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11/13/24, 8\:11 PM Guide | Ophthalmic history

Ophthalmic history

Table of contents

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain that you'd like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you're running through a checklist in your head doesn't mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal
Active listening\: through body language and your verbal responses to what the patient has said
An appropriate level of eye contact throughout the consultation
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair)
Making sure not to interrupt the patient throughout the consultation
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next
Summarising at regular intervals

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
" W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?"
" T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g .
"
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
" O k , c a n y o u t e l l m e m o r e a b o u t t h a t ?"
" C a n y o u e x p l a i n w h a t t h a t p a i n w a s l i k e ?"
Once the patient has
complaints, work with them to establish a shared agenda for the rest of the consultation\:
" O k , s o y o u’ v e m e n t i o n e d t h a t y o u h a v e t h r e e p r o b l e m s t o d a y t h a t y o u’ d l i k e a d d r e s s i n g. A s t h e r e m a y n o t b e t i m e t o a d d r e s s
t h e m a l l t h o r o u g h l y i n t h i s c o n s u l t a t i o n , i t w o u l d b e h e l p f u l t o k n o w w h i c h o f t h e i s s u e s y o u f e e l i s m o s t i m p o r t a n t t o d e a l
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w i t h t o d a y . I’ l l t h e n l e t y o u k n o w w h i c h o f t h e s e i s s u e s I f e e l i s t h e p r i o r i t y a n d w e c a n a gr e e o n w h a t t h e f o c u s o f t o d a y’ s
c o n s u l t a t i o n s h o u l d b e . D o e s t h a t s o u n d o k ?"
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di

History of presenting complaint

Begin by clarifying some key details including\:
the primary complaint (e.g. visual disturbance, red-eye and/or pain)
whether one or both eyes are a
how the problem started
Key ophthalmic symptoms
Some key ophthalmic symptoms which should be screened for include\:
Visual disturbance\:
“ H a s t h e r e b e e n a n y c h a n g e t o y o u r v i s i o n r e c e n t l y ?”
Red eye\:
“ H a v e y o u n o t i c e d y o u r e y e s l o o k r e d ?”
“ D i d s o m e b o d y e l s e c o m m e n t o n t h e a p p e a r a n c e o f y o u r e y e s ?"
“ I s t h i s r e d n e s s a l l o v e r t h e w h i t e o f y o u r e y e s o r o n l y o n o n e p a r t ?”
Eye discharge and/or watering\:
“ D o y o u h a v e a n y d i s c h a r g e c o m i n g f r o m y o u r e y e s ?”
“ I s i t w a t e r y a n d c l e a r o r s t i c k y a n d y e l l o w ?”
“ D o y o u r e y e s w a t e r ?”
Grittiness or dryness of the eyes\:
“ D o e s i t f e e l l i k e y o u’ v e g o t s o m e t h i n g s t u c k i n t h e e y e ?”
“ D o y o u r e y e s f e e l d r y ?”
Itching of the eyes\:
“ D o y o u f e e l l i k e y o u’ r e c o n s t a n t l y h a v i n g t o r u b y o u r e y e s ?”
Photophobia\:
“ D o e s i t h u r t w h e n y o u g o i n t o b r i g h t l i gh t ?”
“ D o y o u p r e f e r t o b e i n a d a r k e n e d r o o m , a w a y f r o m l i g h t ?”
Swelling or tenderness of the eyes\:
“ H a v e y o u n o t i c e d a n y s w e l l i n g o r p a i n a r o u n d o r o n t h e e y e ?”
“ D o e s i t h u r t w h e n y o u t o u c h i t ?”
Red
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Some examples of red
Eye pain\: moderate to severe pain should always be treated as a red-
angle glaucoma, uveitis or aggressive keratitis.
Photophobia\: can indicate corneal disease such as bacterial keratitis or in
uveitis). These both require specialist review.
Visual disturbances\: sudden and persistent (>60 minutes) visual loss is always a red
profound loss of vision. This may represent an acute vascular event of the retina, optic nerve (temporal arteritis) or
brain.
Red-eye\: marked redness especially if associated with pain and/or loss of vision should be referred for a specialist
opinion.
Trauma\: a high-velocity injury (e.g. sudden eye pain whilst using power tools) requires urgent ophthalmological review
to assess for a penetrating foreign body (e.g. X-ray orbit). Signi
increases in intraocular pressure, retinal detachment and potentially globe rupture.

