Author details

Dr. Bilal Abou El Ela Bourquin (MB BChir BSc FInstLM)

Foundation Year Two Doctor, Hinchingbrooke Hospital, Northwest Anglia NHS Trust, UK

>>Contact author<<

Aims

This article aims to introduce the reader to the principles and practice of efficient history taking in Ophthalmology. It provides a structured approach to information gathering. It does not, however, aim to discuss ophthalmic diagnoses in detail or explain the pathophysiology behind different symptomatology.

Benefits of taking an accurate history

Doctors and allied health professionals are often presented with patients who complain of an issue with their eye. Many professionals do not feel confident taking an accurate and comprehensive ophthalmic history. Learning how to take a good history has several benefits.

It helps to:

• Focus your examination and aid choice of investigations.

• Devise a differential diagnoses, rule conditions in or out, and ultimately proceed with a working hypothesis.

• Build initial rapport with patients, which helps put them at ease for the subsequent physical examination.

• Comprehend the impact of the disease on the patient, and identify any potential hindrances to treatment adherence.

• Form a patient-doctor relationship based on trust, respect and empathy.

A structured approach to ophthalmic history taking

1. Personal and demographic data

• Full name.

• Address and phone number for follow-up.

• Age and gender.

• Spoken language.

• Disabilities.

2. Presenting Complaint (PC) i.e., reason for visiting.

Ask the patient about what issues made them attend. Document the presenting complaints in the patient’s own words. Chronology of complaints is important.

• Why did the patient present?

• Was it for a routine review or for a new issue?

• Who referred them? Is the referral reason and timeline warranted?

• Screen for other eye-specific complaints so as not to miss anything important:

• Floaters and flashing lights (classic symptoms of retinal detachment and retinal tears)

• Transient vision loss (think micro-emboli in older patients)

• Blurry vision

• Redness and pain

• Chronic itching and tearing (think allergies, blepharitis)

• Headaches and scalp tenderness (think giant cell arteritis)

3. History of Presenting Complaint (HPC):

Interrogating ophthalmic complaints requires specific questions regarding:

• Location (one eye or both eyes?)

• Onset (sudden or gradual, which eye first?)

• Character (e.g., of the pain, sharp pain or dull ache?)

• Precipitants

• Associated symptoms (pain, redness, floaters, flashing lights, itching, discharge, photophobia, blurry vision, headaches, scalp tenderness)

• Timing (duration, time of day)

• Exacerbating factors (what makes it worse?)

• Relieving factors (what makes it better?)

• Severity (how severe is the pain out of 10?)

• Past episodes of similar problems

• What ideas, concerns and expectations does the patient have? e.g., a floater might seem trivial to an ophthalmologist but may be distressing to the patient.

• The practitioner muse be able to estimate diagnostic probabilities based on the information gathered, and ask follow-up questions to rule diagnoses in or out.

4. Past Ocular History (POH):

Ask for detail about previous ocular problems. A patient’s past medical history will aid with your differential diagnosis. If the patient is a poor historian you may be able to elucidate some of their past ocular history from their ocular medications and physical examination findings.

• Past clinic visits with similar eye complaints. Important for relapsing conditions such as herpes simplex keratitis, allergic conjunctivitis, anterior uveitis, and corneal erosions.

• Past complaints in the other eye. This is relevant in bilateral conditions.

• Previous/concurrent eye diseases (including glaucoma)

• Past eye surgery (including cataract surgery, muscle surgery, or retinal surgery)

• Past trauma. This may explain problems such as cataract and retinal detachment.

• Refractive error and use of spectacles including contact lenses.

5. General Medical History:

This should include general questions about any medical problems, but with specific emphasis on conditions that could directly contribute to their eye problems (e.g., diabetes, hypertension, hypercholesterolaemia, eczema, arthritis). Also ask about thyroid problems and asthma before prescribing a beta-blocker.

6. Family Eye History:

Family history is relevant to hereditary diseases (e.g some corneal dystrophies, retinitis pigmentosa, retinoblastoma) and to infective conditions (e.g. conjunctivitis, tuberculosis, HIV etc). As a minimum, focus on a history of glaucoma and blindness. Ask about age of onset as these could affect how likely the patient is to suffer from similar conditions.

7. Medication History:

• What eye drops is the patient taking (or has taken in the past) and why? How compliant are they with their prescribed course dose, length and frequency? (This will help determine whether the medication is actually ineffective or simply not taken appropriately). Are they using a regular eye drop? Did they bring their eye drops with them to the appointment?

• What other medications do they take? Important to consider this in order to avoid drug dangerous contraindications (e.g. asthma, COPD and beta blockers) and interactions – these can be checked online e.g., in the British National Formulary.

• Make sure to ask about traditional/herbal medication in a non-judgemental manner.

8. Allergy History:

• Allergies to previous medications (including eye drops) or any other substances (e.g., latex) or foods. What specific reaction did they have?

• Make sure to document allergies clearly to make the multi-disciplinary team aware.

9. Social History (SH):

• Smoking (amount, duration, type).

• Alcohol intake (amount in Units, duration, type).

• Home environment/social context.

• Independent in activities of daily living? Will they manage regular eye drops? Do they have the manual dexterity and memory to do this?

• Occupation.

• Driving.

• This is a good opportunity to ask the patient about how the condition is affecting their life.

10. Birth and immunisation history:

• For children, the birth history and vaccination status are significant.

Top tips

• Introduce yourself clearly to your patients – this helps them remember you and establishes a friendly atmosphere.

• Always respect patient confidentiality while taking a history. Many ophthalmic departments have an open plan layout – so maximise patient privacy as much as you are able.

• Ask simple and clear questions. Open to start off with (to elucidate all the patient’s complaints) and closed yes/no questions as the consultation develops further (to gain further detail and clarification).

• Avoid medical jargon and acronyms. Patients have a tendency to nod but oftentimes they are not 100% clear as to what has been discussed.

• Listen attentively, make eye contact, and demonstrate good body language.

• Understand the patient’s perspective. Empathy for a patient’s ideas, concerns and expectations is key.

• Be mindful that older patients or those with disabilities (hearing, speech, or learning

Impairments) might need ample time to understand your statements/questions and to reply.