OPHTHALMOLOGYPROFORMAS

I
dent
if
icat
ionDat
a:

Name
Age
Sex
Address
Occupati
on
I
nformant(f
orchi
l
dren)

Chi
efCompl
aint
s:

Deal
tsepar
atel
ycasewi
se

Hi
stor
yofPr
esentI
ll
ness:

Deal
tsepar
atel
ycasewi
se

PastHi
stor
y:

Hist
oryofsimil
arcomplaints
Hist
oryofChronici
ll
nesses
Pastmedicalandsurgi
cal hi
stor
y

Fami
lyHi
stor
y:

Hi
stor
yofsi
mi l
arcomplaint
s
Hi
stor
yofChronici
ll
nesses

Per
sonalHi
stor
y:

Di
et
Appet
it
e
Sl
eep
BowelandBl
adder
Addi
cti
ons
Menstr
ualHi
stor
y

Dr
ugHi
stor
y:

Hi
stor
yofdr
ugst
aken

Al
ler
gicHi
stor
y:

Hi
stor
yofanyknownal
l
ergens
Gener
alExami
nat
ion:

CCC,
bui
l
t,nour
ishment
,et
c.

PI
CCKLE

Vi
tal
s:

Temper
atur
e
Pul
se
BP
RR

LocalExami
nat
ion:

OnI
nspect
ionwi
tht
orchl
ight
:

1)HeadPosture:
Anyabnor
malpost
ureduet
ost
rabi
smusorpt
osi
s.

2)Face:
Sy
mmetrymaint
ainedornot
,anyasy
mmet
ry,
faci
alpal
sy,
her
peszost
er,
swel
l
ing,
etc.

3)Ey
e:

Ri
ghtEy
e Lef
tEy
e

Vi
sualAcui
ty:

Checkforvi
sualacuit
yi nbotheyesusingcount
ing
fi
ngersmethod, star
ti
ngf r
om 6met r
es.I
facuit
y
i
swor sethancount i
ngfingerscl
osetoface,
thentr
yhandmov ements.I
fworsethanthat
,
perf
orm percepti
onofl i
ght.

Ey
eBr
ows:

Checkforanyel
evat
ion,
lossofhai
ror
depigment
ati
on.

Or
bit
s:
Anysi
gnsofcel
l
uli
ti
s,f
ract
ures.

Ey
ebal
ls:

1)Posi
ti
onandDi r
ect
ion:Anyexophthalmos,
enopht
halmos,str
abismusetc.
2)Movements:Ful
lornotfull
.
3)Si
zeandshape: Mi
crophthal
mia,
pht hi
sisbubl
iet
c

Ey
eli
ds:

1)Positi
on: anyect ropion, entr
opionorpt osis.
2)Mov ement s:
restrictedi nsy mbl epharon
3)Palpebral aperture:nor mal ,narroworwi de
4)Mar gi
ns: Anyi nfl
ammat i
on,thickening, crust
ing
5)Lashes: Anymi sdirection( tr
ichiasis),madar osis
multiplerows( distichiasis),orpoliosis
6)Glands:Ifanyswel ling, describei tsextent,size,
shape, colour,et c.
7)Lacrimal punct a:ever si
onoroccl usi
on

Lacr
imal
Appar
atus:

I
nspectthepuncta,
lacri
mal sacareaforanyswel
li
ng
orrednessoraf i
stula.Ifaswell
ingispr
esent
,
esti
mateitsextent,size,shape,
etc.

Conj
unct
iva:

Lookf
oranycongest i
on,oranyvascul
arorpal
efl
eshy
growth,oranyotheranomali
es,
inbul
bar,
palpebr
alandfornices.

Forf
leshyvascul
argr
owths,defi
nethesizeandlength
ofcorneaandpupi
lencroachedbythegrowth.
Foranyspots,
descr
ibetheircol
orandlocati
on.
Scl
era:

Anysi
gnsofepiscl
eri
ti
sorscleri
ti
sorstaphylomas,
scl
erathi
nni
ng,etc.Lookforanyfor
eignbody,
nodul
esoranyotherpigmentati
onanomalies.

Cor
nea:

1)Size:Est imat et hev er ti

cal andhor i
zontal
diamet er.Nor mal =11, 12mm
2)Curvatur e:Coni cal,Gl obul arorFl at
3)Transpar ency :Anyopaci tyshoul dbe
noted, andi nfil
tratesoful cershoul dbe
diff
erent i
atedwi thmacul a, nebula,
l
eucoma.Ar cusseni li
s/ j
uv enili
snot ed.
4)Surface: Exami nedbywi ndowr eflex.
5)Sensat ions: Exami nedusi ngacot ton
wisp.
6)Anyot heranomal i
esl ike,sy nechiae,
vascular i
sation, foreignbodyorKPs, et
c.
Anyul ceroropaci t
yi sdescr i
bedi nterms
ofsize, extent,clockposi tion.Ulcer
describedi naddi ti
onwi t
hmar gins, i
fany
sloughing, etc.

