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Post-operative evaluation form - Intraocular surgery
Identification
Last name
*
First name
*
Follow-up date
*
YYYY dash MM dash DD
Date of birth
*
YYYY dash MM dash DD
Age
#chart/at our clinic
Symptoms
Distance vision
excellent
good
difficult
unsatisfactory
Intermediate
excellent
good
difficult
unsatisfactory
Near vision
excellent
good
difficult
unsatisfactory
Dryness
absent
minor
important
intermittent veil
Glare
absent
mineur
modéré
gênant
Perception of halos
absent
minor
moderate
important
Pain
absent
minor
moderate
important
Perception of flotters
none
absent
minor
moderate
important
Additional comments
Surgery
Delay since surgery - OD
1 week
1 month
3 month
other
Delay since surgery - OS
1 week
1 month
3 month
other
Type of IOL - OD
mono
multifocal
toric
Type of IOL - OS
mono
multifocal
toric
Targeted correction - OD
DV
IV
NV
other
Targeted correction - OS
DV
IV
NV
other
UCVA DV
UCVA DV - OU
6/
UCVA DV - OD
UCVA DV - OS
6/
TS 6/
6/
TS 6/
UCVA NV
UCVA NV - OU
M
at cm
UCVA NV - OD
UCVA NV - OS
M
at cm
M
at cm
Refraction
Subjective refraction - OD
Subjective refraction - OS
Réfraction subjective - OD
réfraction subjective - od 6/
Réfraction subjective - OS
réfraction subjective - os 6/
Electronic refraction - OD
Electronic refraction - OS
Réfraction subjective - OD
réfraction subjective - od 6/
Réfraction subjective - OS
réfraction subjective - os 6/
Intraocular pressure
:
Hours
Minutes
Method
NCT (Air blast)
Goldmann (applanation)
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
Edema Conj/Lid - OD
none
present
Edema Conj/Lid - OS
none
present
Incision - OD
sealed
leak
Incision - OS
sealed
leak
Cornea - OD
clear
edema
Cornea - OS
clear
edema
Anterior chamber - OD
quiet
cell/flare
Anterior chamber - OS
quiet
cell/flare
Posterior capsule - OD
clean
opacity
folds
Posterior capsule - OS
clean
opacity
folds
Macula - OD
Sane
Omk
Macula - OS
Sane
Omk
Recommandations
Next appointment
Communication
I have additional information for this patient and I would like you to contact me
Urgent
Optometrist
*
no member
*
Clinic
*
Phone
Fax
