This document provides an overview of how to take a basic history and perform an eye examination. It discusses the types of patients that may be encountered, how to structurally organize the history, and what to include under sections like personal data, presenting complaints, past ocular and medical history, medications, and family history. It also outlines the various components of an eye exam, including checking vital signs, inspecting adnexa, and examining the anterior and posterior segments of the eye using a slit lamp. Key areas of focus are the conjunctiva, cornea, anterior chamber, pupil, iris, lens, vitreous, optic nerve, macula and retinal vessels. Common abnormalities are also highlighted.

1. BASIC HISTORY AND
EYE EXAMINATION
DR. WILLARD BWALYA MUMBI
(BSC.HB, MBCHB, PG. DIP. BA, MMED, FCO-ECSA)
CONSULTATION OPHTHALMOLOGIST
KABWE GENERAL HOSPITAL EYE DEPARTMENT
ZAMBIA
26TH OCTOBER, 2016

2. DISCLOSURES:
 No financial disclosures
 Sources of pictures:
 American Academy series
 Kabwe General Hospital, Eye Department
 Stanford Medicine
 Wills Eye Manual

3. HISTORY
 TYPES OF PATIENTS THAT YOU WILL ENCOUNTER IN THE
CLINIC
1. Patients with ocular symptoms
2. Patients with diagnosis who comes for follow up
3. Patients who desire routine ocular examination and refraction

4. STRUCTURAL ORGANISATION OF
HISTORY
1. PERSONAL DATA
2. PRESENTING COMPLAINTS (P/C)
3. HISTORY OF PRESENTING COMPLAINTS (HxPC)
4. PAST OCULAR HISTORY (POHx)
5. PAST MEDICAL HISTORY (PMHx)
6. DRUG HISTORY (DHx)
7. ALLERGIC HISTORY (AHx)
8. FAMILY HISTORY (FHx)
9. SOCIAL HISTORY (SHx)

5. 1. PERSONAL DATA
 File #
 Name
 Age
 Sex
 Marital Status
 NOK with contact phone #
 Residence
 Contact phone #
 RELEVENCE OF THE DETAILS:
o Patient follow up and case tracing
o Guide in making a diagnosis
o Notification of relatives in case of any
eventuality such as death
o In research, retrospective study, helps to
trace the file from archives
o Make it personal ambition to ensure this
demographic data is quality, rough
estimate of age is better than “F/A”

6. PRESENTING COMPLAINTS (P/C)
 Headlines of ophthalmic history ( main reason patient has come to the
hospital)
 Specify laterality(BE, RE, LE)
 Specify duration ( avoid writing dates, calculate duration)

7. HISTORY OF PRESENTING
COMPLAINTS (HxPC
 Briefly explore and develop the chief
complaints
 Be concise, focused and chronological
o When did the problem begin
o What happened?
o How was the progression?
o Where one or both eyes affected?
o What treatment was received?
o What are the aggravating factors?
o Course of symptoms.

8. Visual Symptoms
 Blurred vision
 Double vision
 Red eye
 Itchiness
 Pain
 Unable to read small prints
 Discharge (watery, mucopurulent,
purulent and mucoid).
 Headache.
 Asthenopia.
 Floating spots and light flashes.
 Tearing.
 Abnormal appearance.

9. PAST OCULAR HISTORY (POHx)
 Any ocular medications, surgery, eye hospital
visits
 Use of spectacles, contact lenses etc.
 Last time spectacles where changed.

