OPHTHALMOLOGIC HISTORY 2.

Seasonal
F. Documentation
I. GENERAL DATA
A. Name G. Nationality III. PAST OCULAR HISTORY
B. Age H. Religion A. Previous Eye problems
C. Gender I. Occupation B. Ocular Surgery
D. Address J. # of Admission C. Ocular Medications
E. Birthday K. Date of Admission D. Trauma
F. Birthplace L. Handedness
I. CHIEF COMPLAINT IV. GENERAL MEDICAL AND SURGICAL HISTORY
A. VISUAL DISTURBANCE A. Allergies
1. Blurred/ decreased vision 1. Environmental
a. distance or near 2. Systemic
b. permanent or transient 3. Topical
c. central or peripheral B. Medications: anti plt meds
d. floaters C. Physical Illness
2. Color Vision Abnormalities D. Surgeries
3. Decreased Peripheral Vision
4. Nyctalopia D. Pediatric Px 1. Prenatal
5. Iridiscent Vision- halos 2. Natal
6. Floaters 3. Post Natal
7. Photopsias- 4. Developmental
a. flashes of lt, V. FAMILY HISTORY
b. rings, A. Glaucoma
c. flashes, B. Cataract
d. luminous bodies C. Retinal Detachment
8. Altered image size C. Poor Vision of Unknown Cause
a. Micropsia
b. Macropsia
9. Diplopia EIGHT PART EYE EXAMINATION
10. Oscillopsia: movt of objects, inadeq fixn stablzn
11. Reading problems I. VISUAL ACUITY
12. Metamorphopsia – distorted A. DISTANCE
B. PAIN OR DISCOMFORT 1. Snellen’s / Illiterate “E” / Allen Object Recog’n Chart
1. Superficial Foreign Body Sensation a. without glasses (sc)
2. Deep Pain i. pinhole
3. Headache b. with glasses (cc)
4. Burning or Itching i. pinhole
5. Photophobia c. counting fingers
C. ABNORMAL EYE SECRETIONS d. hand movement
1. Overabundance e. light perception
a. Epiphora- w/ spillage i. light projection -good 4 quad
b. Lacrimation – w/o spillage -fair 2-3 quad
2. Eye Dryness -poor 1 quad
3. Eye Discharge B. NEAR
a. watery 1. Jaeger Notation / Snellen’s 14/ 14 Reference
b. mucoid
c. mucopurulent II. GROSS EXAMINATION
II. HISTORY OF THE PRESENT ILLNESS A. Orbit 1. Facial Hemiatrophy
A. Onset/ Time 2. Facial Asymmetry
1. Sudden 3. Proptosis
a. Persistent, Unilateral Decrease of Vision 4. Exo/ Enophthalmos
i. Angle Closure Glaucoma a. Exophthalmometry
ii. Iridocyclitis 5. Echymosis
iii. Vitreous Hemorrhage 6. Crepitus
iv. Retinal Detachment/ 7. Swelling/ Inflammation/ Masses
Venous Occlusion
v. Optic Neuritis B. Eyelids 1. Lid Lag, Lid Retractions
b. Bilateral 2. Ptosis
i. Hysteria a. Levator Fxn Test: N: 15mm
ii. Drug Toxicity: barbiturates, digox :Good >8mm
2. Gradual :Fair 5-7mm
a. Unilateral Visual Loss :Poor<4mm
i. Corneal Opacities 2. Puncta: Patency, Apposition
ii. Cataract
iii. Vitreous Opacity 3. Inflammation a. Infection
iv. Glaucoma b. Allergic
v. Retinal Detachment
vi. Macular Degeneration 4. Intercanthal Distance : telecanthus
vii. Intraocular inflammation
B. Laterality 5. Masses a. Ext hordeola
1. Unilateral b. Chalazion
2. Bilateral c. Sebaceous Cell CA
C. Precipitating factors d. Tumor
1. Prior therapeutic efforts e. Melanoma
2. When px refractive prescription was changed f. Hemangioma
D. Severity g. Xanthelasma
1. Worsened h. Papilloma
2. Improved
3. Remained the same 6. Margins : dry flaky: Blepharitis
E. Timing oiliness
1. Intermittent
 6. Eyelash a. Trichiasis
b. Districhiasis G. Sensory Assessment
c. Poliosis 1. Worth’s 4 dot Test
7. Ectropion/ Intropion 2. Titmus Stereo Test

