8th December 2023

History taking

This should consist of a general history and a more focused ophthalmic history.

General history 

This should aim to elicit history of systemic conditions with known ocular complications, use of oculotoxic drugs, and any history of intercurrent or recent illness.

Ophthalmic history 

History of presenting complaint:

• Onset and duration
• Laterality
• Pain history using a SOCRATES approach, important to distinguish periorbital from ocular pain
• Appearance of the eye
  • Redness, swelling or lumps in the eyelids
  • Redness of the conjunctiva or sclera, visible lesions
  • Cloudiness of the cornea
• Discharge – colour and onset
• Foreign body sensation or itching
• Photophobia
• Visual symptoms such as decreased/blurred vision, diplopia, scotomas and transient visual obscurations
• Possible precipitants such as trauma or chemical injury
• Previous episodes
  • Past ocular history – refractive errors, contact lens wear, previous ocular surgery, congenital problems, chronic eye conditions
  • Drugs applied directly to the eye or peri-ocularly
  • Family history of ophthalmic conditions

References

• Leibowitz HM. The Red Eye. http://dx.doi.org/101056/NEJM200008033430507 2009; 343: 345–351.
• Diagnosis | Diagnosis | Red eye | CKS | NICE, https://cks.nice.org.uk/topics/red-eye/diagnosis/diagnosis/(accessed 5 May 2022).
• Smith J, Severn P, Clarke L. Assessment of red eye Straight to the point of care. BMJ Best Pract  2022; 1–118.