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Ophthalmology Postings: History Taking & Examination Guide

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PART 1 - HISTORY TAKING

The Ophthalmic History Framework

1. Main Complaint

• Rapidity of onset - sudden vs. gradual? Sudden painless loss of vision suggests vascular causes (CRAO, CRVO, vitreous hemorrhage); gradual suggests refractive error, cataract, glaucoma.
• Circumstances of onset - after trauma, on waking, after reading?
• Severity - how much vision is affected? Can they count fingers, read, drive?
• Duration - hours, days, weeks, months?
• Frequency - constant, intermittent, episodic (e.g., amaurosis fugax)?

Common presenting symptoms to probe:

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2. Past Ocular History

• Previous eye surgery (cataract, vitrectomy, strabismus, laser)
• Previous ocular inflammation (uveitis, scleritis)
• Previous trauma
• Glasses/contact lens use - which type, how long?
• Previous laser or intravitreal injections
• Amblyopia or squint in childhood

3. Past Medical History

• Diabetes - diabetic retinopathy, cataract, cranial nerve palsies
• Hypertension - hypertensive retinopathy, BRAO, BRVO
• Thyroid disease - thyroid eye disease (proptosis, lid lag, diplopia)
• Rheumatoid arthritis / SLE - dry eye, scleritis, uveitis
• HIV/immunosuppression - CMV retinitis, toxoplasmosis
• Sarcoidosis - uveitis, retinal vasculitis
• Multiple sclerosis - optic neuritis

4. Systemic Medications

• Corticosteroids (topical or systemic) - posterior subcapsular cataract, raised IOP
• Tamsulosin / alpha blockers - intraoperative floppy iris syndrome (IFIS) - critical to know before cataract surgery
• Hydroxychloroquine - bull's eye maculopathy
• Amiodarone - corneal verticillata, optic neuropathy
• Ethambutol - toxic optic neuropathy
• Vigabatrin - visual field defects
• Topiramate - acute angle closure

5. Allergies

• Antibiotic drops (neomycin, chloramphenicol)
• Topical glaucoma medications
• Contact lens solution preservatives

6. Family History

• Glaucoma - most important; first-degree relatives have 4-9x risk
• Macular degeneration (AMD)
• Inherited retinal dystrophies (retinitis pigmentosa, Stargardt disease)
• Squint or amblyopia
• Refractive error (high myopia)

7. Social History

• Occupation (VDU use, outdoor work, occupational hazards)
• Driving (legal requirement to mention if affected)
• Smoking (major risk factor for AMD and diabetic retinopathy progression)
• Alcohol

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PART 2 - OPHTHALMIC EXAMINATION

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Step 1: Visual Acuity (VA) - The Single Most Important Test

• Use a Snellen chart at 6 metres (or LogMAR/ETDRS chart which is preferred in trials for accuracy)
• Test each eye separately - cover the other eye
• Always test with best correction (glasses/contact lenses)
• If the patient cannot see the top letter at 6m, move them closer and record (e.g., 3/60)
• If still no letters: Count Fingers (CF), Hand Motion (HM), Perception of Light (PL), or No Perception of Light (NPL)
• Use a pinhole if VA is reduced - improvement with pinhole suggests a refractive cause rather than organic pathology

• Use a near vision chart (e.g., Jaeger test types) held at a comfortable distance (~33cm)
• Sensitive for early macular disease
• Note if patient uses reading glasses

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Step 2: Colour Vision

• Use Ishihara plates (test for red-green deficiency - screens for optic nerve disease)
• Useful in optic neuritis (red desaturation is an early sign)
• A light brightness comparison test can be done informally: hold a pen torch alternately in front of each eye and ask the patient to compare brightness - a dim perception in one eye suggests relative afferent pupillary defect (RAPD) or optic neuropathy

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Step 3: Visual Fields

• Confrontation testing (bedside): Sit opposite the patient at arm's length. Cover one eye each. Bring a finger in from the periphery in each quadrant. Compare with your own field as reference.
• For subtle defects use a red hatpin - colour desaturation in a scotoma is detected before white-target loss
• Formal fields: Humphrey automated perimetry (standard in glaucoma monitoring), Goldmann kinetic perimetry
• Amsler grid - for central/macular distortion; the patient fixates on the central dot and reports if any lines appear wavy or missing (metamorphopsia in AMD, CSCR)

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Step 4: Pupil Examination

• Size and symmetry at rest (anisocoria?)
• Direct light reflex - shine a light in one eye, the same pupil constricts
• Consensual reflex - the opposite pupil also constricts
• Swinging flashlight test for RAPD (Relative Afferent Pupillary Defect): Swing a torch from eye to eye every 2-3 seconds. If the pupil dilates when the light is swung to it (paradoxical dilation), there is an RAPD in that eye - indicating optic nerve disease or severe retinal disease on that side.
• Accommodation reflex - ask patient to look at a distant object then at your finger close up; pupil should constrict and eyes converge

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Step 5: Ocular Motility & Cover Test

• Ask patient to follow your finger through the 9 positions of gaze (H-pattern)
• Note any limitation, pain, or diplopia in any position
• Look for nystagmus

• Cover-uncover test: Cover one eye; watch the uncovered eye for movement (movement = manifest deviation/tropia)
• Alternating cover test: Rapidly alternate cover from eye to eye; detects latent deviation (phoria)

