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Presented by Parikshit
Yadav(Optometrist)
Importance-
A good history commonly leads to a
diagnosis.
It helps to focus your examination
Indicates when/what investigations
are needed.
Helps determine the functional
impact of condition.
Structural organisation of history
 Personal data(Demographic data)
 Presenting complaints (P/C)
 Past ocular history(POHx)
 Past medical history(PMHx)
 Drug history(DHx)
 Allergic history(AHx)
 Family history(FHx)
 Social history(SHx)
Personal data
IT INCLUDES-
NAME AND ADDRESS
AGE/SEX
OCCUPATION
RELIGION
Name and address-
It is primarily required for patient’s identification .It is
also proves useful for demographical research.
Age and Sex-
 Patient identification
 Patient follow up and tracking
 Ruling out particular disease pertaining to different age
groups and particular sex.
Patient Occupation-
An information about patient’s occupation is helpful
since ophthalmic manifestations due to occupational
hazards are well known e.g.:
 Ocular injuries and trauma due to foreign bodies
have typical pattern in factory worker, lathe worker
, formers and sport person.
 Computer vision syndrome is emerging as a
significant ocular health problem in computer
professionals.
 Heat cataract is known in glass factory workers.
 Photophthalmitis is known in welders not taking
adequate protective measures.
Religion-
 Recording to the religion of the patient may be helpul
in ascertaining of disease which is more common in
particular community.
Chief presenting complaints
 Defective vision
 Watering and/or discharge of eye
 Redness
 Asthenopic symptoms
 Photophobia , Burning /itching/f.b. Sensation
 Pain( Eye ache and headache)
 Deviation of vision
 Diplopia
 Black spot in front of eye
 Coloured halos
 Distorted vision
History of present illness
 Eye OD ,OS or OU
 Mode of onset,duration
 Severity
 prognosis
 Accompaniment of each symptom
History of past illness
 Previous eye problems such as uveitis ,herpes simplex
keratits , corneal erosions, glaucoma.
 Refractive errors
 Ocular surgery
 Ocular trauma
 Squint
 Lazy eye
 H/O systemic disease in the past such as tuberculosis ,
syphilis , leprosy
 H/O drug intake And allergies
Past medical history
 Diabetes?
 Hypertension?
 Rheumatoid arthritis?
 HIV?
 Asthma?
 Eczema or skin problem?
 Cardiac disease?
Present drug history
 Beta blockers (H.T.)
 Anti coagulants (Cardiac)
 Steroids
 Anti glaucoma
 Diabetes
 A.T.T.
 Asthma
Family history-
 Squint
 Glaucoma
 Myopia
 Congenital Cataracts
 Poor vision etc
Birth history-
 For children only
 Prematurity
 Forceps delivery
 Low birth weight
Social history-
 Smoking
 Alcohol
 Occupation
 Home circumstances
Common ocular symptoms and
their causes
Defective vision—
Sudden painless loss of VN-
• CRAO
• Massive vitreous haemorrhage
• RD
• Ischaemic CRVO
Sudden painless onset of defective
Vn
 Central serous retinopathy
 Optic neuritis
 Methyl alcohol amblyopia
 Non ischemic CRVO
sudden painful loss of Vn
 Acute congestive glaucoma
 Acute iridocyclitis
 Chemical injuries to the eye ball
 Mechanical injuries to the eye ball
Gradual painless defective Vn
 Refractive errors
 Corneal degenerations
 Developmental cataract
 Senile cataract
 Optic atrophy
 Chorioretinal degenerations
 Diabetic retinopathy
 Progressive pterygium
Gradual painful defective Vn
 Chronic iridocyclitis
 Corneal ulceration
 Chronic simple glaucoma
Transient loss of Vn
 Carotid artery disease
 Papilloedema
 Giant cell arteritis
 Migraine
 Reynaud's disease
 Severe hypertension
 Prodromal symptom of CRAO
Night blindness(Nyctolopia)
 Vitamin A deficiency
 Retinitis pigmentosa
 Congenital night blindness
 Pathological myopia
 Peripheral cortical cataract
Day blindness(Hamarlopia)
 Central nuclear or polar cataract
 Central corneal opacity
 Central vitreous opacity
 Congenital deficiency of cones
Diminution of near Vn only
 Presbyopia