Ant
eri
orChamber
:

1)Depth:Nor mali
s2. 5mm.Usi ngtorch
l
ightiti
sdet er
minedi fACisshal
lowor
normal.Throwlightf rom t
hesideover
l
ateralhalfofi
ri
s, andi ft
heotherhal
fis
seen,it
snor malorel seshall
ow.
2)Contents:Anyhy popy on,
aqueosfl
are
hyphema, pseudohy popyon,subl
uxated
l
ens, ACIOLetc.

I
ri
s:
 1)Colour:Colourisnot edandnotedforany
heterochromi air
idi
s/ir
idi
um,muddyi r
is,
etc.
2)Pattern:Normal patterni
salt
ernate
cryptsandel evati
ons,anyabnormal
patternnoted.
3)Positi
on: Synechiaearenoted.
4)Anyi r
idodial
ysis,ir
idodonesi
snoted.

Pupi
l:

1)Size: Wit
houtusingl i
ght,notedforany
anomal ylikeanisokori
a
2)Shape: Ifroundornot ,ordeformeddue
tosy nechiae.
3)Mar gin:Examinedf orany
pseudoexf oli
ati
on,etc.
4)React i
on:Ifdir
ectandconsensual
rrf
lexesar eint
act,withallpart
soft he
pupi lr
eactingtoli
ghtornot ,anysluggi
sh
reactionorRAPD.Accomodat i
onand
psy chosensoryrefl
exal sotested.

Lens:

1)Colour:JetBlack( Aphakia),Shimmer ing

l
ightreflex(Pseudophaki a),Greywhite
(I
mmat urecat aract),
Pear l
ywhi t
e
(Maturecat aract),Milkywhi t
e
(Hypermat urecat aract),
Greenish/Yell
ow/ Amber /Brown/ Bl
ack
(NuclearSclerosi s)
2)I
risShadow: Seeni nimmat urecataract
3)Posit
ion: Anydi slocationorsubluxation
4)Purki
njei mages: 4(Clearlens),2
(Aphakia),3(Mat urecataract)

Notexami
ned. Notexami
ned.
Fundus:

Checkedf
orpost
eri
orsegmentpat
hol
ogi
es.
OnPal
pat
ion:

Ri
ghtEy
e Lef
tEy
e

I
OP:

Bydi
git
altonometryusingi ndexfi
ngersofbothhands,
perf
ormf l
uctuati
ont estondownwar dgaze
beyondthetarsalplate,menti
onthefindi
ng,i
f
fi
rm(normal),softorhard.

Regur
gitat
ionOnPressur
eov
erLAcr
imalSac
(ROPLAS):

Pr
essovert
hemedialcant
husandlookfor
regur
git
ati
on,Menti
onifposi
ti
ve/
negat
ivewi
th
natur
eofthesecret
ion.

Swel
li
ng:

I
fther
ei saswelli
ngi nli
d/atmedi alcanthus,palpat
e
toconfirmthef i
ndingsoni nspection:si
ze,
shape,surface,adhesiontounder lyi
ng
struct
uresorov erl
yingskin,planeofor i
gin,l
ocal
ri
seoft emperature,tenderness,mobilit
y,
reduci
bili
ty,et
c.

Sy
stemi
cExami
nat
ion:

CNS
Hi
gherf
unct
ions,
crani
alner
ves,
sensor
yandmot
or

CVS
Hear
tsounds,
Mur
mur
s

Respi
rat
ory
Bi
lat
eral
AirEnt
ry,
TypeofBr
eat
hsounds
 GIT
Pal
pat
ionofAbdomen

Pr
ovi
sionalDi
agnosi
s:

Deal
tsepar
atel
ycasewi
se

ACASEOFDI
MINI
SHEDVI
SION:

1)Cataract
2)Ptery
gium
3)Pseudophakia
4)Aphakia
5)CornealUlcer
/Opaci
ty

Chi
efCompl
aint
s:

Ment
ionchi
efcompl
aint
sinpat
ient
’sownwor
dsi
nchr
onol
ogi
cal
orderwi
thdur
ati
on.

Dimi nuti
on/
Lossofvi
sion
Diplopia
Foreignbodysensat
ion
Reddi shwhit
egrowt
h
Pain
Redness
Discharge
Phot ophobi
a

Hi
stor
yofPr
esentI
ll
ness:

Appar
ent
lyasy
mpt
omat
ic_
___t
imebackandt
hendev
eloped….

Askabouteachcompl
aint
,it
sonset
,dur
ati
on,
progr
essi
on,
aggr
avat
ing,
rel
i
evi
ngf
act
ors,
andeff
ectontaki
ngmedicat
ion.

Fordecreaseorl ossofv i
sionconcent r
ateonageofonset ,pai
n,progressi
on,any
associat
edfactorsli
kediur
nalv ar
iat
ion,glar
e,color
edhalos,for
eignbodysensati
on,
i
tching,r
edness,phot
ophobi
a, anywater
ingordischar
ge,
diplopi
aorpoly
opia,etc.

