Name Ophthalmologist/ Practice Email Ophthalmologist/ Practice Country

Date of birth patient Gender patient MALE FEMALE

incident date select date before december 24, 2018 december 25 2018 december 26 2018 december 27 2018 december 28 2018 december 29 2018 december 30 2018 december 31 2018 januari 1 2019 januari 2 2019 januari 3 2019 januari 4 2019 januari 5 2019 after januari 5, 2019 Caused by self set off set off by bystander (Il)legal fireworks? legal illegal unknown Type fireworks please select crackers rockets show fireworks unknown

Number of visits to the clinic 1 2 more than 2 eyes affected 1 eye 2 eyes if both eyes are affected please specify for both

OD	type of injury	OS
	NO PERMANENT DAMAGE
	PROBABLY LOSS OF FUNCTION
	CERTAINLY LOSS OF FUNCTION
	TOTAAL LOSS SIGHT
	LOSS OF BULBUS
OD	therapy	OS
	NONE
	OINTMENT and/or DROPS
	RINSING
	EXAMINATION UNDER ANESTHESIA
	SUGERY REQUIRED
	FURTHER TREATMENT NEEDED AFTER SURGERY

PLASTIC SURGERY

is a plastic surgeaon involved in treatment? yes no

OTHER INJURIES BESIDES EYE(S)

please specify:

date remarks

After submitting this page you'll find an overview of the received data.

Thanks for contributing.