Annex B. Xerophthalmia field survey forms

The following field survey forms are modifications of those found useful in the Indonesian Nutritional Blindness Prevention Project. They are examples of the types of information and format that can be employed, but should be modified depending upon local conditions, interests, and abilities. They have been kept simple and include only those factors felt to be most relevant to an understanding of the xerophthalmia problem.

 

Clinical Examination Form

This form is primarily intended for children under the age of six. If older individuals are to be examined or other major causes of blindness exist or are of interest (e.g., trachoma, onchocerciasis, etc.), it should be modified and expanded. A full-scale paediatric or nutritional survey would include many additional measurements.

The ocular examination must be carried out by someone familiar with the clinical manifestations of xerophthalmia, preferably an ophthalmologist. The location and size of all corneal abnormalities should be carefully indicated in the circles provided.

The summation coding format maintains discrete information while economizing on punch-card columns. Simply circle the score for each abnormality present. add the scores for each section, and transfer the totals to the appropriate columns alongside. Where none of the abnormalities listed is present, the total is "O"; this should be entered in the appropriate space. At the completion of the examination, there should be a digit in each of the numbered spaces, even if it is "O".

 

Clinic Based Case Reporting Form

A simple line listing as shown here, is sufficiently detailed to monitor the number, types, and origin of cases presenting at treatment facilities. It has been kept short and simple to facilitate its use by overworked clinic personnel.

Clinical Examination Form

Data
Enumerator
Team
Ophthalmologist
Sample site

Head of family.	Name	Family number	(1)	(2)	(3)
Individual.	Name	Number	(4)	(5)	(6)
				(7)	(8)
* Sex:1 = male		2 = female			(9)
* Age:: data of birth	month	year
** Age in months completed (99 = unknown)				(10)	(11)
Age in years completed (often estimated)				(12)	(13)
Examination completed:	0=yes	1 = no			(14)

* Include only if not already part of a census/socioeconomic form.
** Collect only for those 6 years and under.

Estimate of potential visual acuity		OD	OS	OD	OS
Clarity of cornea leas than 6/60		1	1
Clarity of lens lass than 6/60		2	2
	Total
Lida				(15)	(16)
Entropion		OD	OS	OD	OS
		1	1
Trichiasis		2	2
Inflamed		4	4
	Total			(17)	(18)
Chalazion		1	1
Inflamed chalazion		2	2
	Total			(19)	(20)
Conjunctiva
Injection		1	1
Phlyctenula		2	2
	Total			(21)	(22)
Non-purulant discharge		1	1
Purulent discharge		2	2
	Total			(23)	(24)
Xerosis temporal		1	1
nasal		2	2
other		4	4
Total				(25)	(26)
"Foam" or "cheese": temporal		1	1
nasal		2	2
other		4	4
Total				(27)	(28)
Cornea
		OD	OS	OD	OS
Xerosis		1	1
Erosion		2	2
Ulcer		4	4
Total				(29)	(30)

FIG. 5.A.b. Clinical Examination Form

FIG. 5.A.b. (cont.)

Historical data on corneal scars and destruction

Historian
0 - reliable
1 - possibly reliable
2 - unreliable or unavailable				(37)
Age at which lesion occurred
0 = less than 1 month of ago	5 = 3 years completed
1 - 1-6 months of age	6 = 4 years completed
2 - 7-12 months of age	7 = 5-6 years completed
3 - 1 year completed	8 = over 6 years completed
4 - 2 years completed	9 = unknown
Other events 4 weeks or less before lesion occurred:
Eye trauma	1	1
Measles	2	2
Purulent infection	4	4
Total			(40)	(41)
Marked diarrhoea	1	1
Marked malnutrition	2	2
Marked cough	4	4
Total			(42)	(43)
Was medicine applied to the aye before corneal lesion appeared?
0=no 1=yes			(44)	(45)
Diagnosis based on clinical examination and history
1 - trauma
2- measles
3 - purulent aye infection
4 - congenital
6 - keratomalacia
8 - other
7 – uncertain			(46)	(47)
Additional data
Classification
1 - random subsample
2 - abnormol
3 - ago/eax/local matched control
Height (to nearest 0.5 cm)				(48)
	(49)	(50)	(51 )	(52)
Weight (to nearest 0.1 kg)		(53)	(54)	(55)
Blood obtained 0 = yes 1 = no				(56)
Serum vitamin A level			(57)	(58)

FIG. 5.A b. (cont.)

Xerophthalmia case-reporting form

Clinical facility

Case number

Date

Patient's name

Village or locality

Age

Sex

Record all abnormalities present

XN

X1B

X2

X3

OD

OS

OD

OS

OD

OS

1

2

3

4

5

6

7

8

9

10

FIG. 5.A.b. (cont)