|
Pediatric
Keratoplasty Association
Dermoid and Astigmatism Woorsheet |
| Surgeon's Name ______________________ |
Surgeon's E-mail _____________________ |
| Surgeon's Phone # ____________________ |
Surgeon's Fax # _____________________ |
|
|
| Patient's Initials ______________________ |
Patient's date of birth _________________ |
| Involved Eye _________________________ |
Sex |
| Widest Diameter _____________________ |
Location |
| Other ocular Abnormalities
_________________________________________________ |
| Systematic Abnormalities
_________________________________________________ |
|
(Fill in only for the involved eye) |
|
|
| Date of Pre-op Exams _________________ |
Date of Pre-op Exams ________________ |
| Date of Excision ______________________ |
Date of Excision _____________________ |
| Date of Post-op Exam _________________ |
Date of Post-op Exam ________________ |
| Pre-op Vsc OD _______________________ |
Pre-op Vsc OD ______________________ |
| Post-op Vsc OD ______________________ |
Post-op Vsc OD _____________________ |
| Pre-op MR OD _______________________ |
Pre-op MR OD ______________________ |
| Post-op MR OD ______________________ |
Post-op MR OD ______________________ |
| Pre-op CR OD _______________________ |
Pre-op CR OD _______________________ |
| Post-op CR OD ______________________ |
Post-op CR OD ______________________ |
| Pre-op Vcc OD ______________________ |
Pre-op Vcc OD ______________________ |
| Post-op Vcc OD _____________________ |
Post-op Vcc OD _____________________ |
| Pre-op K's OD _______________________ |
Pre-op K's OD _______________________ |
| Post-op K's OD ______________________ |
Post-op K's OD ______________________ |
| Pre-op Topo OD (yes or no) ____________ |
Pre-op Topo OD (yes or no) ____________ |
| Post-op Topo OD (yes or no) ___________ |
Post-op Topo OD (yes or no) ___________ |
| Pre-op Photo OD (yes or no) ___________ |
Pre-op Photo OD (yes or no) ___________ |
| Post-op Photo OD (yes or no) __________ |
Post-op Photo OD (yes or no) __________ |
