OCULAR

EXAMINATION AND
DIAGNOSIS
BY KA SUKO E NOC K. C @
2 0 2 3

HISTORY TAKING
14 GENERAL PARTS OF HISTORY TAKING
[Link] data 6. Patients ocular history [Link] medical
history
[Link] presenting 7. Patient medical history
Complaints
[Link] dental
[Link] of 8. Patient drug history history
symptoms
9. Obstetric History [Link] Allergy
[Link] factors Below Ages Of 15 History

[Link] factors [Link] ocular history [Link] social

history
[Link] DATA
This Entails Getting Details From The Patient. It includes;
Age ( This Is Already There On The Cover Book )
Marital status ( You Write )
Name Of The Patient ( This Is Already There On The Cover Book )
Sex ( This Is Already There On The Cover Book )
Occupation ( You Write )
Religion ( Christianity, Muslim, Or Hinduism )
Phone Number ( This Is Already There On The Cover Book )
Address ( This Is Already There On The Cover Book )
The Main Purpose Of Collecting This Data Is Because There Some Diseases / Conditions That Only Affect A
Certain Group Of People ( Male, Female, Children, Or Adults ).
 For Example, Presbyopia Comes In When Someone Reaches The Age Of 35 – 40 Yrs
 We Include Religion Because Different Religion Believe Differently In Terms Of Treating The Eye Conditions.
 We Get The Phone Number Because During Refraction We Might Make A Mistake And We Might Need The
2. CHIEF PRESENTING COMPLAINTS
( C/C )
• Here Just write presenting complaints because among the complaints only one or two will be the chief.
• Note: Others Will Write Presenting Illness.
• Here now you start the examination of the patient. Asking the patient what the problem really is and listen first don’t rush into
writing the complaints
• Don’t put words in patients mouth, for example patient says headaches from the sides, write like that, or from the back
( occipital headache related with hypertension), you can just put in bracket to say headache from the sides (temporal
headaches). Make sure its really the problem by asking again to say madam/sir you said headaches from the sides, then they
say yes yes. Then from there ask for how long, is it affecting both sides, eyes or what.
• For example, they say tearing, photophobia, blurred vision, headaches….
• If it is tearing, ask does it happen when you wake up, going to sleep, or does it happen when you come out of the house, when
exposed to sunlight.
• Ask how long the patient has been tearing, or having headaches.
• Note: if they say Asthenopia, ask them is it both eyes, left eye or right eye only.
• E,g – Asthenopia for 3 months RE, BE, LE. So you write the condition, duration, and the affected eye. Because even when
correcting for example with lenses if it one eye meaning the affected eye will have a plano lens.
• And you should also ask which one started first, for example double vision, asthenopia, photophobia. Arrange in ascending
order.
3. DEVELOPMENT OF SYMPTOMS /
HISTORY OF PRESENTING ILLNESS
• Here now you are looking at the onset ( gradual, chronic, on/off ) in a chronological order.
• And write patient, with the above presented complaints they’ve been of gradual onset for example, usually
tearing start first followed by headache or patient experience headache associated with tearing
• So since for example my patient said asthenopia, ask was it gradual or chronic in onset or on/off. So you look at
the symptoms they gave you, ask for example was the blurred vision of gradual onset, chronic or on/off.
• Gradual Means the situation started many years ago bit by bit but then they ignored or they were not aware of it,
it now it becomes worse, in short it has been there for a long time.
• Chronic Means continuing or occurring again and again for a long time. Something that lasts for a long time, keeps
coming back.
 ASSOCIATED WITH: if they say they are photophobic ask if it is associated with tearing for example. It could be that the
symptoms are grittiness ask them what is it associated with. (if not associated just write not associated with any )
 Like mostly we know that grittiness is associated with conjunctivitis
 So in short, use the symptoms and brake them down to what they are associated with.
 E.g. blurred vision for 3 weeks of gradual onset associated with headaches.
 Note: Atleast have a health talk with your patient if for example they’ve applied a lot of make up, mascara and the
likes, tell them about blepharitis, stye, how they can affect them
[Link] FACTORS

• Here you now ask what makes the symptoms worse.

