History and Examination of an ophthalmic case
MAHGOUB SALEEM
ASSOCIATE PROFESSOR
FACULTY OF MEDICINE AL NEELAIN UNIVERCITY
Sept 2013
Learning objectives :
Take & understand an ophthalmic history
Examine the function of the eye (VA & VF)
Test pupillary reflexes
Examine eye movements
Examine the structure of the eye
Understand the use of fluorescen dye
Use the ophthalmoscope
Use slit lamp
A. History
B. Examination
- History:
Important
Encourage patient to narrate his C/Os
Make relevant enquiries
Demographic Data :
`name
` age (DOB)
`Gender (sex)
`Occupation
`Home
`Ethnicity ,, original race & tribe
` ID
(HPI) Chief complain & history of the presentillness:
1.Present status of visual function,
`Any Dimness of vision :
a)Mode of onset
i) sudden
`CRAO , CRVO , RD . Papillitis,
`Acute Congestive glaucoma ,
`Vitreous haemorrhage
ii) Gradual
`Catract , Chronic Simple Glaucoma ,
`Others ( inflamations , amblyopia , destrophies
b) Duration
i) short
ii) long
c) For distance or near
d) Any double vision
`paralytic squint ??
e) Any history of vision correction
`glasses , contact lenses, or refractive surgery
f) Night blindness
` Vit A dficiency
` RP (Retinitis Pigmentosa)
` congenital
` drugs
` acquired ( Drug,,chloroquine toxicity etc..)
g) Associations
[corneal (keratitis), uveal lesions (uvitis)]
` photophobia
` lacrimation
` blepharospasm
2.Pain in the eyes
` mode of onset ( sudden or gradual )
` severity ( mild , moderate , severe )
` relation to close work
( Refractive errors {REs}eg : presbyopia )
` time of the day gets more worse
( if worse in evening ? Res)
` associations
( nausea , vomiting , photophpbia , drop of vision )
3) Headache
` location (frontal, occipital, temporal,, temporal artritis)
` time of the day get worse
` severity ( mild , moderate , severe )
` associations ( nausea , vomiting , blurring of vision,etc..)
` type ( dull , throbbing , ? Strain ,,,,asthenopia )
[asthenopia: (vague symptoms),,,,?Eye fatigue from muscular, environmental, or ?psychological causes, ,,heaviness,tiredness,eyes discomfort,dull ache,deep pain behind the eyes,headache,blurring of vision,etc....from? REs,,prespyobia ]
` frequency.
` aura ( migraine aura )
` relation to far or near vision
` Relieving factors
( analgesics , sleep , rest etc…)
` Aggravating factors
( tension exhaustion etc..)
ocular causes of headache
REs (Refractive Errors)
poor accommodation & convergence ,A/C
CL over wear / ??? Glasses over wear ~ strain
Acute congestive glaucoma
Iritis
HZ (Herpes Zoster)
Orbital cellulites
Superior orbital syndrome
Migraine
4) Redness & congestion (inflammation) :
`eyelids
`eyeball
`surrounding the eye
5) Tearing / Watering ( excessive lacrimation):
` Duration
` Constant
` Intermittent
` Relations : ( close work, travelling , TV, cinema,,,)
` Associates: ( redness,FBs,,)
6)Discharges:
` Any stickiness of the lids
` Type of discharge:
Purulent = Bacterial
Mucopurulent = Bacterial
Slightly Mucopurulent = Chlamydial
Watery = Viral / Allergic
Stringy mucus = Vernal conjunctivitis
Watery and Foamy = Xerophthalmia
7)Photophobia ( dislike for light ):
` Corneal lesions : keratitis , FBs
` Uvitis
` ? Conjuctivitis
Past Ophthalmic History (POH):
` Redness
` Recurrent attacks of Red eye
` Surgeries ( eyes ..etc)
` Rx
` REs
` Contact Lenses ( Soft , Hard , cosmetics CLs )
` Eye traumas
Medical History (MH) :
` DM , HTN , Thyroid diseases , Strokes , Nerves Palsies
` Cancers , TB , Dermatological diseases ..etc
Drug History (DxH) :
` Steroids , Anti-Glaucoma , Anti-TB, Anti-Malaria ,
Anti-rheumatics , Cardiac(Chlorpromazine)…etc.
Family History (FH) :
` Glaucoma , corneal dystrophies , REs , Congenital
Diseases ( RP , Blindness ..etc )
Social History (SH) :
` smoking , alcohol , drugs , House crowding ,
?Financial status , Education…etc.
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