SYMPTOMATOLOGY AND

HISTORY TAKING IN
OPHTHALMOLOGY
CHARULATHA.K
STRUCTURAL ORGANIZATION OF HISTORY :
• Personal demographic data
• Chief complaints
• History of presenting illness
• Past history
• Personal history
• Family history
• Socioeconomic history
• General examination
• Ocular examination
DEMOGRAPHIC DATA :
• Name and address : patient’s identification
• Age and sex : presbyopia, senile cataract, age related macular
degeneration
• Occupation : occupational hazards
• Ocular injuries and trauma due to foreign bodies in factory workers, farmers,
sports persons
• Computer vision syndrome in computer professionals
• Heat cataract in glass factory workers
• Photo-ophthalmitis in welders
CHIEF COMPLAINTS :
• Complaints should always be recorded in chronological order with their
duration.
• Defective vision
• Watering/ discharge from the eyes
• Redness
• Asthenopic symptoms
• Photophobia
• Burning / itching/ foreign body sensation
• Pain (eyeache / headache )
• Diplopia
• Black spots in front of eyes
• Coloured halos
• Distorted vision ,glare and others
• 1)DEFECTIVE VISION :onset (sudden or gradual ) , duration ,painless /
painfull ,more during Day / Night / Constant
• SUDDEN PAINLESS LOSS OF VISION :
• Central retinal artery occlusion
• Massive vitreous haemorrhage
• Retinal detachment involving macular area
• Ischaemic central retinal vein occlusion
• SUDDEN PAINLESS ONSET OF DEFECTIVE VISION :
• Central serous chorioretinopathy
• Optic neuritis
• Methyl alcohol amblyopia
• Non ischaemic central vein occlusion
• SUDDEN PAINFUL LOSS OF VISION :
• Acute congestive glaucoma
• Acute iridocyclitis
• Chemical injuries to the eyeball
• Mechanical injuries to the eyeball
• GRADUAL PAINLESS DEFECTIVE VISION :
• Conjunctiva :Progressive pterygium involving pupillary area
• Cornea : Degenerations and Dystrophies
• Lens : cataract
• Retina :Age related macular degeneration, Diabetic retinopathy ,
Chorioretinal degenerations
• Refractive errors
• Optic nerve : optic atrophy , drug induced optic neuropathies and toxic
ambylopia
• GRADUAL PAINFUL DEFECTIVE VISION :
• Chronic iridocyclitis
• Corneal ulceration
• TRANSIENT LOSS OF VISION(Amaurosis fugax ):
• It is characterized by sudden, temporary loss of vision due to
transient hypoxia of visual system.
• Carotid artery disease, papilloedema, Giant cell arteritis, migraine,
severe hypertension , prodromal symptom of CRAO, Raynaud’s
disease.
• NIGHT BLINDNESS(Nyctalopia) :
• Vitamin A deficiency, Retinitis pigmentosa, congenital night blindness,
peripheral cortical cataract
• DAY BLINDNESS (Hemeralopia) :
• Central nuclear or polar cataracts, Central corneal opacity, Central
vitreous opacity, Congenital deficiency of cones
• 2)WATERING FROM EYES :
• Excessive lacrimation : excessive formation of tears
• Primary : direct stimulation of lacrimal gland, early stages of lacrimal
gland tumors
• Reflex : Stimulation of sensory branches of 5th nerve due to irritation
of cornea and conjunctiva.
• Central : exact area concerned with central lacrimation is not known.
It is seen in emotional states, voluntary & hysterical lacrimation.
• Epiphora : watering of eyes due to blockage in the flow of lacrimal
drainage system.
• Physiological :lacrimal pump failure due to lower lid laxity / weakness
of orbicularis muscle.
• Mechanical obstruction : dacryocystitis, dacryolithiasis, specific
infections like tuberculosis & syphilis.
• DISCHARGE FROM EYES :
• Whether mucoid, mucopurulent, purulent, ropy
• Feature of conjunctivitis, corneal ulcer, stye, dacryocystitis.
