This document discusses the importance of taking a thorough history in ophthalmology. It notes that a good history can often lead to a diagnosis, helps focus the examination, and indicates what investigations may be needed. It provides details on what should be included in a thorough history, such as the presenting complaint, past ocular and medical history, medications, allergies, family history, and social history. Common presenting complaints, past medical conditions to inquire about, and other relevant history topics are outlined.

1. History taking in ophthalmologyHistory taking in ophthalmology
HistoryHistory
 A good history commonly leads to aA good history commonly leads to a
diagnosisdiagnosis
 Helps you focus your examinationHelps you focus your examination
 Indicates when/what investigations areIndicates when/what investigations are
neededneeded
 Helps determine the functional impact ofHelps determine the functional impact of
the conditionthe condition

2. HistoryHistory
 Record age and genderRecord age and gender
 Presenting complaintPresenting complaint
 History of presenting complaintHistory of presenting complaint
 Past ophthalmic historyPast ophthalmic history
 Past medical historyPast medical history
 MedicationsMedications
 Family historyFamily history
 AllergiesAllergies
 Social historySocial history

3. HistoryHistory
Presenting complaintPresenting complaint
History of presenting complaintHistory of presenting complaint
 How long?How long?
 Involving one or both eyes?Involving one or both eyes?
 Any associated symptoms?Any associated symptoms?
 Any similar problems before?Any similar problems before?

4. Presenting complaintsPresenting complaints
 Visual disturbanceVisual disturbance
 PainPain
 Red eyeRed eye
 DischargeDischarge
 Itchy/dry/gritty eyesItchy/dry/gritty eyes
 Alteration in appearanceAlteration in appearance
 Ptosis, lid swelling, squintPtosis, lid swelling, squint

5. Past ocular historyPast ocular history
 Previous eye problemsPrevious eye problems
 Refractive errors (myopia, hyperopia,Refractive errors (myopia, hyperopia,
astigmatism)astigmatism)
 Ocular surgeryOcular surgery
 Ocular traumaOcular trauma
 SquintSquint
 Lazy eyeLazy eye

6. Past medical historyPast medical history
 Diabetes?Diabetes?
 Hypertension?Hypertension?
 Rheumatoid arthritis?Rheumatoid arthritis?
 Sarcoidosis?Sarcoidosis?
 Asthma?Asthma?
 Eczema or other skin problems?Eczema or other skin problems?
 OtherOther

7. MedicationsMedications
 Present and pastPresent and past

8. AllergiesAllergies
 AntibioticsAntibiotics
 Hay feverHay fever
 Any other medicationAny other medication

9. Family historyFamily history
 SquintSquint
 GlaucomaGlaucoma
 MyopiaMyopia
 CataractsCataracts
 Poor vision etc.Poor vision etc.

10. Birth historyBirth history
 For children onlyFor children only
 PrematurityPrematurity
 Forceps deliveryForceps delivery
 Low birth weightLow birth weight

11. Social historySocial history
 SmokingSmoking
 AlcoholAlcohol
 OccupationOccupation
 Home circumstancesHome circumstances

14. Central retinal
artery occlusion,
note- pale posterior
pole (from
ischaemia and
retinal oedema) red
macula (due to
choroidal circulation
visable through
thinnest part of the
retina at macula )

15. Central retinal vein
occlusion

16. Proliferative diabetic
retinopathy

17. Inferior retinal detachmentInferior retinal detachment

18. Retinitis
pigmentosa
Leads to loss
of peripheral
vision and
night blindness
Note pale disc,
attenuated
vessels and
pigmentary
changes in the
periphery.

19. Pan retinal
photocoagu
lation for
diabetic
retinopathy

20. Swollen disc from
ischaemic optic
neuropathy

21. Neovascular age
related macular
degeneration

22. Acute angle closure
glaucoma

23. Acute angle closure glaucomaAcute angle closure glaucoma
Note red conjunctiva, hazy cornea due to corneal oedema, dilated pupil.Note red conjunctiva, hazy cornea due to corneal oedema, dilated pupil.
This patient will have a very hard eye.This patient will have a very hard eye.

24. Dendritic ulcerDendritic ulcer
Note branching pattern of stainjng with fluorescein underNote branching pattern of stainjng with fluorescein under
blue ultra violet lightblue ultra violet light

25. PtosisPtosis

26. ExophthalmosExophthalmos
Note – lid retraction on rightNote – lid retraction on right
also bilateral cataracts as greyishalso bilateral cataracts as greyish
colour in pupils and bilateral arcuscolour in pupils and bilateral arcus
senilis (white rings around margins ofsenilis (white rings around margins of
both corneas)both corneas)

27. Corneal ulcer and
hypopion