HISTORY TAKING AND

EXAMINATION
 HISTORY TAKING
• Personal data – Name, Age, Sex, Occupation
• Chief presenting illness
• History of present illness
• History of past illness – DM, HTN, Asthma, Cardiac
Disease, drug intake
• Family history
PERSONAL DATA
• Name – personal identity
• Age – some diseases are common in younger,
some in elder – help in diagnosis
• Occupation – injuries are more common in
farmers, factory workers, welders
CHIEF PRESENTING ILLNESS
Ocular symptomatology can be classified as
• Related to vision
• Not related to vision
• Due to adnexa of eye
HISTORY OF PRESENTING COMPLAINTS

• Briefly explore and • When did the problem begin

develop the chief • How was the progression?
complaints • Where one or both eyes
affected?
• Be concise, focused
• What treatment was received?
and chronological
• What are the aggravating
factors?
PAST HISTORY
• History of similar complaints in the past –
recurrent corneal erosions, uveitis, keratitis
• History of similar complaints in the other eye –
cataract , uveitis, retinal detachment
• History of trauma to the eye – traumatic cataract,
retinal detachment
• Any ocular medications, surgery, eye hospital visits
• Use of spectacles, contact lenses etc, if present
last time spectacles where changed
PAST HISTORY
• Any systemic diseases – diabetic, hypertension, or
infections – must be treated before taking up for
surgery
• History of any drug intake and allergies
FAMILY HISTORY
• To rule out refractive error congenital cataract,
ptosis, squint, glaucoma
CHIEF PRESENTING COMPLAINTS -
RELATED OF VISION
1. Blurring of vision 8. Photophobia
2. Diminution of vision 9. Distorted vision
3. Loss of vision 10. Diplopia
4. Transient loss of 11. Colored halos
vision 12. Day blindness
5. Floaters 13. Night blindness
6. Flashes of light 14. Diminution for near
7. Glare vision
1. BLURRING OF VISION – QUALITY of vision - hazy
vision or foggy vision, details are not visible
• Minimal amount of astigmatism
• Nebular grade corneal opacity
• Early cataract

2. DIMINUTION OF VISION
• Decrease in QUANTITY of vision, which can be
measured by snellen’s visual acuity chart
• Onset, both eyes, duration, progression, pattern,
associated symptoms.
GRADUAL PAINLESS GRADUAL PAINFUL
• Refractive error • Corneal ulcer
• Cataract • Chronic iridocylitis
• Pterygium encroaching
the cornea
• Primary open angle
glaucoma
• Diabetic retinopathy
• Corneal, macular,
chorioretinal
dystrophies and
degeneration
SUDDEN PAINLESS SUDDEN PAINFUL
• Retinal vascular • Acute angle closure
occlusions glaucoma
• Optic neuritis • Acute iridocyclitis
• Central serous • Mechanical or chemical
retinopathy trauma
• Vitreous hemorrhage • Endophthalmitis
• Retinal detachment
3. LOSS OF VISION – inability to perceive light
• Retinal and optic nerve disorders

4. AMAUROSIS FUGAX – transient loss of vision – lasts

for few seconds to minutes – due to transient
hypoxia of visual system
• Migraine
• Papilloedema
• Prodromal symptom of CRAO
• Hypoperfusion of retinal arteries – hypotension, CCF
• Carotid artery disease and atherosclerosic CVA
5. FLOATERS - black spots in front of eye – moves with
eyeball movement – opacity beyond the nodal point
casts a shadow on the retina
• Posterior vitreous detachment
• Vitreous degeneration and liquefaction
• Vitreous hemorrhage
6. FLASHES OF LIGHT OR PHOTOPSIA – percieving a
sensation of flickering of light – vitreoretinal
traction irritating the retina causing electrical
impulses
• Posterior vitreous detachment
• Retinal tear
• Papilledema
• Prodromal symptom of retinal detachment
7. GLARE – difficulty to see in bright light – diffraction
of light caused by opacification in the refractive
medium
• Corneal opacity
• Lenticular opacity