• 3) REDNESS OF EYE :
• 4) ASTHENOPIC SYMPTOMS :
• Asthenopia refers to mild eyeache, headache,
tiredness of eyes aggravated by near work

• It is a feature of extraocular muscle imbalance and

uncorrected refractive errors in astigmatism.
• 5) PHOTOPHOBIA :
• Discomfort caused by abnormal sensitivity to
ambient light conditions
• Corneal abrasion, acute conjunctivitis, keratitis,
anterior uveitis, dilated pupil.
• 6) BURNING/ITCHING/ FOREIGN BODY SENSATION:
• Allergic conjunctivitis, blepharitis, trachoma, dry
eye, trichiasis, entropion
• OCULAR PAIN :
• Onset, severity, type, associated symptoms
• Ocular inflammations, acute glaucoma, sinusitis,
dental caries, abscess.
• 8) DIPLOPIA :perceiving double images of a object
• Uniocular : subluxated lens, double pupil, incipient
cataract, eccentric IOL
• Binocular : paralytic squint, myasthenia gravis,
diabetes, thyroid disorders, blow-out fracture of
orbit
• 9)BLACK SPOTS/ FLOATERS IN FRONT OF EYES :
• Move with movements of eye & become more
apparent when view against a clear surface (e.g.
sky)
• Vitreous haemorrhage, degeneration, exudates in
vitreous
• 10) COLOURED HALOS :
• Patient may perceive rainbow colour rings around
light
• Feature of acute congestive glaucoma, early stages
of cataract, bullous keratopathy, mucopurulent
conjunctivitis.
• 11)DISTORTED VISION :
• Central chorioretinitis, central serous
chorioretinopathy, keratoconus, corneal irregularity,
ARMD, CNVM
• 12) PHOTOPSIA : Flashes of light in front of eyes
• Occur due to traction of retina in conditions like posterior vitreous
detachment, prodromal symptom of retinal detachment, retinitis,
migraine with aura
• 13) GLARE : Too much light shines directly into eye thus reducing
vision
• Early cataract, corneal oedema, status postrefractive surgery
• OTHERS OCULAR SYMPTOMS :
• Deviation of eyeball(Squint)
• Protrusion of eyeball(Proptosis)
• Drooping of upper lid(ptosis)
• Sagging down of lower lids ( ectropion )
• Swelling on the lids ( chalazion )
HISTORY OF PRESENT ILLNESS :
• Mode of onset
• Duration
• Severity
• Progression
• Accompained symptoms
PAST HISTORY :
• h/o Previous eye problems – uveitis, Herpes simplex keratitis, corneal
erosions, glaucoma
• h/o similar complaints in other eye – uveitis, senile cataract
• h/o ocular trauma in past
• h/o ocular surgery in the past
• h/o comorbidities like diabetes, hypertension, HIV, asthma,
tuberculosis, syphilis, leprosy
PERSONAL HISTORY :
• Diet
• Hygiene
• Habits- h/o smoking & alcohol (amount, duration, type )
• h/o present and past medications for both ocular & medical
conditions
• h/o drug allergy
 FAMILY HISTORY :
• To rule out familial predisposition of inheritable ocular disorders like
• Congenital cataract
• Ptosis
• Squint
• Corneal dystrophies
• Glaucoma
• Refractive error
SOCIOECONOMIC HISTORY :
• Socio economic class
• Home conditions (sanitation, home and surrounding area )
GENERAL EXAMINATION :
• Conscious, orientation, built
• Vitals : pulse, temperature, Blood pressure
• Pallor, cyanosis, clubbing, lymphadenopathy, edema
 OCULAR EXAMINATION:
• Test for visual acuity
• External ocular examination
• Fundus examination
• Visual field examination
TEST FOR VISUAL ACUITY :
• Measure of sharpness and clarity of vision, representing an
individual’s ability to identify objects or patterns at a given distance
• For testing, patient is seated at a distance of 6m from the Snellen’s
chart, so that the rays of light are practically parallel and patients
exert minimal accommodation
