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How To Take A Complete Eye History
How To Take A Complete Eye History
I
t is impossible to over-emphasise
the importance of taking a careful
history when assessing an eye
patient. Taking a good history can
ADRIANE OHANESIAN/SIGHTSAVERS
help to focus your examination
and indicate what investigations
are needed. It can also help you
to understand the impact of the
condition on the patient and
pinpoint any difficulties they may
have adhering to treatment. Make careful notes when you take a history. SOUTH SUDAN
This is also your opportunity to focus
on the patient as a person and to form a relationship of Personal and demographic data
trust, respect and mutual understanding. Ask the patient’s personal details:
• Name, for identification, filing and patient follow-up
How to structure history taking
• Address and mobile phone number, for follow-up
To ensure you don’t miss anything important, structure and to identify patients from areas with endemic
your history taking carefully. Ask about: diseases
• Personal and demographic data • Age and gender, for noting
Tip: You can use • Reason for visit or presenting complaint down and ruling out any Recording the age,
this bulleted list as a diseases associated with gender, language
checklist Copy and • History of presenting complaint and disability status
keep it where you • Past eye history different age groups and/or sex
of patients allows
can see it during • General medical history • Language you to monitor who
history taking to
• Family eye history • Disability is, and is not,
help you to stay on
• Medication history • Patient’s occupation, daily tasks coming to your eye
track and ensure clinic or hospital.
that you will not • Allergy history and hobbies.
Compare these
miss anything • Social history Understanding a patient’s figures with the
important. population to
Each of these is discussed in more detail below. occupation, daily tasks (e.g., identify groups that
looking after grandchildren) and are under-
hobbies is helpful for finding represented, e.g.,
Top tips for taking a good history out a patient’s visual needs girls with other
disabilities, and
and understanding any eye
• Introduce yourself to the patient – this creates a friendly environment. manifestations or symptoms as a
plan ways to reach
out to them.
• Respect the patient’s privacy and confidentiality while taking the history result of occupational hazards.
• Ask questions that are direct, simple and clear. Avoid using medical
terms and explain things in ordinary language as much as possible. Reason for visit/Presenting complaint
• Be a good listener. Avoid interrupting or rushing the patient. Show Ask the main reason why the patient has come to seek
them that you are listening and paying attention: make eye contact an eye examination.
as appropriate and ask if you are not sure about something they Record the main presenting symptoms in the patient’s
said. It is often useful to use open questions (e.g., how are you?) and own words and in a chronological order. The four main
closed questions (e.g., yes/no answers) to help focus the discussion. groups of symptoms are:
• Try to see things from the patient’s point of view and make an effort
to understand them and their circumstances, especially when these 1 Red, sore, painful eye or eyes (including injury to
are very different from your own. the eye)
• Be aware that patients who are older, or who have disabilities 2 Decreased distance vision in one or both eyes,
(including hearing impairment, speech difficulties or a learning whether suddenly or gradually
disability) may need a bit more time or may struggle to express 3 A reduced ability to read small print or see near
themselves. This may cause them some anxiety, so remain patient objects after the age of 40 years
and reassure them that you are there to listen. 4 Any other specific eye symptom, such as double
vision, swelling of an eyelid, watering or squint.
CLARE GILBERT
• Onset (sudden or gradual) Medication history
• Course (how it has progressed) Ask about present and past medications for
• Duration (how long) both ocular and medical conditions. Don’t A case of age-related
• Severity overlook any medications that the patient may cataract (history of gradual
• Location (involving one or both eyes) have stopped taking some time ago. Some loss of vision)
• Any relevant associated symptoms medications are important in the etiology of
• Any similar problems in the past ocular conditions.
• Previous medical advice and any current
It is also helpful to ask whether the patient has
medication.
been able to use the medication as prescribed
Past eye history (their compliance). If a medication is ineffective,
P. VIJAYALAKSHM
Ask for detail about any previous eye problems you want to know whether the patient is
actually using the medication as prescribed, for
• History of similar eye complaints in the past. example glaucoma medications.
This is important in recurrent conditions such as A case of red eye due to
herpes simplex keratitis, allergic conjunctivitis, Using your own discretion, it is helpful to find bacterial conjunctivitis
uveitis and recurrent corneal erosions out whether access to medication prescribed is
a problem. This helps to ascertain whether cost
• History of similar complaints in the other eye
or other concerns are a potential reason for
is important in bilateral conditions such as
non-compliance. There could also be practical
uveitis, cataract
issues, such as difficulty instilling eyedrops or
MURRAY MCGAVIN
• History of past trauma to the eye may explain forgetting to do so.
occurrence of conditions such as cataract and
retinal detachment Do not forget to ask in a non-judgmental way
about traditional/herbal medication use. A case of ophthalmia
• History of eye surgery. It is important to ask neonatorum (history of
about any ocular surgery in the past such as Allergies
purulent discharge in a
cataract extraction, muscle surgery, glaucoma, or Ask about any allergies to medications or other
newborn)
retinal surgery substances.
Letter to When something goes wrong are more difficult to discern. There may be fear that
the editor Thank you so much for your courageous coverage acknowledging inadvertent harm could threaten public
health programmes that deliver substantial benefits.
of medical error in the most recent issue of the
Community
V O L U M E 3 2 • N U M B E R 1 0 6 • 2 0 19
Community Eye Health Journal. Inadvertent harm in Consequently, as described in a recent article (http://
Eye Health Journal
health care settings can be devastating for patients and bit.ly/glob-apol), apology in public health is less often
caregivers alike. Not too long ago, when I was trained the norm. We in public health can be inspired and
in medicine, disclosure of medical error and apology challenged by the progress made by eye health in
Being involved in a
medical error can be
devastating; health
workers will need
the support of senior
colleagues (p. 26).
STOCK IMAGE
When something goes wrong were discouraged because of the potential for lawsuits. acknowledging unintended harm.
in medical care
As health workers, we do everything within our power to ensure that our patients
have the best visual and clinical outcomes possible. What should we do if
something goes wrong?
Such an approach disrespected patients and morally Your remarkable coverage of this topic in the Community
harmed caregivers. It was therefore tremendously
David Yorston
Consultant
H
Ophthalmologist: ealth care is an inherently dangerous activity. We The guidance emphasises that the explanation and apology
Tennent Institute of