8. PHOTOPHOBIA – difficulty to open the eyes in

normal intensity light – stimulation of sensory
corneal nerve endings
• Corneal – abrasion, edema, ulcer, keratitis
• Anterior or posterior uveitis
9. DISTORTED VISION - objects have altered shape or
size – micropsia, macropsia, metamorphosia
• Macula – hole, edema, CSR, ARMD
10. DIPLOPIA – double images are seen

UNIOCULAR – disappears BINOCULAR – disappears

when affected eye when either eye closed.
closed.
• EOM palsy
• Large iridotomy
• Fractures of orbit
• Incipient cataract
causing entrapment of
• Subluxation of clear muscle
lens
• iridodialysis • Thyroid orbitopathy
• Double pupil • Myasthenia gravis
• Keratoconus
11. COLOURED HALOS – colour rings around lights –
dispersion of light in the refractive media
• Immature Cataract
• Mucus plugs – when cross across the pupillary area–
conjunctivitis
• Corneal edema – acute angle closure glaucoma
• Finscham test, Stenopaeic slit
12. DAY BLINDNESS OR HEMERALOPIA - decreased
vision in day
• Central corneal opacities
• Polar cataract
• Cone dystrophy

13. NIGHT BLINDNESS OR NYCTALOPIA – decreased

vision in night
• Peripheral cortical cataract
• Pathological myopia
• Xerophthalmia
• Retinitis pigmentosa – disease of rods
14. DIMINUTION OF VISION FOR NEAR ONLY
• Presbyopia
• Paralysis of accomodation – cycloplegia,
ophthalmoplegia
 CHIEF PRESENTING COMPLAINTS –
NOT RELATED OF VISION
1. Redness
2. Watering
3. Discharge
4. Itching
5. Ocular Pain
6. Headache
7. Deviation of eye
8. Protrusion of eyeball
1. REDNESS
• Acute conjunctivitis
• Acute iridocyclitis
• Acute congestive glaucoma
• Inflammatory conditions

2. WATERING
• HYPERLACRIMATION - Foreign particle, Inflammation,
Chemical injuries, Psychogenic factors
• EPIPHORA – obstruction of NLD
3. DISCHARGE –watery- viral,
mucoid, mucopurulent – mild and virulent bacterial
serosanguineous – chlamydial
ropy - allergy
• Conjunctivitis
• Dacrocystitis

4. ITCHING
• Allergic conjuctivitis

5. OCULAR PAIN
• Inflammation of eye and adnexa
• Sinusitis or dental problems
• Angle closure glaucoma
6. HEADACHE
• OCULAR – uncorrected refractive errors, EOM
imbalance, deficiency of accomodation,
convergence insufficency, ocular inflammation,
glaucoma
• NON – OCULAR – neurological disorders –
intracranial space occupying lesions, meningitis,
ENT diseases – sinusitis, rhinitis, Psychiatric
problems, systemic hypertension, Primary
headache – migraine
8. DEVIATION OF EYE
• Misalingment of visual axis of the two eyes –
deviation of eye – squint

9. PROTRUSION OF EYEBALL
• Forward displacement of normal sized eyeball
beyond the orbital margins
 CHIEF PRESENTING COMPLAINTS –
DUE TO ADNEXA OF EYE
• Drooping of upper eyelid - ptosis
• Retraction of eyelid
• Inward or outward turning of eyelid margin –
entropion or ectropion
• Increased blinking rate of eyelids – blepharospasm
• Inability to close eyelids – lagophthalmos
• Inward misdirection of eyelashes – trichiasis
• Swelling of lacrimal sac region
 EXAMINATION
1. Head posture 1. Visual acuity
2. Eyebrow
2. Facial symmetry 3. Eyelids
3. Ocular position 4. Lacrimal Apparatus
5. Eyeball
4. Extra ocular movements
6. Conjunctiva
7. Sclera
8. Cornea
9. Anterior Chamber
10. Iris
11. Pupil
12. Lens
13. IOP
1. HEAD POSTURE
• NORMAL – erect and straight
• ABNORMAL – face turn, head tilt, chin up/down
• ptosis, EOM palsy.

