History Taking in Clinical Ophthalmology

By/Mohamed Ahmed El –Shafie

Assistant Lecturer in ophthalmology department KafrELShiekh University

Historyاسمع العيان

A good history commonly leads to a diagnosis

Helps you focus your examination

Indicates when/what investigations are needed

Introduce yourself. • Note – never forget patient names•Respect patient privacy.

General Approach

Try to see things from patient point of view. Understand patient mental status, anxiety, irritation or depression.

Listening

Questioning: simple/clear/avoid medical terms/leading, interrupting, direct questions and summarizing.

History Personal history

History of presenting complaint

Past history

Family history

Social history

PERSONAL HISTORY Name: To be familiar with your patient Age: Buphthalmos in infantsKeratoconus in teenageSenile cataract in old age Sex:Males as Retinitis pigmentosaFemales as Autoimmune Diseases

Address: to know socioeconomic state Telephone no: to keep contact with your patients Special habits: Sports and smoking Occupations: metal workers

COMPLAINTS

Patient Own Words

حتى لو بالعربى

Chief Complaint• The main reason push the pt. to seek for visiting a ophthalmic

consultation.

• Usually a single symptoms, occasionally more than one complaints e.g. blurred vision, swelling, pain, trauma, inflammation etc.

• The patient describe the problem in their own words.

• It should be recorded in his/her own words.

• What brings your here? How can I help you? What seems to be the problem?

How long? Involving one or both eyes? Any associated symptoms? Any similar problems before?

Analysis of complaints

COMPLAINTS

*Diplopia: uniocular or binocular*Flashes of lights: RD*Floaters as Musca volitans*Metamorphopsia as in macular diseases*Field defects: glaucoma

Visual :*Diminution of vision: Gradual: Cataract or errors of

refraction Sudden: CRAO

COMPLAINTS Non Visual: Eyelid Oedema Redness Lacrimation Discharge Itching Burning FB sensation Pain Phtophopia

CAUSE OF CONJUNCTIVAL CONGESTION

Allergic conjunctivitis & other form of conjunctivitisChemical conjunctivitis because of drugs,Carotid-cavernous fistulaMalignant lymphoma  CAUSE OF CILIARY CONGESTIONKeratitisAcute & chronic iridocyclitisAcute congestive glucoma

PAST HISTORY Past Ocular History: MedicalTopical medications or same illness before

Past Medical History:DMHypertensionAllergy- EczemaDrug co-morbidity

Surgical: any eye operation done before

FAMILY HISTORY Certain diseases run in families as :Retinitis PigmentosaProgressive MyopiaGlaucoma

irrlevant

SOCIAL HISTORY Smoking Alcohol Occupation Home circumstances

EXAMINATION General Appearance as:

Lid retraction

Madarosis

Ptosis

Exophthalmos

EXAMINATION

Visual Acuity(VA)

NORMAL VISUAL RESPONSEAge Visual responseNewborn Light perception

4-7 weeks Eye contact with mother4-12 weeks Fixates and follows interesting

bright coloured objects3 months Change expression smiles and

cries3-4 months Reach objects using vision6-9 months Crawling and later walking

avoiding objectsGwiazda et al 1980

FIXATION TARGETS (fix and follow) : If appropriate targets are used, this reflex can be demonstrated by

about 6 wk of age.

Binocular fixation preference :

OPTICOKINETIC NYSTAGMUS :

Evaluation of the presence or absence of opticokinetic nystagmus was the first “technologic” approach to acuity measurement in preverbal children.

VISUAL ACUITYRules

It is a test for central vision only Discuss gratings with your patient Start with one eye (uniocular) Good illuminated chart with higher

contrast

VISUAL ACUITYPin Hole test

To differentiate refractive errors from organic diseases by blocking peripheral rayes

VEDIO

VISUAL ACUITY

InterpretationUCVABCVA6/620/201.00