Exploring visual disturbance

The di
important to thoroughly explore a complaint of visual disturbance to narrow the di

You should always begin by asking an open question such as\:
" H a s t h e r e b e e n a n y c h a n g e i n y o u r v i s i o n r e c e n t l y ?"
Patients often struggle to describe the nature of their visual disturbance and therefore closed questions can be helpful in
exploring the symptom further. Some examples of questions you should seek answers to are shown below.
Closed questions relevant to visual disturbance
Are one, or both eyes a
When did the visual disturbance begin?
Was the onset sudden or gradual?
Does the visual disturbance come and go?
How severe is the visual disturbance (e.g. vision slightly blurry or only able to see hand movements or bright light)?
Does anything make the visual disturbance worse or better?
Does the visual disturbance a
Does the visual disturbance only a
Is there any double vision?
Does the double vision involve images side-by-side, on top of each other or at an oblique angle (e.g. when looking to the
side, in the distance or when looking down when using stairs)?
Does double vision a
Are there any 'positive' visual symptoms?
Flashing lights or
Presence of a black curtain across their
Glare from the low sun or car headlights
Halos around lights
Are there any visual distortions?
Straight lines appear wavy (metamorphopsia)
Sparkling shimmering lights moving across the visual
Objects appearing larger or smaller than you know they really are
https\://app.geekymedics.com/osce-guides/history/ophthalmic-history/ 3/911/13/24, 8\:11 PM Guide | Ophthalmic history
Vision loss due to a functional neurological disorder
Vision loss due to a functional neurological disorder is a common presentation, although it should always be a diagnosis
of exclusion. It is more common in teenagers and often related to underlying stress and anxiety stemming from
relationship di
Intermittent blurred vision sometimes with brow ache and photophobia are common, however, complete loss of vision
and double vision are also well-recognised presentations. It can be di
underlying organic basis to the symptoms and a referral to an ophthalmologist may be needed. The Functional
Neurological Disorder website is a helpful resource.
Transient visual loss (lasts \<24hrs)
Migraine\: marching sparkling shimmering lights \<60
minutes - both eyes but typically only one hemi
Amaurosis fugax\: profound loss of vision in one eye
lasting minutes to hours. Caused by vascular
disease/vasculitis
Papilloedema\: a complete brief loss of vision
(obscurations), which may be unilateral or bilateral
Persistent visual loss (lasts >24 hours)
Sudden, painless
loss
Retinal
vein
or
artery occlusion
Anterior ischaemic
optic neuropathy
(e.g.
temporal arteritis
)
Stroke
a
visual pathways
Vitreous
haemorrhage
Wet
age-related
macular
degeneration
Retinal
detachment
Gradual,
painless loss
Painful loss
Cataract
Acute closed-angle
glaucoma
Refractive error Optic neuritis
Dry
age-related
macular
degeneration
(AMD)
Anterior ischaemic optic
neuropathy (e.g.
temporal arteritis
). N.B. this involves
headache rather than
actual eye pain
Open-angle
glaucoma
Uveitis
Tumours
a
visual pathway
Keratitis
Nutritional optic
neuropathy
Endophthalmitis

