3Components of the Ocular History Chief complaintWhat are the main problems that you are having with your eyes?What other problems are you having with your eyes?Why did you come (or why were you sent) here?In what way are you hoping that you might be help?What is it about your eyes that worries or concerns you?What is the main problem that you would like me to address?
42. Diplopia -monocular vs. binocular 1. Visual Loss-A. transient visual loss- migraine, ischemia to eye /visual cortexB. acute, persistent visual lossC. chronic, progressive, visual loss- refractive, problems with ocular media or visual pathway2. Diplopia -monocular vs. binocular
6Common ComplaintsDecreased blurred central vision (distance, near or both)Decreased peripheral visionAltered image size (micropsia, macropsia, metamorphopsia)Diplopia (monocular, binocular, horizontal, vertical or oblique)Photopsias (flashes of light)
7Iridescent vision (halos, rainbows) Dark adaptation problemsDyslexia (medical inability to read with normal understanding)Color vision abnormalitiesBlindnessOscillopsia (apparent movement or shaking of images)
8History of Present Illness Onset (sudden or gradual); severity (improved, worsened or remained the same); Influences/Precipitating Condition; Constancy and Temporal Variation; Laterality: unilateral or bilaterallist ocular medications as well
9Ocular Medications Medication should be recorded including dosages, frequency and duration of use, over-the-counter drugs and home remediesColor coded of the cap of containerGreen: cholinergic or miotic drugs (pilocarpine, carbachol)Red: anticholinergic or dilating cycloplegic (atropine, tropicamide, cyclopentolate, phenylephrine)Yellow: Beta-adrenergic blocking agent (timoptol)White: antibiotics, artificial tears, corticosteroidsOrange: (dorzolamide)
10Past medical history general state of health principal systemic illnessesVascular disorders commonly associated with ocular manifestations-such as diabetes and hypertension-should be askedlist the patient's systemic medicationsany drug allergies should be recordedUse of eyeglasses or contact lensUse of ocular medications in the pastOcular surgeryOcular trauma
11Systemic MedicationsUse of aspirin, anticoagulant agent, antibiotics, tranquilizers, narcotics, anti-inflammatory agents, anticonvulsants, contraceptives, or vitamins
13Family historystrabismus, amblyopia, glaucoma, cataracts, and retinal problems, such as retinal detachment or macular degeneration.Medical diseases such as diabetes may be relevant as well
14COMMON OCULAR SYMPTOMS three basic categories:I. abnormalities of visionII. abnormalities of ocular appearanceIII. and abnormalities of ocular sensation-pain and discomfort.
15I. ABNORMALITIES OF VISION 1. Visual Lossdue to abnormalities anywhere along the optical and neurologic visual pathway.consider refractive (focusing) error, lid ptosis, clouding or interference from the ocular media (eg, corneal edema, cataract, or hemorrhage in the vitreous or aqueous space), and malfunction of the retina (macula), optic nerve, or intracranial visual pathway.
162. Visual Aberrations Glare or haloes Visual distortion -may result from uncorrected refractive error, scratches on spectacle lenses, excessive pupillary dilation, and hazy ocular media, such as corneal edema or cataract.Visual distortion(apart from blurring) may be manifested as an irregular pattern of dimness, wavy or jagged lines, and image magnification or minification.Flashing or flickeringlights may indicate retinal traction (if instantaneous) or migrainous scintillations that last for several seconds or minutes.
17Double vision (monocular or binocular) Monocular diplopia Floating spotsmay represent normal vitreous strands due to vitreous "syneresis" or separation or the pathologic presence of pigment, blood, or inflammatory cells.Double vision (monocular or binocular)(ie, disappears if one eye is covered).Monocular diplopiaPersists when one eye is coveredIt is caused by an optical aberration (cataract, uncorrected refractive error, presbyopia, keratopathy).Binocular diplopiadisappears when either eye is covered.It results from misalignment of the eyes, and may be caused by:a central nervous system lesionan ocular motor nerve lesiona neuromuscular junction lesionextraocular muscle lesion
18SYMPTOMS Early Difficulty reading, driving, etc Straight lines may be crookedAdvanced: central blind spotPeripheral vision remainsIndependent living skillsDisturbance of vision firstProgressing to diminutionCataract size & location determine impairment
19II. Abnormal appearances Ptosis (drooping of the eyelid)Proptosis (protrusion of the eyes)Enophthalmos (opposite of proptosis)BlepharitisMisalignment of the eyesRedness, other discolorations, opacities and massesAnisocoria (inequality of the pupils)
20III. Ocular pain or discomfort Foreign body sensationCiliary deep painPhotophobia (pain that is present upon exposure to light)HeadacheBurningDrynessItchingAsthenopia (eyestrain)
21Abnormal ocular secretions LacrimationEpiphora (actual spilling of tears)DrynessDischarge
22VISUAL ACUITYnumerator - testing distance from the eye to the chart being used (20 feet or 6 meters);denominator - distance to which the subject with an impaired vision can read the same figure.
23Testing Distance Visual Acuity 1. Ask the patient to stand or to sit at a designated testing distance, 20 feet from a well-illuminated wall chart.Occlude the left eye.Ask the patient to read aloud each letter, number or picture from left to right.Note the corresponding acuity measurement shown at that line of the chart. Record the VA of each eye separately with correction and without correction.Repeat steps 1-4 for the left eye, with the right eye covered.20 ft
24Pinhole acuity testThe pinhole admits only central rays of light which do not require refraction by the cornea or lens.A single pinhole no more than 2.4 mm in diameter should be used.
25Testing Pinhole Visual Acuity Position the patient and occlude the eye not being tested, as done for the distance acuity test.Ask the patient to hold the pinhole occluder in front of the eye that is to be tested.Instruct the patient to look at the distance chart through the single pinhole or through any one of the multiple pinholes.Instruct the patient to use small hand or eye movements to align the pinhole to resolve the sharpest image on the chart.Ask the patient to begin to read the line with the smallest letters that are legible as determined on the previous vision test without the use of the pinhole.Record the Snellen acuity obtained and precede or follow it with the abbreviation PH.
27Jaeger chart Used to express near visual acuity. The test is usually performed at 16 in or 40 cm.
28Testing Near Visual Acuity Instruct the patient to hold the test card at the distance specified on the card (16 in or 40 cm).Ask the patient to occlude the left eye.Ask the patient to read each word on the line of smallest character that is legible in the card.Record the VA for each eye separately.Repeat the procedure with the right eye occluded.
29Testing Poor Vision Count fingers (CF) Hand moving (HM) Light perception (LP)If cannot perceive light: totally blind (NLP or no light perception)
30Testing Peripheral Vision Confrontation testSimultaneous confrontation test
31Test for Pupils Direct response to light Consensual constriction Swinging penlight test for Marcus Gunn Pupil or relative afferant pupillary defect
32The “swinging flashlight test” assesses CN II, CN III (parasympathetic innervation of the sphincter pupillae muscle), and sympathetic innervation of the dilator pupillae muscle.
38Specialized Ophthalmologic Examinations Perimetrysystematic measurement of visual field function (the total area where objects can be seen in the peripheral vision while the eye is focused on a central point
39Specialized Ophthalmologic Examinations Amsler Gridtool for monitoring central visual field.to detect early and sometimes subtle visual changes in a variety of macular diseases such as age-related macular degeneration and diabetic macular edema