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How to write a thesis by Dr Rupak Roy

ID No

1.Name______

2. Age years

3. Sex 1.Male, 2. Female

4. ID NO ______

5.Date of Birth

(dd/mm/yyyy)

6.Contact Address ______

______

______

______

Pincode

7.Contact number

Alternate telephone number

8. Email id______

9. Date of Examination

(dd/mm/yyyy)

10. Father’s name______

11.Place of Birth______

12.Ethnicity:

13.Occupation(1) Student, (2) Employee (Professional,

(3) Employee (others), (4) Others

If 1. Specify ______

14. Smoking status

Yes No

If yes,

  1. No of years______
  1. No. of packs/cigarettes a day______

If past smoker

  1. No of years______
  1. No. of packs/day______
  1. Stopped smoking since (yrs) ______

15. Alcohol statusYes No

If yes,

  1. Occasional drinker
  1. Social drinker
  1. Chronic drinker

If past drinker

  1. No of years______
  1. Quantity / week______
  1. Stopped drinking since (yrs) ______

16. Paan Use (with tobacco)

Yes No

If yes, Dose

If past paan (with tobacco) user

  1. No of years______
  1. Quantity ______
  1. Stopped using since (yrs) ______

17. Present Eye ComplaintYesNo

(A) if yes ODOS

1. Blurred Vision

2. Distorted near vision

3. Metamorphopsia

4. Micropsia

5. Scotoma

6. Floaters/Flashes

7. Redness

8. Pain

9. Colored Halves

10. Others______

(B) Past HistoryODOS

18. Any Past Eye ComplaintYes No

(A) if yes

A. Nature of eye problem OD OS

  1. Glaucoma
  1. Cataract
  1. Retina

4. Others (specify) ______

B. Any medications ______

for the same

C. Nature & dosage of treatment______

D. Remarks, if any ______

19. Any systemic Illness Yes No

If yes

  1. Nature of Illness
  1. Hypertension
  1. Diabetic mellitus
  1. Asthma
  1. IHD
  1. Cerebrovascular Accident
  1. Hypercholesterolemia
  2. Others (Specify) ______

20. Any surgery / Laser done to either eye

A. If yes, reason for surgery OD OS

  1. Cataract
  2. Glaucoma
  3. Retina
  4. Others ______

21. Family history of ARMD

If yes, relationship to subject ______

22. Allergies, if any ______

23. Diet Veg Non-Veg

(No meat, No fish, No egg)

Any other details ______

24. Any other Medication

  1. Multivitamins
  2. Antioxidants
  3. Others (Specify)______
  4. AREDS protocol Yes No

If No

1. Type of Medication______

2. Dose______

3. Duration ______

25. Visual AcuityDistance Near

OD OSODOS

  1. BCVA + + +
  1. Spherical (D) ______
  1. Cylindrical (D) ______
  1. Axis ______
  1. ETDRS
  1. Done
  1. Not Done

If done

  1. Distance Near
  1. OD OSODOS

c. BCVA + +

  1. Spherical (D) ______
  1. Cylindrical (D) ______
  1. Axis ______

26. PupilsODOS

  1. Reaction to light
  2. RAPD
  3. Present
  4. Absent

SLIT LAMP EXAMINATION

27. Anterior segment abnormalities Yes No

If Yes Specify ______

28. LensOD OS

  1. a. Phakic

b. Pseudophakic

c. Aphakic

B. If Pseudophakic

a. ACIOL

b. PCIOL

c. Others (Specify)

29. AT OD OS

Measured

Value (mm Hg)

Time (HRS)

If not done,

Specify reasons______

30. Fundus Examination OD OS

  1. Disc

(i)Normal

(ii)Pale

(iii)C:D ratio

  1. Drusen

Present

Number

Size

i. Small < 63uM

ii. Intermediate (63-125uM)

iii. Large (>125uM)

Type

  1. Hard
  2. Soft
  3. Confluent drusen

C. Geographic Atrophy OD OS

(i)Involving macular centre

(ii)Not involving macular centre

(iii)Size

D. RPE changes

i. Hyperpigmentation

ii. Hypopigmentation

iii Size

  1. Retinal Ped OD OS

(i)Serous Ped

(ii)Drusenoid Ped

(iii)Fibrovascular Ped

(iv)Haemorrhagic Ped

(v)Size

  1. CNVM
  1. Sub retinal haemorrhage
  2. Sub RPE haemorrage
  3. Sub retinal fibrosis
  4. Sub RPE fibrosis
  5. Scars consistent with treatment
  6. Disciform Scar
  7. Sub retinal fluid
  8. Others ______

31. Clinical staging of AMD ______

32. FFA ODOS

  1. Drusen
  2. Hard
  3. Soft
  4. RPE changes
  5. Hyperpigmentation
  6. Hypopigmentation
  1. Geographic atrophy OD OS

(i)Involving macular center

(ii)Not involving macular center

  1. CNVM

(1) Location

a. Sub foveal

b. Juxtafoveal

c. Extrafoveal

(2) Type

a. Classic

b. Occult

c. Predominantly classic

d. Minimally classic

E. RPE detachments OD OS

  1. Fibrovascular Ped
  2. Serous Ped
  3. Haemorrhagic Ped
  4. Drusenoid Ped
  5. Disciform Scar
  1. Other features
  2. Feeder vessel
  3. RAP lesion
  4. RPE Tears

33. ICG OD OS

  1. Hot spot
  2. Plaque

34. OCT

  1. Drusen
  2. Ped
  3. CNVM

(i)Type I

(ii)Type II

  1. SRF
  2. RPE RIP
  3. Scar

35. Treatment OD OS

Done

Not Done

36. Treatment Done

  1. Thermal Laser
  2. Transpupillary thermotherapy
  3. Photodynamic therapy
  4. Anti VEGF
  5. Macugen
  6. Lucentis
  7. Avastin
  8. Intravitreal Triamcinalone
  9. Surgery

37. Single most important

cause of decrease in vision ______

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