Eye Trauma to be reported includes all serious eye injury resulting in permanent and significant (i.e., measurable or observable on routine eye examination) structural or functional change to the eye.  Mild ocular contusions, subconjunctival hemorrhages, and superficial abrasions by themselves usually would not meet the Registry’s criterion of serious and/or reportable injuries, and we rely greatly on your professional judgment as to which ocular injuries should be reported. If there is a question whether an injury is serious, please report the injury, and the six month follow-up will clarify whether it was serious or not.

The initial report should be filed shortly after the patient's initial presentation in your office.  In general, initial reports should be prepared on the basis of the history and clinical findings recorded at the first examination after injury.  A separate report should be filed for each eye involved in bilateral injuries.  Please indicate whether the injured eye had any preexisting disease or condition by circling the appropriate response to "Was Eye Normal Prior to Injury?."  Please list any preexisting maladies in the Comments section.

A.

IDENTIFICATION:  This column is provided for you to enter information that will make it possible for you to identify the patient from your records, but stops short of providing data which could identify the patient to the Registry or others.  We encourage offices that do not use medical record numbers for patient identification to devise some type of in-office coding to be used for their reported eye injuries.  This assignment will facilitate your identification of the patient for follow-up reporting purposes, and will reduce those "Lost to follow-up" because the identification initially reported proved insufficient for later re-identification.  The anonymity of each patient reported must be maintained, so do not report patient names to the Registry.  Most other entries within this category are self-explanatory, but please use care that all entries are completed.  Entries concerning dates appear throughout the form, and their completion is of particular importance for injury surveillance.  If applicable, please report who initially treated the patient for purposes of follow-up of any unreported information.  The Registry will automatically contact you or the person you designate on the last line of this section for a six-month follow-up report.

An open globe injury is defined as an eye injury resulting in a full thickness defect of the eye wall. 

The defect may be a penetrating (single laceration) caused by a sharp object or a rupture caused by blunt force.  A perforating injury is defined as two full-thickness lacerations (entrance + exit) of the eye wall, usually caused by a sharp object or missile.  See BETT.

If an applicable option is not provided in any of the following categories, please use the Other or Comments section for any explanations you may have; these responses are coded into the database and will be available for future research.

B.

EYE PROTECTION:  Please check the appropriate response for eye protection worn when injured.

C.

WAS PATIENT A BYSTANDER?:  Bystander, operator, or spectator status is of particular importance in the identification of trends of certain eye injuries.

D.

WORK-RELATED:  Please check the appropriate response.  This information is particularly important in prevention strategies.  If this injury is work-related, please record the patient's occupation in the "pop up list" next to the word occupation.  This list is in Alphabetical order, and you may scroll down the list to search for the patient’s occupation, or enter the first letter of the occupation, hit the enter key, and you will automatically go to the proper alpha area in the list.  When you find the proper occupation listed, "click" on it, and it will automatically appear in the box.  NOTE: When first using the list, please scroll down the list in order to become familiar with the occupations listed.  If NONE of those listed apply, you may enter the patient’s occupation.  Please do this only as a last resort.

E.

PLACE OF INJURY:  Place of injury occurrences have been standardized by the World Health Organization, and the most commonly reported locations are listed for your convenience. Simply choose the selection that applies. If none of these options apply, please select Other.  In the area marked "Specify" you will find a "pop up" list like the one under Occupation.  Please give a more detailed description of the Place of injury.  Example #1:  The place of injury is School, and the injury occurred in the classroom.  Select "classroom" from the list. Example #2:  The place of injury is Public Building, and the injury occurred in an airport.  Select "airport" from the list. The list is in Alphabetical order, and you may scroll down the list to search for the appropriate "place," or enter the first letter of the place description, and hit the enter key.  You will automatically go to the proper alpha area in the list. When you find the proper place description listed, "click" on it, and it will automatically appear in the box.  NOTE: When first using the list, please scroll down the list in order to become familiar with the list.  If NONE of those listed apply, you may enter the place description.  Please do this only as a last resort.

F.

