OPHTHALMOLOGY PROFORMAS
Identification Data:
Name
Age
Sex
Address
Occupation
Informant (for children)
Chief Complaints:
Dealt separately case wise
History of Present Illness:
Dealt separately case wise
Past History:
History of similar complaints
History of Chronic illnesses
Past medical and surgical history
Family History:
History of similar complaints
History of Chronic illnesses
Personal History:
Diet
Appetite
Sleep
Bowel and Bladder
Addictions
Menstrual History
Drug History:
History of drugs taken
Allergic History:
History of any known allergens
General Examination:
CCC, built, nourishment, etc.
PICCKLE
Vitals:
Temperature
Pulse
BP
RR
Local Examination:
On Inspection with torch light:
1) Head Posture:
Any abnormal posture due to strabismus or ptosis.
2) Face:
Symmetry maintained or not, any asymmetry, facial palsy, herpes zoster, swelling, etc.
3) Eye:
Right Eye Left Eye
Visual Acuity:
Check for visual acuity in both eyes using counting
fingers method, starting from 6 metres. If acuity is
worse than counting fingers close to face, then try
hand movements. If worse than that, perform
perception of light.
Eye Brows:
Check for any elevation, loss of hair or
depigmentation.
Orbits:
Any signs of cellulitis, fractures.
Eyeballs:
1) Position and Direction: Any exophthalmos,
enophthalmos, strabismus etc.
2) Movements: Full or not full.
3) Size and shape: Microphthalmia, phthisis bubli
etc
Eyelids:
1) Position: any ectropion, entropion or ptosis.
2) Movements: restricted in symblepharon
3) Palpebral aperture: normal, narrow or wide
4) Margins: Any inflammation, thickening, crusting
5) Lashes: Any misdirection (trichiasis), madarosis
multiple rows (distichiasis), or poliosis
6) Glands: If any swelling, describe its extent, size,
shape, colour, etc.
7) Lacrimal puncta: eversion or occlusion
Lacrimal Apparatus:
Inspect the puncta, lacrimal sac area for any
swelling or redness or a fistula. If a swelling is
present, estimate its extent, size, shape, etc.
Conjunctiva:
Look for any congestion, or any vascular or pale
fleshy growth, or any other anomalies, in bulbar,
palpebral and fornices.
For fleshy vascular growths, define the size and
length of cornea and pupil encroached by the
growth. For any spots, describe their color and
location.
Sclera:
Any signs of episcleritis or scleritis or staphylomas,
sclera thinning, etc. Look for any foreign body,
nodules or any other pigmentation anomalies.
Cornea:
1) Size: Estimate the vertical and horizontal
diameter. Normal= 11,12mm
2) Curvature: Conical, Globular or Flat
3) Transparency: Any opacity should be noted,
and infiltrates of ulcer should be
differentiated with macula, nebula, leucoma.
Arcus senilis/juvenilis noted.
4) Surface: Examined by window reflex.
5) Sensations: Examined using a cotton wisp.
6) Any other anomalies like, synechiae,
vascularisation, foreign body or KPs, etc.
Any ulcer or opacity is described in terms of
size, extent, clock position. Ulcer described
in addition with margins, if any sloughing,
etc.
Anterior Chamber:
1) Depth: Normal is 2.5mm. Using torch light it
is determined if AC is shallow or normal.
Throw light from the side over lateral half of
iris, and if the other half is seen, its normal
or else shallow.
2) Contents: Any hypopyon,aqueos flare
hyphema, pseudohypopyon, subluxated
lens, ACIOL etc.
Iris:
1) Colour: Colour is noted and noted for any
heterochromia iridis/iridium, muddy iris, etc.
2) Pattern: Normal pattern is alternate crypts
and elevations, any abnormal pattern noted.
3) Position: Synechiae are noted.
4) Any iridodialysis, iridodonesis noted.
Pupil:
1) Size: Without using light, noted for any
anomaly like anisokoria
2) Shape: If round or not, or deformed due to
synechiae.
3) Margin: Examined for any pseudoexfoliation,
etc.
4) Reaction: If direct and consensual rrflexes
are intact, with all parts of the pupil reacting
to light or not, any sluggish reaction or
RAPD. Accomodation and psychosensory
reflex also tested.
Lens:
1) Colour: Jet Black (Aphakia), Shimmering light
reflex (Pseudophakia), Grey white (Immature
cataract), Pearly white (Mature cataract),
Milky white (Hypermature cataract),
Greenish/Yellow/Amber/Brown/Black
(Nuclear Sclerosis)
2) Iris Shadow: Seen in immature cataract
3) Position: Any dislocation or subluxation
4) Purkinje images: 4 (Clear lens), 2 (Aphakia), 3
(Mature cataract)
Not examined. Not examined.
