Post-Operative Refraction/ Follow Up. DATE

$Post-Operative Refraction/ Follow Up. DATE$

Patient name and address / Accredited optometrist name. Name and addressof practice / GP name and address

Post-Operative Refraction/ Follow up. DATE :-

Step 1

Establish date of surgery, provider, and whether a follow up or refraction only is required. / Right eye Date
Provider
REFRACTION ONLY
FOLLOW UP / Left eye Date
Provider
REFRACTION ONLY
FOLLOW UP

Step 2

Ask the patient about these symptoms and consider the explanatory notes / Right Eye / Post-operative questions / Left Eye
No / Yes / Do you have persistent pain? / No / Yes
No / Yes / Any persistent discharge? / No / Yes
No / Yes / Any persistent swelling? / No / Yes
No / Yes / Any new flashes and floaters since the operation? / No / Yes

Step 3

Complete the post-op refraction details / Unaided vision / Sph / Cyl / Axis / Prism / Base / VA / Add / Near VA
RE
LE

Step 4

Examine the eyes for post-operative complications and consider the explanatory notes / Right Eye / Left Eye
No / Yes / Raised IOP
Applanation >21 mmHg or
Non contact tonometer (3 readings) >26mmHg / No / Yes
No / Yes / Corneal Oedema / No / Yes
No / Yes / Marked limbal/conjunctival injection / No / Yes
No / Yes / Post-operative uveitis grades 1-2 / No / Yes
No / Yes / Post-operative uveitis grade 3 / No / Yes
No / Yes / Post-operative hypopyon / No / Yes
No / Yes / New floaters since surgery / No / Yes
No / Yes / Unexplained poor vision worse than 6/12 or definite signs of cystoid macular oedema / No / Yes

Step 5

Outcome / Complications noted? / Yes / No
Patient referred back to surgeon/provider. / Yes / No
Please telephone the surgical provider, and then fax this form for conditions marked in red. For all other patients this form should be faxed through to the provider immediately. Please retain a copy for your records and forward a copy to Doreen Wiltshire, Wiltshire PCT, Southgate House, Pans Lane, DevizesSN10 5EQ so payment can be made to you.
Optometrist comments. IOP measured at mmHg