• For example, when we are in class there's a projector in front, so if its
on and its making me have the headaches then the projector becomes
the aggravating factor.
• It could be that the patient Is photophobic, once they go in the sun, it
makes it worse.
• So you go symptoms by symptoms.
• And ask what the patient does to relieve the pain.
[Link] FACTORS

• So this patient has Asthenopic symptoms like earlier

mentioned
• So ask what they do to relieve the pain.
• For example, asthenopia – some will take paracetamol ( Panadol )
others will have their glasses on .
• Others will wash off the face
• Others uses herbal medicine, write don’t discourage them, encourage them at
the end on the health talk.
6. PATIENT OCULAR HISTORY
• Here now you have already the symptoms from the patient.
• You are looking two things, past ocular hx and present ocular hx. First thing is ask patient last eye
examination of the patient, if the pt says June 2020, ask where, what was the outcome from there and at
the end tell the patient about their condition.
• If you see the patient in spectacles ask them when the started using them. Ask what they use them for, are
they for reading, distance, protection or just for fashion.
• Get the lenses to the lab if possible and check for the powers of the lens.
• For example, RE = +2.00Ds..LE = +2.50Dsph. And ask how long they’ve been wearing them, because some patients are
given glasses but they don’t use them, now they come to our clinic with so much poor vision maybe amblyopia would’ve
set in even, so the vision after refraction might not even be 6/6. so once you do refraction, let the patient come with old
glasses so that you compare which one is better, so that pt doesn’t say my own glasses are better than the ones we have
given them. Because maybe the patient was refracted while the sugar was high, so we need to compare new ones from old
ones
• Ask the patient if they had an eye trauma before, ask which year.
• Ask if they had an eye surgery before. And here you can also do IOP check up, to confirm glaucoma.
• Note: if the patient had no surgery before, do not write NIL but instead write No present history of eye
surgery.
• E.g patient uses spectacles – reading or distance vision, how long been used
• Eye trauma – 2020, 6th grade
[Link]’S MEDICAL HISTORY
• Here again you ask about past diseases ( TB, Malaria,) and present ones ( DM, Asthma, HTN, HIV, those we live
with) if the patient has any systemic diseases. Systemic diseases like DEATHES. Ask if theyre on any medication
for any.
• D – Diabetes ( Sugar , ) how long, hx of medication, recent of sugar check up either random blood sugar, or
fasting blood sugar. If patient didn’t check for a while write pt hasn’t checked for the past so months. Then in
your plan write refraction after pt present sugar results for example
• E – Epilepsy (Seizure Disorder, Px Experience Abnormal Behavior, usually these experience double vision and
muscle misalignment),
• A – Asthma,
• T – Tuberculosis ,
• H – Hypertension (Looking At BP) And
• S – Syphilis
• And here again be very careful when asking questions, do not ask the patient to say do you have HIV/AIDS. But
develop a way of asking in a polite way, you can ask to say have you had an HIV test before, then the patient will
tell you, then from there you can catch the status of the patient because uveitis is very common in these pts and
HZO.
• If the patient disagrees to say this is my normal sugar levels, but you suspect abnormal , but pt insist refraction,
OBSTETRIC HISTORY
• This should come next if the pt is below the age of 16hrs, that is in the pediatric group
• If the people who've brought this child do not know, just write information not available ,obstetric history of the
pt. Ask
1. Was the pregnancy a full term or not. Full term means 9months, less than 9 months then the child was
born premature birth. So after birth the child is put on oxygen, and so many drugs of which might interfere
with the development of the retina and other ocular structures
2. What was the mode of delivery. Was it a caesarian section, was it a forceps delivery or normal delivery. In
forceps delivery, they put some forceps in the head of the baby and pull, so they might smash the muscles
of the eye, hence squint and this squint can only be improved by surgery and refer to ophthalmology. In
normal delivery we have very few complications
3. Birth weight of the child. Low birth weight children are exposed to so many things like oxygen and the likes.
Normal birth weight is 2.5kg, below 2.5kg the child is observed by doctors before discharge.
4. Incubation. Was the child incubated, because there we have lots of chemicals like blue light and oxygen
tube. So oxygen is going to affect the development of the retina and ask how long the baby was incubated.
5. Milestones. Important things at specific age, for example at 1yr child should be able to walk, but this child
upto 5yr not walking, so they're stages of life when a baby should sit and the like, so if these poorly develop
then probably the eye development as well will be affected.
6. Immunization. 0 – 5 yrs is when children receive things like BCG and other things, and within 0 – 5 yrs is
when now the eye is completing in developing
8. DRUG HISTORY
• Here now, write the drug the patient is taking regarding the medical history of the
patient.
• If they cant read, ask the caregiver to tell you the drug they’ve been taking or ask
them to bring the drug with them.
• For example
• D – Diabetes – Insulin Therapy
• E – Epilepsy – Gabapentin
• A – Asthma – Steroids
• T – Tuberculosis – Pyrazinamide
• H – Hypertension – Diuretics
• S – Syphilis – Penicillin
[Link] OCULAR HISTORY

