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Opthalmology history taking and physical examinations :

History taking :
1. Presenting complaint :
- Red eye, visual disturbance, pain, discharge, itchy/gritty/dry eyes or alteration
in appearance ( squint, ptosis, lid swelling)
2. History of presenting complaint :
- How long have they been present ?
- Are they continuous or intermittent ?
- What precipitated them ?
- What makes them better or worse ?
- How are they changing ?
- Are there any associated symptoms ?
- Is there a history of previous eye, or relevant systemic diseases ?
- Is there a relevant drug history, family history or social history ?
3. Past ophthalmic history :
- Refractive errors (myopia/ hyperopia/ astigmatism)
- Ocular surgery (laser, injections) or trauma
- Squint
- Lazy eye
4. Past medical history :
- Diabetes mellitus, hypertension
- Systemic inflammatory disease (rheumatoid arthritis, sarcoidosis )
- Asthma (important when give patient beta-blocker eye drops may cause
5. Medications :
- Present and past medications
- Drugs induced eye toxicity ( antibiotics, isoniazid, chloroquine)
6. Family history :
- Squint, myopia, glaucoma, cataracts and poor vision
7. Allergies :
- Asthma , eczema or skin problems
- Medications
8. Social history :
- Smoking, alcohol, occupation and home circumstances
9. Birth history :
- For children only
- Prematurity, forceps delivery and low birth weight

Physical examination :
a) Eye lid + eye lashes
- Look for scars, lump/masses, ptosis, lig lag/ retraction, entropion or ectropion

b) Conjunctiva and lens

- Colour (yellow/ red)
- Redness ( circular ciliary injection or diffuse redness )
- Diffuse redness suggest conjunctivitis. Circum-ciliary injection suggests
keratitis, iritis or angle closure glaucoma.
c) Cornea
- Clear/ transparent/ cloudy
- Cornea abrasion (diagnostic use of fluorescein )
- Cornea ulcer ( whitish opacity)
d) Anterior chamber depth
- Deep or shallow
- Not normal if the shadow has less than 2/3 coverage
- Normal or deep presented with eclipse sign
- In angle closure glaucoma = has shallow anterior chamber
e) Iris + pupil
- Symmetry, shape (ovoid or irregular)
- Direct light reflex
- Consensual light reflex (must use 2 pen torches)
- Relative afferent pupillary defect (to highlight the
severity of optic neuropathy of one eye)

Miosis constricted
Mydriasis dilated

- Accomodation reflex (focus on distant object followed by close object. Pupil
will constrict )

g) Ocular movement
- Head still, only has eye movement
- Follow a H shape movement, look for diplopia and nystagmus
h) Fundoscopy
- Red eye reflex ( media is clear , involves cornea, aqueous humour, lens and
vitreous humour)
- Optic disc ( colour = pink or pale) , ( margin = well or ill-defined), (optic cup to
disc ratio = normal is 0.3 )
- Retinal vessels ( tortous dilated or normal )
- Look for any neovascularisation or haemorrhages ( describe in 4 quadrants
superior/inferior, temporal or nasal. If there is haemorrhages , describe the
size and distance it based on the size of optic disc)
- Macula ( look directly into the light)

Visual acuity test test visual resolving power of the eye using Snellens chart
If patient cannot see for 1/60, perform Counting finger(CF) , hand movement (HM),
perception to light (PTL).

Visual fields check the peripheral extent of visual world

Optic disc diameter is around 1.88mm vertically and 1.77mm horizontally