Recording Of Ophthalmologocal Features In Suspected Paediatric Trauma Form

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RECORDING OF OPHTHAMOLOGICAL FEATURES
IN SUSPECTED PAEDIATRIC HEAD TRAUMA
HISTORY
Continue on reverse
PATIENTS DETAILS
Visual Acuity
Right eye
Left eye
OCULAR MOTILITY
Left eye
Right eye
PERIOCULAR BRUISING:
Pupil size and
(mark areas of bruising)
Pupillary re exes
SUBCONJUNCTIVAL HAEMORRHAGES
Right eye
Left eye
Yes
No
Yes
No
Pupils dilated with
ANTERIOR SEGMENT
Right Eye
Left Eye
FUNDUS
RIGHT EYE
LEFT EYE
Circle if present
Retinal Haemorrhages
YES
NO
YES
NO
NUMBER. of
Few (1-10)
Many(10-20)
Too numerous
Few (1-10)
Many(10-20)
Too numerous
to count
to count
Retinal haemorrhage
LOCATION of
retinal haemorrhages
Pre retinal Intraretinal
Subretinal
Multilayered
Pre retinal
Intraretinal
Subretinal
Multilayered
DISTRIBUTION
Posterior Pole
Periphery
Posterior Pole
Periphery
of retinal haemorrhages
too numerous
too numerous
too numerous
too numerous
Few/many/
Few/many/
Few/many/
Few/many/
to count
to count
to count
to count
(
Zone 1- ROP classi cation)
(outside Zone1)
(Zone 1- ROP classi cation)
(outside Zone1)
of
SIZE
Small (< 1dd)
Medium 1-2dd
Large >2dd
Small (< 1dd)
Medium 1-2dd
Large >2dd
retinal haemorrhages
MORPHOLOGY
of haemorrhages
White centered or other
Macula Retinoschisis
Perimacular folds
Optic disc
OTHER ndings
Fundus examined with
Name and signature
Indirect ophthalmoscope (and 20d / 28d / 30d / 2.2d )
Retcam
OR
Photography
Date and time of examination
OCT

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