09/12/2025
History Taking Made Easy As An Optometrist.
By Dr. Christian (OD)
A thorough, systematic history is essential for accurate diagnosis and appropriate treatment in ophthalmology. Each component provides crucial information that guides clinical decision-making.
It is also a time to build rapport with the patient and it helps you to see the patient as human not just a sick person!!!
Before taking a patient's history, use the LSTD approach:
- Listen: Pay full attention to the patient without interrupting
- See: Perform a thorough clinical examination
- Think: Consider 3-4 possible diagnoses based on findings
- Do: Order tests to confirm diagnosis before starting treatment
The Seven Components of Eye History
1. Preliminary Data
Basic patient information including name, ID, age, s*x, and location. Different age groups and demographics have different risk factors:
- Children/teens: refractive errors cause blurry vision
- Over 40: presbyopia (near vision problems) is common
- Elderly: cataracts cause blurred vision
- Males: color blindness is more common
- Females: autoimmune conditions are more prevalent
2. Chief Complaints
Document the patient's main concerns in their own words:
- List of complaints: What problems are they experiencing?
- Laterality: Which eye (right, left, or both)?
- Duration: How long has this been happening?
Symptom Categories:
- Non-Ocular: Headache, vomiting (may indicate serious conditions like glaucoma)
- Vision-Related: Blurry vision, flashes, floaters, color vision problems
- Non-Vision Related: Lid bumps, swelling, watering, or discharge
- Acute Red Eye: Pain, redness, light sensitivity, watering, discharge
3. History of Presenting Illness (HPI)
Use the SUN classification to describe the problem:
Onset:
- Sudden: Patient knows exactly when it started
- Insidious: Slow, creeping start
Duration:
- Limited: ≤ 3 months
- Persistent: > 3 months
Course:
- Acute: Sudden onset, limited duration (emergency)
- Chronic: Persistent (> 3 months) with periods of improvement
- Recurrent: Episodes separated by 3+ months of being symptom-free
Progression:
- Gradually increasing (e.g., cataract)
- Gradually decreasing (e.g., keratitis improving with treatment)
- Stable (e.g., amblyopia)
Use SOCRATES for pain assessment:
- Site, Onset, Character, Radiation, Associated symptoms, Time/Duration, Exacerbating/Relieving factors, Severity
Key questions:
- Associated symptoms that confirm diagnosis (e.g., colored halos in glaucoma)
- Negative symptoms to rule out other conditions
- Systemic symptoms (fever, joint pain)
- History of trauma (must always ask)
4. Past History
Focus on previous similar episodes indicating recurrent conditions:
- Infection: Viral keratitis recurs when immunity drops
- Inflammation: Scleritis, episcleritis, anterior uveitis recur
- Exogenous triggers: Improper contact lens wear, allergens
5. Eye Treatment History
A. Medical Treatment:
- Eye drops/ointments: Note if using steroids or glaucoma medications
- Milky color: Indicates prednisolone acetate drops
- Allergies: Ask about medication allergies
B. Injections:
- Periocular or intravitreal injections
- Frequency indicates chronicity
C. Glasses/Contact Lenses:
- Frequent changes suggest glaucoma or cataracts
- Myopic shift in early cataracts can temporarily improve near vision
- High myopia increases retinal detachment risk
- Thick "aphakic" glasses indicate past cataract surgery without lens implant
Contact Lens Use:
- Always ask about the "Three S's" in acute red eye:
1. Solutions: Are they using proper solutions?
2. Swimming: Increases infection risk
3. Sleeping: Increases infection risk
D. Patching:
- Affected eye: For nerve palsies or exposure protection
- Unaffected eye: For childhood amblyopia treatment
E. Surgical/Laser Treatment:
- LASIK, PRK, YAG for vision improvement
- Laser Peripheral Iridotomy for narrow angles
- Retinal lasers for diabetic retinopathy
- Cataract surgery (most common)
- Glaucoma surgery (trabeculectomy/shunt)
- Retinal surgery (vitrectomy)
- Corneal surgery (transplants, pterygium removal)
6. Systemic History
The eye is a "window to the body" - many diseases affect the eyes. It's easier to ask what medications patients take than to ask for specific diagnoses.
Key Disease Categories:
-Vascular: Diabetes, hypertension, stroke
- Autoimmune: Ankylosing spondylitis, HLA-B27, thyroid disease
- Infectious: Tuberculosis, syphilis, herpes/shingles
- Neoplastic: Breast cancer can spread to the eye
Systemic Treatment Side Effects:
- Hydroxychloroquine (arthritis): Causes maculopathy
- Ethambutol (TB): Causes optic neuropathy
- Tamoxifen (breast cancer): Causes maculopathy
- Tamsulosin/Flomax (prostate): Causes Intraoperative Floppy Iris Syndrome during cataract surgery
7. Personal History
Habits/Addictions:
- Smoking: Major risk for thyroid eye disease and toxic optic neuropathy
- Alcohol/Methanol: Can cause toxic optic neuropathy and sudden vision loss
Food/Water Intake:
- Poor hygiene/uncooked food: Risk of toxoplasma infection (causes uveitis)
- Malnutrition: Can lead to nutritional optic neuropathy
Sexual History:
- Rule out HIV or syphilis-related eye disease
- Investigate neonatal conjunctivitis from Chlamydia or Gonococcus
8. Family History
Genetic/Hereditary Conditions:
- Glaucoma, retinoblastoma, retinal dystrophies
- Create a pedigree chart to determine inheritance patterns
Contact/Contagion:
- Ask about family members with infectious conditions like conjunctivitis or tuberculosis
Support System:
- Who helps with instilling eye drops or transportation?
- This affects treatment adherence and success
