Ophthalmic History Taking and Differential Diagnoses

History of Presenting Complaint

Overview

With each symptom, always (if relevant) ask about:

• When did it start?
• Did it come on suddenly or gradually?
• Is it continuous or intermittent?
• Has this ever happened before?
• Is it one or both eyes?

All patients

In all patients with ophthalmic presentations, always ask:

• Has there been any trauma to the eye?
• Has your vision been affected?
• Are your eyes uncomfortable or painful?
• Do you wear glasses or contact lenses?
• What’s your vision usually like? Do you know your prescription?

Pain

Use SOCRATEs:

• Sharp/stabbing pains are more suggestive of problems on the eye surface
• Dull aches (similar to toothaches) are more suggestive of raised intraocular pressure, uveitis, and scleritis

Red eye

• Is it one eye or both?
  • Unilateral – infection, uveitis, acute glaucoma
  • Bilateral – allergy
• Is there eye pain?
• Is there grittiness?
• Is there eye itchiness?
• Are you sensitive to lights?
• Is there any discharge?
  • Is it watery?
  • Is there pus in it?
  • Is it mucus-like?
• Are there any vision changes?
  • Is the change due to the wateriness/discharge?
  • Is the vision change persistent?
• Have you had a cold recently?

Sudden loss of vision

• Where is the vision loss? – central/peripheral/hemianopia?
• Is it profound, blurring, or distortion?
• Is the eye painful?
• Is the eye red?
• Is there any headache?
• Is there any nausea?
• Is there any pain in eye movements?
• Are there halos around lights?
• Are there any features of stroke?
  • Arm weakness?
  • Facial drooping?
  • Numbness?
  • Tingling?
  • Speech problems such as slurring?

Gradual loss of vision

• Where is the vision loss? – central/peripheral?
• Is there any glare with bright lights?
• Are there halos around lights?
• Do colours appear the same or do they look washed out?

Double vision

• Is it vertical or horizontal?
• Is it in both eyes?
• Is it intermittent or continuous?
• Are there any triggers for it?
• Any features of hyperthyroidism? – weight loss, diarrhoea, heat intolerance, sweating
• Any features of intracranial hypertension? – headaches
• Any features of myasthenia gravis? – weakness/swallowing problems/symptoms worse at the end of the day? 

Flashes and floaters

• Did it come on suddenly? – posterior vitreous detachment/retinal detachment
• Does it come and go with movement? – posterior vitreous detachment
• Is it intermittent with a pattern? – migraine?

Proptosis

• Are there any vision changes?
• Any features of hyperthyroidism?
• Any features of orbital cellulitis? – fevers/rashes/headaches?

Eye irritation

• Do your eyes feel dry?
• Any features of blepharitis? sticky/crusty/worse in the mornings?
• Do they have any skin conditions like eczema/rosacea?

Eye trauma

• How did they get hurt? – sharp/blunt/chemical
• Did something get into the eye?
• Is there any double vision?
• Are there any other injuries?

Red flags

• Sudden vision loss
• Photophobia
• Pain in eye movement
• Double-vision
• Flashing lights
• Associated headache
• Associated fever
• Bleeding in the eye
• Trauma to the eye
• Jaw claudication
• Scalp tenderness
• Unexplained weight loss

Other associated conditions

• Consider asking about:
  • Features of multiple sclerosis?
  • Features of rheumatological disease? – ankylosing spondylitis, reactive arthritis, psoriatic arthritis, rheumatoid arthritis, systemic lupus erythematosus, Marfan syndrome

Past Medical History

Previous conditions and/or surgery

• Do they have any other medical conditions?
• Have they ever had any previous surgery?
• Have they ever injured their eye?
• Have they ever had lazy eye?

Drug history

• Do they take any regular medications?
  • Corticosteroids? – cataracts risk
  • Hydroxychloroquine? – retinopathy
• Do they take any over-the-counter medications, herbal remedies, or supplements?
• Do they take any eyedrops? – some patients may forget that these count as regular medications

Family History

• Is there any family history of anything similar?
• Is there a history of eye disease or vision loss in your family?
• Is there any history of autoimmune disease?

Allergy History

• Are they allergic to anything?
  • What happens during the allergic reaction?

Social History

• Do they smoke?
  • If so, how much and how long?
• Do they drink alcohol?
  • If so, how much and how long?
• Do they use any illicit drugs?
  • If so, how much and how long?
• What is their occupation?
• Who’s at home?
  • What support do they have?
• How has this impacted their activities of daily living?
• Has there been any recent foreign travel?
• Do they drive?

Physical Examinations

An eye examination along with checking visual acuity are indicated. A focused neurological examination may also be considered depending on the suspected cause.

Red Eye Differential Diagnoses

Blepharitis

• Patients often describe grittiness or the sensation of a foreign body
• The eyes may be “sticky”
• Eyelids are inflamed
• Symptoms including eyelid-sticking are usually worse in the morning

Infectious keratitis

• Unilateral painful eye that may present similarly to conjunctivitis
• Discharge and watery eye may be present
• Contact lens wearers are at higher risk – may have pain out of proportion to clinical findings suggesting Acanthamoeba infections
• Dendritic corneal ulcers suggest herpes simplex keratitis

Allergic conjunctivitis

• Sudden onset of symptoms after exposure to an allergen, usually bilateral
• Eye itchiness
• Eye grittiness and foreign-body sensation
• Associated rhinitis and urticaria may be seen
• Seasonal variation may be seen

Bacterial conjunctivitis

• Usually unilateral but can become bilateral
• Purulent discharge is seen – if severe, consider gonococcal infection
• Eyes may be “sticky” with eyelid-sticking and symptoms worse in the morning

