Patient last name
Date of birth (dd/mm/yy)
Male	Female
OD	OS

Indication for surgery

Keratoconus Herpes scar Postinfection scar Corneal dystrophy Post corneal refractive surgery

Surgery

Deep anterior lamellar keratoplasty Penetrating keratoplasty

Surgeon last name
Date of surgery (dd/mm/yy)

Examination

Preoperative 6 months postoperative 12 months postoperative

Visual acuity

UCVA BSCVA Contact lens

n.d. 1.0 0.8 0.6 0.5 0.4 0.3 0.25 0.2 0.15 0.1 3/60 1/60 3/300 1/300 LP+ LP-

S

C-

axis

Keratometer

D

x

D

Videotopography made

Eye pressure

Applanation Puff Palpetory

n.d. 45+ 40 36 32 28 24 20 16 13 10 8 6 4 2 0 n.m.

Eyelids

Normal

Anterior segment

Quiet eye or transplant Dry eye Persistent epithelial defect Loose suture Suture inflammation Suture vascularization Suture removal Allograft rejection Uveitis anterior Wound dehiscence Cataract

Slit-lamp photo made

Endothelial cell counts

Posterior segment

Not evaluated Normal

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