Professional title of reporter
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Ophthalmologist Ophthalmology Resident / Fellow Emergency room physician Family physician Other physician specialist Optometrist Nurse Practitioner Nurse Other (please specify)
Other title
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Hospital or clinic city, province
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Please confirm that patient signed consent form to be kept in patient's file.
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Patient age in years
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Patient's province of residence
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Patient assigned sex at birth
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Female
Male
Unknown
Other (please specify)
Other sex
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Patient race/ethnicity (check all that apply)
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Other ethnicity
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Patient country of origin (please specify)
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Did the patient have any ocular symptoms or visual changes in the setting of possible/confirmed COVID-19 or following COVID-19 vaccination?
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Yes
No
What was the presentation of ocular symptoms?
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Other ocular symptoms
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Did the patient have new orbital, anterior segment, posterior segment, optic nerve, or ocular signs / changes in the setting of possible/confirmed COVID-19 or following COVID-19 vaccination?
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Yes
No
Which part(s) of the eye was(were) affected?
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Was affection unilateral or bilateral?
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Unilateral Bilateral Unknown
Other ocular signs
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What were the signs / likely diagnosis affecting the surrounding skin?
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Other skin signs
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What were the signs / likely diagnosis affecting the lids/lashes?
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Other lids/lashes signs
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What were the signs / likely diagnosis affecting the orbit?
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Other orbit signs
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What were the signs / likely diagnosis affecting the extraocular muscles/movements?
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Other muscles/movements signs
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What were the signs / likely diagnosis affecting the conjunctiva?
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Other conjunctival signs
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What were the signs / likely diagnosis affecting the sclera?
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Other sclera signs
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What were the signs / likely diagnosis affecting the cornea?
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Other cornea signs
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What were the signs / likely diagnosis affecting the anterior chamber?
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Other anterior chamber signs
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What were the signs / likely diagnosis affecting the intraocular pressure?
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Other intraocular pressure signs
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What were the signs / likely diagnosis affecting the iris?
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Other iris signs
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What were the signs / likely diagnosis affecting the lens?
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Other lens signs
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What were the signs / likely diagnosis affecting the vitreous?
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Other vitreous signs
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What were the signs / likely diagnosis affecting the retina?
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Other retinal signs
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What were the signs / likely diagnosis affecting the vessels?
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Other vascular signs
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What were the signs / likely diagnosis affecting the optic nerve?
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Other optic nerve signs
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In your clinical opinion, what is the likely etiology of the ocular findings?
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Type / name of COVID-19 vaccine
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COVID-19 vaccine dose number (1st, 2nd, 3rd dose)
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Date of COVID-19 vaccine
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Today D-M-Y
Other etiology
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Please describe the ophthalmology-related COVID-19 case in 1-5 sentences.
If there are clinical imaging, you may upload them here.
Was this patient followed for a pre-existing ocular condition?
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Yes
No
What is(are) the patient's pre-existing ocular condition(s)? Mark all that apply.
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Other ocular conditions
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What was the symptom activity of the patient's ocular disease at the time of COVID-19 symptom onset (or COVID-19 diagnosis if asymptomatic)?
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Remission
Minimal or low disease activity
Moderate disease activity
Severe or high disease activity
Unknown
When was the patient last followed for this ocular condition?
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More than a year ago
1 year ago
9 months ago
6 months ago
3 months ago
1 month ago
2 weeks ago
Less than 1 week ago
Unknown
Other (please specify)
Other follow-up
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Which health professional followed this patient for this pre-existing ocular condition?
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Ophthalmology subspecialist General ophthalmologist Optometrist Emergency room physician Family physician Unknown Other (please specify)
Other professional
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Did the patient's ocular disease change at the time of COVID-19 symptom onset (or COVID-19 diagnosis if asymptomatic)?
