Corneal Topography/Tomography Interpretation Report

Patient: [name, MRN, DOB]    Encounter Date: [date]    Test Date: [if different]

Device: [manufacturer, model]    Modality: [Topography (Placido) / Tomography (Scheimpflug/OCT) / Combined]    Laterality: [OD / OS / OU]

Ordering Clinician: [name]    Interpreting Clinician: [name]

Indication & Context

• Primary indication: [ectasia evaluation / surgical screening / specialty CL fitting / progression monitoring / post-surgical assessment]
• Relevant history: [pertinent ocular history, symptoms, prior corneal surgery, known ectasia]
• Contact lens status: [lens type, abstinence interval] (Flag if worn within recommended abstinence window)
• [Other relevant context as needed] (Limit to 3–6 total bullets)

Quality Assessment

OD: [Good / Fair / Poor / Uninterpretable] — [limiting factors if any; reliability statement for intended use]

OS: [Good / Fair / Poor / Uninterpretable] — [limiting factors if any; reliability statement for intended use]

(If Uninterpretable for either eye, note: Interpretation deferred; repeat testing recommended after addressing [specific issue].)

Findings

(Document objective measurements and map interpretations; reserve diagnostic conclusions for Impression. Include device-specific indices by name when available.)

OD

Core Metrics: K1/K2/Km [D], Kmax [D], astigmatism [D @ axis], thinnest pachymetry [µm] at [location]; anterior/posterior elevation at thinnest [µm] (if tomography)

Map Interpretation: [Overall pattern: symmetric bowtie / inferior steepening / irregular] — [cone location if present] — [irregularity indices with values, e.g., BAD-D, ABCD staging] — [posterior-anterior concordance and thinning-steepening co-location if tomography]

Comparison: [Prior study date and key parameter deltas (ΔKmax, Δpachymetry, elevation trends) with statement on measurement variability] or [No prior available for comparison]

OS

Core Metrics: K1/K2/Km [D], Kmax [D], astigmatism [D @ axis], thinnest pachymetry [µm] at [location]; anterior/posterior elevation at thinnest [µm] (if tomography)

Map Interpretation: [Overall pattern: symmetric bowtie / inferior steepening / irregular] — [cone location if present] — [irregularity indices with values, e.g., BAD-D, ABCD staging] — [posterior-anterior concordance and thinning-steepening co-location if tomography]

Comparison: [Prior study date and key parameter deltas (ΔKmax, Δpachymetry, elevation trends) with statement on measurement variability] or [No prior available for comparison]

Impression & Recommendations

OD: [Normal / Ectasia suspect / Keratoconus (mild/moderate/severe) / PMD-pattern / Post-refractive ectasia features] — [brief synthesis]

OS: [Normal / Ectasia suspect / Keratoconus (mild/moderate/severe) / PMD-pattern / Post-refractive ectasia features] — [brief synthesis]

Recommendations:

• Surgical screening: [clear / contraindicated / defer] — [rationale] (Include only if indication is surgical screening)
• Ectasia management: CXL referral [indicated / not indicated / consider]; follow-up interval [timeframe] (Include only if ectasia evaluation or monitoring)
• CL fitting guidance: [corneal GP / scleral / hybrid] based on [key shape characteristics] (Include only if indication is CL fitting)
• [Referrals, repeat testing conditions, or significant limitations affecting interpretation as applicable]

Attestation

Interpreting Clinician: [name, credentials]

Signature: [electronic signature]

Date: [interpretation date]