2. FACIAL SYMMETRY
• NORMAL – one half –mirror image
of the other half
• symmetrical on both sides
• ABNORMAL – Facial nerve palsy ,
Bony defects.
3. OCULAR POSTURE - Hirschberg test
• NORMAL - two eyes are parallel to each other –
orthophoric
• ABNORMAL – misalignment of visual axis –
strabismus or squint

4. EXTRAOCULAR MOVEMENTS -
• NORMAL – full in range
• ABNORMAL – restricted in one or many gaze – EOM
palsy, fracture orbit entraping the muscle
 OCULAR EXAMINATION RIGHT EYE LEFT EYE
1. Visual Acuity
2. Eyebrow
3. Eyelids
4. Lacrimal Appartus
5. Conjunctiva
• Bulbar
• Palpebral
• Fornix
6. Limbus
7. Sclera
8. Cornea
• Size
• Shape
• Surface
• Transparency
9. Anterior chamber
• Depth
• Contents
 OCULAR EXAMINATION RIGHT EYE LEFT EYE
10. Iris
• Colour
• Pattern
11. Pupil
• Number
• Size and shape
• Position
• Pupillary reaction
12. Lens
13. Intra ocular pressure -
digitally

• Summary
• Diagnosis
1. VISUAL ACUITY
• One eye at a time
• DISTANCE VISION – read at 6m distance - Snellen’s
chart, Snellen’s E chart, Landolt’s C chart
Why at 6 metres?
At 6 metres rays are practically parallel
Patinet exerts minimum accomodation.

6/60 : normal person should read the letter

from 60 metres
Whereas this patient reads from 6 metres.
• Unaided, with pin hole (if vision is less than
6/6), best corrected

IMPROVEMENT NO IMPROVEMENT DECREASE IN VISUAL

ACUITY
Refractive error Pathologies of cornea, Central corneal opacity
lens, retina, optic N. Central lens opacity
Macular pathologies
• NEAR VISION – patient is asked to read near vision
chart at a distance of 30cm – Jaeger chart

• COLOR VISION – patient is asked to read the number

or trace the line – Ishihara’s plate, Farnsworth –
Munsell 100 hue test
• VISUAL FIELD TEST – Confrontation and perimetry
2. EYEBROW
• NORMAL – symmetrical placed,
symmetrical collection of hair follicles

• ABNORMAL –
• Altered position – raised on side of ptosis
• Scanty hair follicles – leprosy
• Graying (Poliosis) – vitiligo
3. EYELIDS
NORMAL
• Position – upper eye lid covers 1/6th of cornea,
lower eye lid touches the inferior limbus
• Margin – rounded anterior border, sharp
posterior border
• Movements – 12-16 per min
• Palpebral fissure width – vertical 10mm,
horizontal 30mm
• Eyelashes – upper eyelid directed forwards,
upwards and backwards, lower eyelid directed
forwards, downwards, backwards
ABNORMAL
• Position -
Ptosis – upper eyelid covers more than 2mm
Upper lid retraction – superior limbus is visible
(scleral show) - hyperthyroidism
• Margin -
Ectropion – outward turning
Entropion – inward turning
• Movements
Increased – blepharospasm (corneal ulcer)
Decreased – lagophthalmos (facial nerve palsy,
symblepharon)

• Palpebral aperture width

Vertical – narrow – ptosis , phthisis bulbi
Vertical – wide – proptosis
• Eyelashes
Trichiasis – misdirection of eyelashes towards globe
Distichiasis – posterior row of eyelashes directed towards
globe
• Madarosis – loss or decrease in the number of cilia of
eyelashes or eyebrows
• Poliosis – hypopigmented hair follicles
• Tylosis- thickening of lid margin.
• Skin - external or internal hordeolum, chalazion,
edema, ecchymosis
4. LACRIMAL APPARATUS
• Lacrimal puncta – absent, everted , stenosis
• Skin – redness, swelling, fistula
• ROPLAS – Regurgitation On Pressure over LAcrimal
Sac
Negative - normal
Positive – chronic dacrocystitis
False negative – chronic dacrocystitis
with mucocele
• Syringing
5. EYEBALL
NORMAL
• Position – measured by plastic scale, placed tightly
on the lateral orbital margin and the level of apex of
cornea is read from the scale

