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Submit Referral Online
Registry Criterion
Related Projects
Information for Participants
Partnerships
Latest News
Get Involved
(Referrals accepted from Ophthalmologists, Optometrists and other professionals in Australia and New Zealand)
Note:
All participants will be asked to provide a DNA sample (blood or saliva) to assist in the search for new genes related to glaucoma. This will be coordinated by staff at the Australian and New Zealand Registry of Advanced Glaucoma.
Referral Name (Eye Practitioner)
Address (Specialist)
Suburb
State
Postcode
Phone Number (Specialist)
*
Fax Number (Specialist)
*
Email Address (Specialist)
*
Patient Last Name
*
Patient First Name
*
Patient Middle Name
Date of Birth
01
02
03
04
05
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09
10
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19
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26
27
28
29
30
31
day
/
January
February
March
April
May
June
July
August
September
October
November
December
month
/
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
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1991
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1989
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1982
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1980
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1971
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1969
1968
1967
1966
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1964
1963
1962
1961
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1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
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1945
1944
1943
1942
1941
1940
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1933
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1931
1930
1929
1928
1927
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1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
year
Hospital ID (if known)
Gender
*
Male
Female
Identifies As
Ethnicity
Indigenous
African
Caucasian
Hispanic
Polynesian
Melanesian
Middle Eastern
Mixed Ethnicity
Asian
other
Cultural Background (e.g. Irish, Italian)
Patient Address
PostCode
Suburb
State
Country
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Congo (Brazzaville)
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Macedonia
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wales
Yemen
Zambia
Zimbabwe
Patient Mobile
Patient Phone
Patient Email
Family History of Glaucoma?
Yes
No
If Yes, please list number & relationships
GP Address
GP Suburb
State
PostCode
GP Phone
Fax
Email
Does the patient have Advanced Glaucoma ? *Check Criteria: https://anzrag.com.au/registry-criterion/
Non Advanced
Advanced
Age at Diagnosis (years)
Select Applicable Diagnoses
GLAUCOMA
Glaucoma Suspect (monitored)
JOAG
Aphakic Glaucoma
Primary Congenital Glaucoma
Pseudoexfoliation
Pigment Dispersion
Steroid Responder
Angle Closure Glaucoma
Optic Disc Drusen
Nanophthalmos
Anterior Segment Dysgenesis
Riegers/Axenfeld Syndrome
Uveitis / Inflammatory
Trauma
Family Member of existing ANZRAG Participant
Rubeotic
Iridocorneal Endothelial Syndrome
Other
Referral Comments
Right Eye
BCVA (RE)
Highest Recorded IOP (mmHg) (RE)
Was this pressure at diagnosis? (RE)
Yes
No
Refraction (spherical equivalent) (RE)
Central Corneal Thickness (RE)
Vertical Cup Disc Ratio (RE)
Mean Deviation (dB) (RE)
Central Field Loss (<10°) (RE)
Yes
No
Disc Haemorrhage (RE)
No
Yes
Recurrent
Unknown
DRY Macular Degeneration (RE)
No
Yes
Unknown
WET Macular Degeneration (RE)
No
Yes
Unknown
LENS Status (RE)
Phakic
IOL/Pseudophakic
Lens Dislocation (RE)
Zonules/Wobbly Lens
Long Anterior Zonules
Subluxation
Dislocated Lens
GLAUCOMA TREATMENT:
Eye Drops (RE) (current)
No
Yes
Unknown
Laser Trabeculoplasty (RE)
PI
ALT
SLT
Glaucoma Surgery (RE)
No
Yes
Unknown
MIGS/Stent
XEN
PreserFlo
Tube
Trab
Retinal Detachment Surgery (RE)
No
Yes
Unknown
Left Eye
BCVA (LE)
Highest Recorded IOP (mmHg) (LE)
Was this pressure at diagnosis? (LE)
Yes
No
Refraction (spherical equivalent) (LE)
Central Corneal Thickness (LE)
Vertical Cup Disc Ratio (LE)
Mean Deviation (dB) (LE)
Central Field Loss (<10°) (LE)
Yes
No
Disc Haemorrhage (LE)
No
Yes
Recurrent
Unknown
DRY Macular Degeneration (LE)
No
Yes
Unknown
WET Macular Degeneration (LE)
No
Yes
Unknown
LENS Status (LE)
Phakic
IOL/Pseudophakic
Lens Dislocation (LE)
Zonules/Wobbly Lens
Long Anterior Zonules
Subluxation
Dislocated Lens
GLAUCOMA TREATMENT:
Eye Drops (LE) (current)
No
Yes
Unknown
Laser Trabeculoplasty (LE)
PI
ALT
SLT
Glaucoma Surgery (LE)
No
Yes
Unknown
MIGS/Stent
XEN
PreserFlo
Tube
Trab
Retinal Detachment Surgery (LE)
No
Yes
Unknown
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