• The patient is asked to read the chart with each eye separately and
recorded as a fraction, numerator being the distance of the patient
from letters and the denominator being the smallest letters
accurately read
• When the patient is able to read upto 6m line, visual acuity is
recorded as 6/6, which is normal
• Pin hole test :
• It should be performed if distant visual acuity found abnormal
• For example, if Snellen’s test is 6/24, after pinhole it improves
• EXTERNAL OCULAR EXAMINATION:
• 1)Head posture
• 2)Facial symmetry
• 3)Ocular position
• 4)Extra ocular movements
FINDINGS RIGHT EYE LEFT EYE
Visual acuity
Eyebrows & eyelids
Conjuctiva
Cornea
Anterior chamber
Iris
Pupil
Lens
IOP
Lacrimal sac
• 1) EXAMINATION OF HEAD POSTURE :
• Face turn, towards right/ left
• Head tilt, towards right / left shoulder
• Chin lifted/ depressed
• Head posture may be abnormal in :
• A patient with paralytic squint ( head is turned in the direction of the
action of paralysed muscle to avoid diplopia )
• In complete ptosis ( chin is elevated to uncover the pupillary area in a
bid to see clearly )
• 2) EXAMINATION OF FOREHEAD AND FACIAL SYMMETRY :
• Forehead may show increased wrinkling in ptosis ( due to overaction
of frontalis muscle
• Complete loss of wrinkling in one- half of the forehead in LMN palsy
• Facial symmetry may be noted in Bell’s palsy and facial hemiatrophy
• 3)EXAMINATION OF EYEBROWS :
• Level of two eyebrows may be changed in ptosis( due to overaction
of frontalis )
• Cilia of lateral one- third of the eyebrows may be absent(madarosis)
in leprosy/ myxoedema
• 4)EXAMINATION OF THE EYELIDS:
• Position :Normally the lower lid just touches the limbus while the
upper lid covers about 1/6th of cornea
• In ptosis, upper lid covers more than 1/6th of cornea
• Lid movement :Normally the upper lid follows the eye ball in
downward movement but it lags in thyroid ophthalmology
• Blinking( normal rate is 12-16 per min )
• Lagophthalmos(patient not able to close eyelid) causes are facial
nerve palsy symblepharon
• Lid margin : entropion (inward turning ), ectropion (outward turning )
,eyelash abnormalities ( trichiasis, distichiasis, madarosis, poliosis ,
scales in blepharitis, swelling )
• Abnormalities of skin : herpetic blisters, molluscum lesions, warts,
ulcers ,scar, cyst etc…
• Palpebral aperture : it is exposed space between 2 lid margins which
measures 8-10 mm horizontally & 8-10 mm vertically ( in the centre )
• Ankyloblepharon, blepharophimosis, ptosis, enophthalmos,
anophthalmos,atrophic bulbi, phthisis bulbi
• 5) EXAMINATION OF LACRIMAL APPARATUS :
• Inspection of lacrimal sac – redness , swelling / fistula
• Inspection of lacrimal puncta – eversion, stenosis, absence/ discharge
• Regurgitation test – pressing over sac area for discharge over puncta ,
positive ( dacryocystitis ), false negative ( internal fistula, encysted
mucocele- wrong method )
• Lacrimal syringing – to locate the site of blockage in patient with
epiphora
• Other tests like jones dye test I & II , dacryocystography when
indicated
• 6)EXAMINATION OF EYEBALL :
• Position : normal/ exophthalmos/ endophthalmos
• Visual axes – normal/ squint
• Size – big (buphthalmos , myopia) , small ( congenital, phthisis &
atrophic bulbi )
• Movements – uniocular (ductions ),binocular (versions, vergences) in
all 6 cardinal direction of gaze
• Ductions : adduction , abduction, supraduction, infraduction,
intorsion, extorsion
• Versions : dextroversion, levoversion, supraversion, infraversion,
dextroelevation, dextrodepression, levoelevation, levodepression.
