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Transport Canada > Civil Aviation > Civil Aviation Medicine > TP 13312 - Handbook for Civil Aviation Medical Examiners > TP 13312 - Handbook for Civil Aviation Medical Examiners

Photorefractive Keratectomy (PRK) and Laser Assisted in Situ Keratomeulesis (LASIK)

Patient’s Name: _________________________ 
File No. __________________________________
Date of Surgery: _____________________________
Surgical Technique: ___________________________
Number of treatments: ________________________ 
Size(s) of Ablation Zone(s): _____________________

Uncorrected Acuity

Pre-operative data:
OD __________
OS __________

3 Months Post PRK:
(may be completed by an Optometrist)
OD __________
OS __________
  
6 Months Post PRK:
(may be completed by an Optometrist)
OD __________
OS __________

 Refraction & Corrected Acuity


__________ = _________
__________ = _________

  

__________ = _________
__________ = _________



__________ = _________
__________ = _________

Are there any of the following:

Glare sensitivity or “haloing” Yes _____ No _____
Night vision difficulty Yes _____ No _____
Diurnal variation of vision Yes _____ No _____
Use of ocular medication Yes _____ No _____
Corneal haze Yes _____ No _____
Loss of contrast sensitivity/acuity (this has potentially 
serious implications in the aviation environment) 		Yes _____ No _____

 

Signature of attending Ophthalmologist/ Optometrist _________
Date: ___________ Phone: ( ) __________

May 1999  

 

 
Last updated: 2004-11-26 Top of Page Important Notices