Pediatric Plastic Surgery, PLLC - the Craniofacial Center

The Craniofacial Center

Medical City Dallas Children¡¯s Hospital

Craniomaxillofacial, Cleft, Plastic and Reconstructive Surgery

Jeffrey A. Fearon, M.D., F.A.C.S., F.A.A.P., Director

EYE EXAMINATIONS FOR PATIENTS WITH CRANIOSYNOSTOSIS

Please have your child¡¯s eye doctor check the following items during the eye

examination:

Patient Name:

Date of Exam:

Yes

No

Changes in visual acuity

[ ]

[ ]

Changes in appearance of optic nerve

[ ]

[ ]

Papilledema

[ ]

[ ]

Clinically significant strabismus

[ ]

[ ]

Corneal scarring

[ ]

[ ]

Any comments for Dr. Fearon:

Name of Specialist Performing Exam: __________________________________

Please forward completed form to our office at your earliest convenience.

7777 Forest Lane, Suite C700, Dallas, Texas 75230

Telephone: (972) 566-6464 FAX: (972) 566-6279



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