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Worsened Improved Stayed the same Unknown
Which medications was the patient taking for their ocular condition prior to the time of COVID-19 symptom onset (or COVID-19 diagnosis if asymptomatic)? Mark all that apply.
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None
Artificial tears
Lubricating ointment
Topical cycloplegics (including atropine)
Topical miotics (including pilocarpine)
Topical anti-inflammatory (including ketorolac, diclofenac)
Topical glucocorticoids (including fluorometholone, loteprednol, prednisolone)
Topical cyclosporine
Oral doxycycline
Oral glucocorticoids (prednisone, methylprednisolone)
Topical antibiotics
Topical antihistamine +/- mast cell stabilizer (including epinastine, bepotastine, ketotifen, olopatadine, cromolyn, lodoxamide)
Bandage contact lens
Topical beta-blockers (including timolol, levobunolol)
Topical alpha-agonists (including brimonidine)
Topical carbonic anhydrase inhibitors (including dorzolamide, brinzolamide)
Topical prostaglandin agonists (including latanoprost, bimatoprost, travoprost, latanoprostene bunod)
Topical preservative free agents (including preservative free Cosopt, monoprost)
Topical Rho kinase inhibitor (including netarsudil)
Oral carbonic anhydrase inhibitor (including acetazolamide, methazolamide)
Topical hyperosmotic agents (including mannitol)
Oral non-steroidal anti-inflammatory drugs (including naproxen, indomethacin, ibuprofen)
Oral vitamins
Intravitreal anti-vascular epithelial growth factor (anti-VEGF) (including ranibizumab, aflibercept, bevacizumab, pegaptanib)
Antimalarials (including hydroxychloroquine, chloroquine)
Azathioprine
CD-20 inhibitors (including rituximab, ofatumumab)
Cyclophosphamide
IL-1 inhibitors (including anakinra, canakinumab, rilonacept)
IL-12/23 inhibitors (including ustekinemab
IL-23 inhibitors (including guselkumab, tildrakizumab, Risankizumab)
IL-17 inhibitors (including secukinumab, ixekizumab)
IL-6 inhibitors (including tocilizumab, sarilumab)
Isotretinoin
IVIG
JAK inhibitors (including tofacitinib, baricitinib, upadacitinib)
Leflunomide
Methotrexate
Minocycline
Mycophenolate mofetil / mycophenolic acid
Spironolactone
Sulfasalazine
Tacrolimus
Thalidomide / lenalidomide
TNF-inhibitors (including infliximab, etanercept, adalimumab, golimumab, certolizumab, and biosimilars)
Unknown
Other (please specify)
Other ocular medications
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Did the patient require a change in management following COVID-19 infection?
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What was the change in treatment?
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What was the change in follow-up?
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Did the patient develop COVID-19?
Yes
No
In the 14 days before onset of COVID-19 illness did the patient have any of the following contacts?
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None (community acquired) Close contact with a probable case of COVID-19 infection Close contact with a laboratory confirmed case of COVID-19 infection Presence in a healthcare facility where COVID-19 infections have been managed Unknown Other (please specify)
Other contact
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Do you know the date of the patient's COVID-19 diagnosis?
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Yes
No
Date of diagnosis
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Today D-M-Y
What kind of COVID-19 testing was performed? Please mark all that apply, including both antibody and PCR testing.
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Other testing
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Did the patient have any non-ocular COVID-19 symptoms?
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Other systemic symptoms
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Was any COVID-19 specific treatment given? Please mark all that apply.
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Other treatment for COVID-19
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Was the patient hospitalized during COVID-19 illness?
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Yes No Unknown
Were there any COVID-19 complications?
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Other COVID-19 complications
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Did the patient die of COVID-19 or of other complications caused by or contributed to by COVID-19?
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Yes No Unknown
Patient smoking status
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Current smoker Former smoker Never smoked Unknown smoking status
Does the patient have any of the following other medical conditions? Mark all that apply.
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Other medical conditions
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