Case Assignment No. ______
Progressive Symptomatic Retinal Detachment Complicating Retinoschisis
In association with the British Ophthalmological Surveillance Unit Ethics ref: 13/NW/0037
Initial Reporting Questionnaire
Case Definition: any patient presenting with recent onset of 'sight-threatening' retinal detachment (as suggested by symptomatic visual field loss, reduced visual acuity or objective evidence of progression) arising from a peripheral retinoschisis.
PATIENT DETAILS
Hospital number: Months and year of birth: month year Gender: male or female
INITIAL CLINICAL ASSESSMENT
Date of diagnosis:
1. Visual acuity at presentation Right eye Left eye Best correct VA (pin hole if required)
2. Presenting symptom of schisis RD Floaters Photopsia Visual field loss Central vision loss Asymptomatic (with objective evidence of RD)
3. Location of retinoschisis (please tick combinations as required) Superior Temporal Inferior Nasal
4. Ocular co-morbidities None Cataract Glaucoma AMD Diabetic retinopathy Other (please specify)
BOSU schisis RD questionnaire v1.2 (09/07/2013) 1
Case Assignment No. ______
Please answer the following sections for affected eyes only.
5. Lens status Right eye Left eye Clear phakic Cataract (sufficient to warrant lens surgery prior to vitrectomy) Pseudophakic Aphakic
6. Location and extent of RD (please select combinations as required) Superior Temporal Inferior Nasal RD in clock hours at ora Fovea on Fovea off Fovea splitting
7. Retinal breaks present Outer leaf break anterior to equator Outer leaf break posterior to equator Inner leaf break anterior to equator Inner leaf break posterior to equator 'U' tear Round hole Giant retinal tear
8. Associated features Peripheral cystoid degeneration Pars plana cyst Evidence of previous prophylactic retinopexy Other (please specify)
9. Vitreous PVD present Vitreous haemorrhage
10. Proliferative vitreoretinopathy (PVR) None Grade A Grade B Grade Ca Grade Cp
IMAGING 11. Imaging performed
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Case Assignment No. ______
Fundus photography Optomap photography OCT Other (please specify):
INITIAL MANAGEMENT
Date:
12. Management plan Observation only Laser retinopexy only Surgery (please complete the following section)
13. Surgical procedure (if applicable) Scleral buckle Solid explant Scleral sponge Circumferential buckle (no. of clock hrs: ) Radial buckle Encircling buckle Cryopexy Laser retinopexy 360 Degrees retinopexy External drainage of subretinal fluid (SRF) Other procedures (please specify):
Pars plana vitrectomy Lens extraction IOL implantation PVD induced PVD already present Deroofing of schisis cavity Retinotomy + internal drainage of SRF Retinectomy Cryopexy Laser retinopexy Tamponade agent (please specify type and concentration): Other procedures (please specify):
Intra-operative complications Iatrogenic break Len touch Choroidal haemorrhage Deep suture Incarceration Other (please specify):
14. Patient status The patient was referred from another unit The patient has been referred to another unit
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Case Assignment No. ______
REPORTER DETAILS
Name: Grade: Hospital: Email:
Thank you for completing this questionnaire. Please note that you will receive one more questionnaire six months from the date of initial treatment to gather information about any further treatment that has taken place and the clinical outcomes.
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Case Assignment No. ______
Progressive Symptomatic Retinal Detachment Complicating Retinoschisis
In association with the British Ophthalmological Surveillance Unit Ethics ref: 13/NW/0037
6 Months Follow-up Questionnaire
Thank you for previously completing an initial reporting questionnaire regarding a case of retinoschisis detachment. From the information given the reported patient should now be at least 6 months following the initial management. This final questionnaire concerns the patient’s further management and clinical outcome.
PATIENT DETAILS
Hospital number: Months and year of birth: month year Gender: male or female
FURTHER MANAGEMENT
15. Date of final (or most recent) follow-up appointment: We have indicated below what was reported as the initial treatment in the first questionnaire. Please indicate all subsequent treatments (if any).
Initial Treatment Subsequent Treatment
Observation only Laser retinopexy only Lens extraction IOL implantation
Scleral buckle Solid explant Scleral sponge Circumferential buckle Radial buckle Encircling buckle Cryopexy Laser retinopexy 360 Degrees retinopexy External drainage of SRF Other procedures (please specify)
Pars plana vitrectomy PVD induced PVD already present
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Case Assignment No. ______
Deroofing of schisis cavity Retinotomy & internal drainage of SRF Retinectomy Cryopexy Laser retinopexy Tamponade agent (type & concentration) Other procedures (please specify)
FINAL OUTCOME
16. Visual outcome Right eye Left eye Best correct VA (pin hole if required)
17. Current Retina status Retina attached with no tamponade present Retina attached with tamponade present Retina attached with stable SRF present Retina attached with residual schisis cavity present Recurrent rhegmatogenous RD
18. Current Patient status Remains under your care Discharged Referred to another unit (please specify for validation purposes only):
19. Is the patient eligible for CVI (certificate of visual impairment) registration? Not eligible for registration Eligible for registration as partially sighted Eligible for registration as severely sight impaired
REPORTER DETAILS
Name: Grade: Hospital: Email:
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