How to Take an Ophthalmic History and Present a Case

Last updated: October 2026

A good history narrows the diagnosis before you touch the slit lamp, and a good presentation gets your consultant to the right decision in under a minute. This page gives you a structure for both.

Part 1: Taking an ophthalmic history

Presenting complaint

• Which eye? Always ask. Then ask whether the other eye is truly normal.
• Onset and course: sudden or gradual; getting better, worse or fluctuating.
• Painful or painless: one of the most useful divisions in ophthalmology.
• Visual symptoms checklist:
  • Blur for distance, near, or both
  • Distortion (metamorphopsia) or a central spot
  • Flashes, floaters, or a curtain
  • Double vision: does it go when one eye is covered? (monocular vs binocular)
  • Missing areas of vision, glare, haloes, colour change
• Red eye checklist: pain, discharge (watery, sticky), itch, photophobia, contact lens wear, trauma.

Background

• Past ocular history: glasses or contact lenses, amblyopia or squint in childhood, previous surgery, laser, injections or trauma.
• Medications, ocular and systemic. Always ask about steroids (all routes), hydroxychloroquine, tamsulosin, anticoagulants and topiramate.
• Allergies, including sulfa allergy before acetazolamide.
• Medical history: diabetes, hypertension, thyroid disease, autoimmune disease, HIV.
• Family history: glaucoma, keratoconus, retinal dystrophies, squint, retinoblastoma.
• Social history: smoking, occupation, driving, ability to put in drops, and who is at home to help.
• Targeted review: for example, headache, jaw claudication and scalp tenderness in an older patient with sudden visual loss (giant cell arteritis).

Part 2: Examination order that avoids mistakes

1. Visual acuity for each eye separately, with correction and pinhole
2. Pupils, before any dilating drops
3. Eye movements and alignment
4. Confrontation visual fields (or formal fields)
5. Slit lamp examination of the anterior segment
6. Intraocular pressure
7. Dilated fundus examination

For the technique, see pupil examination and eye examination.

Part 3: Presenting a case to your consultant

Start with a one-line summary

"Mr Shah is a 64-year-old diabetic with two weeks of painless, gradual blurring in his right eye. Vision is 6/36 right, 6/9 left. OCT shows centre-involving diabetic macular oedema in the right eye."

Then follow a consistent order

1. History: the key positives and the relevant negatives
2. Examination: vision, pupils and IOP first, then findings eye by eye (right then left), front to back
3. Investigations: what has been done and what it shows
4. Impression: your most likely diagnosis, plus one or two differentials
5. Plan: what you suggest, so the consultant can agree or correct you

Tips that make consultants trust you

• Always name the eye. "The eye" is not good enough.
• Commit to a diagnosis and a plan. It is fine to be wrong; it is not fine to have no opinion.
• For an emergency call at night, lead with the problem and what you have already done: "I have a patient with suspected acute angle closure, IOP 52, and I have started acetazolamide and topical drops."
• Know the numbers you will be asked: vision, IOP, and the key OCT measurements.
• Say "I don't know, but I will find out" when you don't know, and then find out.

Next steps: practise with Spot the Diagnosis, learn the abbreviations, and prepare for emergencies on call.