendation., comment=May be coded, using a terminology, if required., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Do not treat
  • Intravitreal anti-VEGF injection
  • High dose Antioxidant Vitamin and Mineral Supplements
  • Photodynamic Therapy (PDT)
  • Thermal Laser Photocoagulation Surgery
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  • Visual acuity decrease with macular fluid
  • Macular fluid
  • New macular haemorrhage
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  • Very low VA
  • Healed lesions
  • Multimorbidity
  • Reaction to anti-VEGF
  • VA decrease
  • Morphologic deterioration
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