Normal 16mm
Borderline 16-20mm
Proptosis more than 21mm or difference of more than 2mm
between two eyes
ABNORMAL
• Position –
Proptosis – abnormal forward displacement of eyeball

UNILATERAL BILATERAL ACUTE PULSATING INTERMITTENT

Dermoid cyst, Exophthalmos, Orbital Carotid Orbital varices,

Orbital cellulitis, cavernous sinus infections, cavernous Recurrent
Orbital thrombosis, orbital fistula orbital
hemorrhage or Cranio facial emphysema, hemorrhage,
emphysema, dystosias Orbital Orbital
Orbital varices hemorrhage, emphysema
Thyroid,
Systemic
diseases
6. CONJUNCTIVA
NORMAL - bulbar, palpebral and fornix
Bulbar Conjunctiva is examined using torch light,
Lower palpebral conjunctiva examined by pulling the
lower lid.
Upper palpebral conjunctiva examined by everting the
upper lid.
It is done by grasping the lid pulling it downward and
forward and then folding it back over the middle
finger placed at the upper margin of the tarsus,
while the patient continually maintains downward
fixation.
FORNIX : double eversion .
ABNORMAL:
• Chemosis – ocular inflammatory conditions,
systemic conditions, passive congestion due to
mechanical obstruction of venous outflow.

• Sub conjunctival hemorrhage - island of deep

red blood – trauma, post op, conjunctivitis
• Pterygium – fleshy growth

• Xerosis – dry, lusterless conjunctiva

Circumciliary congestion Conjuctival congestion
• Purplish • Bright red
• Around limbus • More in the fornix
• Does not move with • Moves with movement of
movement of conjunctiva conjunctiva
• Diffuse • Individual vessel seen
• Blood flow away from the • Blood flow towards the
limbus limbus
• Blanching -ve • Blanching +ve.
SCLERAL - ciliary vessels seen in episcleritis and
scleritis, limited to a sector or quadrant, dull
red in colour, will blanch
7. SCLERA
NORMAL - white
ABNORMAL
• Raised congested nodules of episcleritis
• Deep red, dusky congestion with peripheral keratitis
and uveitis – deep scleritis
• Definite blue colour - staphyloma
8. CORNEA
NORMAL
• Size – horizontal diameter – 11.7mm, vertical
diameter – 11mm - callipers
• Shape – concavoconvex
• Sensations – blinking response when touched
with whisp of cotton
• Transparent
ABNORMAL
• Size –
Microcornea – less than 10 mm - microphthalmos,
cataract, glaucoma, aniridia

Macrocornea – 12mm at birth and 13mm after 2 years -

megaophthalmos
• Shape –
Increased – keratoconus, keratoglobus
Decreased – cornea plana

• Surface -
Corneal epithelial defects
Abrasions
Corneal ulcer
• Sensation
Paralysis of trigeminal nerve as a result of
trauma, surgery, neoplasm

Damage to the sensory nerve endings of cornea

as following keratoplasty, refractive corneal
surgeries, contact lens wear, herpes simplex
keratitis
• Transparency
Corneal edema, corneal opacity, corneal
degeneration, corneal dystrophies
NEBULA
• Iris and its pattern visible
• Upto superficial stroma

MACULA
• Iris visible but pattern not appreciated
• Half the stroma

LEUCOMA
• Iris not visible
• Complete stromal involement
9. ANTERIOR CHAMBER
NORMAL-
Depth – 2.5mm, torch light method – ECLIPSE SIGN
Contents - aqueous humor
ABNORMAL
• Depth
Shallow – hypermetropia, narrow angle glaucoma,
intumescent glaucoma, phacomorphic glaucoma,
malignant glaucoma, postop – wound leak

