Department of Prosthodontics and Maxillofacial Prosthetics,

Peoples Dental College and Hospital,

Naya Bazar, Kathmandu
Case history sheet for Customized Prosthetic eye
Registration number:
Case number:
Date:
Personal details:
Name of the patient:
Age/sex: Address: permanent___________________
present______________________
Marital status:
Occupation:
Education:
Phone nos: Residence:
Mobile:
Email id:
Clinical presentation:
Enucleation Evisceration
Atropy others_________________________
Cause:


History of presenting illness:



Duration:

If surgery: What:

When:

Medical history/status:


Psychological history:

Prosthetic history:
If yes,
Ready-made Customized
Duration:
Patients opinion regarding the previous prosthesis:
Evaluation of prosthesis:
Examination of normal eye:
Opening: adequate inadequate
Eyelids:
Mobility:
Size of iris: 10 10.5 11 11.5 12
Color:

Pupil size: During clinical light__________mm
During light activation__________mm
Sclera color:
Any characterization:
Blood vessels:

Examination of anapthalmic socket:
Site: Right Left

Healing: Adequate Inadequate

Socket bed: Healing Inflamed

Irritation: Absent Mild Severe

Mobility of bed: Adequate Mild Absent

Depth of fornices: Upper Lower

Ocular implant: Present Absent

Position of ocular implant

Size of socket

Any other condition: Tissue adhesion Growth Others
Examination of anapthalmic eyelids
Opening of : upper
lower
Tonicity:

Musculature support: adequate inadequate

Relationship of palpebral fissure with normal site:
a) Opening symmetrical asymmetrical
b) Closing symmetrical asymmetrical

Any other findings:
Grafted eyelid scar contracture wound dehiscence

Any discharge:


Diagnosis:

Treatment plan:

Laboratory evaluation of the final prosthesis:




Clinical evaluation of the final prosthesis:
Size
Shape
Color of pupil/iris/sclera
Support
Mobility
Retention
Symmetry
Characterization
Patients opinion: