In depth slides about a detailed history taking with reference to Optometrists

1. HISTORY TAKING SKILLS

2. DEFINED DATA BASE
• Patient profile
• Chief complaint
• Present illness
• Review of systems
• Physical examination
• Laboratory reports

3. DEMOGRAPHIC INFORMATION
• Name . General allergy
• Age . Occupational &
Visual requirements
• Sex
• Marital status
• Address
• Telephone number
• E-mail ID
• Occupation
• Previous drug allergy

4. OCULAR HISTORY
• EXISTING SPECTACLE
WEARER:
• PGP noted down
• How old
• Last refraction done
• Type of lens
• Any tints present
• Bifocals/single
vision/multifocals
• Prisms induced
• EXISTING CONTACT LENS
WEARERS:
• How old
• How many hours/day
• Type of lens
• Material/power/diameter
• In case of RGP optic zone
base curve/diameter/
central thickness
•Any eye injuries, previous diseases of the eye, any
surgeries, had undergone any treatment, etc.,

7. MNEMONICS – THE CHIEF COMPLAINT
B : Blurred vision
E : Eye strain
D : Disturbances in vision
H : Headache
E : External eye symptoms
D : Deviating eye
P : Protrusion of eye
U : Unequal pupil size
R : Reading/learning problems

12. Remember!
• Avoid leading questions.
• You don’t smoke do you?
• You haven’t had any eye pain earlier?
• You haven’t visited any other doctor?
• Avoid compound questions.
• Do you have trouble sleeping?
• How much sleep do you get?
• Do you use cocaine/marijuana, alcohol etc.,?

13. BLURRED VISION
LOCATION AGE DEFECT
For distance Children Myopia
For near In middle aged adult Presbyopia
After prolonged close
work
In non presbyopic age Hyperopia
In reduced illumination Young/old Night myopia/RP
In bright light/daylight Young/old Intermittent
squint/NS/PSC
Transient loss of vision In elderly adult Temporal
arteritis/carotid artery
occlusive
disease/migraine/multipl
e sclerosis

14. • Blurred vision is unilateral – Amblyopia – cause
to be found whether strabismic/anisometropic/
or high astigmatism.
• Blurred vision in an adult – if accompanies
change in refraction – more myopia/less
hyperopia – NS or blood sugar levels increased.
• Usually unilateral – NS & bilateral – increase in
blood sugar levels.
• No change in refraction – lens opacities/ARMD
• Blurred vision with decreased visual acuity – no
change in refraction – requires additional
testing – retinal, optic nerve/lenticular
problems.

15. EYE STRAIN/ASTHENOPIA
• Feeling of fatigue
• Discomfort or pain localized in or around the
eyes and thought to be associated with the
use of eyes.
• Pulling sensation
• Poor concentration
• Strain around the eyebrow
• Often confused with headache

16. • Myopia: C/O eyestrain or visual fatigue is not
common.
• Hyperopia: excessive use of accommodation
leads to asthenopia
• Astigmatism: Hyperopic astigmatism: one or
both focal lines fall behind the retina. Hence
the circle of least confusionis on or near the
retina, thereby improving the visual acuity,
but causes asthenopia.
• Myopic astigmatism: will not improve with
accommodation and hence no asthenopia.

17. BINOCULAR ANOMALIES
Convergence Convergence Divergence Divergence
Excess Insufficiency Excess Insufficiency
for near for distance
AC/A ratio › AC/A ratio ‹ AC//A ratio› AC/A ratio
Near than distance distance ‹ distance
Distance than near than near than near

18. • Anisometropia: uncorrected anisometropia, even of
moderate amount can cause eyestrain due to
difficulty in maintaining clear images on both retina
at the same time.
• Anisokonia: a difference in the size and shape of the
retinal images for the two eyes is usually the result
of magnification differences brought about by
corrective lenses & this causes eyestrain &
headache.
•
• Strabismus: manifest or latent. Eyestrain more
common in latent than in manifest. Functional or
paralytic. Functional- eyestrain more common than
in paralytic. Paralytic usually asthenopia is in later
stage.

19. DISTURBANCES IN VISION
• To: Temporary loss of vision
• Day: Distortion in size & shapes of objects
• Faint: Flashes & floaters
• Drizzle with: Diplopia
• Hot &: Halos
• Cold: Curtain coming down
• Showers: Spots

20. Temporary loss of vision
• Migraine
• Multiple sclerosis (MS)
• Carotid artery occlusive disease (CAOD)
• Temporal arteritis (TA)
• Migraine: visual aura, sick headache, heat
waves & light flashes, temporary loss of vision.
DD: through history
• Multiple sclerosis: temporary loss of vision
due to retrobulbar neuritis are early
symptoms, positive scotoma, scotoma is
ameboid in nature and patient can plot it.

21. • Migraine & MS usually young and middle aged.
• CAOD & TA most commonly beyond 55 or 60yrs.
• CAOD: due to deposition of atheromatous
plaques within the internal carotid arteries.
Most common ocular symptom is Amaurosis
Fugax – a sudden transient painless loss of vision.
Vision loss is due to migration of emboli
consisting of platelets, fibrin, and cholesterol into
the retinal arterial tree.
Patient during an attack sees both yellow or
white emboli.
White emboli – platelets & fibrin
Yellow emboli – cholesterol – Hollenhorst plaques

22. • TA: Giant cell arteritis and cranial arteritis.
Inflammation of the temporal branch of the
internal carotid artery which supplies central
artery of the retina.
Headache in the temporal region
General feeling of malaise
Loss of appetite, scalp tenderness
Claudication of the jaw while chewing.

23. Distortion of objects
• Distortion in size can be perceptual or optical.
• Occasionally patient’s perception of
environmental visual clues to size breaks down.
• They may be alarmed that the faces and things
appear larger/smaller than they think it should
be.
• Optical can be due to newly prescribed +/- lenses
and accommodative micropsia is minification of
retinal image due to excessive accommodation.
• Macular problems – metamorphopsia.

24. Flashes & floaters
• Muscae valitantes: vitreous becomes partially
liquified mostly in myopes and older people.
Vitreous opacities cast shadows on the retina.
Commonly seen when looking at the sky or some
unstructured background.
Patient describes them as spots, stings, cobwebs,
or rings etc.,
They move across the visual field when eye
movement is made.
They move faster than the eye movement.

25. • Pars planaitis: chronic anterior uveitis.
Usually due to presence of cells in the retro-
lental space/anterior vitreous.
This remains stationary and gradually
increases over a period of time.
Common complications are PSC and cystoid
macular oedema.
• Retinal heamorrhages: c/o red spots
Due to retinal heamorrhages in the vitreous.
DR, HR, etc.,

26. Flashes:
Muscae valiantes
Pars planitis
Retinal heamorrhages
PVD (arc of flash)
Migraine
Lesions of visual cortex

27. Diplopia
Monocular Binocular
• Keratoconus . Binocular vision
• Corneal edema anomalies,
• Refractive errors
• Cataract . Recent onset
acquired muscle
palsy,
. Cerebral
vascular
accident

28. Halos
• Rainbow colors around the light.
• Usually in angle closure glaucoma, due to
corneal edema.
• Can be due to tiny hillocks in corneal
epithelium.

29. • How to differentiate between glaucomatous
halo & that due to radical structure of
crystalline lens?
• If a vertically oriented stenopic slit is moved
back and forth, horizontally in front of the
pupil,
• a halo caused by radical structure of the lens
will appear to rotate with a wheel like motion.
• a halo due to corneal edema – the halo will
not rotate.

30. Curtain in front of the eyes
• Classic symptom of a retinal detachment.
• It appears like a curtain is falling in front of the
eye.
• Its an emergency.
Spots
• Same as that of floaters

31. HEADACHES
OCULAR NON-OCULAR

32. OCULAR

33. • Which part of the head does it hurt –
forehead/sides/back of the head etc.,

39. NON-OCULAR MNEMONICS
• My - Migraine
• Mother - Muscular contractions
• Cook - Cluster
• Nice - Nasal sinusitis
• Hot - Hypertensive
• Tasty - Temporal arteritis
• Tiffins - Trigeminal neuralgia

40. MIGRAINE
• Prodrmal visual aura
• Unilateral, throbbing headache with nausea
• Scintillating scotoma
• Constriction of the internal carotid artery
supplying visual cortex
• First dilation & then congestion of the arteries
• Treatment both prophylactic and symptomatic
medication.

41. MUSCULAR CONTRACTION
• Vice like pain in the forehead, or pain in the
cortex.
• Also known as tension headache.
• Pain in the occipital area along with muscular
stiffness in the neck.
• Mainly due to stress & psychological
• Treatment is with analgesics, muscle relaxants
and sedatives.

42. CLUSTER
• Also known as Histamine Cephalgia
• Severe boring headache, unilateral occuring in
the temporal region accompanied by
ipsilateral lacrimation & nasal congestion.
• Cluster because one or more headaches occur
daily within a short period of time.
• Typically occurs at night mainly when the
person is lying down.
• Treatment similar to that of migraine.

43. NASAL SINUSITIS
• Most predominant in acute nasal sinusitis
than in chronic nasal sinusitis.
• Pain in the frontal region & increases on
stooping down.
• Other symptoms associated are coughing due
to postnasal drip, low grade fever &
temporary loss of the sense of smell.

44. HYPERTENSIVE
• Severe occuring early in the morning on
awakening and disappearing during the course
of the day.
• Reduces on taking a cup of black coffee
immediately on arising.
• Early treatment of hypertension reduces the
risks.

45. TRIGEMINAL NEURALGIA
• Extremely sharp, piercing, knife like pain of
sudden onset in the facial region.
• Can be due to inflammation of any three divisions
– least common is ophthalmic division.
• Trigger zone – pain cab be brought by touching a
specific area while washing the face, cleaning the
teeth or shaving, etc.,
• Usually middle aged or elderly.
• State of constant fear.
• Usually not confused with other types of
headaches, as this presents in the areas
distributed by the maxillary & mandibular.
• Treatment is anti-convulsives .

46. EXTERNAL EYE SYMPTOMS
• Itching & burning sensation of the eyes
• Pain & foreign body sensation
• Sensitivity to light
• Excessive tearing
• Feeling of dryness.
• Mostly manifestations of asthenopia-
uncorrected refractive errors or binocular
vision problems

47. ITCHING & BURNING SENSATION
• Asthenopia causing this is due to triggering the local
axon reflex.
• Effort to compensate for the refractive error
stimulates nerve ending, there by leading to
increased blood supply to the localised area.
• This leads to hyperemia & itching.
• Due to rubbing, increase in bacterial content of the
tears & this leads to inflammation.
• Hence this leads to recurrent styes in small refractive
errors.
BLEPHERITIS ALLERGIC CONJUNCTIVITIS VIRAL CONJUNCTIVITIS BACTERIAL
CONJUNCTIVITIS

48. Pain & foreign body sensation
Superficial Deep seated
• Foreign body either in the . Corneal ulcers
conjunctiva or corneal or acute Iritis or
epithelium. acute Glaucoma
• Visual acuity not affected . Visual acuity
• Treatment by removal . Presence of
A/C cells & flare

49. SENSITIVITY TO LIGHT
Pain Photophobia Lacrimation
• Conditions with predominant photophobia
are:
a) epidemic kerato- b) congenital
conjunctivitis glaucoma
 Follicular conjunctivitis . Extreme photophobia
 Pain & tearing . Excessive tearing in
 After 7 days raised epi-lesions the first few months
 Stains with fluroscein of the life.
 Scattered over cornea . Suspect glaucoma
 Marked photophobia . Noticeable enlarge-
 After 7 days sunepithelial opacities ment in the size of
the eye. (buphthalmos)

50. EXCESSIVE TEARING
• Stenosis of the lacrimal duct
• Ectropion
FEELING OF DRYNESS
• Aqueous deficiency
• Mucin deficiency
• Lid surfacing abnormalities
DEVIATING EYE
• Pseudo strabismus
• True deviations: a) phoria, b) tropia.

51. PROTRUDING EYE
• Congenital or infantile glaucoma
• Microphthalmos of the other eye
• Exophthalmos due to mass affecting the orbit
or optic nerve.

52. Vision Related Learning Problems
• Physical Symptoms
• Jerky eye movements, one eye turning in or
out
• Squinting, eye rubbing, or excessive blinking
• Blurred or double vision
• Headaches, dizziness, or nausea after
reading
• Head tilting, closing or blocking one eye
when reading

53. Vision Related Learning Problems
• Secondary Symptoms
• Smart in everything but school
• Low self-esteem, poor self image
• Temper flare ups, aggressiveness
• Frequent crying
• Short attention span
• Fatigue, frustration, stress
• Irritability
• Day dreaming

54. Vision Related Learning Problems
• Performance Clues
• Avoidance of near work
• Frequent loss of place
• Omits, inserts, or rereads letters/words
• Confuses similar looking words
• Failure to recognize the same word in the next
sentence
• Poor reading comprehension
• Difficulty copying from the chalkboard
• Book held too close to the eyes
• Inconsistent or poor sports performance

55. Vision Related Learning Problems
• Social Labels
• Lazy
• Dyslexic
• Attention Deficit Disorder
• Slow learner
• Behavioral problems
• Working below potential