Watching a senior resident conduct a targeted history and physical exam, feels like a magic trick. I’m not at that level yet, so I don’t have the luxury of skipping to the answer. Honestly, I am pumped if my answer is in the right chapter of the Wills Eye Manual! 

My goal is a slow, steady, and systematic approach that doesn’t miss anything important. I remember shadowing and being so focused on looking cool on the slit lamp that I glossed over the history. The resident came in and quickly found out the patient, a farmer, had been cleaning his barn rafters and accidentally swept a mystery substance into his eye.

Lesson Learned: Farmers are built differently. If I had asked my grandma, she’d likely couldn’t remember half her injuries. Getting something in her eye was just another Tuesday. Take a solid history, because your patient might be too tough for their own good!

The History: Setting the Stage

Past Medical History: Don’t just check boxes, look for these ophtho-specific clues:

• Systemic Links: Diabetes, hypertension, thyroid disease, or autoimmune issues (e.g., acute unilateral vision loss in a 35-year-old woman should make you wonder about Multiple Sclerosis associated optic neuritis).
• Past Ocular History: Is this new change or their normal baseline vision? Do they have a known ocular pathology?

Pro Tip: Pinhole everyone with poor vision to rule out refractive errors!

• The Ophtho Classics: Eye trauma, surgery, or contact lens use.
• Family History: Conditions such as blindness, macular degeneration, glaucoma.
• Occupations/Hobbies: High-velocity projectiles (e.g., hammering metal), chemical (e.g., bleach), or UV light (e.g., welding)
  
  • Ask if they do anything where they should be wearing eye protection, then ask if they actually were. 
• Allergies: Especially if examining bilateral red eyes.
• Medications: Can verify comorbidities (e.g., glaucoma) and dictate management (e.g., beta-blockers often contraindicated for asthmatics).

History of Presenting Illness: the SOViETS

Ophtho histories can be shorter at times but are no less important! Often the diagnosis is in the history, and glossing over history can leave you stranded in an ocean of slit lamp, indirect, and imaging studies. Use the SOViETs (Story, Ouchies, Vision, Equality, Timelines) mnemonic to cover your bases:

1. Story: Trauma? Contact lenses? Recent surgery or injection? Systemic symptoms such as headache or jaw pain? General appearance (e.g., head tilt could be self-correcting vertical diplopia)?

2. Ouchies: Painful vs painless. Is there photophobia? Pain with eye movements?

3. Vision: Blurry, dark missing areas (negative dysphotopsia)? Colourful or flashing phenomenon (positive dysphotopsia)? Is there a “curtain” coming down? Central vs peripheral? Transient or persistent? Vertical or horizontal diplopia?

• Be specific. Like we learned in pre-med biology, structure and function are intrinsically linked. This is true with vision (function), and a structural change in the eye, or even brain! So, getting the specific vision change a patient is experiencing can narrow your differential before even starting your eye exam!

4. Equality: SOViETs love equality. One eye or both? Monocular vs binocular changes your entire differential. 

• Memory trick: OU for both eyes, OS for left eye, and OD for right eye. Want to be a Dr? Just remember that OD is right eye, OD-right=Dr.

5. Timelines: Sudden vs gradual. Constant vs intermittent. Sudden vision loss should make you pause. Gradual changes are problematic, but rarely emergencies. Vision that is okay in the morning but blurry in the evening should cue you to dry eyes.

Putting it all together: 

When seeing the patient, you should work your way through a systematic history that gathers all of the relevant clues needed to build up your differential diagnoses to your resident or staff. A conversation with the patient that goes something like:

Hello, my name is Corey one of the med students working with the ophthalmology team. Which eye is bugging you? What are you noticing in that eye specifically - entire field loss/blurriness or part of the vision missing and where? Has the other eye had any problems? When did this all start? Has this happened before? What were you doing when it started? Has it been getting worse or has it been stable? Any other symptoms (pain, photophobia, headache, dizziness, peripheral neurological changes)? Medications changes? PMHx FHx and on and on. 

Next month:

Part 2 of The History and Eye Exam You Actually Need on Ophthalmology Electives–The Physical Exam