a ee 9. Treatment History 10. Family history 11. Personal history 12. General Examination 13. Vital date 14. Ocular Examination Feature RE 1, Visual Acuity (for Distant and Near) 2. Head Posture 3. Eyelids 4, Lacrimal Apparatus(Regurgitation) 5. Eyeball as a whole a 6. Conjunctiva 2 vA ‘Sclera 8. Cornea “9. Anterior Chamber 10. Iris ayecpie = 12. Lens a 2: 13. Digital Tonometry z 14. Ocular Movements Provisional diagnosis Management- Investigations Treatment Follow up and Preventive Measures4. Occupation 5. Address Chief Complaints and Duration- Always mention the complaints in chronological order. H/O Presenting Illness 1. Defective Vision @ Onset- Sudden or Gradual @ Duration @ Painless or Painful @ More in night or day or constant 2. Blackspots in front of the eyes 3. Flashes of light in front of eyes(Due to vitreous disease) 4. Coloured halos(ACG, Early stages of Cataract, Mucopurulent Conjunctivitis) 5. Diplopia- Uniocular or binocular 6. Polyopia (Cataract) 7. Watering from the eyes 8. Other discharge from the eyes (Conjunctivitis, Corneal Ulcer, Dacryocystitis, Stye) @ Mucoid/ Purulent/ Mucopurulent/ Sero Sanguinous/ Ropy @ Duration @ Aggravating and Relieving Factors 9. Redness of the eye(Iridocystitis, Acute glaucoma,Conjunctivitis, Corneal ulcer) @ Duration @ Progressive or Stationary 10. Itching, Burning, Foreign body sensations in the eye(CSG, Conjunctivitis, Dry Eye, Trachoma) 11. Ocular Pain (AC Glaucoma, Ocular Inflammations, Referred pain from sinusitis, Dental Abcess) @ Onset- sudden or gradual @ Duration@ Type of Pain @ Continuous or intermittent @ Radiating or not radiating @ Agegravating and relieving factors 12. Asthenopic symptoms like frontal or occipital headache, ache, tiredness of eye, watering, photophobia or blepheritis 13. Fever 14. Bowels and micturition 15. History suggestive of DM, Hypertension, mild eye 7B and exposure to STD H/O Past IlIness (Past H/O trauma may give rise to sympathetic opthalmitis or rosette cataract.) Treatment Histo! H/O past surgeries over the eye H/O long term use of steroids (local or systemic) Family History (Congenital Cataract, Squint, Refractive errors, Ptosis, Corneal dystrophies, glaucoma) Personal History Diet, smoking, taking alcohol General Examination (Ankylosing spondylitis may be associated in a patient with uveitis) 1, Built- ill/ moderate/ well 2. Nourishment: ill/ moderate/well 3. Anemia, Jaundice, Clubbing, Cyanosis, Edema. Lymphadenopathy, PedalVital Data 1, Pulse rate 2. Blood Pressure 3. Respiratory Rate 4. Temperature Examination Of the Eye (Both eyes should be examined either simultan: and the information regarding both eyes should be written. If one ey’ bandaged, please note the point and tell the examiner that yo are examining only one particular eye.) eously or alternatively eis 1. Visual Acuity (For distant vision) Numerator- Distance from Snellen’s Chart Denominator- Distance upto which patient can read clearly Lt eye-() Rt eye-() If patient can’t read the topline of Snellen’s chart Finger counting- Present/ absent at a distance of _ Meters (for eg CF3, CF2, CF1), If patient can’t count fingers Appreciation of Hand Movements- Present/ Absent, If patient can’t appreciate Perception of Light- Present/ Absent Visual acuity for near vision (Not routinely employed) are kept 35cm from the eye and patient is asked to (Near vision charts pto which patient can read clearly can be made out) read and the line u| 2. Head Posture (In paralytic suint head is turned in the direction of paralysed muscle, chin is elevated in complete ptosis) Normal or abnormal Face- symmetrical/ Asymmetrical( as n facial nerve palsy) Wrinkling of forehead- Present or Absent(as in FN palsy) Eye brows- Level is same on both sides or not Complete or incomplete(lateral 1/3 of eyebrow lost in leprosy)3. Eyelids Position- normal/ ptosis/ elevation(as in exapthalmos) Movements- normal(12- s/M eased in ny It! 12- 16 blink: di a /min)/ decreased in blinking eee ee (Facial Nerve Palsy) Lid Margins- jargins- Normal/ ectropion/ entropion/ swelling/ any abnormalities Skin over the lids- normal/ scars/ any abnormalities Palpebral fissure- normal/ narrow/ widened 4. |acrimal Apparatus Lacrimal Sac area- normal/ redness/ sweling/ fistula Regurgitation test- positive/ negative (pressing medial to medial canthus) 5. Eyeball as a Whole Position- normal/ exopthalmos/ enopthalmos Visual Axis Of Eyeball- Straight/ Deviated Size of the eyeball- nor ‘mal/ increased/ decreased Movements of the Eyeball- normal/ decreased 6. Conjunctiva Bulbar Conjunctiva- Normai/ abnormal Lower palpebral conjunctiva and fornix: Normal/ Abnormal Upper Palpebral conjunctiva: Normal/ ‘Abnormal (one hand/ two hand technique) : Superior Fornix- Normal/ Abnormal( using Desmarre’s lid retractor) 7. Sclera Normal/ Abnormal 8. Cornea Size- Normal(11.7mm horizontally and 11mm vertically) or microcornea (<10mm -horizontally) ; megacornea (>13mm -horizontally), Shape - normal ,keratoglobus Sie Hoe eee eee - bright shining(normal)/loss of shining (d Transparency - present/lost/corneal ed a st a pie ema, opacity, ulceration Vai i i pee absent (normal) /present -superficial or deep ations - present(normal)/ abse: zal f nt (lepro: i keratitis, herpitic keratitis, diabetes mellitus) tala 4 cna eee corneal sensation wisp of cotton should be brought from the of the eye, while the patient is asked to look straight ahead ) \f corneal ulcer is present look for size,site, shape in normal eye and after 2% fluorescent dye injection 9. Anterior chamber: Depth -normal (2.5mm)/ deep/ shallow Contents - transparent watery fluid(normal)/blood/pus/ aq. Flare/foreign bodies 10. Iris: Colour- normal(diff in various races) Pattern - normal or muddy as in iodocyclitis Any abnormally noted (absence of iris, synechia Formation nodules,tremulonsness neovascularisation,€sP in the iris-coloboma) 11. Pupil Number-one(normal)/many(polycor's) Location-central/deviated size-normal(3-4mm)/increase/decress= Shape-circular(normal)/verticaly oval/ irregular Colour-greyish black(norme!)/jet black(aphakia)/black(pseudophakia) Pupillary reflex- direct-present/absent Consensual-present/absent Near reflex-present/absent Any abnormality(marcus gunn pupil) 12. Lens Position - normal or absent in patellar fossa Colour- clear(normal) Greyish white (IMsC) Pearly white (msc)Milky white (HMSC) Brown/ black- nuclear cataract Opacities-transparent/any opacity \ris shadow-present/absent Purkinje image test -(not routinely done) 43. Digital tonometry 1OP- appears to be normal/hypotonia/hypertonic » Fundus examination > Provisional diagnosis r Management:investigations and treatment