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Table 1 Sections and the containing variables of case report form

From: Implementation of thyroid eye disease registry in Iran: rationale and research protocol

Categories

Data elements

Demographic data and smoking status

Name*, Last name*, Father’s name, Gender*, File number*, National code*, Weight, Height, Date of birth* (age), City of birth, City of location¶, Telephone, Mobile¶, Smoking* (Tobacco, Opioids, Cannabis), Smoking* (active, passive, past), Ethnicity

Thyroid gland disease

Primary thyroid status*, Onset of disease*, Initial treatment*, History of Thyroid gland surgery*, History of receiving Radioactive Iodine*, Current thyroid status*, Current thyroid medication*, Last thyroid function/antibodies test (T3, FreeT4, TSH, TPO-Ab, TG-Ab, TR-Ab)

General medical History

Dermopathy*, Acropachy*, Diabetes, Hypertension, Hyperlipidemia, Myasthenia Gravis, Cardiovascular disease, Autoimmune disorders, Autoimmune vasculopathy, Malignancy, Current topical and systemic Medications

1st/2nd degree relatives’ involvement of thyroid disease (yes/no)* and its type*

Ocular history

Eye pain*, Watery eye*, Burning*, Eyelid puff*, Diplopia*, Blurred vision*, Proptosis*, Red eye*, Foreign body sensation*, Onset of disease*, History of Orbital radiation* and any Eye surgery*, Full description of Systemic Steroid consumption*, Anti-Glaucoma medication usage

Visual and ocular exams data

Pain on motion*, Pain at rest*, Tearing*, Best corrected Visual Acuity*, Color vision*, RAPD*¶, Optic nerve head* (pink/sharp, pale, edematous), Cup/Disc ratio*, Visual Field (MD¶, PSD¶), IOP¶ in primary gaze*, IOP in up-gaze, Exophthalmometry, MRD¶1*, MRD2*, Lid lag* (lag in down gaze), Lagophthalmos*, Puffiness* (upper/lower lid), Edema* (upper/lower lid), Redness* (upper/lower lid), Diffuse redness* (Grade 1–3), Chemosis*, Swollen Caruncle/plica*, Corneal status* (normal, SPK, Ulcer), Motility restrictions in 4 directions*, Diplopia* (Gaze, Intermittent Primary, Constant),Orbital compliance* (i/ii),

TED status

Severity Scores of NOSPECS*/ EUGOGO*/ Rundle*, Clinical Activity Score* and Status*, Assessment and Plan

  1. *Starred elements are the mandatory fields to complete
  2. ¶City of location: currently living city; Mobile: mobile phone number RAPD: relative afferent pupillary defect; MD: mean deviation; PSD: pattern standard deviation; IOP: intra-ocular pressure; MRD: margin to reflex distance