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Talley Medical Surgical Eye Care Associates, P.C.
Optometric Referral Center
PATIENT: _____________________________________________________________ DATE OF VISIT: _________________________________________
SURGEON: _____________________________________________________ CONSULTING O.D.: _____________________________________________
POST OPERA
TIVE DAY
a OD 1
23456
a OS 1
23456
POST OPERATIVE WEEK
a OD 123456789101112 a OS 123456789101112
DATE OF SURGERY
a CE/IOL OD ________________________________ a CE/IOL OS ____________________________________
a Y
AG OD __________________________________
a Y
AG OS ______________________________________
PATIENT COMPLAINTS
a OD __________________________________________ a OS _______________________________________
CURRENT MEDICATIONS: _______________________________________________________________________________________________________
CORNEA: 1) Clear Neg Pos 1) Clear Neg Pos
2) Striae Neg Pos 2) Striae Neg Pos
3) Edema Neg Pos 3) Edema Neg Pos
ANTERIOR
CHAMBER: 1) Quiet Neg Pos 1) Quiet Neg Pos
2) Cells/Flare Neg +1 +2 +3 +4 2) Cells/Flare Neg +1 +2 +3 +4
3) Hypopyon Neg Pos 3) Hypopyon Neg Pos
PUPIL: Round Irregular Round Irregular
INCISION: 1) Sutures Intact Neg Pos 1) Sutures Intact Neg Pos
2) Gaping Wound Neg Pos 2) Gaping Wound Neg Pos
3) Prolapse of Iris Neg Pos 3) Prolapse of Iris Neg Pos
POSTERIOR
CAPSULE: Clear Hazy Clear Hazy
IMPLANT: Centered Off Center Centered Off Center
FUNDUS: 1) Normal Neg Pos 1) Normal Neg Pos
2) Hemorrhage Neg Pos 2) Hemorrhage Neg Pos
3) Macular Edema Neg Pos 3) Macular Edema Neg Pos
IOP: OD ______ OS ______ UNCORRECTED VA: REFRACTION:
OD 20/____ OS 20/____ OD _____________________ 20/_____
OS _____________________ 20/_____
Rx GIVEN: OD____________________ x _________ Add + ____________
OS____________________ x _________ Add + ____________
PLAN:
Follow up:
a Routine a Refraction ______ a days a weeks a months With: a O.D. a Surgeon
Medication: Appt on: __________________________________
Comments:
If any pain, purulent discharge, redness, and/or decrease in vision develops, call our office at:
In Evansville (812) 424-2020 • Out of Town (800) 489-2020
SIGNATURE___________________________________________________________
OD
OS
POST-OPERATIVE REPORT