useful at this point to discuss support groups and local agencies.

4.Discuss the availability of low vision aids and what help they could provide. In this respect, remember the stages of response to vision loss. Patients are unlikely to have the motivation to successfully use low vision aids when depressed. Do not give up on these patients. As and when they overcome the depression and accept their vision loss, low vision aids may usefully be provided.

5.It can be very useful to explain all this information to the patient’s family if they are present and if the patient is happy for you to do so.

6.Information leaflets are particularly useful in these situations as the patient’s shock at the initial news may mean that much of the remainder of your discussion is forgotten.

2.3 THE CASE HISTORY

The case history is the cornerstone of an eye examination. You must listen to the patient to determine what their problems are and ask appropriate questions to obtain the crucial details about their complaints. The case history puts you in the position of detective. There may be problems to discover and you must use all your skills of observation, listening, and questioning to identify them as completely as possible. Undoubtedly the case history can differentiate an experienced clinician from a novice. It is common for clinical supervisors to have to ask several additional questions of a patient after a student has completed the examination. As a student, you should not worry about this, as you will improve with experience. However, never underestimate the value of history taking and how much there is to learn to be competent at it.

2.3.1 Information provided

Here are a few important points that the case history provides:

■A general observation of the patient. For example, you should notice any peculiarities

of a patient’s gait, head position, facial asymmetry, skin colour, physiological appearance in relation to chronological age, ability to speak and articulate, intellectual level, emotional state, overall state of health.

■Age, gender and race information allows you to think about the most likely problems in the light of the prevalence of ocular disorders and their association with these factors.

■The patient’s chief complaint allows you to mentally list the most likely tentative

diagnoses and ask appropriate supplementary questions to begin differential diagnosis during the case history. Some differential diagnoses, such as a red eye, may rely heavily on case history.

■Information about the patient’s happiness with their current spectacles and/or contact lenses helps you determine whether to prescribe new lenses when the refractive change is low. Similarly, the degree of symptoms, combined with your assessment of personality and the amount of detailed visual work performed helps you to determine whether to prescribe a low-power refractive correction.

■The ocular history indicates whether the patient has had previous ocular treatment or surgery. A history of an ocular abnormality allows you to look for the manifestations of the disorder and any secondary effects (for example, glaucoma following central retinal vein occlusion).

■The medical history may indicate that you should particularly look for certain ocular disorders which manifest in certain systemic disease (most commonly diabetes) and whether it is safe to use certain diagnostic drugs such as phenylephrine.

■The medication information may alert you to possible adverse effects of systemic medications (e.g. dry eye in an elderly hypertensive taking beta-blockers).

■Family history information determines if there are any hereditary ocular and/or medical conditions in the patient’s family.

22 Clinical Procedures in Primary Eye Care

Common examples include a family history of diabetes, hypertension, myopia, strabismus, amblyopia and glaucoma.

■Information regarding the patient’s occupation and hobbies is very useful when you are prescribing spectacles, particularly for near work. For example, you want to know whether the reading addition needs to provide clear vision for computer work, reading, sewing or all three, whether the patient uses protective eyewear when playing sports and whether the patient drives with spectacles or not.

■Using the problem-orientated examination means that the case history decides to some degree which tests/procedures you are going to perform.

2.3.2 Procedure

1.Make sure that the room lights are on before the patient enters the examination room.

2.Observe the patient’s appearance: Observe their stature, walking ability and overall physical appearance. Pay particular attention to any head tilt or obvious abnormalities of the face, eyelids and eyes that will require further investigation, such as facial asymmetry, lid lesions, ptosis, epiphora, entropion, ectropion, a red eye or strabismus.

3.You should sit about 1 m from the patient at eye level. Try to avoid long silences while writing notes and attempt to develop the ability to write down answers as the patient is talking, while retaining intermittent eye contact. Try to avoid long periods without making eye contact with the patient.

