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LASIK Pre-Operative Exam Required Testing By Co-Managing Doctors • Contact lens history-type of lens, time out before exam See Section – for specific information • Medical history- allergies, previous eye surgeries See Section – for specific information • Dominant Eye • Current glasses/date to check refractive stability • Entrance Testing: pupil evaluation, cover test, EOM, confrontation visual fields • Uncorrected distance and near VA • Manifest Refraction including best correctable VA and near add • Cycloplegic Exam with best correctable VA- 1% Cyclopentolate is required • IOP-applanation or non-contact Pressures between 20-30mmhg must have a visual field prior to surgery • Slit lamp evaluation of the anterior chamber including lids, conjunctiva, cornea Dry eye patients/CL wearers must have SPK resolved before surgery • Dilated Fundus Examination including lens, macula, peripheral retina • Intended Target- Monovision, patients under age 21 may be targeted +0.25 due to myopic progression with age • Assessment-patient’s refractive diagnosis and LASIK candidacy, any other medical/ocular conditions and relativity to LASIK • Plan-patient’s intent to have LASIK surgery, documentation of any specific counseling done with patient-halos, starbursts, dry eyes, rx change, etc. • Please initial that you have thoroughly discussed instructions for day of surgery and after surgery, expectations and no guarantee of 20/20, risks/alternatives, presbyopia, enhancements, night vision Testing Done at Dishler Laser Institute • Orbscan- maps anterior and posterior surfaces, pachymetry • Zywave- predicts amount of aberrations, predicted phoropter refraction • Pupil Size- this is tested using the Pupillometer with infrared light • Keratometry/ ∆K- predicts the amount and location of corneal astigmatism • Corneal white to white • Pachymetry- will be confirmed by Visante OCT pachymetry if needed • Humphrey visual field if needed • Day of surgery slit lamp evaluation to check for SPK or other corneal conditions • Final refraction check • Confirm intended target with patient • Answer any final questions • Please fax/send all pre-operative LASIK exams to our office at least one week before the scheduled surgery day so we have time to prepare the charts for surgery • Information must be on a current DLI form (included in this packet) and must be legible • A complete pre-operative exam form must be filled out before all enhancements as well 7 8