Patient presents with symptoms suggestive of retinal tear, including flashes of light (photopsia), floaters (myodesopsia), and possibly a shadow or curtain in the visual field.  Onset of symptoms was [Date of onset] and characterized as [Character of onset - sudden, gradual, intermittent].  Visual acuity measured [OD: right eye visual acuity] and [OS: left eye visual acuity].  Intraocular pressure measured [IOP OD] and [IOP OS].  Dilated funduscopic examination revealed a retinal tear located at [Clock hour location] in the [Right eye OD or Left eye OS], measuring approximately [Size of tear] disc diameters.  The tear is characterized as [Type of tear - U shaped, horseshoe, giant retinal tear].  Associated findings include [Vitreous hemorrhage, subretinal fluid, pigment demarcation lines].  Differential diagnoses considered include posterior vitreous detachment (PVD), retinal detachment, and vitreous syneresis.  Diagnosis of retinal tear was made based on clinical findings.  Treatment plan includes close observation versus laser photocoagulation or cryotherapy to seal the retinal break and prevent progression to retinal detachment.  Patient education provided regarding symptoms of retinal detachment, emphasizing the importance of immediate follow-up if symptoms worsen.  Patient scheduled for follow-up examination in [Duration of follow-up - e.g., one week] to assess treatment response and monitor for any signs of retinal detachment.  ICD-10 code H33.1 (Retinal detachments and breaks) and relevant CPT codes for diagnostic ophthalmoscopy and any procedures performed will be documented for medical billing and coding purposes.