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Table of Contents
Suggest an improvement
Ophthalmic history taking is an important skill that is often assessed in OSCEs. This guide provides a structured approach to exploring common ophthalmic complaints such as visual disturbance, red eye and eye pain in an OSCE setting.
Opening the consultation
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include:
- Demonstrating empathy in response to patient cues: both verbal and non-verbal
- Active listening: through body language and your verbal responses to what the patient has said
- An appropriate level of eye contact throughout the consultation
- Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair)
- Making sure not to interrupt the patient throughout the consultation
- Establishing rapport (e.g. asking the patient how they are and offering them a seat)
- Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next
- Summarising at regular intervals
Use open questioning to explore the patient’s presenting complaint:
- “What’s brought you in to see me today?”
- “Tell me about the issues you’ve been experiencing.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required:
- “Ok, can you tell me more about that?”
- “Can you explain what that pain was like?”
Once the patient has finished speaking, it is helpful to check if there are any other issues. If the patient has multiple presenting complaints, work with them to establish a shared agenda for the rest of the consultation:
- “Ok, so you’ve mentioned that you have three problems today that you’d like addressing. As there may not be time to address them all thoroughly in this consultation, it would be helpful to know which of the issues you feel is most important to deal with today. I’ll then let you know which of these issues I feel is the priority and we can agree on what the focus of today’s consultation should be. Does that sound ok?”
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.
History of presenting complaint
Begin by clarifying some key details including:
- the primary complaint (e.g. visual disturbance, red-eye and/or pain)
- whether one or both eyes are affected
- how the problem started
Key ophthalmic symptoms
Some key ophthalmic symptoms which should be screened for include:
- “Has there been any change to your vision recently?”
- “Have you noticed your eyes look red?”
- “Did somebody else comment on the appearance of your eyes?”
- “Is this redness all over the white of your eyes or only on one part?”
Eye discharge and/or watering:
- “Do you have any discharge coming from your eyes?”
- “Is it watery and clear or sticky and yellow?”
- “Do your eyes water?”
Grittiness or dryness of the eyes:
- “Does it feel like you’ve got something stuck in the eye?”
- “Do your eyes feel dry?”
Itching of the eyes:
- “Do you feel like you’re constantly having to rub your eyes?”
- “Does it hurt when you go into bright light?”
- “Do you prefer to be in a darkened room, away from light?”
Swelling or tenderness of the eyes:
- “Have you noticed any swelling or pain around or on the eye?”
- “Does it hurt when you touch it?”
Red flag features
Some examples of red flag features which indicate serious pathology include:
- Eye pain: moderate to severe pain should always be treated as a red-flag symptom. Causes include acute closed-angle glaucoma, uveitis or aggressive keratitis.
- Photophobia: can indicate corneal disease such as bacterial keratitis or inflammation at the front of the eye (anterior uveitis). These both require specialist review.
- Visual disturbances: sudden and persistent (>60 minutes) visual loss is always a red flag, particularly if there is a profound loss of vision. This may represent an acute vascular event of the retina, optic nerve (temporal arteritis) or brain.
- Red-eye: marked redness especially if associated with pain and/or loss of vision should be referred for a specialist opinion.
- Trauma: a high-velocity injury (e.g. sudden eye pain whilst using power tools) requires urgent ophthalmological review to assess for a penetrating foreign body (e.g. X-ray orbit). Significant blunt trauma to the eye can result in sudden increases in intraocular pressure, retinal detachment and potentially globe rupture.
Exploring visual disturbance
The differential diagnosis for visual disturbance is very broad and contains several serious pathologies. As a result, it is important to thoroughly explore a complaint of visual disturbance to narrow the differential diagnosis and avoid missing red flag features.
You should always begin by asking an open question such as: “Has there been any change in your vision recently?”
Patients often struggle to describe the nature of their visual disturbance and therefore closed questions can be helpful in exploring the symptom further. Some examples of questions you should seek answers to are shown below.
Closed questions relevant to visual disturbance
Are one, or both eyes affected?
When did the visual disturbance begin?
Was the onset sudden or gradual?
Does the visual disturbance come and go?
How severe is the visual disturbance (e.g. vision slightly blurry or only able to see hand movements or bright light)?
Does anything make the visual disturbance worse or better?
Does the visual disturbance affect distance or near vision, or both?
Does the visual disturbance only affect a specific area of vision (e.g. central, peripheral)?
Is there any double vision?
- Does the double vision involve images side-by-side, on top of each other or at an oblique angle (e.g. when looking to the side, in the distance or when looking down when using stairs)?
- Does double vision affect one or both eyes?
Are there any ‘positive’ visual symptoms?
- Flashing lights or floaters
- Presence of a black curtain across their field of vision
- Glare from the low sun or car headlights
- Halos around lights
Are there any visual distortions?