4.Chief Complaint (CC) or Reason For Visit (RFV): Determine the chief complaint by asking a very general open-ended question such as ‘Do you have any problems with your vision or your eyes?’ or ‘Is there any particular reason for your visit, Ms Smith?’ With some patients, you may get a good description of the problem with little prompting. However, you are

unlikely to obtain all the information you require and so will have to ask some questions to ‘fill in the holes’ in what the patient has already told you. The order of the type of questions you would generally ask is given below, to provide a reasonable acronym LOFTSEA for students, rather than a logical sequence. Examples of questions to ask are provided for symptoms of blurred distance vision, headaches and diplopia.

a)Location/laterality. Examples:

■‘Is the blurred vision in both eyes or just one?’, ‘Is the blurred vision greater in one eye or the other?’

■‘In which part of the head is the headache located?’ For a frontal headache, ask ‘Is it above one eye more than the other?’

■‘Is the double vision in all directions of gaze or just one?’

b)Onset. Examples:

■‘How long have you had blurred distance vision?’

■‘When did the headaches start?’

■‘When did you first get double vision?’

c)Frequency/occurrence. Examples:

■If the blurred vision is variable ask ‘How often do you get the blurred vision?’

■‘How often do the headaches occur?’, ‘How long do the headaches last?’

■‘How often do you get double vision?’

d)Type/severity. Examples:

■‘Is the blur constant or intermittent?’, ‘Did the blurred vision start suddenly or gradually?’ If sudden vision loss, ask

‘Was the vision loss partial or total?’

■‘Is it a throbbing, sharp or dull headache?’

■‘Is the double vision one-on-top-of- the-other or side-by-side?’

e)Self-treatment and its effectivity:

■‘Does anything make the blurred vision go away?’ (possibly a family member’s spectacles for example)

■‘Does anything make the headaches go away?’

■‘Does anything make the double vision go away?’

f)Effect on the patient:

■‘Is your poor vision affecting how well you can do your job/ schoolwork?’

■‘How badly do the headaches affect you?’ ‘Have you been to see your GP about the headaches?’

■‘Do you ever get the double vision when driving?’ ‘Have you seen a physician about the double vision?’

g)Associated factors: ‘Are there any other symptoms associated with the problem?’

5.Symptom check:

a)In a patient who has a chief complaint, you then need to ask about other visual problems (unless they were disclosed when discussing the chief complaint). For example, if a patient has a chief complaint of headaches, once you have a complete description of the headaches, you need to ask about their distance vision, near vision, eyestrain, pain or discomfort and diplopia. If a positive response to any of these questions is obtained, you then need to obtain a complete description of that complaint.

b)In a patient stating they have no complaints to the general question asked above and who has just attended for their regular annual/biannual examination, ask the following questions:

■‘How is your distance vision?’ This can be adapted to suit the patient. For example, a student could be asked ‘Any problems reading from the whiteboard?’ and ‘Is everything clear on the TV?’

■‘Any problems with reading?’ This can also be adapted to suit the patient. For example, a secretary could be asked: ‘Can you see the computer screen clearly?’

■‘Do you get any eyestrain?’

■‘Do you get any headaches?’

■‘Do you ever get any pain or burning/discomfort in your eyes?’

■‘Do you ever see double?’

■Direct questioning regarding haloes, flashes and floaters can lead to longwinded and unnecessary descriptions of normal entoptic/light scatter phenomena (flashes of light when you press on the eye or the halo seen around candles) and are generally best not asked routinely, but should be asked of patients with high myopia or with other risk factors for retinal detachment.

6.Ocular History (OH) and Family Ocular History (FOH):

a)If you are unsure, ask if the patient wears spectacles. If they do, then you need a complete description of the spectacles used. This may include:

■‘How many pairs of spectacles do you have?’

■‘What type are they and what do you use them for?’

■‘Do you wear your spectacles all the time?’ (if you suspect that they should) or ‘When do you wear your spectacles?’

■‘How old are your spectacles?’

■‘Where did you get these spectacles from?’

■‘How old were you when you first wore spectacles?’

■‘Do you have prescription sunglasses?’

■Particularly in a patient who has no visual complaints: ‘Are you still happy with the fashion and fit of your spectacle frame?’

b)If you are unsure, ask if the patient wears contact lenses. If they do, then you need a complete description of the contact lenses used:

■‘What type of lens are they?’ (soft, gas permeable, toric, bifocal, etc.)

■‘How old are your contact lenses?’

■‘Who prescribed the lenses?’