Viral conjunctivitis

• Usually unilateral but can become bilateral
• Discharge is more watery and not purulent
• History of recent upper respiratory tract infection may be present
• Preauricular lymphadenopathy may be present

Subconjunctival haemorrhage

• Usually unilateral red eye with no associated pain or visual disturbance
• Usually seen after coughing, vomiting, or straining e.g. lifting heavy weights
• Associated with hypertension, check blood pressure

Neonatal conjunctivitis

• Onset within 1 month of birth
• Discharge is often profuse and purulent
• There may be a history of genitourinary infection or symptoms in the mother

Angle-closure glaucoma

• Severe ocular pain or headache with associated nausea/vomiting
• Blurred vision
• Halos around lights
• Low-light levels may worsen symptoms

Anterior uveitis

• Acute unilateral pain with blurred vision, redness, and photophobia
• There may be an associated irregular pupil, ciliary flush, and hypopyon
• The pain is deep and dull and may be worse with use i.e. reading something close by
• There may be a history of associated autoimmune systemic, infective disease, or diseases associated with HLA-B27

Episcleritis

• Classically non-painful red eye but there may be some mild pain
• Injected vessels are mobile and move with gentle pressure
• Phenylephrine eye drops improve eye redness

Scleritis

• Classically painful red eye but the pain may only be mild
• Watering and/or photophobia may be present
• Injected vessels are not mobile and do not move with gentle pressure

Herpes zoster ophthalmicus

• Pain described as burning or stinging in one of the dermatomes supplied by the branches of the trigeminal nerve
• Hutchinson’s sign may be present – vesicular rash on the tip or side of the nerve
• Vesicular rash may be around the eye

Post-operative endophthalmitis

• Painful red eye with an acute loss of vision following surgery

Acute Loss of Vision Differential Diagnoses

Stroke or transient ischaemic attack

• Sudden onset homonymous/binocular vision loss
• Associated weakness, numbness, tingling, ataxia, slurred speech may be present
• Sensory or motor deficits may be present

Angle-closure glaucoma

• Severe ocular pain or headache with associated nausea/vomiting
• Blurred vision
• Halos around lights
• Low-light levels may worsen symptoms

Giant cell arteritis

• There may be headaches, scalp tenderness, or jaw claudication
• Sudden and painless loss of vision
• There may be associated polymyalgia rheumatica

Central retinal artery occlusion (CRAO)

• Sudden painless loss of vision
• Fundoscopy shows a pale retina with a “cherry red” spot
• Risk factors may be present e.g. hypertension, diabetes mellitus, coronary artery disease

Central retinal vein occlusion (CRVO)

• Sudden painless loss of vision, is more common than CRAO.
• Fundoscopy shows retinal haemorrhages
• Risk factors may be present e.g. hypertension, diabetes mellitus, coronary artery disease 

Vitreous haemorrhage

• Sudden painless loss of vision
• Sudden onset of floaters (dark spots) followed by vision loss
• Associated with diabetes mellitus and other causes of neovascularisation
• No relative afferent pupillary defect

Posterior vitreous detachment

• Sudden onset of flashing lights and floaters
• May precede retinal detachment – when visual loss occurs, retinal detachment is occurring
• Fundoscopy shows a Weiss ring

Retinal detachment

• Sudden painless loss of vision
• Flashes and floaters may precede vision loss
• Vision loss is described as a curtain or veil coming down over the vision
• Relative afferent pupillary defect present

Optic neuritis

• May be the presenting feature of multiple sclerosis
• Decreased visual acuity
• Ophthalmoplegia – pain in eye movement
• Reduced colour saturation
• Relative afferent pupillary defect

Pituitary apoplexy

• Sudden-onset headache similar to a subarachnoid haemorrhage
• Photophobia and neck-stiffness may be present
• Sudden onset diplopia
• May occur on a background of a known pituitary tumour

Gradual Loss of Vision Differential Diagnoses

Primary open-angle glaucoma

• Gradual loss of vision peripherally inwards (“tunnel vision”)
• Patients may not initially notice symptoms
• Blurring and halos may be seen around light
• Fundoscopy may show increased cup-to-disc ratio/optic disc pallor

Dry age-related macular degeneration

• Gradual decline in central vision (central scotoma), may be acute
• Images and lines become distorted
• More commonly in the elderly
• Fundoscopy shows drusen, global atrophy, and no neovascularisation

Wet age-related macular degeneration

• Gradual decline in central vision (central scotoma), may be acute
• Images and lines become distorted
• More commonly in the elderly
• Fundoscopy sub-retinal haemorrhages, and choroidal neovascularisation

Cataracts

• Glare – lights appear brighter than usual
• Faded colours – often appear washed out
• Halos around lights
• Defects in the red reflex may be present
• If severe: relative afferent pupillary defects may be present

Diabetic retinopathy

• History of poorly-controlled/undiagnosed diabetes may be present
• Autonomic neuropathy may reduce pupillary responses
• Non-proliferative: microaneurysms, cotton wool spots, hard exudates, venous beading
• Proliferative: retinal neovascularisation and vitreous haemorrhage

Hypertensive retinopathy

• History of poorly-controlled hypertension/acute malignant hypertension
• Fundoscopy may show: arteriolar narrowing, “silver wiring”, arteriovenous nipping, flame haemorrhages, cotton wool spots, papilloedema

Pituitary tumour

• Classically bitemporal hemianopia
• If secretory, there may be associated prolactinoma, acromegaly etc.
• May be non-secretory and patients may not have associated endocrine symptoms