 Cycloplegia
 Internal or total ophthalmoplegia
 Insufficiency of accommodation
Other visual symptoms
 Black spot or floaters in front of eye common causes -
 Vitreous haemorrhage
 Vitreous degeneration
 Exudates in vitreous
Flashes of light
 Posterior vitreous detachment
 Vitreous traction band
 Sometimes sign of retinal tear
 Retinitis
 migraine
Distortion of Vn
 Central chorioretinitis
 Central serous chorioretinopathy
 ARMD
 CNVM
 Keratoconus
 Early cataract
 Post refractive surgery
Photophobia
 Corneal abrasion
 Acute conjunctivitis
 Keratitits
 Anterior uveitis
 Dilated pupil
Coloured halos
 Acute congestive glaucoma
 Corneal edema
 Early stage of cataract
 Mucopurulent conjunctivitis
Diplopia (uniocular and binocular)
 Uniocular Diplopia -
 Subluxated lens
 Double pupil
 Incipient cataract
 Keratoconus
 Eccentric IOL
Binocular diplopia
 Paralytic squint
 Myasthenia gravis
 Diabetes mellitus
 Thyroid disorder
 Blow out fracture of floor of orbit
 Anisometropic glasses
Discharge from eye
 It should be ascertained whether it is mucoid ,
mucopurulent , purulent , ropy.
Discharge from the eye is a featuring of conjunctivitis,
corneal ulcer, stye , burst orbital abscess and DCR.
Itching, burning and foreign body
sensation
 Conjunctivitis(allergic, GPC)
 Blephritis
 Dry eye
 Trichiasis and entropion
 Foreign body
Redness of eye
 Conjunctivitis
 Keratitis
 Iridocyclitis
 Acute glaucoma's
 Episcleritis
 Scleritis
 Sub conjunctival haemorrhage
 endophthalmitis
Thank you

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History taking in ophthalmology

  • 2. Importance- A good history commonly leads to a diagnosis. It helps to focus your examination Indicates when/what investigations are needed. Helps determine the functional impact of condition.
  • 3. Structural organisation of history  Personal data(Demographic data)  Presenting complaints (P/C)  Past ocular history(POHx)  Past medical history(PMHx)  Drug history(DHx)  Allergic history(AHx)  Family history(FHx)  Social history(SHx)
  • 4. Personal data IT INCLUDES- NAME AND ADDRESS AGE/SEX OCCUPATION RELIGION
  • 5. Name and address- It is primarily required for patient’s identification .It is also proves useful for demographical research. Age and Sex-  Patient identification  Patient follow up and tracking  Ruling out particular disease pertaining to different age groups and particular sex.
  • 6. Patient Occupation- An information about patient’s occupation is helpful since ophthalmic manifestations due to occupational hazards are well known e.g.:  Ocular injuries and trauma due to foreign bodies have typical pattern in factory worker, lathe worker , formers and sport person.  Computer vision syndrome is emerging as a significant ocular health problem in computer professionals.  Heat cataract is known in glass factory workers.  Photophthalmitis is known in welders not taking adequate protective measures.
  • 7. Religion-  Recording to the religion of the patient may be helpul in ascertaining of disease which is more common in particular community.
  • 8. Chief presenting complaints  Defective vision  Watering and/or discharge of eye  Redness  Asthenopic symptoms  Photophobia , Burning /itching/f.b. Sensation  Pain( Eye ache and headache)  Deviation of vision  Diplopia  Black spot in front of eye  Coloured halos  Distorted vision
  • 9. History of present illness  Eye OD ,OS or OU  Mode of onset,duration  Severity  prognosis  Accompaniment of each symptom
  • 10. History of past illness  Previous eye problems such as uveitis ,herpes simplex keratits , corneal erosions, glaucoma.  Refractive errors  Ocular surgery  Ocular trauma  Squint  Lazy eye  H/O systemic disease in the past such as tuberculosis , syphilis , leprosy  H/O drug intake And allergies
  • 11. Past medical history  Diabetes?  Hypertension?  Rheumatoid arthritis?  HIV?  Asthma?  Eczema or skin problem?  Cardiac disease?