■‘How long do you usually wear the lenses each day?’ and ‘How many days per week?’ Also: ‘What is the longest that you will wear your lenses?’

24Clinical Procedures in Primary Eye Care

■‘When did you put your contact lenses in today?’

■‘What cleaning solutions do you use?’

■‘When was your last contact lens aftercare?’

■‘When is your next aftercare check scheduled?’

■‘Have you had to stop contact lens wear for any reason, even for a short time?’

■‘When did you first start wearing contact lenses?’

c)If the patient wears both spectacles and contact lenses, you will have to ask about visual symptoms (i.e. distance blur, near blur, headaches, eyestrain, etc.) in both situations.

d)Ask whether the patient has had any previous eye injuries, infections, surgery or treatment. Follow up any positive responses by asking the patient how old they were at the time, who managed the condition and over what period and what treatment they received. For example, if a patient indicates they have amblyopia, discover the age they were diagnosed (the later the diagnosis, the higher the likely degree of amblyopia) and whether and at what time they

had an ‘eye-patch’, ‘eye exercises’, spectacles or surgery.

e)If you do not already know, ask the patient when their last eye examination (LEE) was and by whom it was done.

f)Family Ocular History (FOH): An openended question such as ‘Has anybody in your family had any eye problem or disease?’ should be asked. This can be clarified by providing examples of common hereditary conditions such as cataract or glaucoma for older patients, or spectacles, squint or lazy eyes with children.

7.General Health Information: A general question of ‘how is your general health?’ can be misleading because some patients think that systemic diseases are not relevant when they are borderline or are controlled by

medication. It is better to follow up the initial question and give some examples of what is being specifically sought after, such as ‘any high blood pressure or diabetes?’ If you get a positive response to this question, you must ask the patient how long they have had the condition as ocular effects of systemic diseases are more likely the longer the patient has had the condition. For example, the duration of diabetes is a major risk factor for diabetic retinopathy (Moss et al. 1998). If the patient has diabetes or hypertension, ask how well the condition is controlled. The risk of diabetic retinopathy is greatly reduced with good glycaemic control in diabetic patients (Shamoon et al. 1993) and by good blood pressure control in a patient with diabetes and hypertension (Stearne et al. 1998). An alternative or additional question for a female who may be pregnant is to ask the patient if they see their GP or a practice nurse regularly. It is important to ask patients whether they are taking any medication even if they indicate that their general health is fine. Patients may believe their general health is fine because it is controlled by medication. Patients may also be taking medications, but be unsure why, because the medical diagnosis was not properly explained or was poorly understood. It is important to determine any medications that the patient is taking as some can have adverse ocular effects. For example, it is well known that beta-blockers prescribed for systemic hypertension can cause dry eyes and oral corticosteroids can cause posterior subcapsular cataracts. Typically, the higher the dosage of the drug and the longer the patient has been taking them, the more likely are adverse ocular effects. Therefore it is important to ask about the dosage and number of tablets taken per day and how long they have taken the drug. Note that patients may not consider ‘over-the-counter’ tablets, such as travel sickness pills, antihistamines, sleeping pills and painkillers as medications, so it can be useful to ask about them specifically, particularly with patients with unexplained symptoms. Similarly, female patients may not consider birth control pills to be medication, yet the

drugs in these pills can have adverse ocular effects. Ask the following questions:

a)‘How is your general health?’ and add a follow-up question such as ‘any high blood pressure or diabetes?’

b)If you receive a positive response, ask the patient how long they have had the condition. For some conditions, such as diabetes and hypertension, ask whether the condition is well controlled.

c)‘Do you take any medication?’

d)If you receive a positive response, ask the patient how long the medication has been taken, the present dosage and the number of tablets taken per day.

e)‘Any allergies?’

f)Ask the patient when they last visited their GP (last medical examination, LME) and obtain the name of the GP.

g)Family Medical History (FMH): Ask an open-ended question, clarified by examples, such as ‘Has anybody in your family had any medical problem?’ This can be clarified by providing examples of common hereditary conditions such as ‘any diabetes or high blood pressure in the family?’

8.Vocation, sports, hobbies, computer use and driving: Determine the patient’s visual demands, including the safety hazards/ protection for the patient’s vocation as well as their sports and hobbies. For presbyopic patients, you need to discover the distance used for reading and other near tasks and the use of any additional reading lights (e.g. anglepoise or goose-neck lights, etc.; section 4.23). Question whether they use a computer on a regular basis and determine approximate weekly usage. Determine

whether the patient drives and whether they wear contact lenses or spectacles when driving.

9.History of falls: It can be useful to ask patients who are at risk of falling (over 75 years of age, using more than three medications, antidepressant use, systemic conditions that reduce mobility, cardiac problems, etc.) or who may be more dependent on their vision

for balance control (elderly patients with somatosensory system dysfunction such as diabetes and/or peripheral neuropathy or those with vestibular system dysfunction, such as Ménière’s disease), whether they have a history of falling. A history of falls increases their risk of falling again. Patients at high risk of falling need to be identified as they should have more regular eye examinations, earlier cataract surgery and an altered spectacle prescribing strategy (section 4.24.5; Buckley & Elliott 2006).

10.Summarise the case history: Summarise the pertinent information from the case history and allow the patient to clarify any misunderstanding on your part or to add any additional information that has been missed. For example, ‘So Mrs Jones, the main reasons for your visit are that reading has become a little difficult, even with your glasses, and that you particularly want me to perform all the glaucoma diagnostic tests because your mother has glaucoma. Is that correct?’

11.Remember that a case history continues throughout the examination. Certain signs or test results during the examination may suggest the need for further questioning.

Box 2.1 Summary of case history procedure

1.Determine the chief complaint. Use LOFTSEA or similar to collect all the appropriate information

2.Symptom check: Check the following if not part of the chief complaint: distance vision, near vision, headaches, eyestrain, pain or discomfort and diplopia

3.Ask about the patient’s ocular history, family ocular history and LEE

4.Obtain general health information: All systemic diseases, medications, allergies, family medical history and LME

5.Vocation, sports, hobbies, computer use and driving

6.Summarise the case history

7.Remember that a case history continues throughout the examination

2.3.3 Recording

Both positive and negative patient responses must be recorded. Remember that from a legal viewpoint, if the response was not recorded the question was not asked. Use standard abbreviations (Table 2.3) and avoid personal ones. Using the patient’s own words, recorded in quotation marks, can be useful. Here are some examples:

1. 12-year-old Px. Caucasian. Student.

–

CC: ‘Can’t see blackboard’ c Rx last 6/12 in

– both eyes, gradual onset. TV OK s Rx,

–

sits close. NV good s Rx. No H/A. No other Sxs.

OH: Wears Rx for school only (w/board, not outside). 1st wore age 10, this Rx 2 years old. F&F OK, no other OH. LEE: 2 yr, Dr Hurst, Oldham. FOH: mum and dad both myopic.

GH OK, no meds. No allergies. LME: 6/12, Dr Jarse, Saddleworth. FMH: mat grandfather has IDDM.

Hobbies: football (no Rx worn), computer games. Uses PC 1 hour/day.

2.48-year-old Caucasian female (secretary). RFV: NV blurred OU, grad p last 4/12. PC

work OK, although gets dull frontal h/as after 1 hr, last 2/12, gen. pm, goes if rest eyes & better on weekend, not seen GP. DV fine. No other Sxs.

OH: No specs. Has ‘squint’ and ‘lazy eye’ OD; Rx age 18/12 for strab; can’t remember eyepatch; had surgery age 15 yrs and did eye

exercises before and after surgery. Stopped wearing Rx after surgery. LEE: 5 yrs, Dr Bullimore, Ohio. FOH: Mother cataracts aged 65.

GH: Good, no meds. Allergic to penicillin. LME: 4/12, Dr Who, Main Street, Ohio. FMH: Mother and sister high BP, no other.

Hobbies: reading, cycling. Drives. Uses PC5 hrs/day.

3.Case Hx: 68-year-old Asian female (retired).

–

CC: Routine 2yr exam. DV & NV fine c Rx. No h/as. Eyes sl. red last 9/12, ‘Eyes burn’, no pain, no discharge, no itching. Not had prev. Worse with reading & stops reading after 30 mins. No other Sxs.