Warning: mysql_connect(): Access denied for user 'pnr_pnruser'@'localhost' (using password: YES) in /home/ftppnreton/public_html/classes/adodb/drivers/adodb-mysql.inc.php on line 363
The Philippine National Registry for Ethambutol-related Toxic Neuropathy
 
 
 
 
 
 

Philippine National Registry for EMB-related Toxic Optic Neuropathy

The following fields are required.

A. GENERAL INFORMATION
1. EyeMD/REPORTER Information
2. PATIENT Information
1a. Name 2a. Name 2b. Age
1b. Clinic Address 2c. Gender 2d. Ht 2e. Wt
2f. City of Residence
1c. Tel# 1d. Mobile# 2g. Contact #
1e. Email 3. Date of Initial Consult

B. HISTORY/SYMPTOMATOLOGY/DRUG INFO
4. Past Ocular Hx (List all previous Dx, if any) 4a.OD others 4b.OS others
5. Systemic Disease (special note: inquire about kidney disease/status)
6. Concomitant Drug Intake (other than anti-TB)

7. Anti-TB REGIMEN 1: Brand Name (optional) OR SPECIFY:
Component Daily Dose in mg. Start of Tx (mm/dd/yy) End of Tx (mm/dd/yy) Ongoing
Ethambutol (EMB)
Isoniazid (INH)
Rifampicin (RIF)
Pyrazinamide (PZA)
Px Compliance (check one)

8. Anti-TB REGIMEN 2: Brand Name (optional) OR SPECIFY:
Component Daily Dose in mg. Start of Tx (mm/dd/yy) End of Tx (mm/dd/yy) Ongoing
Ethambutol (EMB)
Isoniazid (INH)
Rifampicin (RIF)
Pyrazinamide (PZA)
Px Compliance (check one)

9. Prescribing Individual’s Medical Field/Specialty others
10. Was the patient warned about potential adverse ocular effects of anti-TB drugs? Yes No
11. How soon after intake of anti-TB meds did visual symptoms occur?
12. Visual symptoms first noted in:
13. FIRST visual parameter affected Others

C. EYE EXAMINATION
 
OD
OS
 
14. Best Corrected Distance Visual Acuity on 1st Consult
 
15. Visual Field Defect
others
16. Color Vision (Ishihara Color Plates)
out
out
17. Other Color Tests (please specify )
 
18. Fundus Appearance
others
19. Concomitant Eye Disease/Diagnosis
others
20. Relative Afferent Pupillary Defect (RAPD)