PLACE OF INJURY ZIP CODE:  If available, the zip code provides invaluable epidemiologic data regarding the "clustering" of eye injury occurrences and in determining where preventive efforts are best concentrated.  Obviously, this information will not always be available to the report filer. 

G.

INTENT:  The intention of an injury is of tremendous importance. Injuries can be of three types.

H.

ALCOHOL USE ?: OR DRUG USE?:  Please select the appropriate responses. If knowledge of specific kind of drug is available to you, please list in the "Description of Drug Use" section. You will find the same "pop up" list format previously used to provide further information in the Place and Occupation. Again, scroll through the list to find the appropriate "drug" or type it in only if the drug used is not listed.

I.

SOURCE OF INJURY:  Common sources of injuries are listed for your convenience; please select the appropriate response.  Then go to the Description of Source list, and you will find a "pop up" list similar to the ones used in the Occupation, Place, and Drug Use lists.  The Source list has sub-categories for Fireworks and Sports-related source of injury. For a sports-related injury, click in the box and type in "sp," hit the return key, and a list of all "sp" or "sport-related” injuries are listed.  Select the appropriate sport, and it will automatically appear in the box.  Example #1:  The source of injury is a basketball.  The Source selected should be Blunt Object.  In the Description of Source list, type in "sp," and hit the return key.  A list of all "sp" or "sport-related” injuries are listed.  Select "spBasketball", and "spBasketball" will appear in the box.  Example #2:  The source of injury is a bottlerocket.  The Source selected should be Fireworks.  In the Description of Source list type in "fw," and hit the return key.  A list of all "fw" or "fireworks-related” injuries are listed. Select "fwBottlerocket" and "fwBottlerocket" will appear in the box. This method of sub-categorization provides user friendly methods to be utilized during research.  Example #3:  The patient is injured in a drive-by shooting.  The source of injury is Gunshot, and the Description of the Source is Drive-by.  Example #4:  The injury is caused by a rock thrown by a weed-eater. The source of injury is Lawn equipment, and the Description of the Source is Weed-eater.  Please also note that Types of Fireworks and Lawn Equipment are requested to differentiate between the numerous kinds of fireworks available and the various kinds of lawn equipment causing ocular injury.  We are not interested in "Brand Names," but rather product types.

J.

TISSUES INVOLVED:  Ocular and adnexal tissues are divided into convenient categories, and all appropriate categories should be selected.

K.

VISION:  Standard visual acuity range designations are provided ranging from NLP to 19/200; the appropriate response should be checked. If acuity is 20/200 or better, please specify in the space provided. Please provide acuity for injured eye as well as acuity for fellow uninjured eye.  If the injury is bilateral, please fill out two separate report forms.  We are interested in the first recorded visual acuity obtained post-injury, and the date of this testing.

L.

COMMENTS:  Please provide a narrative description to clarify or expand upon information provided in the above categories.  The Registry will use this information to assign an ICD-9-CM External Causes Code (E-Code) for each reported injury.

M.

INITIAL DIAGNOSES:  Most commonly reported initial diagnoses are listed anatomically, anterior to posterior, and grouped in order of tissues involved. You are encouraged to select all applicable initial diagnoses, and to record other applicable diagnoses in Item 99.0 Other or Comments.  Space limitations prevent the listing of all diagnoses, but the Registry has master code assignments for many other diagnoses not listed here.  The list of Master Codes is available on the log in screen under "Menu Items" and may be printed out on your printer.  Standard ICD-9CM coding is also utilized for less frequently reported diagnoses Particular care should be undertaken when reporting corneal, scleral, or corneal/scleral lacerations, or ruptures. Length and location of the wound is requested as well as uveal prolapse and visual axis involvement.  Blank spaces within this section request additional information such as the percentage of hyphema, the type of retinal defects and detachments, and the number of quadrants involved in a retinal detachment.  The causative organism in a diagnosis of  Endophthalmitis is to be entered in the "pop up" list area under organism. 

If at any time particular diagnosis information is unavailable or unknown, please record "U" in the blanks provided, alerting the Registry that you have considered these categories and have not overlooked them.

N.

