HISTORY TAKING IN OPHTHALMOLOGY

History Taking in Ophthalmology By Dr Nor Azimah Abd Aziz

History -90% of diagnosis Guidance for:  physical examination  workup-laboratory work etc  Appropriate therapy Failure to take history can lead to missing vision or life threatening conditions.

Common presenting complains

Disturbance of vision

Squint

Eyelid & orbital problem Proptosis- Bulging of the eyeball Lid swelling

• • • • •

Pain, discomfort Redness Itchiness Eye dischage Watery

Floaters & Flashes

DISTURBANCES OF VISION

Nature of BOV  Generalized, central scotoma, visual field defect  Peripheral vision- eg glaucoma, retinitis pigmentosa, migraine  Central scotoma-macula & optic nerve problem  Altered image size -micropsia, macropsia, metamorphopsiausually macula problem eg ARMD, macula edema

 Distance vision , near or both  Severity  Laterality

Blurring of vision

Onset • Gradual – eg refactive error, cataract, glaucoma, macula disease, dystrophy • Sudden –usually vascular event eg CRVO, CRAO, AION, TIA • Acute – eg acute glaucoma (due to cornea edema), uveitis, recurrent- eg optic neuritis, cornea ulcer/kertatitis Causes depends on Elderly or young Risk factor-eg family history, past ocular history Associated symptoms

Floaters & flashes Floaters- moving vitreous opacities Ask about..

• • • •

Onset Nature of floaters –single, numerous Progression Relation with eye movement

‘ cobweb’ or thread -dt condensation of collagen fibre within the collapsed vitreous cortex, usually PVD ‘Sudden shower’- usually due to vitreous haemorrhage

Causes of Floaters • Acute/Sudden – Posterior vitreous detachment – Vitreous hemorrhage • Proliferative retinopathy – – – – –

• • • • •

Diabetic retinopathy Occlusive vasculopathy OIS Radiation retinopathy Blood dyscriasis

BRVO/CRVO Breakthrough bleeding of CNV Retinal Talengiectasia PVD Trauma

– Retinal detachment

• Progressive – Debris/FB in vitreous – Intermediate/posterior uveitis • Infectious – – – –

Toxoplasmosis Tuberculosis Syphillis Endophthalmitis

• Non Infectious – – – –

Connective tissue disease eg SLE Sarcoidosis Behcet’s ds VKH

– Malignancy/masquerade syndrome

Flashes (photopsia) Common cause: • Retinal break • Retinal detachmentflashes, floaters & VF defect • PVD Ask about..

• Other causes- migraine with aura, occipital lobe infart.

• Onset • Risk factor of RDtrauma, surgery, myopia, associated eye disease (eg uveitis, diabetic retinopathy)

Diplopia Binocular - allignment problem eg • Neurological- eg 3rd nerve palsy • Myasthenia Gravis • Restrictive -orbital disease (eg TED), trauma-orbital wall fracture

Monocular -abN within the eye Eg • Astigmatism • Dry eye • Cataract • Pupil abnormality

• Color vision abnormalities • Dark adaptation problems, night blindness • Oscillopsia -shaking of images

BOV in children • Poor eye contact • Frequent bumps on object • Poor school performance • Lazy eye (amblyopia) Squint

Ocular pain or discomfort

• Ciliary pain -aching, severe pain in or around the eye, often radiating to the ipsilateral forehead, molar area • Photophobia –cornea problem, uveitis, pupil abnormalitymydriasis • Burning, irritation, foreign body sensation • Dryness • Itchy –allergy, conjunctivitis

Eye redness • Diffuse • Circumciliary • Sectoral

Abnormal ocular secretions • Lacrimation, epiphora • Dryness • Discharge (purulent, mucopurulent, mucoid, watery)

• Epiphora – Watering/tearing – secondary to abnormal excretory system – Normal tear secretion

• Lacrimation – Watering/tearing – secondary to excessive tear production – Normal excretory system

Causes of tearing Hypersecretion (lacrimation)

• Local irritant (FB, trichiasis) • Systemic disease (TED) • Chronic lid disease (blepharitis) • Chronic conjunctival or corneal disease (allergic conjuctivitis, dry eye syndrome)

Decreased tear elimination (epiphora)

Anatomical obstruction

• • • • •

Strictures Obstructions Infection Trauma Foreign bodies (e.g., stones) • Tumors

Physiological dysfunction

• Orbicularis muscle weakness • Punctal or eyelid malpositions • Nasal obstruction with normal lacrimal pathway

Eyelid swelling • Diffuse or localized • Can be vision & life threatening • History of trauma, insect bite • Symptoms related to head & neck –sinusitis etc

Protrusion of the eyeballProptosis Onset Acute• infective (orbital cellulitis) • inflammatory (eg TED, orbital pseudotumour)can be recurrent • Tumour-can present acutely, usually gradually progressive

• Ask related systemic history

Drooping of eyelidptosis • Severity-partial or complete • Laterality • Symmetry • Onset • Nature-progressive, -fluctuating & worst in the evening Myasthenia Gravis

Aetiology • congenital, • paralytic (eg 3rd nerve palsy, Horner Syndrome) • Myogenic (eg MG) • Senile • Mechanical

Systemic history Related systemic diseases Eg DM, HPT TED

Related systemic symptoms Eg in Uveitis..

- systemic infection (eg TB, syphilis, etc) -inflammatory condition, autoimmune disease- Joint pain, oral ulcer etc

Personal history & premorbid vision • Occupation - driver - doctor -labourer, rubber tapper, mechanic, welderhigh risk of ocular injury #Any important & relevant details

• Past ocular surgery • History of trauma • Birth historyprematurity

Drug history • Related to systemic diseasedz control Side effect of treatment -eg: steroidcataract, glaucoma Chloroquine Bull’s eye maculopathy

Family history Inherited ocular disease Eg: Glaucoma, strabismus, retinoblastoma, cornea dystrophy, retina dystrophy, ocular albinism