Professional title of reporter* must provide value
Ophthalmologist Ophthalmology Resident / Fellow Emergency room physician Family physician Other physician specialist Optometrist Nurse Practitioner Nurse Other (please specify)
Other title* must provide value
Hospital or clinic city, province* must provide value
English consent form French consent form Please confirm that patient signed consent form to be kept in patient's file.* must provide value
Patient signed consent
Patient age in years* must provide value
Patient's province of residence* must provide value
Patient assigned sex at birth* must provide value
Female
Male
Unknown
Other (please specify)
Other sex* must provide value
Patient race/ethnicity (check all that apply)* must provide value
Caucasian
Asian
Black - African
Afro - Caribbean
Native Indian
Hispanic or Latino
Unknown
Other (please specify)
Other ethnicity* must provide value
Patient country of origin (please specify)* must provide value
Did the patient have any ocular symptoms or visual changes in the setting of possible/confirmed COVID-19 or following COVID-19 vaccination?* must provide value
Yes
No
What was the presentation of ocular symptoms?* must provide value
Decreased visual acuity / Blurry vision
Eye redness
Eye pain
Headache
Flashes
Floaters
Dysphotopsias
Metamorphopsia
Colour blindness
Scotoma
Visual field loss
Unknown
Other (please specify)
Other ocular symptoms* must provide value
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?* must provide value
Yes
No
Which part(s) of the eye was(were) affected?* must provide value
Surrounding skin
Lids/Lashes
Orbit
Extraocular muscles/movements
Conjunctiva
Sclera
Cornea
Anterior chamber
Intraocular pressure
Iris
Lens
Vitreous
Retina
Vessels
Optic nerve
Unknown
Other (please specify)
Was affection unilateral or bilateral?* must provide value
Unilateral Bilateral Unknown
Other ocular signs* must provide value
What were the signs / likely diagnosis affecting the surrounding skin?* must provide value
Rash
Vesicular lesions
Unknown
Other (please specify)
Other skin signs* must provide value
What were the signs / likely diagnosis affecting the lids/lashes?* must provide value
Blepharitis
Lid lag
Ptosis
7th cranial nerve palsy
Unknown
Other (please specify)
Other lids/lashes signs* must provide value
What were the signs / likely diagnosis affecting the orbit?* must provide value
Exophthalmos
Unknown
Other (please specify)
Other orbit signs* must provide value
What were the signs / likely diagnosis affecting the extraocular muscles/movements?* must provide value
3rd cranial nerve palsy
4th cranial nerve palsy
6th cranial nerve palsy
Strabismus
Muscle inflammation / swelling
Unknown
Other (please specify)
Other muscles/movements signs* must provide value
What were the signs / likely diagnosis affecting the conjunctiva?* must provide value
Follicular conjunctivitis
Papillary conjunctivitis
Undefined conjunctivitis / redness
Subconjunctival hemorrhage
Unknown
Other (please specify)
Other conjunctival signs* must provide value
What were the signs / likely diagnosis affecting the sclera?* must provide value
Episcleritis
Scleritis
Unknown
Other (please specify)
Other sclera signs* must provide value
What were the signs / likely diagnosis affecting the cornea?* must provide value
Keratitis
Peripheral corneal thinning
Corneal ulcer
Corneal edema
Punctate epithelial erosions
Unknown
Other (please specify)
Other cornea signs* must provide value
What were the signs / likely diagnosis affecting the anterior chamber?* must provide value
Anterior uveitis
Granulomatous keratic precipitates
Non-granulomatous keratic precipitates
Flare
Fibrin
Hypopyon
Hyphema
Unknown
Other (please specify)
Other anterior chamber signs* must provide value
What were the signs / likely diagnosis affecting the intraocular pressure?* must provide value
Ocular hypertension requiring drops
Ocular hypertension requiring laser
Ocular hypertension requiring device / surgery
Ocular hypotension
Unknown
Other (please specify)
Other intraocular pressure signs* must provide value
What were the signs / likely diagnosis affecting the iris?* must provide value
Neovascularization of the iris
Nodules
Transillumination defects
Anterior synechiae
Posterior synechiae
Unknown
Other (please specify)
Other iris signs* must provide value
What were the signs / likely diagnosis affecting the lens?* must provide value
Opacification
Subluxation/luxation
Unknown
Other (please specify)
Other lens signs* must provide value
What were the signs / likely diagnosis affecting the vitreous?* must provide value
Intermediate uveitis
Posterior uveitis
Snowballs
Panuveitis
Posterior vitreous detachment
Vitreous hemorrhage
Proliferative vitreoretinopathy
Unknown
Other (please specify)
Other vitreous signs* must provide value
What were the signs / likely diagnosis affecting the retina?* must provide value
Subretinal hemorrhage
Intraretinal hemorrhage
Choroidal hemorrhage
Hard exudate
Cotton-wool spots
Hollenhorst's spot
Retinitis
Choroiditis
Atrophy
Pigmentation
Serous retinal detachment
Rhegmatogenous retinal detachment
Macular edema
Neuroretinopathy
Unknown
Other (please specify)
Other retinal signs* must provide value
What were the signs / likely diagnosis affecting the vessels?* must provide value
Central retinal vein occlusion
Central retinal artery occlusion
Branch retinal vein occlusion
Branch retinal artery occlusion
Vasculitis
Vascular sheathing
Vascular leakage
Unknown
Other (please specify)
Other vascular signs* must provide value
What were the signs / likely diagnosis affecting the optic nerve?* must provide value
Cupping
Hyperemia
Swollen disc
Papilledema
Papillitis
Optic neuritis
Neuroretinitis
Disc hemorrhage
Disc atrophy/pallor
Neovascularization of the optic nerve head
Unknown
Other (please specify)
Other optic nerve signs* must provide value
In your clinical opinion, what is the likely etiology of the ocular findings?* must provide value
