ROS Const: sick contacts, fever, chills, wt loss, malaise, weakness, dizziness, appetite HEENT: blurry vision,

photophobia, vision, hearin, sore throat, tinnitus, drainae !esp: "#$, couh, sputum, pleuritic chest pain,
hemoptysis Card: orthop, %N&, &#E, 'E edema, pain chest( left arm( shoulder( neck( )aw( back, syncope, palp,
claudication *+: N, ,, reur, heartburn, odynophaia, dysphaia for solids(li-uids, abd pain, diarrhea,
constipation, bloat, hemetem, melena, hematochezia, mucus *.: urency( fre-uency( incontinence, dysuria,
hematuria, hesitancy, post/ void dribblin, impotence, testicular masses,vainal dc, dyspareunia, bleedin Endo:
thirst, polyuria, heat( cold intole, tremor, menstrual irre, hair( skin( nails, libido, body hair "kin: rashes,
itch $reast: masses, pain, dischare, lactation 0sk: arthralias, deformity, swellin, myalias, muscle weakness
Hematoloic: bruisin, h(o e1cessive bleedin, '2& Neuroloic: H2, focal weakness, seizure, tremor, falls,
memory loss, paresthesias, sensory loss, vertio %sychiatric: "leep( interest( uilt( enery( concentration(
appetite( psychomotor( suicide
Ophthalmology History and Examination
Introduce, consent
Name, Age, OCCUPATION especially important in ophthalmology case
Presenting complaint:
o
SQITARS(siteandradiation,quality,intensity,timing,aggravatinga!tors,
relieving a!tors, se!ondary symptoms" #OTE$ remember the value o
open !uestioning, the attached are "ust some speciic !uestions that may
be useul in demonstrating sub"ect #no$ledge and in establishing a
diagnosis% Use as appropriate, it is not essential to as# all%%%%there $ill not
be time&
o %hi!h eye is &orse' may be diicult to establish% 'as patient tried
covering one eye(
o (ou)le vision $hen( 'o$ oten( )onocular *Cataract+ or binocular(
Any time better or
$orse, $hat $ere you doing $hen this came on, any double vision
previously(
o A!uity loss o ability to see aces( *Classic A,)-+% One eye or both
eyes, slo$ onset or
ast, had this beore
o *olourvision+anyinherited!olourvisionimpairment,no&n'
reddesaturationonlyli,ely
to be established via thorough e.amination
o -eripheralields+
)umpingintothings.requen!yo!ara!!identsi/e/glau!oma+li,e
tunnel vision
o #ightvision
o 0lashesolight
o 0loatersi/e-1(,smallhaemorrhages,orretinaldeta!hment
o -AI#023+eyemovements,photopho)iaet!
o Historyotrauma+doesthis!oin!ide&ithsymptoms
o -rogression+)etteror&orse,over&hatsortotimeperiod+
yearsor&ee,s'
o
Anyglare,mono!ulardiplopia,!olour!hange(&hiteo)4e!tappearingyello
&",&avingo
lines all symptoms o cataracts
o (O5O2%EAR63ASSES.*O#TA*TS+
essentialquestion,anyre!ent!hangein
prescription could indicate ne$ pathology *cataract+, long or short
sighted( And do they
#no$ by ho$ much% )yopic patients are more at ris# o developing
glaucoma
o Heada!hes,4a&!laudi!ation,temporalpain+
maypre!edesuddenlossovisioni/e/
temporal arteritis, also consider migraine
o (oyouhaveregulareye!he!,ups+
dia)eti!sshouldhaveyearlyrevie&s
o Have you or anyone noti!ed a !hange in appearan!e o your eyes'
/ could be a history
o proptosis or red eye
o Any redness' / associated !uestions to try and establish li#ely causes:
Itchiness(
-ischarge $orse in morning( Allergies(
Trauma(
0ye pain(
-o you $ear lens( i%e trauma Photophobia(
1oth eyes(n
-r , Clar#e $$$%as#doctorclar#e%com 2
Author: -r Ale.ander 1rentn
PO':
o 0verhadthisproblembeore
o -oyouseeanopthamologist3optometristorhadeyeproblemsbeore(
Isodoyou#no$
your pressures( 4ome patients $ill #no$ their IOP5s
o 6amilyhistoryoeyeproblemsi%eglaucoma
o 'o$ have they investigated you( 'o$ are you treated
o Previouseyesurgery(
i%e%ithepatienthashadcataractsurgeryandisno$e.periencing
symptoms similar to their pre op state could they be e.periencing opacity
o the posterior lens capsule( / )ay re!uire 7A8 laser treatment
P)':
o -)('TN(9ellcontrolled,ho$controlled(
as#lotsodetailsaboutthis,theseareli#ely
chronic conditions you may get in an e.am, $hat are the recent 1)s, $hat
have they been
