How to take an ophthalmic history

Anna Louise Pouncey, Peggy Frith


As with other specialties, a detailed history and through examination is essential in diagnosis. A methodical approach should be employed when taking an ophthalmic history and conducting an examination. This article provides the basic structure of an ocular history, an approach to common presentations, and highlighting the early warning signs of severe pathology. Clinical note taking and customary abbreviations are can be daunting for the unexperienced and are illustrated by an example clerking.

Keywords: red eye, history, slit-lamp examination