Download cornea transplant notification form

CORNEA TRANSPLANT NOTIFICATION FORM
Office
use:
Centre:
Instruction: Complete this Cornea transplant data form for all patients who have undergone transplantation
Where check boxes
are provided, check (√) one or more boxes. Where radio buttons
are provided,
check (√) one box only.
NA refers to Not Applicable. Fill in the date with dd/mm/yyyy format.
Please fill in one form per cornea transplant. Please return the form to NTR within one month post
tranplantation.
National Transplant Registry
Address:
Level 5, Menara Wisma Sejarah
230, Jalan Tun Razak
50400 Kuala Lumpur
i. Name of reporting centre:
/
ii. Date of Notification :
(dd/mm/yyyy)
*
iii. Name of transplant centre:
iv. Date of Transplant :
*
*
Local
USA
iv. Place of transplant centre:
China
Singapore
(dd/mm/yyyy)
India
UK
/
/
/
/
Australia
Others, specify:
SECTION 1 : RECIPIENT DETAILS
1. Name :
*
2. R/N No.:
(Please print in capital
letters)
3. NRIC :
-
MyKad:
Old IC:
-
*
Other ID document No:
Specify document type
(if others):
Registration number
Passport
I/C Guardian:
<12 years: Birth cert # :
4. Address:
Postcode:
State :
5. Contact
number:
*
Johor Darul Takzim
Kedah Darul Aman
Kelantan Darul Naim
Melaka
Negeri Sembilan Darul Khusus
Date of Birth
Lab number
Pahang Darul Makmur
Perak Darul Ridzuan
Perlis Indera Kayangan
Pulau Pinang
Sabah
/
Wilayah Persekutuan
Labuan, Sabah
Sarawak
Selangor Darul Ehsan
Terengganu Darul Iman
Wilayah Persekutuan Kuala
Lumpur
Wilayah Persekutuan
Putrajaya
Not applicable - Foreign
d. Ext:
c. Work:
(autofill if MyKad is available)
6b. Age:
(autocalculate)
If the exact date is not known, please enter 01/07/yyyy
7. Gender:
.
*
Male
Female
Malay
Indian
Bumiputra Sarawak, specify:
*
Chinese
Bumiputra Sabah, specify:
Others, specify:
9. Nationality:
Malaysian
Non-Malaysian, specify:
8. Ethnic group:
Others
Sibling
ranking:
Mother / Father
b. Handphone:
/
(dd/mm/yyyy)
Armed Force ID
Work Permit #
Town / City:
a. Home:
6a. Date of Birth:
Mother's I/C
Father's I/C
SECTION 2: PRE TRANSPLANT DATA
1. Diagnosis:
Pseudophakic Bullous keratopathy
*
Other bullous keratopathy, specify cause:
Keratoconus
Failed previous graft
Corneal dystrophy, specify:
Congenital opacity
Corneal perforation
Microbial keratitis
Corneal scar, specify cause:
Others, specify:
2. Operated Eye:
*
3. Indication of
transplant:
Right
Left
Therapeutic
Others, specify:
Optical
Tectonic
4. No of previous grafts in grafted eye:
0
1
5. Ocular comorbidity
No vascularization
a. Cornea
vascularization:
2
Others, specify:
Superficial vascularization
Deep vascularization
b. History of glaucoma:
Yes
No
c. Current ocular inflammation:
Yes
No
If Yes
quadrant:
1
2
3
4
d. Others, specify
Version 3.0 last updated on 07/05/2010
* Mandatory Fields
Page 1 of 2
CORNEA TRANSPLANT NOTIFICATION FORM
Office
use:
Centre:
Instruction: Complete this Cornea transplant data form for all patients who have undergone transplantation
Where check boxes
are provided, check (√) one or more boxes. Where radio buttons
are provided,
check (√) one box only.
/
SECTION 2: PRE TRANSPLANT DATA (cont'd)
6. Pre-op
Visual data
a) Unaided VA
*
6/6
6/36
3/60
6/9
6/60
2/60
6/12
1/60
5/60
6/18
4/60
CF
6/24
Others, specify:
b) Best Corrected VA
HM
PL
NPL
6/6
6/36
6/9
6/60
6/12
5/60
6/18
4/60
6/24
Others, specify:
NIPH
* * If refraction not performed, leave box blank. a) SPH - Spherical
c) Improved with refraction
3/60
2/60
1/60
HM
PL
NPL
CF
NIPH
Refraction**
a) SPH:
Yes
b) CYL:
No
c) AXIS:
b) CYL - Cylinder
SECTION 3 : DONOR DETAILS
1. Eye Bank No / IC No:
2. Source of Donor:
Local
If Yes
Ethnic
group:
USA
Malay
Chinese
Indian
Sri Lanka
Bumiputra Sarawak, specify:
Bumiputra Sabah, specify:
Others, specify:
Others, specify:
3. Preservation Media:
MK Medium
Optisol GS
Moist Chamber
Others, specify:
4. Age:
5. Cause of death:
Unknown
Cardiac / Circulatory System
Cerebrovascular System
Malignancies, specify:
Trauma / Accident
Respiratory System
Others, specify:
6. a. Date of death (dd/mm/yyyy):
/
6. b. Time of death (hh:mm):
/
(24 hrs clock)
:
7. Procurement centre:
8. Endothelial Cell Count (mm 2):
Yes, specify:
NA
SECTION 4: TRANSPLANT SURGERY DATA
1. Name of Surgeon:
*
2. Type of surgery:
*
3. Combined Surgery:
Penetrating Keratoplasty
Deep Anterior Lamellar Keratoplasty
Posterior Lamellar Keratoplasty
Cornea Scleral Lamellar Keratoplasty
Other Anterior Lamellar Keratoplasty
Others, specify:
Yes
If Yes
Glaucoma
If Yes
Trabeculectomy
Cataract Extraction
If Yes
ECCE
If Yes
IOL
Setons
ICCE
AC Lens
Scleral fixated
Phaco
PC Lens
Iris fixated
Retinal Surgery +/- Internal Temponade
Anterior vitrectomy
No
Limbal Stem Cell Transplantation
Others, specify:
4. Graft Size:
a. Recipient:
(mm)
.
Freehand
5.Type of trephine used
(recipient):
Manual
Mechanical
6. Suture Technique:
Interrupted
Continuous
7. Intraoperative Complication:
Yes, specify:
b. Donor:
(mm)
Combined
.
Freehand
Sutureless
No
Form Completed By:
(Name and Official Stamp)
Signature:
Version 3.0 last updated on 07/05/2010
* Mandatory Fields
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