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

Indication for surgery

Pseudophakic bullous keratopathy Fuchs' endothelial dystrophy

Surgery

Posterior 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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