• Vergence: convergence, divergence
• 7) EXAMINATION OF CONJUNCTIVA :
• Bulbar conjunctiva
• Lower palpebral conjunctiva
• Upper palpebral conjunctiva
• Superior fornix
• Conjunctival signs : normal is thin semi transparent structure. A fine
network of vessels is distinctly seen in it. See for discolouration,
congestion of vessels , chemosis, follicles, papillae, concretions,
foreign bodies, scarring, pinguecula, pterygium, cysts & tumors
• 8) EXAMINATION OF CORNEA :
• Size – normal (elliptical), see for micro/macro cornea
• Shape – normal (like watch glass with uniform curve in its centre)
• See for keratoglobus, keratoconus, cornea plana
• Surface – smooth/ abrasion/ ulceration/ scars/ facets
• Sheen – normal (bright shiny )/ dry eye
• Transparency – lost in oedema, opacity, ulceration, dystrophies,
degeneration
• Vascularisation – avascular normally, check abnormality
• Sensation – sensitive normally, diminished in herpetic &
neuroparalytic keratitis, leprosy, diabetes, glaucoma
• Back of cornea – keratic precipitates sign of anterior uveitis (mutton
fat KP’s, granular KP’s, stellate& old KP’s )
• 9) EXAMINATION OF ANTERIOR CHAMBER :
• Depth – normal 2.5 mm in centre, see for shallow/deep/ irregular
• Contents- normally contains aqueous humor
• Abnormally - aqueous flare, hypopyon, pseudohypopyon, foreign
bodies, crystalline lens, lens particle, blood (hyphaema),parasitic cyst,
artificial lens.
• 10)EXAMINATION OF IRIS :
• Colour
• Pattern
• Persistent pupillary membrane
• Synechiae – adhesion of iris to other intraocular structure
• Iridodonesis –tremulousness of iris
• Nodules
• Rubeosis iridis – new vessel formation
• Gap /hole in iris
• Aniridia – absence of iris
• Cyst
• 11) EXAMINATION OF PUPIL :
• Number –one / polycoria
• Location- central / eccentric
• Size – normal (3-4mm ) / miosis/ mydriasis
• Shape – normal (circular )/ narrow / festooned/ pear shaped
• Colour- greyish black/ jetblack/ greyish white/ milky white / pearly
white/ brown
• Pupillary reflexes – direct LR, consensual LR, swinging flash LR, near
reflex
• 12) EXAMINATION OF LENS :
• Position – patellar fossa / dislocation/ subluxation/ aphakia/
pseudophakia.
• Shape – biconvex
• Colour – almost clear or faint blue hue
• Transparency- transparent / opacity ( cataract )
• Deposits on the anterior surface
• Purkinje images test
• 13) INTRAOCULAR PRESSURE :
• Measurement of IOP is done by tonometer.
• Indentation (Schiotz tonometer ) and applanation (e.g. goldman’s
tonometer) are frequently used
• Normal IOP range is 10-21 mmhg
• Hypotony (IOP<10 mmhg),causes are ruptured globe, phthisis bulbi,
retinal / choroidal detachment, iridocyclitis, ocular ischaemia,
traumatic ciliary body shut down
• Glaucoma should be suspected when IOP>21 mmhg
FUNDUS EXAMINATION :
• This is essential to diagnose the diseases of the vitreous, optic nerve
head, retina and choroid.
• For examination, pupil should be dilated with 5% phenylephrine / 1%
tropicamide eye drops
• Fundus examination done by ophthalmoscopy and slit- lamp
biomicroscopic examination
VISUAL FIELD EXAMINATION:
• Perimetry used for visual field examination
• Types of field defects are :
• Altitudinal field defects – ischaemic optic neuropathy, high myopia,
optic disc disease and optic neuritis
• Enlargement of blind spot – glaucoma, papilloedema, coloboma of
optic disc
• Central scotoma- macular disease, optic neuritis, toxic amblyopia
• Constriction of peripheral fields- glaucoma, retinitis pigmentosa,
chronic papilloedema
• Homonymous hemianopia : lesion of optic tract, lateral geniculate
body
• Bitemporal hemianopia : lesion involving optic chiasma such as
meningioma, pituitary adenoma
• Binasal field defects- tumours or aneurysm compressing optic nerve,
retinitis pigmentosa, glaucoma
• Arcuate scotoma- glaucoma, optic disc drusen, high myopia, optic
neuritis.
• THANK YOU