Study Number …………..

A 1 year BOSUstudy into dysthyroid optic neuropathy;

epidemiology, presenting features and current management.

Please complete this initial questionnaire using information gathered from the patient's first presentation with dysthyroid optic neuropathy (DON).

Patient details

1aHospital number______

1bFirst half of postcode______

1cMonth and year of birth (mm/yyyy)_____/______

1dGenderMaleFemale

1eEthnicity

White / Asian or Asian British / Black or Black British / Chinese / Mixed Race / Other ethnic group
 British
 Irish
 Other (please specify) /  Indian
 Pakistani
 Bangladeshi
 Other (please specify) /  Caribbean
 African
 Other (please specify) /  Chinese
 Other (please specify) /  White & Black Caribbean
 White & Black African
 White & Asian
 Other (please specify) /  Other (please specify)

Medical, drug and social history

2aWhat was the patients thyroid status?HypothyroidHyperthyroid

EuthyroidNot Known

2bPlease tick all current thyroid medicationsNo thyroid medication

ThyroxineCarbimazole

PropylthiouracilNot known

2cHad the patient received radioactive iodineYesNo

in the past 12 months?

 Not known

2dWhat was the patients smoking status?Current smoker Never smoked

Ex SmokerNot known

Graves orbitopathy: features at presentation

3aDate of diagnosis of DON______/______(mm / yyyy)

3bDate of first assessment at your______/______(mm / yyyy)centre if diagnosis made elsewhere

RightLeft

3cWhich eye(s) were affected by DON?

3dWhen the patient presented with DON whatRightLeft

symptoms did they describe?(tick all that apply)

Blurred vision

Awareness of field defect / scotoma Awareness of a change in colour vision  

No symptoms 

Not known: they presented elsewhere

3eBest corrected acuity (at presentation)______

Method = Snellen LogMar Other

3fColour vision(correct / total tested)______

Method = Ishihara HRR Other

RightLeft

3gProptosis______

Inter canthal distance ______

3hDid the patient have vertical diplopia or upgazeYesYes

restriction?

NoNo

Not KnownNot known

3jRegardingpresentation, please tick the most appropriate response for each eye.

Sign / Right / Left
Yes / Equivocal / No / Yes / Equivocal / No
Chemosis
RAPD
Optic disc swelling
Optic atrophy
Choroidal folds

3kWereany additional investigationsperformedto clarify DON?If “No” then proceed directly to question 3m. If “yes” then please simply “tick” to complete the table.

RIGHT EYE / LEFT EYE
Investigation
performed? / Normal / Abnormal
due to
DON / Abnormal:
for other
reasons / Normal / Abnormal
due to
DON / Abnormal:
for other
reasons
Perimetry
VEP
CT orbits
MRI orbits
Other investigation
……………..
(specify)

3mDoes the patient have another conditioncontributing to visual loss?For each eye please tick “no” or specify condition and eye. (there may be several)

RightLeft

nono

GlaucomaGlaucoma

AMDAMD

CataractCataract

Diabetes Diabetes

Other(specify)______Other(specify)______

3nDo you believe that DON is the primarycause of visual loss?

(please tick one response per eye)

RightLeft

YesYes

NoNo

Nosignificant visual loss No significantvisual loss

INITIAL TREATMENT

Question 4only concernsthe INITIAL managementinitiatedor planned in your centre

4a.Please tick all treatments for DON initiated in the first 72 hoursfollowing diagnosis / referral. If radiotherapy is planned as part of primary management then please tick last box.

 IV Methylprednisolone ______specify regime for first 2 weeks

(e.g. 1g x3 then further 1 g at 1 week)

Oral prednisolone______specify regime for first 2 weeks

Other immunosuppressive______specify

 Orbital bony decompression______

(specifywhich side (R/L), and which walls removed)

 Other treatment ______specify

 Scheduled orbital radiotherapy

4bDid patient morbidity influence your decisionYes ______

regarding the management of DON?specify what

(eg unfit for surgery / diabetes etc)No

4cDid you refer the patient to another unit?Yes ______

specify where

No

THANK-YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE

Please post your response to Dr Yun Wong,

C/O Miss Lucy Clarke, Orbital Surgeon, Eye department, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP