History-Taking for a New Patient with Glaucoma and Cataract

1. Presenting Complaint & Duration

• "What brought you in today? Has your vision changed recently?"
• "When did you first notice any problem with your vision?"
• Which eye is affected - right, left, or both?
• Has it come on gradually or suddenly?

2. Glaucoma-Specific Questions

Symptoms

• Peripheral vision loss - "Have you noticed anything missing from the sides of your vision?" (Open-angle glaucoma causes peripheral field loss first, often missed until late)
• Halos/coloured rings around lights, especially at night (angle-closure)
• Eye pain or headache - sudden severe pain is a red flag for acute angle-closure glaucoma
• Nausea/vomiting accompanying eye pain (acute angle-closure emergency)
• Red eye - unilateral redness with pain suggests angle closure
• Blurred vision - intermittent or persistent
• Difficulty reading, loss of contrast sensitivity (early open-angle symptom)

Glaucoma-Specific History

• When was glaucoma first diagnosed? By whom?
• What type - open-angle or closed-angle? Or unknown?
• Were you told your intraocular pressure (IOP) readings? What were they?
• Have you had any visual field tests (perimetry)? What did they show?
• Have you had optic nerve or cup-to-disc ratio assessments?
• Any previous laser treatment (trabeculoplasty, iridotomy) or surgery (trabeculectomy, tube shunt)?
• Are you currently using eye drops? Which ones? Are you using them as prescribed? (Compliance is a major clinical issue)
• Any side effects from drops - e.g. stinging, redness, change in eye colour, darkening of lashes (prostaglandins), bradycardia or wheeze (beta-blockers)?

Glaucoma Risk Factors to Elicit

• Family history of glaucoma (first-degree relatives significantly increase risk)
• African ancestry (increased risk for primary open-angle glaucoma, earlier onset, more severe)
• Age (risk rises after 40)
• High myopia (myopic eyes at higher risk)
• Thin corneas (affects IOP measurement accuracy)
• Systemic hypotension or low blood pressure
• Disc haemorrhages - ever mentioned by a previous eye doctor?
• Trauma to the eye (secondary glaucoma)
• Uveitis or inflammatory eye disease (secondary glaucoma)
• Diabetes (associated with neovascular glaucoma)
• Previous steroid use - topical eye drops, inhaled, or systemic (steroid-induced glaucoma)

3. Cataract-Specific Questions

Symptoms

• Blurring of vision - near, distance, or both?
• Glare and light sensitivity - especially when driving at night or in bright sunlight
• Halos around lights at night
• Faded or yellowed colours
• Double vision in one eye (monocular diplopia)
• "Second sight" - paradoxically improved near vision without glasses as nuclear sclerosis increases the refractive index of the lens (this is a classic early nuclear cataract symptom - worth asking about)
• Frequent change in glasses prescription recently
• Which eye is worse?

Cataract-Specific History

• When was cataract first diagnosed?
• How has the vision changed over time - slowly progressive?
• Has surgery been discussed or recommended?
• Any previous ocular surgery (e.g. prior cataract surgery in one eye, vitrectomy, retinal surgery - silicone oil is a recognised cause of cataract)

Cataract Risk Factors to Elicit

• Age (most important - nuclear sclerosis compresses with age)
• Diabetes mellitus (osmotic lens changes, posterior subcapsular cataract)
• Long-term corticosteroid use - topical, systemic, or inhaled (posterior subcapsular cataract)
• UV/sunlight exposure (cortical cataract risk)
• Smoking history
• Alcohol use
• Blunt or penetrating trauma to the eye
• Radiation exposure (head/neck radiotherapy)
• Previous uveitis or intraocular inflammation
• Systemic conditions - hypothyroidism, myotonic dystrophy, Down syndrome (paediatric)

4. Shared & Systemic History

5. Surgical History & Current Eye Drop Compliance

• Any previous eye surgeries on either eye?
• Are eye drops being used correctly? Demonstrate technique if possible
• Ask about storage of drops (some require refrigeration)
• Are they affordable and accessible? (Non-compliance due to cost is common with glaucoma drops)

6. Functional & Quality-of-Life Impact

• "How much has your vision affected your daily activities?" (reading, cooking, stairs, driving)
• Are you still driving? (Major safety and legal concern with visual field loss from glaucoma)
• Do you have falls or difficulty with steps/kerbs? (Peripheral field loss from glaucoma)
• Is there any difficulty with night driving? (Glare from cataract + field loss from glaucoma combined)
• "What are your main concerns/goals from today's visit?"

Key Clinical Flags to Watch For

• Acute angle-closure signs: sudden severe pain + red eye + nausea = ophthalmic emergency
• Non-compliance with glaucoma drops is the most common cause of progression - probe gently
• Cataract surgery can precipitate or worsen angle-closure glaucoma if the eye is anatomically narrow - this connection makes combined history critical
• Conversely, phacoemulsification (cataract extraction) can also lower IOP in some patients with glaucoma and may reduce the need for drops postoperatively - worth knowing the patient's expectations