- Straight lines appear wavy (metamorphopsia)
- Sparkling shimmering lights moving across the visual field over 30 to 60 minutes (scintillations)
- Objects appearing larger or smaller than you know they really are
Vision loss due to a functional neurological disorder
Vision loss due to a functional neurological disorder is a common presentation, although it should always be a diagnosis of exclusion. It is more common in teenagers and often related to underlying stress and anxiety stemming from relationship difficulties at home and at school with family and friends. The main complaints can be highly varied. Intermittent blurred vision sometimes with brow ache and photophobia are common, however, complete loss of vision and double vision are also well-recognised presentations. It can be difficult to feel confident that there is not an underlying organic basis to the symptoms and a referral to an ophthalmologist may be needed. The Functional Neurological Disorder website is a helpful resource.
Transient visual loss (lasts <24hrs)
Persistent visual loss (lasts >24 hours)
Sudden, painless loss
Gradual, painless loss
Migraine: marching sparkling shimmering lights <60 minutes – both eyes but typically only one hemifield
Retinal vein or artery occlusion
Amaurosis fugax: profound loss of vision in one eye lasting minutes to hours. Caused by vascular disease/vasculitis
Anterior ischaemic optic neuropathy (e.g. temporal arteritis)
Papilloedema: a complete brief loss of vision (obscurations), which may be unilateral or bilateral
Stroke affecting the visual pathways
Dry age-related macular degeneration (AMD)
Anterior ischaemic optic neuropathy (e.g. temporal arteritis). N.B. this involves headache rather than actual eye pain
Tumours affecting the visual pathway
Nutritional optic neuropathy
Exploring eye pain
The SOCRATES acronym is a useful tool for exploring presenting symptoms. It is most commonly used to explore pain, but it can be applied to other symptoms (although some of the elements of SOCRATES may not be relevant to all symptoms).
Try to understand if it really is the eye that is sore or if the pain is around the eye/forehead.
Ask about the location of the pain:
- “Where is the pain?”
- “Can you point to where you experience the pain?”
Patients may describe the location as being:
- Under the eyelid (e.g. foreign body)
- Within the eyeball itself (e.g. acute glaucoma)
- Behind the eye (e.g. optic neuritis)
- A frontal headache that radiates around the eyes (e.g. migraine)
Clarify how and when the pain developed:
- “How did the pain start?”
- “Did the pain come on suddenly or gradually?”
- “What were you doing when the pain started?”
- “Did the pain wake you from sleep?”
Ask about the specific characteristics of the eye pain:
- “How would you describe the pain?” (e.g. dull ache, throbbing, sharp)
- “Is the pain worse when you move the eye?”
- “Does it feel like you’ve got something in the eye?”
- “Does the eye feel gritty?”
Ask if the symptom moves anywhere else:
- “Does the pain spread elsewhere?”
Ask if there are other symptoms associated with the primary symptom:
- “Are there any other symptoms that seem associated with the pain?”
Examples of associated symptoms might include:
- Nausea/vomiting (e.g. acute glaucoma)
- Unilateral headache (e.g. migraine with aura)
- Visual disturbance
- Red eye
- Discharge or watering
- Grittiness or dryness
Clarify how the symptom has changed over time:
- “How has the pain changed over time?”
- “Does the pain come and go?”
- “Do you feel the pain is getting worse over time?
Exacerbating or relieving factors
Ask if anything makes the pain worse or better:
- “Does anything make the pain worse?” (e.g. blinking, touching the eye, moving the eye, bright light)
- “Does anything make the pain better?” (e.g. analgesia, cool water, warm compress, removing contact lenses, dimming the lights)
Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10:
- “On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”
Moderate to severe pain is a red flag symptom. Patients should be referred to a high street optometrist or the hospital eye clinic for an ophthalmology opinion promptly.
Severe pain is often associated with acute angle-closure glaucoma, in which case the patient will also likely complain of visual disturbance, nausea and vomiting.
Exploring eye trauma
If there is a history of trauma, always keep in mind the possibility of a serious injury such as intraocular foreign body, globe rupture or penetration.
It is important to determine the mechanism of injury (e.g. chemical, blunt or sharp).
Documenting the use of power tools, hammer and chisel, and the absence of safety goggles is very important.
The size, speed and nature of the flying object should be determined and the history correlated with the examination findings. If a serious injury is suspected then you must ask for an urgent ophthalmological opinion.
Ideas, concerns and expectations
A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.
The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.
Explore the patient’s ideas about the current issue:
- “What do you think the problem is?”
- “What are your thoughts about what is happening?”
- “It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”
Explore the patient’s current concerns:
- “Is there anything, in particular, that’s worrying you?”
- “What’s your number one concern regarding this problem at the moment?”
- “What’s the worst thing you were thinking it might be?”
Ask what the patient hopes to gain from the consultation:
- “What were you hoping I’d be able to do for you today?”
- “What would ideally need to happen for you to feel today’s consultation was a success?”
- “What do you think might be the best plan of action?”
Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history.
Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.
Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”
What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”
A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.
Many conditions where the primary disease is not ophthalmological, may present with ophthalmological features. It may be relevant to go through some questions briefly to rule out the involvement of other body systems.