Exploring eye pain

The SOCRATES acronym is a useful tool for exploring presenting symptoms. It is most commonly used to explore pain, but it
can be applied to other symptoms (although some of the elements of SOCRATES may not be relevant to all symptoms).
Site
Try to understand if it really is the eye that is sore or if the pain is around the eye/forehead.
Ask about the location of the pain\:
" W h e r e i s t h e p a i n ?"
" C a n y o u p o i n t t o w h e r e y o u e x p e r i e n c e t h e p a i n ?"
Patients may describe the location as being\:
Under the eyelid (e.g. foreign body)
Within the eyeball itself (e.g. acute glaucoma)
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Behind the eye (e.g. optic neuritis)
A frontal headache that radiates around the eyes (e.g. migraine)
Onset
Clarify how and when the pain developed\:
" H o w d i d t h e p a i n s t a r t ?"
" D i d t h e p a i n c o m e o n s u d d e n l y o r g r a d u a l l y ?"
" W h a t w e r e y o u d o i n g w h e n t h e p a i n s t a r t e d ?"
" D i d t h e p a i n w a k e y o u f r o m s l e e p ?"
Character
Ask about the speci
" H o w w o u l d y o u d e s c r i b e t h e p a i n ?" (e.g. dull ache, throbbing, sharp)
" I s t h e p a i n w o r s e w h e n y o u m o v e t h e e y e ?"
" D o e s i t f e e l l i k e y o u' v e g o t s o m e t h i n g i n t h e e y e ?"
" D o e s t h e e y e f e e l g r i t t y ?"
Radiation
Ask if the symptom moves anywhere else\:
" D o e s t h e p a i n s p r e a d e l s e w h e r e ?"
Associated symptoms
Ask if there are other symptoms associated with the primary symptom\:
" A r e t h e r e a n y o t h e r s y m p t o m s t h a t s e e m a s s o c i a t e d w i t h t h e p a i n ?"
Examples of associated symptoms might include\:
Nausea/vomiting (e.g. acute glaucoma)
Unilateral headache (e.g. migraine with aura)
Visual disturbance
Red eye
Discharge or watering
Grittiness or dryness
Itching
Photophobia
Swelling
Time course
Clarify how the symptom has changed over time\:
" H o w h a s t h e p a i n c h a n g e d o v e r t i m e ?"
" D o e s t h e p a i n c o m e a n d g o ?"
" D o y o u f e e l t h e p a i n i s g e t t i n g w o r s e o v e r t i m e ?
Exacerbating or relieving factors
Ask if anything makes the pain worse or better\:
" D o e s a n y t h i n g m a k e t h e p a i n w o r s e ?" (e.g. blinking, touching the eye, moving the eye, bright light)
" D o e s a n y t h i n g m a k e t h e p a i n b e t t e r ?" (e.g. analgesia, cool water, warm compress, removing contact lenses, dimming the
lights)
Severity
Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10\:
" O n a s c a l e o f 0-1 0 , h o w s e v e r e i s t h e p a i n , i f 0 i s n o p a i n a n d 1 0 i s t h e w o r s t p a i n y o u’ v e e v e r e x p e r i e n c e d ?"
Moderate to severe pain is a red
clinic for an ophthalmology opinion promptly.
Severe pain is often associated with acute angle-closure glaucoma, in which case the patient will also likely complain of visual
disturbance, nausea and vomiting.
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Exploring eye trauma

If there is a history of trauma, always keep in mind the possibility of a serious injury such as intraocular foreign body, globe
rupture or penetration.
It is important to determine the mechanism of injury (e.g. chemical, blunt or sharp).
Documenting the use of power tools, hammer and chisel, and the absence of safety goggles is very important.
The size, speed and nature of the
If a serious injury is suspected then you must ask for an urgent ophthalmological opinion.

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient's ideas about the current issue\:
" W h a t d o y o u t h i n k t h e p r o b l e m i s ?"
" W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g?"
" I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u g h t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
"
Concerns
Explore the patient's current concerns\:
" I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?"
" W h a t’ s y o u r n u m b e r o n e c o n c e r n r e ga r d i n g t h i s p r o b l e m a t t h e m o m e n t ?"
" W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i gh t b e ?"
Expectations
Ask what the patient hopes to gain from the consultation\:
" W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?"
" W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?"
" W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?"

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient's history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
"
" O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u' r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
"
" N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l
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Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Many conditions where the primary disease is not ophthalmological, may present with ophthalmological features. It may be
relevant to go through some questions brie
Some examples of symptoms you could screen for in each system include\:
Systemic\: fevers, weight loss, malaise (e.g. temporal arteritis)
Cardiovascular\: chest pain (e.g. pericarditis/myocarditis in autoimmune conditions), scalp pain and jaw claudication (e.g.
temporal arteritis)
Respiratory\: dyspnoea, cough, pleuritic chest pain (e.g. pleuritis in autoimmune conditions)
Gastrointestinal\: nausea/vomiting (e.g. acute-angle-closure glaucoma), diarrhoea (e.g. ulcerative colitis)
Genitourinary\: dysuria, discharge, bleeding, pelvic pain (e.g. chlamydia, gonorrhoea)
Neurological\: headache (e.g migraine, hypertension, raised intracranial pressure, temporal arteritis), weakness, ataxia and
sensory disturbances (e.g. multiple sclerosis, diabetes, stroke)
Musculoskeletal\: joint pain/sti
Dermatological\: rashes (e.g eczema, psoriasis, rosacea), butter
Endocrine\: polyuria/polydipsia (e.g. diabetes mellitus), feeling hot (e.g. hyperthyroidism)