Due to delayed follow-up or referral caused by the COVID-19 pandemic
Likely related to COVID-19 itself
COVID-19 related inflammatory process
COVID-19 related thrombogenic process
Likely related to a drug given for COVID-19 treatment
Likely related to a drug given for a condition other than COVID-19
Likely related to another microbiological cause
Likely related to an unrelated ophthalmological diagnosis
Likely related to COVID-19 vaccination (please specify vaccine type/name, dose number, and vaccination date)
Other (please specify)
Unsure
Type / name of COVID-19 vaccine* must provide value
COVID-19 vaccine dose number (1st, 2nd, 3rd dose)* must provide value
Date of COVID-19 vaccine* must provide value
Today D-M-Y
Other etiology* must provide value
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?* must provide value
Yes
No
What is(are) the patient's pre-existing ocular condition(s)? Mark all that apply.* must provide value
Dry eye syndrome
Blepharitis
Keratoconus
Corneal edema / Fuchs' dystrophy
Refractive errors
Amblyopia
Strabismus
Glaucoma suspect
Primary open angle glaucoma
Primary closed angle glaucoma
Mixed glaucoma
Uveitic glaucoma
Non-proliferative diabetic retinopathy
Proliferative diabetic retinopathy
Diabetic macular edema
Dry age-related macular degeneration
Wet age-related macular degeneration
Acute anterior uveitis
Acute intermediate uveitis
Acute posterior uveitis
Acute panuveitis
Chronic anterior uveitis
Chronic intermediate uveitis
Chronic posterior uveitis
Chronic panuveitis
Cataracts
Aphakia
Pseudophakia
Ocular malignancy
Thyroid-related orbitopathy
Unknown
Other (please specify)
Other ocular conditions* must provide value
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)?* must provide value
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?* must provide value
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* must provide value
Which health professional followed this patient for this pre-existing ocular condition?* must provide value
Ophthalmology subspecialist General ophthalmologist Optometrist Emergency room physician Family physician Unknown Other (please specify)
Other professional* must provide value
Did the patient's ocular disease change at the time of COVID-19 symptom onset (or COVID-19 diagnosis if asymptomatic)?* must provide value
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.* must provide value
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* must provide value
Did the patient require a change in management following COVID-19 infection?* must provide value
Change in treatment (please specify)
Change in follow-up (please specify)
No change
Unknown
What was the change in treatment?* must provide value
What was the change in follow-up?* must provide value
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?* must provide value
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* must provide value
Do you know the date of the patient's COVID-19 diagnosis?* must provide value
Yes
No
Date of diagnosis* must provide value
Today D-M-Y
What kind of COVID-19 testing was performed? Please mark all that apply, including both antibody and PCR testing.* must provide value
Presumptive diagnosis based on symptoms only
PCR positive
Antibody positive
PCR negative
Antibody negative
Metagenomic testing
Laboratory assay positive, type unknown
Laboratory assay negative, type unknown
Unknown if a COVID-19 test was performed
Other (please specify)
Other testing* must provide value
Did the patient have any non-ocular COVID-19 symptoms?* must provide value
None (Asymptomatic)
Fever
Chills
Headache
Sore throat
Cough
Shortness of breath
Arthralgia
Myalgia
Chest pain
Abdominal pain
Diarrhea, vomiting or nausea
Rhinorrhea
Irritability/confusion
Malaise
Anosmia
Dysgeusia
Unknown
Other (please specify)
Other systemic symptoms* must provide value
Was any COVID-19 specific treatment given? Please mark all that apply.* must provide value
No treatment except supportive care
Antibiotics
Remdesivir
Lopinavir/ritonavir
Anti-malarials (e.g. chloroquine, hydroxychloroquine)
IL-6 inhibitors (e.g. tocilizumab, sarilumab, siltuximab)
Bevacizumab JAK inhibitors (e.g. tofacitinib, baricitinib, upadacitinib)
Serpin inhibitors
Ciclesonide
Glucocorticoids
IVIG
Plasma from recovered patients
Interferon
Unknown
Other (please specify)
Other treatment for COVID-19* must provide value
Was the patient hospitalized during COVID-19 illness?* must provide value
Yes No Unknown
Were there any COVID-19 complications?* must provide value
No known complications
Acute Respiratory Distress Syndrome or ARDS
Sepsis
Myocarditis or new heart failure
Concomitant or secondary infection (e.g. Influenza)
Acute Kidney Injury
Thrombotic event, unknown origin
Deep Vein Thrombosis (DVT)
Thrombotic stroke
Pulmonary embolism
Unknown
Other serious complication (please specify)
Other COVID-19 complications* must provide value
Did the patient die of COVID-19 or of other complications caused by or contributed to by COVID-19?* must provide value
Yes No Unknown
Patient smoking status* must provide value
Current smoker Former smoker Never smoked Unknown smoking status
Does the patient have any of the following other medical conditions? Mark all that apply.* must provide value
None
Interstitial lung disease (e.g. NSIP, UIP, IPF)
Obstructive lung disease (COPD/asthma)
Diabetes
Morbid obesity (BMI 40+)
Hypertension
Cardiovascular disease (coronary artery disease, congestive heart failure)
Pulmonary hypertension
Chronic renal insufficiency or end stage renal disease
Cancer
Organ transplant recipient
Immunodeficiency
Inflammatory bowel disease
Liver disease
Chronic neurological or neuromuscular disease
Trisomy 21
Psychiatric condition (e.g., schizophrenia, bipolar disorder)
Pregnancy
Post-partum (< 6 weeks)
Rheumatologic disease
Unknown
Other (please specify)
Other medical conditions* must provide value
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