The Significance of History and Record During Eye Exam

Eye Exam History

Eye exam history is very useful in the examination and evaluation of binocular vision.
This way, we can arrange a customized examination.

There are 3 questions that need to be answered:

• Does the patient have any issue?

• If so, what kind of issue?

• In which way does this affect the patient’s life? Is it mild, moderate, or severe for him?

In some cases, we have to elicit some answers by asking specific questions in order to gather the information we need.
A suitable way to tease out the real truth is to ask direct, specific questions.

Example:

• If the patient is a contact lens wearer, ask:

  • “How often do you sleep with your CL on?”

  • Instead of: “Do you sleep with your CL on sometimes?”

Avoid general questions such as: “How are you? Is everything ok?”
Direct questions usually get better results.

Some of the information the history file must include:

• Examination date

• Patient’s age

• Patient’s gender

• Occupation, daily activities, sports, etc.

• Visual expectations (demanding visual life?)

• Medical health history (including some family history)

• Medication and allergies

• Eye health history (including some family history)

• Reason for visit (any special issue recently)

• Last prescription (glasses or CL currently used)

Especially in children, most of the information comes from the parents.

The first step is to observe the patient:

• How he moves or walks

• How his head tilts (if any)

• How his fixation works (head vs eye movement)

Medical Health History

Some medications can have side effects on visual and ocular health:

• Steroids: anti-inflammatory (often in drops), may increase IOP or induce cataract

• Allergy and glaucoma treatments (eye drops): may cause dry eye

• Neurological medications: may cause ocular surface dryness

• Contraceptives: may contribute to dry eye

Ocular and Vision Health History

Family ocular history:

• Is there any member in your family with vision or ocular issues?

• Examples to guide the patient:

  • Glaucoma

  • AMD – Aged Macular Degeneration (dry or wet type)

  • Strabismus or eye patch

  • High refractive error (myopia, hyperopia, astigmatism)

  • Keratoconus

Symptoms of Binocular Disorders

Add these crucial questions to the history:

• Is there fatigue during or after near-task work?

• Do you avoid reading?

• Is there blurry vision at far or near distances?

• Is it both eyes?

For some patients, a simple prescription may not be enough. Our role is to provide the optical solution they need for daily life.
Vision is about health, and that’s what we are for.

Importance of Filing and Record Keeping

• Keeping full records ensures continuity of care and full clinical management.

• Files act as protection for the practitioner in case of complaints.

• A full record should include all significant clinical details.

• Enables another practitioner or ophthalmologist to take over if needed.

• Records should contain all important information related to binocular vision and ocular health.

Information to include in the patient file:

• Visual acuity (with or without habitual prescription)

• Ocular motility (with habitual prescription)

• Visual acuity with new prescription

• Ocular motility with new prescription

• Slit lamp examination

• Near point of convergence

• Pupil reaction

• Objective refraction (autorefractor or retinoscopy)

• Fundus imaging

• IOP findings

• Accommodation findings (status)

• MEM retinoscopy

• Contact lens information

• Keratometric readings

• Any other important binocular vision information

Finally, it should be clearly written the final management of the patient’s vision and ocular health.