Past ocular history

Ask about previous episodes similar to their current presenting complaint.
Ask about other eye problems/diagnoses including amblyopia ('lazy eye').
Ask about a history of previous eye trauma.
Ask about a history of ocular surgery (if recent, there is a risk of post-op endophthalmitis).
Ask if the patient uses prescription glasses and if these are used for distance or near vision.
Ask if the patient uses contact lenses and if so, clarify the following details\:
Daily disposable, monthly disposable or extended wear lenses
If the patient sleeps, showers, or swims with lenses on
Ask about the patient's contact lens hygiene regimen (e.g. daily cleaning of lenses, only using recommended cleaning
solutions etc)

Past medical history

Ask if the patient has any medical conditions\:
" D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?"
" A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e g u l a r l y ?"
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition
including hospital admissions.
Allergies
anaphylaxis).
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs
Examples of relevant medical conditions
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Medical conditions relevant to ophthalmic disease include\:
Diabetes mellitus
Hypertension
Autoimmune conditions (e.g. rheumatoid arthritis, ankylosing spondylitis, SLE)\: a vast range of ocular manifestations,
however, dry eyes and uveitis tend to be the most common presentations
Atopy (asthma, allergic rhinitis, eczema)\: relevant to allergic conjunctivitis and keratitis (eyedrops containing beta-
blockers are also contraindicated in asthma)

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form
and route.
If the patient is on topical eye medication, their prescription may read “g.
” or “guttae” for drops and “occ” for ointments. For
example 'g. Chloramphenicol'
.
Also, note if patients are on a preservative-free formulation (the box will say “preservative-free” or “minims”).
Ask the patient if they are currently experiencing any side e
medication and prolonged use of formulations containing preservatives).
Medication examples
Medications frequently prescribed to patients with ophthalmic disease include\:
Lubricants
Antimicrobials (antibiotics/antivirals - topical/oral)
Corticosteroids (topical/oral)
Glaucoma medications (prostaglandin analogues, beta-blockers, adrenergic agonists, carbonic anhydrase inhibitors,
cholinergic agents)
Analgesics (topical NSAIDs, oral analgesics)
Anti-histamines (topical and oral)

Family history

Ask the patient if there is any family history of similar complaints or formal diagnoses of eye disease. This is particularly
relevant for conditions such as glaucoma or retinal detachment.
Ask if there is any family history of hypertension, diabetes or rheumatological disease.

Social history

Taking a comprehensive social history is particularly important in the context of a person su
General social context
Explore the patient's general social context including\:
any low visual aids that they use (e.g. magni
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stairlift)
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who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
if they have any carer input (e.g. twice daily carer visits)
Smoking
Record the patient's smoking history, including the type and amount of tobacco used.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
Longstanding alcohol dependency can lead to malnourishment. Folate and B12 de
leading to gradual vision loss.
Moonshine (illicitly distilled alcohol) and ingestion of products contaminated with industrial alcohol pose a risk of methanol
toxicity. This can present as a more acute toxic optic neuropathy.
See our alcohol history taking guide for more information.
Recreational drug use
Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.
Acute vascular events in the retina and macular toxicity resulting in a sudden loss of vision are well-recognised
complications.
Intravenous drug use is also a risk factor for endophthalmitis.
Occupation
Assess the impact of the patient's symptoms on their ability to work.
Clarify what tasks the patient's occupation involves.
Identify potential occupational hazards such as\:
High-powered tools (a risk factor for penetrating eye trauma)
Welding (a risk factor for photokeratitis)
Driving
If the patient drives and has presented with signi
important to advise them not to drive until they have been fully investigated and to inform the relevant driving authority (e.g.
DVLA) of their current medical issues.

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

Reviewer

Dr Andrew Blaikie
C o n s u l t a n t O p h t h a l m o l o g i s t
Source\: geekymedics.com
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