beore, do they go to their regular appointments
o 4mo#erho$muchorho$long(
o Asthma,COP-bbloc#ereyedropcontraindicatedinsuchpatients
o Other
suchassystemicinlammatoryconditionsthatmaybeaectingtheeyes
-rugs:
o )edications or eyes( -rops( 'ave you had drops today( in e.ams
patients may $ell
have one purposeully dilated pupil or you to perorm your e.am you $ill
impress not only i you note it during an e.am but also i you have as#ed in
your history and so $hen you come to e.amine you #no$ it is iatrogenic as
opposed to pathological&
o Anyeyesurgeryorlasertreatment
o 9hy(
o Anyothermedicationsi%eorsystemicinlammatoryconditions o
A::0,8I04
6amily history glaucoma has some inherited lin#s
4OCIA: ho$ does this aect your lie( e.aminer5s love this& o ;ob
o -riving
o Independencedoesthepatient!ualiyorblindorpartiallysightedresister( o
Anyaidsre!uired
o ,eadingetc
o 6alls
o 4)O<0&&
o drin#
Is there anything that I might have missed that you $ant to tell me(
4ummarisen
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Author: -r Ale.ander 1rentn
Examination
#ote$ This is "ust a guide to a ull e.amination o the eye% In a real
e.amination you may be guided
to "ust ocus on one part such as visual ields or ophthalmoscopy%
Introdu!e, !onsent, exposure have the patient sitting opposite you on
the same eye level%
Inspe!tion$
o 'aveageneralinspectionaroundthepatientortospotanyclues
glasses,$al#ingstic#, >$hite5 stic# etc%
o
Thenstandoverthepatientandloo#do$nacrosstheiroreheadto$ardstheireye
sasthis is a good $ay to assess proptosis *eye protruding rom orbit+ uni
or bilateral(
o Closerinspectionaroundeye
asymmetry,lumps,s#inchanges,scarsites,itisimportant to note any
malposition o eyelids ectropion, entropion or ptosis
o Inspecteye
redness,strabismus*s!uint+,tryandnoteany>holes5intheiristhatcouldbe
potential peripheral iridotomy sites used to treat angle closure glaucoma,
pupil note the si?e, e!uality o both, shape,
1isual a!uity$
o
A:9A74A4<T'0PATI0NTTOPUTON8:A44043:0N4asappropriateorthe
distance $hen testing acuity% It is the corrected acuity you $ant so you can
denote any recent changes that could be pathological
o Using snellen charts sit the patient @m a$ay% 8et them to cover on eye
and read do$n the chart% ,ecord the acuity or each eye% Please note that
in small rooms a mirror is used at Am $hich eectively doubles the reading
distance to @m%
o ItisbesttodorecordBAbeoredilatingthepupilorshiningalightintheeye
o
Ithepatient5sBAisreallypooryoucanbringthem$ithinAmtothechart,andistillno
recording then you resort to C6 *counting ingers+, then seeing ') *hand
)ovements+ then
Pl *perception to light+
o
7oushouldma#eyourselamiliar$ith:ogmarchartsasanalternativeto4nellenc
harts o
Itisunli#elythatyou$illbere!uiredtotestNB*nearBision+butincaseyoudoitis
measured at C%Am $ith similar charts to the 4nellen% The average boo#
print is ND% 7our e.amination is e.actly the same as or the 4nellen chart:
$ear glasses i needed, cover alternate eyes and record line read to%
Test -upillary responses$
o
Usetheulnaraspectoyourhandtoplacedo$nthepatient5snosetobloc#anylight
rom your torch aecting the other pupil
o -irectpupilresponsebothsides
o Indirect
o 6inally,AP-s$inginglashlighttest
Response to a!!ommodation$
o
As#thepatienttoocusonara$ayob"ect,thenas#themtoocusonyouringerclos
eto their ace, the pupils should constrict% -o one pupil at a time%
Eye 7ovements$
o The patient must #eep their head still $hilst doing this% I they
persistently ollo$ your inger $ith their head then you may have to hold it
still%
o )ove your inger in the >'5 and >E5 directions% 1eore you start it is
essential that you as# them to tell you i and $hen they see double% 9here
in the movements is vital%
o Alsonoteanylidlagassociated$iththyroiddisturbance%n
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Author: -r Ale.ander 1rentn
1isual 0ields$
o Assessedbyconrontation
o Patienttosit2ma$ayormyouatsameeyelevel
o
As#patienttocovertheirrighteye,e.aminercovershis3herleteye$ithlethand%
