TOPOGRAPHY/WAVE SCAN ORDER AND INTERPRETATION
Patient Name: _______________________________________
Test Date ______________
Indications / Medical Rationale: _______________________________________________________
_________________________________________________________________________________
Performed by: _________________
Technician Comments: Patient understanding & cooperation
_________________________________________________________________________________
______ Good Image Quality
______ Poor Photo Quality, affected by:
Movement/Nystagmus
Blink
Other: ____________________________________________________________
STUDY FINDINGS (Indicate OD, OS, OU in line next to condition)
___ Cornea normal
___ Regular astig
___ Irregular astig / keratoconus
___ Scarring
___ Lesions
___ Pterygium
___ Keratoconus
___ Peripheral corneal degeneration
___ Mooren's ulcer
___ Terrien's degeneration
___ Edema
___ Keratitis
___ Corneal wounds
___ Burns
___ Previous Corneal Surgery
___ Previous Refractive Surgery
Other_____________
INTERPRETATION
______ Condition is NEW
______ Compared to last exam/photo, condition is:
STABLE
IMPROVING
WORSENING
IMPACT ON TREATMENT
______ No treatment at this time, continue to monitor
______ Continue current treatment
______ Refer for treatment (see “treatment plan” details on exam note)
______ Modify existing treatment (see “treatment plan” details on exam note for details)
______ Schedule new treatment (see “treatment plan” details on exam note)
Physician Signature ____________________________
Date __________________