  • 12. Present drug history  Beta blockers (H.T.)  Anti coagulants (Cardiac)  Steroids  Anti glaucoma  Diabetes  A.T.T.  Asthma
  • 13. Family history-  Squint  Glaucoma  Myopia  Congenital Cataracts  Poor vision etc
  • 14. Birth history-  For children only  Prematurity  Forceps delivery  Low birth weight
  • 15. Social history-  Smoking  Alcohol  Occupation  Home circumstances
  • 16. Common ocular symptoms and their causes Defective vision— Sudden painless loss of VN- • CRAO • Massive vitreous haemorrhage • RD • Ischaemic CRVO
  • 17. Sudden painless onset of defective Vn  Central serous retinopathy  Optic neuritis  Methyl alcohol amblyopia  Non ischemic CRVO
  • 18. sudden painful loss of Vn  Acute congestive glaucoma  Acute iridocyclitis  Chemical injuries to the eye ball  Mechanical injuries to the eye ball
  • 19. Gradual painless defective Vn  Refractive errors  Corneal degenerations  Developmental cataract  Senile cataract  Optic atrophy  Chorioretinal degenerations  Diabetic retinopathy  Progressive pterygium
  • 20. Gradual painful defective Vn  Chronic iridocyclitis  Corneal ulceration  Chronic simple glaucoma
  • 21. Transient loss of Vn  Carotid artery disease  Papilloedema  Giant cell arteritis  Migraine  Reynaud's disease  Severe hypertension  Prodromal symptom of CRAO
  • 22. Night blindness(Nyctolopia)  Vitamin A deficiency  Retinitis pigmentosa  Congenital night blindness  Pathological myopia  Peripheral cortical cataract
  • 23. Day blindness(Hamarlopia)  Central nuclear or polar cataract  Central corneal opacity  Central vitreous opacity  Congenital deficiency of cones
  • 24. Diminution of near Vn only  Presbyopia  Cycloplegia  Internal or total ophthalmoplegia  Insufficiency of accommodation
  • 25. Other visual symptoms  Black spot or floaters in front of eye common causes -  Vitreous haemorrhage  Vitreous degeneration  Exudates in vitreous
  • 26. Flashes of light  Posterior vitreous detachment  Vitreous traction band  Sometimes sign of retinal tear  Retinitis  migraine
  • 27. Distortion of Vn  Central chorioretinitis  Central serous chorioretinopathy  ARMD  CNVM  Keratoconus  Early cataract  Post refractive surgery
  • 28. Photophobia  Corneal abrasion  Acute conjunctivitis  Keratitits  Anterior uveitis  Dilated pupil
  • 29. Coloured halos  Acute congestive glaucoma  Corneal edema  Early stage of cataract  Mucopurulent conjunctivitis
  • 30. Diplopia (uniocular and binocular)  Uniocular Diplopia -  Subluxated lens  Double pupil  Incipient cataract  Keratoconus  Eccentric IOL
  • 31. Binocular diplopia  Paralytic squint  Myasthenia gravis  Diabetes mellitus  Thyroid disorder  Blow out fracture of floor of orbit  Anisometropic glasses
  • 32. Discharge from eye  It should be ascertained whether it is mucoid , mucopurulent , purulent , ropy. Discharge from the eye is a featuring of conjunctivitis, corneal ulcer, stye , burst orbital abscess and DCR.
  • 33. Itching, burning and foreign body sensation  Conjunctivitis(allergic, GPC)  Blephritis  Dry eye  Trichiasis and entropion  Foreign body
  • 34. Redness of eye  Conjunctivitis  Keratitis  Iridocyclitis  Acute glaucoma's  Episcleritis  Scleritis  Sub conjunctival haemorrhage  endophthalmitis