Some examples of symptoms you could screen for in each system include:
- Systemic: fevers, weight loss, malaise (e.g. temporal arteritis)
- Cardiovascular: chest pain (e.g. pericarditis/myocarditis in autoimmune conditions), scalp pain and jaw claudication (e.g. temporal arteritis)
- Respiratory: dyspnoea, cough, pleuritic chest pain (e.g. pleuritis in autoimmune conditions)
- Gastrointestinal: nausea/vomiting (e.g. acute-angle-closure glaucoma), diarrhoea (e.g. ulcerative colitis)
- Genitourinary: dysuria, discharge, bleeding, pelvic pain (e.g. chlamydia, gonorrhoea)
- Neurological: headache (e.g migraine, hypertension, raised intracranial pressure, temporal arteritis), weakness, ataxia and sensory disturbances (e.g. multiple sclerosis, diabetes, stroke)
- Musculoskeletal: joint pain/stiffness (e.g. rheumatoid arthritis, ankylosing spondylitis), myalgia (e.g. polymyalgia rheumatica)
- Dermatological: rashes (e.g eczema, psoriasis, rosacea), butterfly rash (e.g. SLE)
- Endocrine: polyuria/polydipsia (e.g. diabetes mellitus), feeling hot (e.g. hyperthyroidism)
Past ocular history
Ask about previous episodes similar to their current presenting complaint.
Ask about other eye problems/diagnoses including amblyopia (‘lazy eye’).
Ask about a history of previous eye trauma.
Ask about a history of ocular surgery (if recent, there is a risk of post-op endophthalmitis).
Ask if the patient uses prescription glasses and if these are used for distance or near vision.
Ask if the patient uses contact lenses and if so, clarify the following details:
- Daily disposable, monthly disposable or extended wear lenses
- If the patient sleeps, showers, or swims with lenses on
- Ask about the patient’s contact lens hygiene regimen (e.g. daily cleaning of lenses, only using recommended cleaning solutions etc)
Past medical history
Ask if the patient has any medical conditions:
- “Do you have any medical conditions?”
- “Are you currently seeing a doctor or specialist regularly?”
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).
Examples of relevant medical conditions
Medical conditions relevant to ophthalmic disease include:
- Diabetes mellitus
- Autoimmune conditions (e.g. rheumatoid arthritis, ankylosing spondylitis, SLE): a vast range of ocular manifestations, however, dry eyes and uveitis tend to be the most common presentations
- Atopy (asthma, allergic rhinitis, eczema): relevant to allergic conjunctivitis and keratitis (eyedrops containing beta-blockers are also contraindicated in asthma)
Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:
- “Are you currently taking any prescribed medications or over-the-counter treatments?”
If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route.
If the patient is on topical eye medication, their prescription may read “g.” or “guttae” for drops and “occ” for ointments. For example ‘g. Chloramphenicol’.
Also, note if patients are on a preservative-free formulation (the box will say “preservative-free” or “minims”).
Ask the patient if they are currently experiencing any side effects from their medication (more common in glaucoma medication and prolonged use of formulations containing preservatives).
Medications frequently prescribed to patients with ophthalmic disease include:
Antimicrobials (antibiotics/antivirals – topical/oral)
Glaucoma medications (prostaglandin analogues, beta-blockers, adrenergic agonists, carbonic anhydrase inhibitors, cholinergic agents)
Analgesics (topical NSAIDs, oral analgesics)
Anti-histamines (topical and oral)
Ask the patient if there is any family history of similar complaints or formal diagnoses of eye disease. This is particularly relevant for conditions such as glaucoma or retinal detachment.
Ask if there is any family history of hypertension, diabetes or rheumatological disease.
Taking a comprehensive social history is particularly important in the context of a person suffering from visual loss.
General social context
Explore the patient’s general social context including:
- any low visual aids that they use (e.g. magnifiers, binoculars, text-to-speech programs)
- the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)
- who else the patient lives with and their personal support network
- what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)
- if they have any carer input (e.g. twice daily carer visits)
Record the patient’s smoking history, including the type and amount of tobacco used.
Record the frequency, type and volume of alcohol consumed on a weekly basis.
Longstanding alcohol dependency can lead to malnourishment. Folate and B12 deficiency may consequently develop, leading to gradual vision loss.
Moonshine (illicitly distilled alcohol) and ingestion of products contaminated with industrial alcohol pose a risk of methanol toxicity. This can present as a more acute toxic optic neuropathy.
See our alcohol history taking guide for more information.
Recreational drug use
Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.
Acute vascular events in the retina and macular toxicity resulting in a sudden loss of vision are well-recognised complications.
Intravenous drug use is also a risk factor for endophthalmitis.
Assess the impact of the patient’s symptoms on their ability to work.
Clarify what tasks the patient’s occupation involves.
Identify potential occupational hazards such as:
- High-powered tools (a risk factor for penetrating eye trauma)
- Welding (a risk factor for photokeratitis)
If the patient drives and has presented with significant visual impairment or other concerning symptoms (e.g. possible TIA) it is important to advise them not to drive until they have been fully investigated and to inform the relevant driving authority (e.g. DVLA) of their current medical issues.
Closing the consultation
Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Dr Lewis Potter