Post-operative evaluation form - Laser surgery

Identification

Last Name*

First Name*

Post-Op Date*

Date of birth*

Age

#chart/at our clinic

Symptoms

Distance vision

excellent
good
difficult
unsatisfactory

Near vision

excellent
good
difficult
unsatisfactory

Dry Eyes

excellent
good
difficult
unsatisfactory

Glare

excellent
good
difficult
unsatisfactory

Halos

excellent
good
difficult
unsatisfactory

Pain

excellent
good
difficult
unsatisfactory

Additional comments

Surgery

Context

1st surgery
Touch-up/2d surgery

Delay since surgery - OD

1 week
1 month
3 month
6 month
1 year
other

Delay since surgery - OS

1 week
1 month
3 month
6 month
1 year
other

Type of surgery - OD

Lasik
Surface ablation (PRK)

Type of Surgery - OS

Lasik
Surface ablation (PRK)

Targeted correction - OD

DV
NV

Targeted correction - OS

DV
NV

UCVA DV

UCVA DV - OU

6/

UCVA DV - OD

UCVA DV - OS

6/

UCVA NV - OU

UCVA NV M at cm - OU

M

At cm

UCVA NV M at cm - OD

UCVA NV M at cm - OS

M

at cm

M

at cm

Refraction

Subjective Refraction - OD

Subjective Refraction - OS

Subjective Refraction - OD

Subjective Refraction - od 6/

Subjective Refraction - OS

Subjective Refraction - os 6/

Electronic Refraction - OD

Electronic Refraction - OS

Subjective Refraction - OD

Subjective Refraction - od 6/

Subjective Refraction - OS

Subjective Refraction - os 6/

Intraocular pressure

:

Method

NCT (Air jet)
Goldmann (aplanation)

IOP - OD

IOP - OS

Left Eye

Right Eye

Grades

1/2: trace 1: minor 2: moderate 3: moderately significant 4: severe

Hyperemia - OD

none
present

Hyperemia - OS

none
present

Epithelial erosion - OD

none
present

Epithelial erosion - OS

none
present

SPK - OD

none
present

SPK - OS

étanche
fuite

Sub-epithelial fibrosis (haze) - OD

none
present

Sub-epithelial fibrosis (haze) - OS

none
present

Flap: Striaes/Folds - OD

none
micro
macro
periph
central

Flap: Striaes/Folds - OS

none
micro
macro
periph
central

FLAP: Margins - OD

régulier
irrégulier

FLAP: Margins - OS

regular
irregular

Interface - OD

clean
debris
opacity
fibrosis

Interface - OS

clean
debris
opacity
fibrosis

Diffuse Lamellar Keratitis (DLK) - OD

absent
present

Diffuse Lamellar Keratitis (DLK) - OS

absent
present

Epithelial ingrowth - OD

absent
present

Epithelial ingrowth - OS

absent
present

Recommandations

Next checkup

Communication

I have additional inormations and I would like you to communicate with me regarding this patient
Urgent

Optometrist*

member number*

Clinic*

Phone

Fax