o
7oumuststateclearlytothepatientthatyouaretestingtheirperipheralieldsandth
eymust
ocus on the tip o your nose at all times and not be tempting to loo# at you
moving hand&
They must #eep their head still
o 7ou then e.tend your ree right hand outside your o$n peripheral ield o
vision% 4lo$ing
bring it to$ards the midline $ith a $aggling inger or red hatpin until they
can see it%
o ,emember you are comparing their ield o vision to theirs so assuming
yours is normal&
o -o this $ith all medial and lateral !uadrants and then do the other eye%
7ou should be able
to map out any areas o visual loss%
o
7oucouldalsoassessthesi?eoapatient5sblindspotbybringingaredhatpininro
mtheir
lateral side but this is not very accurate and is probably unnecessary in an
e.amination% Optic neuropathy can increase the si?e o one5s blind spot,
causing a central scotoma%
0undos!opy$
o This is very diicult $ithout dilated pupils% In e.ams they $ill oten dilate
one side or you do this side irst as it $ill be easiest and the e.aminer
may then not $ant you to do the other%
o 4itthepatientinadar#roomtourtherdilatepupils
o Ad"ustthebeamolighttotheappropriateround$hitebeam
o Ad"ust the settings to correct any o your o$n reractive errors%/ i%e%
using the number dial o Note
youshouldamiliariseyoursel$ithaselectionoundoscopesasinthestressoan
e.amination they can be surprisingly diicult to turn on&
o
4itthepatientdo$nande.plainthatyou$antthemtoocusonadistantpointandno
tto
divert their ga?e% )a#e it clear that you $ill shine a light into each eye
respectully and your
ace $ill get very close to theirs but you $ill not hit them
o 1eoreyoubeginitisessentialtochec#botheyesora,0-,06:0E
these$illbe
absent in prosthetic eyes, cataracts and various retinal detachments
o 0.aminetheirrighteyeusingyourrighteyeandtheirleteyeusingyourleteye
this
re!uires practise on your less dominant side but is important in preventing
>head banging5
$ith your patient
o Use your ree hand to rest on their orehead above the e.amined eye%
This $or#s doubly to
prevent collision $ith your patient and can also be used to gently hold the
eyelid open%
o
4tartromandarmslengthandmoveincloserad"ustingtheocusuntilyouseether
etina% o 4earchoravesselandollo$itinasitgetsbiggerto$ardstheopticdisc%
o 9henyougettotheopticdiscyouneedtonote:
4i?e
Colour *atropy+
Cup:disc ratio increased in glaucoma
)argins should be distinct, blurred could be an indication o
papilloedma%
o Thenollo$thema"orbloodvesselsoneatatimenoting: Calibre
Course i%e tortuous or any AB nipping
Colour
o
Theyoushouldscanall!uadrantsotheretinaloo#ingoranyotherabnormalities
suchas
drusen or more importantly diabetic laser burns note $here these are
you $ill be
e.pected to notice these
o 6inallyas#thepatienttoloo#directlyatthelighttoassessthemacula
dothislastasitcan
be uncomortable%
o Itimecomparetheothersiden
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Author: -r Ale.ander 1rentn
7ou could inish your e.amination by testing or latent and maniest s!uints
as you have deemed necessary in the history% 7ou may also $ant to
mention the use o ishihara charts to assess colour vision%
0undos!opy$
TI- + Important things to be on the search or during undoscopy include
changes indicative o chronic disease such as diabetes and hypertension
and any obvious burn scars rom laser therapy% -O NOT be tempted to
ma#e signs up as rom their history as a diabetic3 hypertensive etc
because a $ell controlled disease may not have any signs% In my
e.amination I had a diabetic $ith a completely normal retina the students
$ho did the best admitted that they could not see any o the changes they
$ere e.pecting to see%
-rostheti! eyes$
TI- + Prosthetic eyes are not al$ays as easy to spot straight o as one
may thin#% 4ome can have normal eye volume and even move
appropriately& The give a$ays in the e.am $ill be an absent red rele., no
pupil responses and ?ero visual acuity% 'opeully you may get this rom the
history any$ay&