8. Skin Fold a. Epiblepharon: extra IV. PUPILS

b. Cutis Laxa: redundant A. General Info 1. Size, Shape, Location
c. Lymphedema of lids 2. Direct Pupil Response (+4)brisk, (+1)slug
C. Lacrimal System
1. Lacrimal Sac a. Mass B. Swinging Flashlight Test 1. Direct and Consensual Reflex
b. Erythema C. Near Response: part of the near synkinesis
c. Tenderness : gaze shifts fr distance to near: convergence
d. Swelling :accommodation
e. Schirmers Test: I > 15mm N :miosis
II > 10 mm N E. Abnormal Pupils
Jones I and II 1. Iris defects: developmental or traumatic
f. Obstruction : Probing a. Surgery
Dcryocystgram b. Inflxn
III. OCULAR MOTILITY c. Direct Blow: Miosis, Mydriasis,
(LR6SO4)3 Levator palpebrae and superioris muscle Sphincter Tears
d. Ant and Post Synechiae
MOTILITY TESTING: comittant or heterotropia; e. Developmental Anomalies
Noncommitant or paralytic
Heterophoria 2. Marcus Gunn Pupil: Optic Nerve Lesion

A. Cover Test 3. Light Near Response Dissociation

1. Monocular Cover Uncover Test 4. Fixed dilated pupil
2. Alternate Cover Test (Prism and Uncover Test) 5. Tonic Pupil
3. Simultaneous Prism Cover Test 6. Horner’s Pupil

B. Corneal Light Reflex Tests V. VISUAL FIELDS: PERIMETRY

A. Screening Tests
1. Hirschberg Test 1. Quadrant Confrontation
1mm 7 degree 15PD 2. Finger Counting
2mm 15 deg 30PD (papillary margin) 3. Double Simultaneous Confrontation
4mm 30 deg 45 PD (mid iris)
6mm 45 deg 60 PD (limbus) B. Tests with Special Instruments

2. Modified Krimsky Method VI. SLIT LAMP

3. Major AMblyopscope Method A. Eyelids and lashes
B. Conjunctiva and Sclera 1. Follicles
C. Dissimilar Image Tests 2.
1. Maddox Rod Test C. Cornea and TEarfilm
2. Double Maddox Rod Test D. Anterior Chamber
3. Red Filter Test E. Iris
F. Lens
D. Dissimilar Target Tests G. Special 1. Gonioscopy zonules, vitreous, retina
1. Lancaster Red-Green Test
2. Major Amblyoscope Test VI. TONOMETRY

E. Pseudostrabismus and Angle Kappa VII. FUNDOSCOPY

Pseudostrabismus- prominent semilunar fold: epicanthu Direct
Angle Kappa Indirect

F. Positions of Gaze
1. 1*:eyes when fixating an obj at initially straight ahead
2. 2*: L and R gaze, straight up & straight down
3. 3*: 4 oblique positions of gaze
4. Cardinal: 6 positions of gaze in w/c 1 muscle of the eye
is the prime mover
5. Midline: straight up and down
6. Diagnostic Positions of Gaze: 1* position, 6 cardinal
positions, 2 midline positions
7. A and V patterns
a. A pattern: esotropia greatest in upgaze;
exotropia greatest in downgaze
b. V pattern: esotropia greatest in downgaze;
exotropa greatest in upgaze
8. Near Fixation Position: tested at 14 in (33 cm)
9. Near point of convergence
a. N: 8- 10 cm
b. Dominant Eye: eye that is able to maintain
fixation
10. Skew Deviation: 3 step test
a. Determine w/c eye is hyperopic,
accomplished with the cover-uncover test
b. Det whether the vertical deviation is greatest
in the R or left gaze
c. DEt w/c of the 2 isolated muscles is the
palsied one; head is tilted first to the left and
then R while deviation is measured in each
position