Ophthalmology Case Sheet Format

1. Identification Data

• Name:
• Age/Sex:
• Address:
• Occupation:
• Date and time of examination:
• Informant and reliability:
• OPD/IPD No.:
• Referred by:

2. Chief Complaints

1. Itching in the right eye for 5 days.
2. Redness/watering/discharge/foreign-body sensation/pain/photophobia/diminution of vision: __________

3. History of Presenting Illness

• Site: Right eye / eyelids / medial or lateral canthus
• Onset: Sudden / insidious
• Duration: 5 days
• Course: Progressive / non-progressive / intermittent
• Severity and diurnal variation:
• Aggravating factors: Dust / smoke / pollen / cosmetics / screen use / eye drops / contact lenses / sunlight
• Relieving factors: Washing eye / cold compress / medication / none
• Similar episodes in the past: Yes / No
• Similar symptoms in the left eye: Yes / No
• Similar complaints among family members, classmates, or coworkers: Yes / No

Associated Ocular Symptoms

• Redness:
• Watering:
• Mucoid/mucopurulent discharge:
• Sticky eyelids on waking:
• Foreign-body sensation:
• Burning sensation:
• Eyelid swelling:
• Pain:
• Photophobia:
• Blurring/diminution of vision:
• Halos around lights:
• Floaters/flashes:
• Diplopia:
• Headache/nausea/vomiting:

Relevant Negative History

• Ocular trauma or foreign-body entry
• Chemical exposure
• Contact-lens use
• Recent eye surgery or ocular procedure
• Use of topical eye drops, especially steroid-containing drops
• Fever, upper respiratory symptoms, sore throat, or recent viral illness
• Exposure to a person with red eye/conjunctivitis
• Reduced vision, severe eye pain, photophobia, or purulent discharge

Allergic History

• Sneezing, rhinorrhea, nasal blockage, or allergic rhinitis
• Asthma, eczema, or other atopic illness
• Food/drug allergy
• Exposure to dust, pollen, animal dander, smoke, or cosmetics

4. Past Ocular History

• Previous episode of red eye/itching:
• Refractive error and use of spectacles:
• Contact-lens use:
• History of trauma:
• Previous ocular surgery:
• Previous use of topical medications:
• History of glaucoma, cataract, uveitis, retinal disease, or squint:
• Last eye examination:

5. Past Medical History

• Diabetes mellitus:
• Hypertension:
• Tuberculosis:
• Thyroid disease:
• Autoimmune disease:
• Skin allergy/atopy/asthma:
• Any chronic illness:
• Hospital admissions/surgeries:

6. Drug and Allergy History

• Current medications:
• Recent topical eye drops:
• Drug allergy:
• Food/environmental allergy:

7. Personal History

• Diet:
• Appetite:
• Sleep:
• Bowel and bladder habits:
• Smoking/tobacco:
• Alcohol:
• Occupation and occupational exposure:
• Screen time:
• Cosmetic use around eyes:
• Pets/animal exposure:

8. Family History

• Similar eye complaints in family:
• History of allergy, asthma, eczema, or allergic rhinitis:
• Family history of glaucoma, cataract, retinal disease, squint, or blindness:

Examination

9. General Physical Examination

• General condition:
• Build and nourishment:
• Pallor/Icterus/Cyanosis/Clubbing/Lymphadenopathy/Edema:
• Pulse:
• Blood pressure:
• Temperature:
• Respiratory system:
• Cardiovascular system:
• CNS examination:

10. Ocular Examination

A. Visual Acuity

B. External Examination

C. Orbit and Ocular Adnexa

• Orbital margins:
• Tenderness:
• Lacrimal sac regurgitation test:
• Preauricular lymph nodes:
• Eyelid eversion: Papillae/follicles/foreign body/concretions:

D. Ocular Motility and Alignment

• Extraocular movements: Full/restricted in __________
• Diplopia: Present/absent
• Cover-uncover test:
• Alternate cover test:
• Convergence:
• Nystagmus:

E. Pupillary Examination

F. Intraocular Pressure

G. Slit-lamp Examination

• Conjunctival congestion: absent/mild/moderate/severe
• Chemosis: present/absent
• Papillae or follicles: present/absent
• Type of discharge: none/watery/mucoid/mucopurulent
• Corneal epithelial defect or staining with fluorescein: present/absent
• Foreign body after upper-lid eversion: present/absent

H. Posterior Segment Examination

I. Visual Fields

• Confrontation visual fields:
• Perimetry, if indicated:

J. Colour Vision

• Ishihara plates:
• Red desaturation, if indicated:

K. Refraction

• Cycloplegic refraction, if indicated:

11. Systemic Examination Relevant to Eye Disease

• Skin: eczema, rash, allergy
• Nose: allergic rhinitis, nasal congestion, rhinorrhea
• Throat: pharyngitis
• Respiratory system: wheeze/asthma
• Joints/other signs of autoimmune disease:

12. Provisional Diagnosis

Right-eye allergic conjunctivitis, to rule out viral/bacterial conjunctivitis, dry-eye disease, blepharitis, retained foreign body, and contact/allergen-related ocular surface irritation.

13. Differential Diagnosis

1. Allergic conjunctivitis
2. Viral conjunctivitis
3. Bacterial conjunctivitis
4. Dry-eye disease
5. Blepharitis/meibomian gland dysfunction
6. Foreign body or ocular surface irritation
7. Contact-lens-related keratitis, if applicable
8. Vernal keratoconjunctivitis, especially in recurrent/severe allergic symptoms

14. Investigations

• Fluorescein staining of cornea
• Tear-film break-up time and Schirmer test
• Conjunctival swab/culture in severe or refractory purulent discharge
• Intraocular pressure measurement
• Refraction
• Fundus examination
• Allergy evaluation in recurrent or severe symptoms

15. Final Diagnosis

• Diagnosis:
• Laterality:
• Severity:
• Associated refractive/systemic condition, if any:

16. Management Plan

• Patient counselling and avoidance of suspected allergens/irritants
• Lid hygiene/cold compresses/lubrication, where appropriate
• Drug treatment as prescribed by the ophthalmologist
• Avoid self-medication and avoid topical steroid drops unless specifically prescribed
• Follow-up after: __________
• Warning symptoms explained: eye pain, photophobia, reduced vision, significant swelling, trauma, or purulent discharge

Example Ophthalmology Case Sheet

Identification Data

• Name: Ms. A
• Age/Sex: 22 years/Female
• Occupation: College student
• Address: __________
• Date of examination: 13 October 2026
• Informant: Patient herself, reliable
• OPD No.: __________

Chief Complaints

1. Itching in the right eye for 5 days.
2. Watering and mild redness in the right eye for 5 days.

History of Presenting Illness

Past Ocular History

• No previous history of recurrent red eye or itching.
• No history of ocular trauma.
• No history of eye surgery.
• No history of spectacle use or contact-lens use.
• No known history of glaucoma, cataract, uveitis, squint, or retinal disease.
• No prior use of topical ocular medication.

Past Medical History

• No history of diabetes mellitus, hypertension, tuberculosis, thyroid disease, or autoimmune illness.
• No history of bronchial asthma or eczema.
• No significant past hospitalization or surgery.

Drug and Allergy History

• Not taking any regular medication.
• No known drug allergy.
• History suggestive of dust allergy.

Personal History

• Diet and appetite normal.
• Sleep normal.
• Bowel and bladder habits normal.
• Non-smoker and non-alcoholic.
• Frequently travels in dusty surroundings.
• No use of eye cosmetics or herbal eye preparations.

Family History

• No family history of glaucoma, retinal disease, squint, or blindness.
• Mother has allergic rhinitis.

Examination

General Physical Examination

• Patient conscious, cooperative, and well-oriented.
• General condition satisfactory.
• Built and nourishment average.
• No pallor, icterus, cyanosis, clubbing, lymphadenopathy, or pedal edema.
• Pulse: 76/min, regular.
• Blood pressure: 110/70 mmHg.
• Temperature: Afebrile.

Systemic Examination

• Respiratory system: Normal vesicular breath sounds; no wheeze.
• Cardiovascular system: S1 and S2 heard; no murmur.
• Central nervous system: No focal neurological deficit.
• Skin: No eczema or skin rash.
• ENT examination: Mild nasal mucosal congestion with clear rhinorrhea.

Local Ophthalmic Examination

Visual Acuity

External Examination

Ocular Movements and Alignment

• Extraocular movements: Full and free in all directions in both eyes.
• Ocular alignment: Orthophoria.
• Diplopia: Absent.
• Nystagmus: Absent.

Pupillary Examination

Intraocular Pressure

Slit-lamp Examination

Fundus Examination

Colour Vision and Visual Fields

• Colour vision: Normal on Ishihara chart.
• Confrontation visual fields: Full in both eyes.

Summary

Provisional Diagnosis

Acute allergic conjunctivitis, right eye, associated with allergic rhinitis.

Differential Diagnosis

1. Viral conjunctivitis
2. Early bacterial conjunctivitis
3. Dry-eye disease
4. Blepharitis with secondary conjunctival irritation
5. Foreign body in the upper fornix
6. Contact allergic blepharoconjunctivitis

Investigations

• Visual acuity assessment
• Slit-lamp examination
• Fluorescein staining of cornea: Negative
• Intraocular pressure measurement: Normal
• No further investigation required at present

Management Plan

1. Explain probable allergic trigger and advise avoidance of dust, smoke, perfume, and eye cosmetics where possible.
2. Cold compresses over closed eyelids.
3. Avoid rubbing the eyes.
4. Preservative-free lubricating eye drops as advised.
5. Topical anti-allergic medication may be prescribed by the ophthalmologist.
6. Treat associated allergic rhinitis if clinically required.
7. Strictly avoid unsupervised topical steroid eye drops.
8. Review after 5 to 7 days, or earlier if symptoms worsen.