IRIE FORM Home » IRIE FORM ACADEMICS VIDEOS MEMBERSHIP Identification DataName * Aadhar No. Race Sex Age Mobile No. Next 1 / 5 HistoryDate & Time of Injury Place of Injury Date & Time of Examination Eye Protection Safety GogglesSpectaclesSunglassesFace ShieldOthers (specify)No protection Intent of Injury UnintentionalSelf – inflictedAssaultBy stander Work related (Yes/No) Occupation Object Causing Injury Activity Alcohol/Drug Abuse (YES / NO) Details : Eye involved RE onlyLE onlyBilateral Whether normal prior to Injury (YES / NO) If no, details : Next 2 / 5 Clinical ExaminationOpen Globe Injury (OD) Type LacerationPenetrationPerforationIOFB or Rupture or Mixed Open Globe Injury (OS) Type LacerationPenetrationPerforationIOFB or Rupture or Mixed Grade – Vision (BCVA) (OD) Grade – Vision (BCVA) (OS) Pupil – RAPD / Rever se RAPD /No RAPD (OD) Pupil – RAPD / Rever se RAPD /No RAPD (OS) Zone (OD) Cornea and limbusLimbus to 5 mm posterior into scleraPosterior to 5 mm from the limbus Zone (OS) Cornea and limbusLimbus to 5 mm posterior into scleraPosterior to 5 mm from the limbus Closed Globe Injury (OD) TypeContusionLamellar LacerationSuperficial foreign body Closed Globe Injury (OS) TypeContusionLamellar LacerationSuperficial foreign body Grade – Vision (BCVA) OD Grade – Vision (BCVA) OS Pupil ODRAPDRevereseNo RAPD Pupil OSRAPDRevereseNo RAPD Zone ODExternal ( bulbar conjunctiva, sclera, cornea)Anterior seg ment ( anterior segment and the pars plicata)Posterior segment ( internal structures posterior to the posterior lens capsule) Zone OSExternal ( bulbar conjunctiva, sclera, cornea)Anterior seg ment ( anterior segment and the pars plicata)Posterior segment ( internal structures posterior to the posterior lens capsule) LidRE (YES / NO) If yes fill the below optionLaceration FullLaceration Partial thicknessLid margin FullLid margin Partial thickness LE (YES / NO) If yes fill the below optionLaceration FullLaceration Partial thicknessLid margin FullLid margin Partial thickness RE Involving lacrimal drainage apparatus (which structure ?)PunctumCanaliculusCommon ductLacrimal sac LE Involving lacrimal drainage apparatus (which structure ?)PunctumCanaliculusCommon ductLacrimal sac Conjunctiva No columns found!No rows found! Cornea No columns found!No rows found! Sclera No columns found!No rows found! Tissue in wound REIrisVitreousLensChoroidRetina Tissue in wound LEIrisVitreousLensChoroidRetina Anterior chamber contents REHyphaemaHypopyonInflammationFlat chamber Anterior chamber contents LEHyphaemaHypopyonInflammationFlat chamber LENS (RE) ClearCataractDislocatedDisruptedSubluxatedExtruded LENS (LE) ClearCataractDislocatedDisruptedSubluxatedExtruded If dislocated (RE) Ant. chamberVit. Cavity If dislocated (LE) Ant. chamberVit. Cavity Posterior chamber contents (RE) Vit hmgExudatesEndophthlmitis Posterior chamber contents (LE) Vit hmgExudatesEndophthlmitis Retina No columns found!No rows found! Detachment ( RE ) RhegmatogenousExudativeTractionalMixed Detachment ( LE ) RhegmatogenousExudativeTractionalMixed Choroid No columns found!No rows found! Optic Nerve (RE) InjuryAvulsionEdemaPallorTRON Optic Nerve (LE) InjuryAvulsionEdemaPallorTRON IOFB : (RE) Type of IOFB. If non – metallic, specifyMetallicNon – metallic IOFB : (LE) Type of IOFB. If non – metallic, specifyMetallicNon – metallic Location of IOFB (RE) Anterior chamberVitreousRetina Location of IOFB (LE) Anterior chamberVitreousRetina EOM (RE) Hirscberg (LE) Orbit : OD Blowout FracturesNoFloorMedial WallBoth Orbit : OS Blowout FracturesNoFloorMedial WallBoth Muscle incarceration (Y/N) for OD If Yes, giv details Muscle incarceration (Y/N) for OS If Yes, giv details Diplopia (OD) Primary GazeMonocularNon – PrimaryBinocular Diplopia (OS) Primary GazeMonocularNon – PrimaryBinocular Next 3 / 5 InvestigationsBscan : OD Bscan : OS UBM : OD UBM : OS CT Scan orbit & Brain : Next 4 / 5 Treatment Eyelid – FullPartial RepairLacrimal RepairGlobe explorationCornea LacerationRupture repairPenetrating KeratoplastyTKPScleral LacerationRupture IOFB Removal RELEBothMagnetForcepsAnt SegmentPost SegmentOrbital AC WashIC Ab (specific)IridoplastyIridotomyIridectomy Lens – Repair (RE) ECCESICSPhacoPars plana lensectomy Lens – Repair (LE) ECCESICSPhacoPars plana lensectomy IOL (RE) AphakiaACIOL [angle/iris]PCIOL [bag/sulcus]Posterior fixated IOL [ SFIOL / Iris claw ] IOL (LE) AphakiaACIOL [angle/iris]PCIOL [bag/sulcus]Posterior fixated IOL [ SFIOL / Iris claw ] RD Px (RE) LaserCryotherapyScleral Buckle RD Px (LE) LaserCryotherapyScleral Buckle RD Mx (RE) Pneumatic RetinopexyScleral BucklingVitrectomy RD Mx (LE) Pneumatic RetinopexyScleral BucklingVitrectomy Vitrectomy RE Anterior / PosteriorOpen – sky / Pars PlanaIVAb (specify)G as (C3F8/SF6) / Silicone Oil / Heavy S.O .) Vitrectomy LE Anterior / PosteriorOpen – sky / Pars PlanaIVAb (specify)G as (C3F8/SF6) / Silicone Oil / Heavy S.O .) Orbital fracture repair : RELE Evisceration RELE Enucleation RELE Any Remarks VerificationPlease enter any two digitsExample: 12This box is for spam protection – please leave it blank 5 / 5