10. PAST MEDICAL HISTORY (PMHx)
 DM
 HTN
 HIV
 RHEUMATOID ATHRITIS
 ASTHMA
 CARDIAC DISEASE
 SCD

11. DRUG HISTORY (DHx)
 BETA BLOCKERS
 ANTI COAGULANTS
 STEROIDS – in steroid responders, causes glaucoma
 TOPICAL GENTAMYCIN – causes epithelial toxicity

12. FAMILY HISTORY (FHx)
 Myopia,
 Squint,
 Glaucoma
 Eye cancer
 Blindness.

13. SHx
 Occupation
 Performance at school

14. EXAMINATION
 OD (oculus dexter) right eye.
 OS (oculus sinister) left eye.
 OU (oculus uterque) both eyes
 RE
 LE
 BE

15. VITAL SIGNS
 BP
 VISUAL ACUITY
 IOP ( 9 – 21mmHg)

16. EXAMINATION
1. ADNEXA
2. ANTERIOR SEGMENT
3. POSTERIORS SEGMENT

17. ADNEXA
 ORBITAL RIM
 EYE BROW
 EYE LIDS
 EYE LASHES
 ORIFICES

18. SLIT LAMP
BIOMICROSCOPE
“SLIT LAMP IS TO THE
OPHTHALMOLOGIST AS THE HOE IS TO
THE FARMER”

19. PALPATE ORBITAL
RIM IN CASE OF #

20. MOLLUSCUM CONTAGIOSUM

21. PIGMENTED EYELIDS IN SEVERE ALLERGIES

22. LOWER LID
EXAMINATION
MADAROSIS

23. LACRIMAL DRAINAGE
SYSTEM

24. ANTERIOR SEGMENT
 CONJUNCTIVA
 CORNEA
 A/C
 PUPIL
 IRIS
 LENS

25. CONJUNCTIVA

26. BULBAR CONJUNCTIVA INJECTION IN HYPERMATURE
CATARACT

27. TARSAL CONJUNCTIVA FLIPPED:
TRACHOMATIS INTENSE WITH EARLY SCARING

28. OSSN (OCULAR SURFACE SQUARE CELL CARCINOMA)-
SQUAMOUS CELL CARCINOMA

29. CORNEA

30. PERIPHERAL ULCERATIVE KERATITIS (PUK)

31. CORNEA STAINING WITH FLUORESCEIN: CORNEAL ULCER; DRY
EYE SYNDROME

32. LMBU
S

33. LIMBAL STEM CELL DEFICIENCY (LSCD) SECONDARY TO SEVERE
ALLERGIC CONJUCTIVITIS

34. ANTERIOR
CHAMBER
(A/C)

35. A/C
 FEAUTRES TO NOTE:
I. DEPTH
II. FLARE
III. IMFLAMATORY CELLS
IV. HYPOPION
V. HYPHAEMA
 IF NORMAL, IT WILL BE DENOTED
AS FOLLOWS:
 A/C : D/Q (DEEP & QUITE)

36. PUPIL

37. PUPIL
 DIRECT LIGHT REFLEX
 CONSENSUAL LIGHT REFLEX
 NORMAL DIAMETER 3mm
 ROUND
 NOTATION:
 RRTL (ROUND REACTING TO LIGHT)
 RELATIVE AFFERENT PUPILARY
DEFECT RAPD
 SYNAECHIAE

38. CATARACT
 KATUBE
 KASANGA
 KABALE

39. POSTERIOR SEGMENT
 VITREOUS: Haziness, cells, h’age
 OPTIC NERVE: CDR, pale, blurred
margin
 VESSELS: aneurysm, Ghost vessels
 MACUALR: normal, dull reflex, h’age.
hole

40. POSTERIOR SEGMENT

41. FUNDU
S

43. OPTIC NERVE HEAD
CONSISTS OF :
1. OPTIC DISC
2. NEURORETINAL RIM
3. OPTIC CUP

44. ABNORMALITIES OF OPTIC NERVE HEAD

45. GLAUCOMATOUS OPTIC NERVE HEAD

46. GLAUCOMA FUNDUS

47. MALIGNANT HYPERTENSION

48. PAPILLOEDEMA
 RAISED INTRA-CRANIAL
PRESSURE
 FEATURES:
o LOSS OF NATURAL
CONTOURS
o MARGINS BLURRED
o ELEVATED
o DISC VESSELS TURNING

49. OPTIC ATROPHY
o FLAT
o PALE – PAPER WHITE

50. DIABETIC
RETINOPATHY

51. DIABETIC RETINOPATHY

52. MACULOPATHY

53. QUIZ