• Ask only the father, mother, and siblings

• If anyone in the family has spectacles, ask what those glasses are for
• Ask the ocular condition for the whole family ( father, mother, and
siblings)
• Because conditions like myopia and glaucoma they can be inherited
• Ask if anyone died blind in the family, because some people can die
with glaucoma.
[Link] MEDICAL HISTORY
• Here again just like patient medical history you want to know if
in the family there is anyone with;

• D – Diabetes,
• E – Epilepsy,
• A – Asthma,
• T – Tuberculosis,
• H – Hypertension And
• S – Syphilis
11. PATIENT’S DENTAL HISTORY

• Ask if the patient has a tooth decay or had a tooth extraction

before.
• Because the teeth and the orbit share the same sinus, so its
easy for infection to spread from the sinus into the orbit if the
patient has got a tooth decay, and cause orbital cellulitis
• Indicate the number and many times the extraction was done
[Link]’S ALLERGY HISTORY
• Does the patient have any allergy.
• Ask the patient if they had a blood sensitivity test before, so that we are sure that the patient is allergic to this.
Failure to which we just say patient not aware of any. If the pt just say they are allergic to soap minus testing,
then they are just sensitive to that
• Then on examination I see papillae then I know that in this patient there is allergy, we have to give mast cell
stabilizers and antihistamine
• Allergy here only signifies with something like soap, lotion, dust or flowers. Then let them say what type of
flowers they are allergic to, and this will only happen when a blood sensitivity test is done, then the patient is
assured.
• If the patient doesn’t have any allergy just write Not aware of any.
• Because we ask this question in relation to the conjunctiva. For example tearing and grittiness is associated
with allergies maybe dust.
• And for conjunctiva, you have three types
 Bacterial conjunctivitis
 Allergic conjunctivitis: itching, redness, swelling of conjunctivitis and eyelids
 Viral conjunctivitis.
13. SOCIAL HISTORY
• If they smoke, because remember smoke provide free radicals and cause
cataracts ( thereby leading to macula degeneration )
• If they drink, ask them the beer because castle has no effect on the eye but
these others have a very big impact on the ocular structures.
• Find a polite way of asking, for example you can say what do you do in your free
time, others like playing football, others sleep, others go out to drink, others
smoke, and so on….what about you what do you do
• This means that, we need to have a very good knowledge on various diseases
and nutrition especially.
• Note: when the px feels pain in a certain direction but the eye moves, you mark
but say there was eye pain. Unless in a case where the eye doesn’t move in a
certain gaze, you mark an X.