WHO/PBL EYE EXAMINATION RECORD FOR CHILDREN WITH BLINDNESS AND LOW VISION

A.1 CENSUS - BLIND SCHOOL / HOSPITAL STUDIES E. PREVIOUS EYE SURGERY Country no Sch/Hosp no Child no. Tick all that apply (1-3) (4-5) (6-8) Right Left Sch/Hosp: ______City/town:______None (37) (38) (39) (40) OR (41) (42) Corneal Graft (43) (44) A.2 CENSUS - POPULATION BASED SURVEYS Optical Iridectomy (45) (46) Country No. Cluster No. Removed (47) (48) (1-3) (4-6) Surgery, type unknown (49) (50) Household No. Child No. Other, (51) (52) (7-9) (10-11) Specify

B. PERSONAL DETAILS OF CHILD Please give full details including dates, if available, Name: ______Right eye Left eye Home Town/Village: ______

Ethnic group (optional): ______

Age: In months (0-11 months) Sex: Male

(12-13) Female In years (1-15yr olds) (16) F. EYE EXAMINATION - Site of ABNORMALITY leading to VISUAL LOSS (14-15) For each eye mark one major abnormality Age at onset of visual loss: Family history: And all others that contribute to visual loss

00 Since birth Is there a family history of Right Eye Left Eye (17-18) 88 First Year of life the same condition? Major Others Major Others 01-15 in Years Yes 99 Unknown No No Whole : (53) (89) Unknown Phthisis 1 (54) (90) (19) Anophthalmos (55) (91) If yes, who is similarly affected? Microphthalmos (56) (92) ______Buphthalmos (57) (93) Glaucoma (58) (94) Is there a history of consanguinity? Yes No Removed (59) (95) If yes, relationship: ______Unknown Disorganised (60) (96) (20) Other (61) (97)

Cornea: C. VISUAL ASSESSMENT Staphyloma (62) (98) 1) Distance Vision: With present glasses Scar (63) (99) unaided (64) (100) (21) Dystrophy (65) (101) Test each eye separately, then together. Other Opacity (66) (102) Right Left Right & Left : 6/6 - 6/18 Cataract (67) (103) less than 6/18 - 6/60 (68) (104) less than 6/60 - 3/60 Other (69) (105) less than 3/60 - PL : No light perception (70) (106) Cannot be tested Coloboma (71) (107) Believed sighted (72) (108) Believed blind Other (73) (109) (22) (23) (24) :

2) Functional Vision: Test with both eyes together Dystrophy (74) (110) Yes No Not Tested Albinism (75) (111) ROP (76) (112) Can see to walk around (25) Retinoblastoma (77) (113) Can recognise faces (26) Other (78) (114) Can see print (27) Believed useful residual (28) : Vision Atrophy (79) (115) 3) Visual Fields: Test each eye separately Hypoplasia (80) (116) Right Left Other (81) (117) Full field Other, not listed (82) (118) Hemianopia o Constricted to less than 10 Other field loss Globe appears normal (complete after refraction see Section G Cannot test Not tested (83) (119) (29) (30) (84) (120) Specify type of test Cortical blindness (85) (121) Idiopathic (86) (122) D. GENERAL ASSESSMENT Normal vision (87) (123) Additional disabilty Tick all that apply None (31) Not examined (88a) (88b)

Hearing loss (32) Mental retardation (33) Physical handicap (34) THE MAJOR SITE OF ABNORMALITY LEADING TO VISUAL Epilepsy (35) LOSS FOR THE CHILD (124) Other (36) Right Specify SELECT RIGHT OR LEFT EYE Left

G. REFRACTION/LOW VISION AID ASSESSMENT Yes No Not Not 1. ACTION NEEDED indicated done 1) Optical Tick all that apply None (185) Vision improves with a pinhole (125) Refraction later (186) Refraction performed now (126) Spectacles (187) Vision assessed with low vision aid (127) 1) If refraction performed, with corrective lenses Low Vision Aid (188) Distance: Test each eye separately, then together Right Left Right & Left 2) Medical/ Surgical Tick all that apply 6/5 - 6/18 None (189) Less than 6/18 - 6/60 Medication (190) Less than 6/60 - 3/60 Surgery (191) Less than 3/60 Specify Other (192) (128) (129) (130) Specify corrective lenses and visual acuity Specify Right eye VA Left eye VA Near: Test with both eyes together Can discern print/ symbols equal to Yes No J. PROGNOSIS FOR VISION Tick one box only for each eye Or smaller than 5mm ( 5mm) (131) Right eye Left eye ≤ Could be improved Example of 5mm symbols Likely to remain stable 2) If assessed with low vision aid (LVA), visual acuity with LVA: Likely to deteriorate Distance: (193) (194) Specify type of LVA and visual acuity Right eye VA

Left eye VA K. EDUCATION Near: Specity type of LVA and near acuity 1) Present Schooling Tick one box only Right eye VA Special school for the blind Left eye VA Special school for the multiple handicapped Right Left Integrated education Can discern print ≤5mm None Can discern print >5mm Other Cannot discern print Specify (195) (132) (133)

2) Recommendations Yes No H. EYE EXAMINATION - AETIOLOGY OF VISUAL LOSS Change in schooling recommended (196) Select one of the categories 1-5 for each eye Specify Tick all that apply within the selected category. Right eye Left eye Definite Suspect Definite Suspect 1) Hereditary Chromosomal (134) (135) L. FULL DIAGNOSIS Disease: Mitochondrial (136) (137) Autosomal dominant (138) (139) Specify full anatomical and aetiological diagnosis: Autosomal recessive (140) (141) X-linked (142) (143) Right eye: Cannot Specify (144) (145)

2) Intrauterine Rubella (146) (147) factor: Toxoplasmosis (148) (149) Drugs/alcohol (150) (151) Other, (152) (153) Specify Left eye:

3) Perinatal/ Cerebral hypoxia/injury (154) (155) Neonatal R.O.P (156) (157) factor: Ophthalmia neonatorum (158) (159) Other, (160) (161) Specify

4) Postnatal/ (162) (163) M. EXAMINER: Infancy/ Measles (164) (165)

Childhood Neoplasm (166) (167) Examined by factor: Trauma (168) (169)

Harmful Trad. Practices (170) (171)

Other, (172) (173) Specify (month) (year) Date

5) Cannot Cataract (174) (175) (197-200) determine Glaucoma/Buphthalmos (176) (177) (unknown Retinoblastoma, no FH (178) (179) aetiology) Abnormality since birth (180) (181) mm 0 5 10 15 20 25 30 Specify Other, (182) (183) 5mm Specify

THE MAIN AETIOLOGY OF VISUAL LOSS FOR THE CHILD

SELECT ONE FROM POSTIONS 134-183 [ ] (184)