This document provides guidance on taking an effective patient history for eye examinations. It outlines the importance of history taking and lists the key components to cover, including: personal data like name, age, occupation; presenting complaints; past ocular, medical, and family histories; current medications; and allergies. Common visual symptoms like defective vision, discharge, redness, and their potential medical causes are also reviewed. A thorough patient history helps focus the exam, determine needed tests, and understand the condition's functional impact.

1. Presented by Parikshit
Yadav(Optometrist)

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

35. Thank you