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Step 6: External Examination

• Periorbital: Swelling, bruising, skin lesions, ptosis
• Lids:
  • Ptosis (measure levator function: MRD1 = margin-to-reflex distance)
  • Entropion, ectropion, trichiasis
  • Lid margin - styes, chalazion, blepharitis (look for meibomian gland dysfunction, lid margin telangiectasia, crusting)
  • Eversion of upper lid to look for foreign bodies (papillae, follicles)
• Conjunctiva:
  • Injection pattern: conjunctival (peripheral/fornices, mobile with conjunctiva), ciliary/circumcorneal (limbal, fixed - suggests corneal/anterior segment disease)
  • Discharge: purulent, mucopurulent, serous
  • Follicles (viral, chlamydial) vs. papillae (allergic, bacterial)
  • Subconjunctival hemorrhage, chemosis, pterygium, pinguecula
• Cornea:
  • Clarity - opacities, scars, infiltrates, ulcers
  • Size - microcornea, megalocornea, buphthalmos
  • Fluorescein staining under cobalt blue light - reveals epithelial defects (abrasion, ulcer, exposure, HSV dendrite)
• Anterior chamber:
  • Depth (shallow = angle closure risk)
  • Hyphema (blood), hypopyon (pus - white/yellow level)
  • Look obliquely across with a slit lamp for flare and cells (uveitis)
• Iris:
  • Colour, posterior synechiae (adhesions to lens from uveitis), rubeosis (new vessels - suggests ischaemia)
  • Iridodonesis (trembling = aphakia or lens subluxation)
• Lens:
  • Clarity - nuclear sclerosis (yellow/brown), posterior subcapsular (PSC), anterior/posterior cortical cataracts
  • Position - subluxation in Marfan syndrome, homocystinuria

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Step 7: Slit Lamp Biomicroscopy (Anterior Segment)

• Diffuse broad beam - general survey, gross abnormalities
• Direct focal illumination (narrow slit beam) - assess depth and layering of corneal lesions, lens opacities
• Scleral scatter - decenter the beam to the limbus; detects subtle corneal stromal haze/infiltrates
• Retroillumination - reflects light from iris or fundus to illuminate cornea from behind; shows epithelial cysts, keratic precipitates (KPs), corneal blood vessels
• Specular reflection - assess corneal endothelium; shows guttata, reduced cell density

• Keratic precipitates (KPs): small/stellate (non-granulomatous uveitis) vs. large mutton-fat (granulomatous uveitis e.g. sarcoid, TB)
• Anterior chamber cells (grade 0-4+) and flare
• Corneal staining with fluorescein

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Step 8: Intraocular Pressure (IOP)

• Normal range: 10-21 mmHg
• Goldmann applanation tonometry - the gold standard; done at slit lamp after instilling topical anaesthetic and fluorescein
• Non-contact tonometry (air puff) - screening only, less accurate
• Icare rebound tonometer - no anaesthetic needed, useful for children and bedside
• Perkins tonometer - portable, for supine/examination under anaesthesia

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Step 9: Gonioscopy (Angle Examination)

• Special contact lens placed on the anaesthetised eye to examine the iridocorneal angle
• Essential for classifying glaucoma (open angle vs. closed angle) and looking for neovascularization of the angle (rubeosis iridis)
• Shaffer grading of angle width (Grade 0 = closed to Grade 4 = wide open)

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Step 10: Fundus Examination (Posterior Segment)

• Handheld, provides 15x magnification
• Upright, monocular image - no stereopsis, small field of view
• Useful at bedside
• Technique: examiner on same side as eye being examined, use same eye as patient's eye
• Start with red reflex check from ~25cm (lens/vitreous opacities block the reflex)
• Then approach to ~3cm, find the optic disc by directing the beam slightly nasally

• Wide field of view, stereoscopic, inverted & laterally reversed image
• Penetrates media opacities better than slit lamp
• Essential for peripheral retina (retinal detachment, peripheral tears)
• Use with scleral indentation for far periphery

• Best for detailed posterior pole examination (macula, disc)
• Inverted, virtual image
• Most common method in clinic

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Quick Reference: The Ophthalmology Examination Order

1. VA (with correction + pinhole)
2. Colour vision (Ishihara)
3. Visual fields (confrontation, Amsler grid)
4. Pupils (direct, consensual, swinging torch for RAPD)
5. Ocular motility + cover test
6. External examination (lids, adnexa)
7. Slit lamp (anterior segment: conjunctiva, cornea, AC, iris, lens)
8. IOP (Goldmann applanation)
9. Gonioscopy (if glaucoma suspected)
10. Dilated fundus exam (disc, macula, vessels, periphery)

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• Always examine both eyes and compare - most findings are more meaningful in context of the fellow eye.
• Document findings using standard abbreviations: RE/LE (right/left eye), BCVA, RAPD, KPs, AC cells/flare grade, C:D ratio.
• Learn to use the slit lamp early - it takes practice. Start with wide beam on low magnification, then narrow down.
• The Amsler grid and confrontation fields take 1-2 minutes but yield enormous diagnostic value - never skip them.
• When in doubt about IOP or disc changes, always refer to a senior or formal perimetry before dismissing the patient.

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