INITIAL OPERATION:  Please be sure to specify the date of the initial operation at the head of this column and then select all applicable procedures.  The procedures listed are those most commonly reported in the initial management of eye trauma.  However, we code all procedures reported, and if other procedures are performed, they should be designated under Item 99.0 Other or Comments, since they will also be added to the database.

REPORT FORM INSTRUCTIONS

SIX MONTH FOLLOW-UP REPORT

In order to evaluate the long-term effectiveness of treatment as well as long-term personal and social impacts of eye injuries, six month post-injury follow-up is essential.  Please make every effort to take a few moments to complete the form, since its value to the Registry and future research cannot be overstated.  Reports less than six months after injury are of value, but examinations six months or greater post injury are recognized to represent the final injury outcome.  If you have no examination occurring at least six months post-injury, please arrange re-examination.  If this is not possible, please report the most current examination and its date.  If applicable, complete this form to describe the eye at the time of enucleation.

A.

IDENTIFICATION:  This section should contain exactly the same information as supplied on the initial report form.  The majority of information contained within this section will be attached to the Initial report by the Registry to help you locate the appropriate patient chart.  It is very important that you provide the "Exam date” for the report information.

O.

CORRECTED VISION, INJURED EYE:  Please note the best corrected vision in the injured eye at six months post-injury, and provide the date this acuity was measured.  If applicable, describe the eye at the time of enucleation.

P

LENS STATUS, INJURED EYE:  Since traumatic cataracts often develop long after initial trauma, it is crucial that we ascertain lens status at this point.  If applicable, describe lens at time of enucleation.

Q.

FIELD OF VIEW, INJURED EYE  (BEST ESTIMATE):  Please select your best estimate of the field of vision for the injured eye.  A documented visual field testing is not necessary to complete this section. 

R.

VISUAL FUNCTION, INJURED EYE:  Please give your best estimate of the stability of visual function in the injured eye.  You are then asked to determine whether the visual function of this eye could potentially be improved with further treatment.  Please select the appropriate responses.

S.

VISUAL LOSS CONTRIBUTING FACTORS:  Please select all applicable responses or use Item 99.0 Other if an appropriate option is not provided.

T.

REHABILITATION STATUS:  There is great interest in residual disability following eye injury.  The choice "Unemployed" is understood to be unemployed due to this injury.  The status of "Retired" is included in

"Former Job" if normal activity is resumed and patient was retired prior to injury.  Please record Occupation of patient, especially in work related injuries. 

U.

WAS PATIENT HOSPITALIZED DUE TO INJURY?:   Whether hospitalization was incurred is another variable to be identified in the overall socioeconomic impact of serious eye injuries.  Hospitalization is defined as an In-patient hospital admittance caused by the reported injury.

V.

COMMENTS:  You are encouraged to provide a narrative description to clarify or expand upon information provided in any of the above categories.  This information is coded into the database as part of the overall injury report.

W.

LATE DIAGNOSES:  Please select all applicable diagnoses which have occurred during the follow-up period. Impairment of the Visual Axis is requested for Corneal diagnoses of scarring and edema as well as successful control of Secondary Glaucoma.  As on the initial reporting form, the type of retinal defects and detachments, number of quadrants in a retinal detachment, and the organism involved in Endophthalmitis are requested if available.  Any time particular diagnosis information is unavailable or unknown, please select "unknown" to alert the Registry that you have considered these categories and have not overlooked them.

X.

ADDITIONAL OPERATIONS:  Please specify dates of the second and subsequent operations required in the spaces provided.  For patients requiring more than one operative session; 1) Enter date, 2) Select all applicable code selections.  If a patient required five or more procedures, please use Comments section to report this information.  Procedure selections in this category are those most commonly reported and are grouped by applicable tissue groups.  When reporting procedure code selection 26.0 Glaucoma Procedure, please record the type of glaucoma procedure performed.  Whenever appropriate, use Item 99.0 Other to record operations not specified

 In this column, that they may be included in the database.

Finally, indicate at the bottom of the column whether additional surgery will be required at some future date, and list that procedure code from the available code selections.