Index
Record History and Examination in Ophthalmology
Read about the standard format ophthalmologists use for recording patient history and examination, including accepted abbreviations, notation conventions, and a detailed case example illustrating how findings are documented.
Image is taken from book : Ophthalmology at a glance (Amazon)
Summary of Common Ophthalmic Abbreviations Used
| Abbreviation | Meaning |
|---|---|
| PC | Presenting Complaint |
| HPC | History of Presenting Complaint |
| POH | Past Ocular History |
| PMH | Past Medical History |
| FH | Family History |
| SH | Social History |
| VA | Visual Acuity |
| UA | Unaided |
| PH | Pinhole |
| NIDDM | Non-Insulin Dependent Diabetes Mellitus |
| RAPD | Relative Afferent Pupillary Defect |
| NS | Nuclear Sclerosis |
| PSCLO | Posterior Subcapsular Lens Opacity |
| IOP | Intraocular Pressure |
| CDR | Cup-Disc Ratio |
| DR | Diabetic Retinopathy |
| LA | Local Anaesthetic |
| IOL | Intraocular Lens |
| W/L | Waiting List |
Ophthalmic Record and Examination Checklist
1. Patient Details
- Name
- Date of birth (DOB)
- Age
- Date of examination
- Hospital/Clinic number
- Contact information (if required)
2. Presenting Complaint (PC)
- Main reason for visit (in patient’s own words)
- Duration and nature of symptoms
- Whether one or both eyes are affected
3. History of Presenting Complaint (HPC)
- Onset (sudden or gradual)
- Duration and progression
- Associated symptoms (pain, glare, redness, floaters, flashes, diplopia, etc.)
- Any precipitating or relieving factors
- Impact on daily activities (e.g., driving, reading, glare at night)
4. Past Ocular History (POH)
- Previous eye diseases (glaucoma, cataract, trauma, uveitis, etc.)
- Previous surgeries or laser treatments
- History of spectacles or contact lens use
- Any use of topical medications
5. Family History (FH)
- Eye diseases in family (e.g., glaucoma, retinitis pigmentosa, diabetic retinopathy)
- Systemic diseases (e.g., diabetes, hypertension)
6. Past Medical History (PMH)
- Systemic conditions (e.g., diabetes, hypertension, thyroid disease, autoimmune disorders)
- Duration and treatment
- Any recent hospital admissions
7. Medications
- Current systemic medications
- Any eye drops or ointments
- Over-the-counter medications or supplements
8. Allergies
- Drug allergies
- Latex, preservatives, or contact lens solution allergies
- Reaction details if known
9. Social History (SH)
- Smoking (amount and duration)
- Alcohol consumption
- Occupation (especially if visual demand or risk of eye trauma is high)
- Driving status
- Use of visual display units (screens)
10. Examination (O/E)
a. Visual Acuity (VA)
- Distance Vision: Unaided, with spectacles, and with pinhole
- Near Vision: With and without correction
- Notation: Snellen or LogMAR chart
b. Pupils
- Size, shape, and reaction to light (direct and consensual)
- Check for Relative Afferent Pupillary Defect (RAPD)
c. Colour Vision
- Ishihara plates or other colour tests
d. External Examination
- Lids and lashes
- Conjunctiva and sclera
- Cornea (clarity, surface)
- Anterior chamber depth and activity (cells/flare)
- Iris (pattern, colour, abnormalities)
- Lens (clarity, presence of cataract)
e. Intraocular Pressure (IOP)
- Measure by Goldmann Applanation or other tonometer
- Record readings for each eye
f. Ocular Motility
- Extraocular muscle movement (EOM)
- Cover test (for strabismus/orthophoria)
- Range of movement (ROM)
- Diplopia charting if needed
g. Visual Fields
- Confrontation test (gross field defects)
- Automated perimetry if indicated
h. Fundus Examination (Posterior Segment)
- Optic Disc: colour, margins, cup-disc ratio (CDR)
- Macula: reflex, edema, pigmentation, drusen
- Retinal Vessels: calibre, tortuosity, hemorrhages, exudates
- Periphery: retinal tears, detachments, degenerations
11. Special Tests (as indicated)
- Slit-lamp biomicroscopy
- Gonioscopy
- Optical Coherence Tomography (OCT)
- Fundus photography
- Visual field testing
- Amsler grid (for macular function)
12. Diagnosis / Impression
- Summary of findings
- Primary and differential diagnoses
13. Management Plan
- Further investigations (if any)
- Treatment prescribed (medical or surgical)
- Patient counselling
- Follow-up date and instructions
14. Documentation Notes
- Signature and designation of examiner
- Date and time of entry
- Ensure right eye (OD) findings are recorded on the left side, and left eye (OS) on the right side of the examination page
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