BISMILLAHIRRAHMANIRRAHIIM

History taking
and
Eye Examination
SITI ANNISA DEVI TRUSDA
History Taking
• Make an interview with
appropriate intonation, manner
and make the patient in
convenience condition
• Retrieve the patient’s main
complain and record in patient’s
word
Collect information about the patient’s
present illness, including :
a.Time and manner of onset
b.Severity
c.Influences
d.Constancy and temporal variations
e.Laterality
• Documentation
Retrieve the information about patient’s past
ocular history in the term of why, when, how,
where, and by whom, as applicable,
including :
a.Use of eyeglasses or contact lenses
b.Use of medication in the past
c.Ocular surgery (including laser surgery)
d.Ocular trauma
History of amblyopia or ocular patching in
childhood
• Collect the information about patient’s ocular
medication
• Collect the information about patient’s general
medical and surgical history
• Collect the information about patient’s
systemic medication
• Retrieve the history about patient’s allergies,
including the onset, the cause and any other
related
• Collect the information about patient’s
social history
• Collect the information about patient’s
family history either ocular or non
ocular family disease
The eyes are rotated by 6 extraocular muscles
Assessing the ocular
movement
• Duction
• Sit facing the patient. Completely occlude
one eye using the palm of patient’s hand.
Hold your finger or a small fixation target
at eye level about 10 to 14 inches in front
of the patient, with the patient looking in
primary position (straight ahead)
• Ask the patient to follow the target as you
move it into the six cardinal fields.
Repeat the steps for the other eye
• Version
• Sit facing the patient. Hold your finger or a small
fixation target at eye level about 10 to 14 inches
in front of the patient, with the patient looking in
primary position (straight ahead)
• Ask the patient to follow the target as you move
it into the six cardinal fields (medial up, lateral
up, medial down. Lateral down. Medial and
lateral gaze) and up and down along the midline.
Elevate the upper eyelid with a finger on your
free hand to observe the down gaze
 HIRSHBERG’S TEST
• Have the patient seated facing you with head straight
and eyes directed in primary gaze
• Holding a penlight in front of the patient’s eye at a
distance of approximately 30 cm, directing the light at
the glabella of the patient. Align yourself with the
light source
• Instructing the patient to look at an object far behind
examiner
• Compare the position of two corneal light reflections
and identify any ocular deviation
• Normal : light reflection exactly on the center of the
pupil on both eyes
 • Right eye
• Ciliary injection
 • Left eye
• Conjunctival injection
Examining the Lower Conjunctiva and Fornix,
Everting the Eye Lid

• With the patient looking down, press the

skin below the lower lid with your thumb
or forefinger against the maxillary bone
and tug down
• Ask the patient to look up, which allows
the lower fornix to prolapse and exposes
most of lower palpebra conjunctiva
Examining the Upper Conjunctiva and Fornix,
Everting the Eye Lid, Two-Hand Method

• Using your thumb and forefinger to grasp

some eyelashes, pull the eyelid margin
away from the globe
• Pull the upper lid margin outward and
upward to fold the upper lid and hold the
lid margin in place against the skin
overlying the superior orbital rim with the
thumb to view the upper tarsal conjunctiva
Examining The Bulbar Conjuctiva and
The Cornea

• Shining an oblique bright light into the

patient’s eye from an appropriate distance
• With binocular loupe, making an attention
to the bulbar conjunctiva, looking for
following symptoms:
• Color/appearance
• Injection
• Neoplasm
• Making attention to the cornea,
looking for the appearance
including shape, size and
transparency
Estimating Anterior Chamber
Depth
• Holding a penlight near the temporal limbus,
and shining the light across the front of the right
eye toward the nose
• Keeping the beam parallel to the plane of the
normal iris
• Observe the medial aspect of the iris as a term of
the part of illuminated iris. Normally, the iris
completely illuminated. An eye with a shallow
anterior chamber will have two thirds of nasal
portion of the iris in shadow
• Anisocoria
Examining The Iris and The
Lens
• Shining a oblique bright light into the
patient’s eye from a appropriate distance
• With binocular loupe, make attention to the
iris. Look for any disturbances of iris size,
shape and any synechia that may be
present
• Making attention to the lens, looking for
the appearance including transparency,
shape and position