Ifabovesuggesti
veofcatar
actaskforhist
oryoftr
auma,metabol
i
cdiseases,usageof
topi
caleyedrops,surger
yinthesameey e,anyexposur
etoheatorr
adiati
on,frequent
changeofglasses,anyat
opi
cdiseases,
etc.

I
fabovesuggesti
veofptery
gium askforanygrowthiney
e,whet
heri
tisst
ati
onar
yor
gr
owing,
tenderornot
,oranychangeinit
scolor
,etc.

I
fabovesuggesti
veofcornealul
cer
/opacit
yaskforhist
oryoftr
aumawithveget
able
mat
ter
,or f or
eign bodi
es,diabet
es,i mmunosupr
essivether
apy,i
nfect
ions l
ike
 conj
unct
ivi
ti
sordacr
yocy
sti
ti
s,cont
actl
enswearet
c.

El
i
citanyr
elev
antposi
ti
veandnegat
ivehi
stor
ytot
hecompl
aint
s.

Pr
ovi
sionalDi
agnosi
s:

*
CaseSummar
y*andpr
ovi
sional
diagnosi
sment
ionedwi
thREf
ir
stf
oll
owedbyLE:

1)I
mmat ur
e/Mature-Senil
e/Presenil
e-Corti
calCat ar
act
2)I
mmat ur
e-Seni
le/Preseni
le-
Nucl earSclerosisGrade…
3)Earl
y/Advanced-?DoubleHeaded- ?Infl
amed- Nasal/TemporalPter
ygi
um
4)CornealUl cer
-pr obably bacterial/
vir
al/fungal/
protozoalin ori
gin,at.
.’
o cl
ock
posit
ion
5)CornealOpacit
y-Macul a/Nebula/Nebula, at..
’
oclockposi t
ion
6)Pseudophakia
7)Aphakia

*
Ment
ioni
nther
elev
antey
eifanyf
indi
ngsofaphaki
a,pseudophaki
a,pt
ery
gium,
etc.

ACASEOFWATERI
NGEYE:

Chr
oni
cDacr
yocy
sti
ti
s

Chi
efCompl
aint
s:

Ment
ionchi
efcompl
aint
sinpat
ient
’sownwor
dsi
nchr
onol
ogi
cal
orderwi
thdur
ati
on.

Wateri
ng/
Discharge
Swell
i
nginMedi alCant
hus

Hi
stor
yofPr
esentI
ll
ness:

Appar
ent
lyasy
mpt
omat
ic_
___t
imeagoandt
hendev
eloped….

Askabouteachcompl
aint
,it
sonset
,dur
ati
on,
progr
essi
on,
aggr
avat
ing,
rel
i
evi
ngf
act
ors,
andeff
ectontaki
ngmedicat
ion.

Forwateri
ngaskf oranyassociatedrednessofey e,i
tchi
ngsensat
ion,anyhist
oryof
tr
auma,recur
rentconj
uncti
vi
tis,anysurgeri
es,nasalsy
mpt oms,l
i
dlaxit
y,for
eignbody
sensat
ion,
usageofcertai
ndrugs.

Fordi
schar
gei
naddi
ti
onaskcol
or,
amount
,smel
l
,ty
pe,
consi
stencyandanyassoci
ated
condi
ti
on.

El
i
citanyr
elev
antposi
ti
veandnegat
ivehi
stor
ytot
hecompl
aint
s.

Pr
ovi
sionalDi
agnosi
s:
 *
CaseSummary
*andprov
isi
onaldi
agnosisis:
RE/LEChroni
cDacr
yocy
sti
ti
sin_
___
___
_st
age
(
wit
hmild/
moderat
econj
uncti
valcongesti
on/bl
ephar
it
is)

ACASEOFSWELLI
NGI
NLI
D:

1)I
nter
nal
Hor
deol
um
2)St
ye/Exter
nal
Hor
deol
um
3)Chal
azion

Chi
efCompl
aint
s:

Ment
ionchi
efcompl
aint
sinpat
ient
’sownwor
dsi
nchr
onol
ogi
cal
orderwi
thdur
ati
on.

Lumpinthel
id
Pai
nintheswel
li
ng

Hi
stor
yofPr
esentI
ll
ness:

Appar
ent
lyasy
mpt
omat
ic_
___t
imeagoandt
hendev
eloped….

Askabouteachcompl
aint
,it
sonset
,dur
ati
on,
progr
essi
on,
aggr
avat
ing,
rel
i
evi
ngf
act
ors,
andeff
ectontaki
ngmedicat
ion.

Askf
orassoci
atedi
tchi
ng,
dist
ort
edv
isi
on,
etc.

El
i
citanyr
elev
antposi
ti
veandnegat
ivehi
stor
ytot
hecompl
aint
s.

Pr
ovi
sionalDi
agnosi
s:

*Case Summary*and pr
ovisi
onaldiagnosi
si s:RE/
LE Chal
azi
on,I
nter
nalHor
deol
um,
Stye/
Exter
nalHor
deolum (
withBlephar
it
is,
etc)

NOTE:Sunconj
uct
ivalHaemor
rhage,
Bit
otSpot
smayal
sobekept
.