Ophthalmic history | Flashcards
In a patient who presents with a red eye, what 6 questions should you ask?
- Past ocular history
- Nature of discomfort
- Discharge
- Uni/bilateral
- Vision
- General medical history
In a patient with a red eye, what would you ask in the past ocular history to help you with the diagnosis (3)? What diagnoses would they indicate?
- Recurrent disease?
- iritis
- herpes simplex keratitis - Hypermetropia and acute glaucoma?
- Contact lens use?
- corneal abrasion or ulceration
In a patient with a red eye, what would you ask about as the nature of the discomfort and what would it suggest (4)?
- Itching
- allergic conjunctivitis - Grittiness
- infective conjunctivitis - Pain
- suggests more serious disease - Photophobia, pain on reading
- iritis
In a patient with red eye, what would you ask about for discharge and what would it suggest (3)?
- Watery discharge?
- viral conjunctivitis and corneal epithelial defects (including abrasions) - Purulent
- bacterial, chlamydial conjunctivitis - Mucoid
- allergic conjunctivitis
In a patient with red eye, what would a unilateral or bilateral eye suggest (2)?
- Unilateral
- infection is initially unilateral, but usually becomes bilateral
- iritis, acute glaucoma, almost always unilateral - Bilateral
- allergy is almost always bilateral
What can the nature of vision loss with red eye indicate (2)?
- Minimal or transient blurring can be caused by watering and discharge alone
- Persistent significant visual loss indicates more serious disease
In a patient with red eye, what other factors in the general medical history could be asked about and what would they indicate (4)?
- URTI
- infective conjunctivitis - History of allergy or atopy
- Systemic associations:
- Iritis and sarcoidosis
- ankylosing spondylitis
- scleritis and connective tissue disease - Rosacea and blepharoconjunctivitis
What would you ask in a patient with gradual vision loss (over days/weeks/months) (4)?
- Past ocular history
- General medical history
- Family history
- Worse for distance or near?
In a patient with gradual vision loss, what specific questions regarding past ocular history would you ask about and what would they indicate (2)?
- Other ocular diseases
- many predispose to cataract - Topical medication, especially steroids
- cataract, glaucoma
In a patient with gradual vision loss, what specific questions regarding general medical history would you ask about and what would they indicate (6)?
- DM
- retinopathy/cataract - Atopy
- cataract - Medication:
- Steroids: cataract, glaucoma
- Chloroquine and tamoxifen (toxic retinopathy) - Recent sight test (refraction)
- Exclude an uncorrected refractive error - Trauma?
- Can lead to cataract, glaucoma and retinal detachment - History of amblyopia (lazy eye)
In a patient with gradual vision loss, what specific questions regarding family history would you ask about and what would they indicate (3)?
- Glaucoma
- Hereditary optic nerve, corneal or retinal disease
- Early onset cataract
In a patient with gradual vision loss, what specific questions regarding loss of distant/near vision would you ask about and what would they indicate (2)?
- Worse for near suggests macular disease or posterior subcapsular cataract
- Worse for distance suggests nuclear sclerotic cataract
What would you ask in a patient with sudden vision loss (immediate/over minutes/over hours) (5)?
- Onset (very sudden, recurrent?)
- Quality of visual loss
- Area of visual field affected
- Associated ocular symptoms
- General medical history
In a patient with sudden vision loss, what specific questions regarding onset would you ask about and what would they indicate?
(3)
- Very sudden onset
- arterial vascular aetiology - Recurrent transient loss
- embolic episodes
- consider also migraine, ischaemic optic neuropathy (including giant cell arteritis), raised ICP - Uncertain onset but suddenly noticed
- retinal vein occlusion
- macular haemorrhage
In a patient with sudden vision loss, what specific questions regarding quality of visual loss would you ask about and what would they indicate (3)?
- Profound loss of vision
- Arterial occlusion - Blurring
- most other conditions, not arterial occlusion - Distortion
- macular disease
In a patient with sudden vision loss, what specific questions regarding areas of visual field affected would you ask about and what would they indicate (3)?
- Central only
- macular diseases - Loss of left or right field
- hemianopia - Progression from periphery to centre
- Retinal detachment
- Retinal artery embolism
- Migraine
In a patient with sudden vision loss, what specific questions regarding associated ocular symptoms affected would you ask about and what would they indicate (3)?
- Pain and red eye:
- acute glaucoma - Headache, nausea, coloured dots, cracked glass effect (scintillating scotomata):
- migraine - Pain on eye movement:
- consideroptic neuritis
In a patient with sudden vision loss, what specific questions regarding general medical history affected would you ask about and what would they indicate (3)?
- A comprehensive vascular history is essential
- Headache, jaw claudication, transient visual loss:
- exclude giant cell arteritis - Neurological disease:
- migraine, demyelination
What would you ask in a patient with double vision (diplopia) (5)?
- Check diplopia is binocular
- Position of images
- Intermittent
- History of trauma
- General medical history
In a patient with diplopia, what specific questions regarding whether diplopia is binocular or not and what would it indicate (2)?
- Binocular - two clear images present when both eyes open, cured by covering either eye:
- indicates ocular misalignment (strabismus) - Monocular ‘diplopia’:
- usually cataract
In a patient with diplopia, what specific questions regarding position of images would you ask and what would it indicate (2)?
- Side by side:
- Usually 6th nerve palsy - Vertical or diagonal:
- any other cause of strabismus
In a patient with diplopia that is intermittent, what would it indicate?
Decompensating latent strabismus
-myasthenia gravis or dysthyroid eye disease
In a patient with diplopia, what specific questions regarding history of trauma would you ask (2)?
- 4th nerve palsy
2. Orbital fracture
In a patient with diplopia, what specific questions regarding general medical history would you ask and what would it indicate (2)?
- Take a comprehensive vascular history
2. Consider symptoms of thyroid dysfunction, raised ICP, myasthenia gravis
What questions regarding social history would you ask about in an ophthalmic history (2)?
- Smoking and alcohol
- Knowledge of the patient’s social situation (especially for elderly and also suitability for surgery)
- Indicators of function, such as reading, crossing the road and shopping
- consider arrangements for surgery e.g. suitability for day case surgery
What causes floaters of the eye?
What group of people are more likely to get it?
Caused by vitreous degeneration
Predominantly occurs in the elderly and myopes
What does sudden onset floaters indicate?
acute posterior vitreous detachment: consider impending retinal detachment
What does sudden onset floaters associated with a reduction in vision indicate?
Consider vitreous haemorrhage
What do floaters associated with inflammatory cells in the vitreous indicate (2)?
- Posterior uveitis
2. Rarely iritis
What do transient flashing lights, associated with head or eye movement indicate?
Acute posterior vitreous detachment
What do recurrent flashing lights for several minutes, often in a ‘zig-zag’ pattern indicate?
consider migraine
What should you ask about with regards to the past ocular history in a patient with floaters or flashing lights?
Myopia: consider vitreous detachment, susceptible to retinal detachment
What should you ask about with regards to general medical history in a patient with floaters or flashing lights (3)?
- Diabetic retinopathy as a cause of vitreous haemorrhage
- Migraine
- Causes of iritis and posterior uveitis
