OPH - History Taking

Question 1

Ophthalmology History Taking

Presenting Complaints
Eye Trauma
Systemic Enquiry
Past Ocular History
Other Histories

Answer 1

1. ) Presenting Complaints - and red flag sx
   - visual disturbance, eye pain, red-eye
   - eye irritation: grittiness, foreign body sensation, discharge/watering, swelling
   - photophobia
2. ) Eye Trauma
   - the type of injury: chemical, blunt or sharp
   - significant blunt trauma can cause sudden ↑IOP, retinal detachment and a potential globe rupture
   - high-velocity injury whilst using power tools causing sudden eye pain requires urgent ophth review to assess for a penetrating foreign body (X-ray orbit)
   - use of safety goggles should be enquired
3. ) Systemic Enquiry
   - systemic: fevers, weight loss, malaise (GCA, tumour)
   - neuro: headache (migraine, HTN, ↑ICP, GCA), weakness, ataxia, sensory (MS, diabetes, stroke)
   - GI: N+V (glaucoma), diarrhoea (IBD)
   - MSK: joint pain/stiffness (RA, AS etc), myalgia (PMR)
   - cardio and resp sx due to autoimmune conditions
   - endocrine: hyperthyroidism, diabetes mellitus
4. ) Past Ocular History
   - previous similar episodes
   - hx of eye problems, trauma or ocular surgery
   - use of prescription glasses or contact lenses
5. ) Other Histories
   - PMH: HTN, DM, autoimmune, atopy
   - DH: eye drops, preservative-free? side effects?
   - FH: similar complaints, eye diagnoses e.g. glaucoma
   - SH: social context, smoking, alcohol, illicit drugs, occupation, driving,

Question 2

Presenting Complaints in Ophthalmology

Visual Disturbance/Loss and Eye Pain
Eye Pain
Eye Irritation
Photophobia

Answer 2

1. ) Visual Disturbance/Loss and Eye Pain - red flags:
   - sudden and persistent (>24h) visual loss
   - moderate to severe eye pain
   - marked redness with eye pain or visual loss
2. ) Eye Pain - differentials include
   - acute glaucoma, anterior uveitis, scleritis, keratitis, corneal abrasion, orbital cellulitis, optic neuritis
   - endophthalmitis, AION (temporal arteritis), dry eye syndrome, cluster headache
3. ) Eye Irritation
   - grittiness: conjunctivitis, blepharitis, dry eyes
   - foreign body sensation: foreign body, conjunctivitis, blepharitis, Meibomian or chalazion cysts, (epi)scleritis
   - discharge/watering: conjunctivitis, blepharitis, (epi-)scleritis, keratitis, dry eye, endophthalmitis
   - swelling: (peri-)orbital cellulitis, blepharitis, tumour, herpes simplex/zoster ophthalmicus, angioedema, atopic/contact dermatitis
4. ) Photophobia
   - corneal disease: anterior uveitis, keratitis, abrasion
   - w/ headache: migraine, cluster headache, meningitis

Question 3

Exploring Visual Disturbance

SOC(R)A(T)ES (SOCAES)

Site and Onset
Character
Associated Visual Symptoms
Exacerbating or Relieving Factors
Severity

Answer 3

1. ) Site and Onset
   - which eye(s)?
   - when did it start? is it intermittent or constant?
2. ) Character - the type of visual disturbance
   - is it affecting near or distance vision?
   - specific area? (e.g. central, peripheral)
   - double vision: monocular or binocular, images side-by-side (looking to the side), on top of each other (in the distance), at an oblique angle (looking downstairs)
3. ) Associated Visual Symptoms
   - photopsia (floaters and flashing lights)
   - black curtain across their field of vision
   - glare or halos around lights
   - visual distortions: straight lines appear wavy, sparking shimmering lights across the visual field, objects appearing a different size to their actual size
4. ) Exacerbating or Relieving Factors
5. ) Severity - is it just slightly blurry or are they only able to see hand movements or bright lights

Question 4

Differentials for Visual Loss

Gradual and Painless Persistent Visual Loss
Sudden Persistent Visual Loss
Transient Visual Loss
Functional Neurological Disorder

Answer 4

1. ) Gradual and Painless Persistent (>24hr) Visual Loss
   - refractive, presbyopia, cataract, glaucoma, dry AMD
   - tumours affecting the visual pathway
   - nutritional optic neuropathy: folic acid, vitB complex
2. ) Sudden Persistent Visual Loss - this is a red flag presenting complaint, requiring secondary care
   - painless: retinal artery/vein occlusion, AION, stroke, retinal detachment, vitreous haemorrhage, wet AMD
   - painful infective: anterior uveitis, endophthalmitis, scleritis, keratitis, orbital cellulitis
   - painful non-infective: glaucoma, optic neuritis, AION
3. ) Transient Visual Loss - less than 24 hours
   - migraine: marching sparkling shimmering lights <1hr, affects both eyes but typically only one hemifield
   - amaurosis fugax: profound, one eye, mins to hours, often due to vascular disease (e.g. TIA) or vasculitis
   - papilloedema: a complete brief loss of vision (obscurations), which may be unilateral or bilateral
4. ) Functional Neurological Disorder - a common presentation which is always a diagnosis of exclusion
   - sx: intermittent blurred vision sometimes with brow ache and photophobia are common, complete loss of vision and diplopia are rarer but still recognised
   - more common in teenagers, related to underlying stress and anxiety from relationship difficulties
   - should refer to ophthalmology if suspected

Question 5

Exploring Eye Pain

Site
Onset
Character
Radiation
Associated Symptoms
Time Course
Exacerbating or Relieving Factors
Severity

Answer 5

1. ) Site - differentiate ocular and periocular pain
   - under the eyelid: foreign body
   - within the eyeball itself: acute glaucoma
   - behind the eye: optic neuritis
   - frontal headache radiating around eyes: migraine
2. ) Onset
   - how did it start? what were you doing when it started? sudden or gradual? did it wake you up from sleep?
3. ) Character
   - pain description, worse on eye movement? gritty? foreign body sensation?

4.) Radiation - does it spread anywhere:

5. ) Associated Symptoms
   - N+V (acute glaucoma), unilateral headache (migraine), visual disturbance, red-eye, discharge/watering, itchy, photophobia, swelling

6.) Time Course - how has the pain changed over time?

7. ) Exacerbating or Relieving Factors
   - worse: blinking, touching/moving, bright lights
   - better: analgesia, cool water, warm compress, dimming the lights, removing contact lenses
8. ) Severity - a scale of 0-10
9. ) Differentials