Fundus:
Checked for posterior segment pathologies.
On Palpation:
Right Eye Left Eye
IOP:
By digital tonometry using index fingers of both
hands, perform fluctuation test on downward gaze
beyond the tarsal plate, mention the finding, if firm
(normal), soft or hard.
Regurgitation On Pressure over LAcrimal Sac
(ROPLAS):
Press over the medial canthus and look for
regurgitation, Mention if positive/negative with
nature of the secretion.
Swelling:
If there is a swelling in lid/at medial canthus,
palpate to confirm the findings on inspection: size,
shape, surface, adhesion to underlying structures or
overlying skin, plane of origin, local rise of
temperature, tenderness, mobility, reducibility, etc.
Systemic Examination:
CNS
Higher functions, cranial nerves, sensory and motor
CVS
Heart sounds, Murmurs
Respiratory
Bilateral Air Entry, Type of Breath sounds
GIT
Palpation of Abdomen
Provisional Diagnosis:
Dealt separately case wise
A CASE OF DIMINISHED VISION:
1) Cataract
2) Pterygium
3) Pseudophakia
4) Aphakia
5) Corneal Ulcer/Opacity
Chief Complaints:
Mention chief complaints in patient’s own words in chronological order with duration.
Diminution/Loss of vision
Diplopia
Foreign body sensation
Reddish white growth
Pain
Redness
Discharge
Photophobia
History of Present Illness:
Apparently asymptomatic ____ time back and then developed….
Ask about each complaint, its onset, duration, progression, aggravating, relieving factors, and
effect on taking medication.
For decrease or loss of vision concentrate on age of onset, pain, progression, any associated
factors like diurnal variation, glare, colored halos, foreign body sensation, itching, redness,
photophobia, any watering or discharge, diplopia or polyopia, etc.
If above suggestive of cataract ask for history of trauma, metabolic diseases, usage of topical
eye drops, surgery in the same eye, any exposure to heat or radiation, frequent change of
glasses, any atopic diseases, etc.
If above suggestive of pterygium ask for any growth in eye, whether it is stationary or growing,
tender or not, or any change in its color, etc.
If above suggestive of corneal ulcer/opacity ask for history of trauma with vegetable matter, or
foreign bodies, diabetes, immunosupressive therapy, infections like conjunctivitis or
dacryocystitis, contact lens wear etc.
Elicit any relevant positive and negative history to the complaints.
Provisional Diagnosis:
*Case Summary*and provisional diagnosis mentioned with RE first followed by LE:
1) Immature/Mature-Senile/Presenile-Cortical Cataract
2) Immature-Senile/Presenile-Nuclear Sclerosis Grade…
3) Early/Advanced-?Double Headed-?Inflamed-Nasal/Temporal Pterygium
4) Corneal Ulcer- probably bacterial/viral/fungal/protozoal in origin, at ..’o clock position
5) Corneal Opacity- Macula/Nebula/Nebula, at ..’o clock position
6) Pseudophakia
7) Aphakia
*Mention in the relevant eye if any findings of aphakia, pseudophakia, pterygium, etc.
A CASE OF WATERING EYE:
Chronic Dacryocystitis
Chief Complaints:
Mention chief complaints in patient’s own words in chronological order with duration.
Watering/Discharge
Swelling in Medial Canthus
History of Present Illness:
Apparently asymptomatic ____ time ago and then developed….
Ask about each complaint, its onset, duration, progression, aggravating, relieving factors, and
effect on taking medication.
For watering ask for any associated redness of eye, itching sensation, any history of trauma,
recurrent conjunctivitis, any surgeries, nasal symptoms, lid laxity, foreign body sensation, usage
of certain drugs.
For discharge in addition ask color, amount, smell, type, consistency and any associated
condition.
Elicit any relevant positive and negative history to the complaints.
Provisional Diagnosis:
*Case Summary*and provisional diagnosis is: RE/LE Chronic Dacryocystitis in ________ stage (with
mild/moderate conjunctival congestion/blepharitis)
A CASE OF SWELLING IN LID:
1) Internal Hordeolum
2) Stye/External Hordeolum
3) Chalazion
Chief Complaints:
Mention chief complaints in patient’s own words in chronological order with duration.
Lump in the lid
Pain in the swelling
History of Present Illness:
Apparently asymptomatic ____ time ago and then developed….
Ask about each complaint, its onset, duration, progression, aggravating, relieving factors, and
effect on taking medication.
Ask for associated itching, distorted vision, etc.
Elicit any relevant positive and negative history to the complaints.
Provisional Diagnosis:
*Case Summary*and provisional diagnosis is: RE/LE Chalazion, Internal Hordeolum, Stye/External
Hordeolum (with Blepharitis, etc)
NOTE: Sunconjuctival Haemorrhage, Bitot Spots may also be kept.
