6 case history

• Baseline data


  Information recorded that aids accuracy and efficiency in future examinations of a patient
• Initial interview

  • Careful questioning allows the optometrist to discover the nature of any problem relating to a patient's vision or ocular health
  • Allied information may be gained that may allow the optometrist to offer advice beyond the presenting needs of the patient
  • The information gained at the beginning of the examination allows the optometrist to adapt the clinical assessment to meet the needs of the patient
• The recording of accurate data based upon a history and symptoms may have legal implications, in that, if a problem occurs subsequent to an examination, then clear recorded evidence that the optometrist asked questions relating to a condition at the time of the examination is important
• Role of auxiliary staff

  Initial information gathering may be carried out by a receptionist or trained optical or clinical assistant
• Interpreting nonverbal information: Gaining affective information

  • Body contact
  • Proximity
  • Orientation
  • Body language (posture, gestures, head-nods, facial expression, eyes, appearance)
  • Nonverbal speech patterns (intonation, rate of speech, pitch, volume, pauses, synchrony and pacing)
• The CLOSER model


  1. Control any distractions and potential interruptions

  2. Lean forward slightly toward the patient

  3. Maintain an open, non-defensive posture and appear relaxed and at ease with the surroundings

  4. Face the patient squarely

  5. Maintain eye contact as appropriate

  6. Respect the patient's personal space and position in the room
• Reason for attendance

  Asking the patient "Tell me why you've come to see me today?" or "Do you have a particular problem with your eyes?"
• Current ocular and optical status

  Details about the patient's current vision, correction, and any symptoms
• Typical list of initial questions

  1. Do you see well in the distance?

  2. Do you see near objects well?

  3. Do you currently wear any vision correction?

  4. Do you experience any headaches, eye pain, floaters, flashes of light, itching, redness, soreness, tearing, burning, or double vision?
• Patient ocular history

  • Last eye examination
  • Optical correction (type, when and how long worn, condition)
  • Injury or trauma
  • Surgery, orthoptic or refractive treatment
  • Eye disease or squint
• Family ocular history

  • Visual problems (high myopia, amblyopia)
  • Squints
  • Eye diseases (glaucoma, nystagmus, retinitis pigmentosa)
• Patient general medical history

  • How is your health at the moment?
  • Do you have to visit your doctor for any reason?
  • Are you taking any medication at present (recently)?
  • Are you being treated or investigated for any general health problems?
• Family medical history


  Any family history of hypertension, stroke or diabetes (and type) may be of importance
• Lifestyle and occupation details

  • Many eye examinations may be directly related to problems in the workplace or driving or carrying out a hobby
  • The practitioner may be able to infer the possible requirement for safety spectacles or advice relating to eye health and safety
• Concluding questions: "Is there anything else about your eyes or vision which concerns you?" or "Is there anything else about your eyes or health that I should know?"
• Taking a case history

  • Find out if there is a problem by asking about symptoms, looking for signs, and measuring vision
  • The history is important because it helps you to find out the problem with a person's eyes, the tests you need to perform, and the action you need to take: treat, refer, person and or community education
• Chief complaint

  The main reason that the person has come to you, which must be discussed and addressed at the end of the eye examination
• Asking for details


  You will need to ask more questions about the problem, the person's eye health, their vision and any previous glasses, their visual needs, and any problems related to the eye like headaches, flashes and floaters