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)
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
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
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
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