Deep – keratoconus, keratoglobus, buphthalmos,

aphakia, myopia

Irregular – adherent leucoma, annular synechia leading

to iris bombe
• Contents –
Hyphaema – blood/RBCs – occular trauma,
hemorrhagic uveitis
Hypopyon – pus- corneal ulcer, endophthalmitis,
iridiocyclitis, panophthalmitis
Pseudohypopyon – tumor cells- retinoblastoma,
malignant melanoma, lens proteins in
phacomorphic glaucoma
Aqueous flare – protein particles – leakage from
damage blood vessels
Aqueous cells – inflammatory cells – iridocyclitis
Grade cells/ field flare
- 0 No flare
1+ 1-10 Faint or just detectable
2+ 11-20 Moderate with clear details of iris and
lens visible
3+ 21-50 Marked with hazy view of iris and lens
4+ >50 Fixed and aplastic aqueous with no
view of iris and lens
10. IRIS
NORMAL
• Color – varies for different races
• Pattern – crypts, ridges, collarette

ABNORMAL
• Color-
1.Heterochromia iridium – iris colour for different eyes
is different - Fuch’s heterochromic iridocyclitis
2.Heterochromia iridis – iris of same eye is
different in different sectors, congenital or
acquired following iris atrophy after angle
closure glaucoma or iridocyclitis
• Pattern – atrophic patches in old iridocyclitis
• Abnormalities
1.Iridodonesis – tremulousness of iris in aphakia
2.Synechiae – adhesions of iris to other intraocular
structures, anterior , peripheral, posterior
3.Pseudoexfoliation – small flakes on the pupillary
margin
4.Persistent pupillary membrane – remnant of
vascular sheath lens
5.Rubeosis iridis – CRVO ,DM, NVG, Fuchs
heterochromic iridocyclitis, anterior segment
ischemia,
6.Coloboma of iris – absence of tissue due to
failure of closure of embryonic fissure
11. PUPIL
NORMAL –
• Size – 3-4mm
• Shape
• Reflexes/ pupillary reaction
light reflex or near reflex –
direct and indirect
ABNORMAL
• Size –

MIOSIS MYDRIASIS
PHYSIOLOGICAL Old age, during sleep, Exposure to dim light
exposure to bright light
PHARMACOLOGICAL Parasympathomimetic – Parasympatholytic – atropine,
pilocarpine, systemic homatropine, cyclopentolate,
morphine tropicamide,
Sympathomimetic - phenylephrine
PATHOLOGICAL Potine hemorrhage, Optic atrophy, absolute glaucoma,
horner’s syndrome third nerve paralysis, total retinal
detachment
• Shape –
Irregular – synechiae – iridocyclitis
Festooned – irregularly dilated pupil after
mydriatics – posterior synechiae
• Pupillary reflex –
Marcus gunn pupil or relative afferent pathway defect
Wernicke’s hemianopic pupil
Argyll Robertson pupil
Hutchinson’s pupil
12.LENS
NORMAL
• Position
• Shape - biconvex, anterior surface less curved
• Transparency - clear
ABNORMAL
• Position – subluxated or dislocated
Congenital simple ectopia lentis, ectopia lentis
with systemic anomalies, trauma,
hypermature cataract

• Shape –
Lenticonus – Alports syndrome
Spherophakia – Weill – Marchesani syndrome
• Color -
Grayish white – immature

Pearly white – mature

Milky white – hypermature

Jet black – aphakia

Glistening or shimmering reflex – pseudophakia

13. INTRAOCULAR PRESSURE
NORMAL – 10 – 21mmHg
ABNORMAL – more than 21 or less 7 mm Hg
METHODS –
Digital tonometry
Indendation tonometry – Schiotz
Applanation tonometry – Goldmann, Perkins hand
held, air puff, Tono pen, non contact.