Case history taking

The most important part of an eye exam (or any medical exam in particular)

Case history taking

For the longest time, I thought the refraction exam was the most important part of the eye exam until I realized how critical case history taking is. I was always so eager to get into the eye examination to move on to the next patient, then I unintentionally find myself wasting both my patient's and my time because I didn't ask for any systemic conditions such as diabetes in the first place--resulting in a fluctuation of refractive errors.

The last thing you want to do as an optometrist is to provide the wrong solutions to a specific problem.

Case history taking is the part of the eye exam wherein you develop a picture of your patient's perspective on the visual problem. It is the duty of the optometrist to listen, understand, clarify misheard words, interpret, and summarize the words of the patient.

The aims of gaining such information include:

1. Identifying the complaints. The patient's first uttered words regarding the visual problem is usually considered as the chief complaint, the rest is known as associated complaints.

The most common is the blurring of vision, you will have to expound on this whether the patient experiences this at distance, at near, or both.

Other common mentions would be headaches and/or dizziness as their chief complaint. If this is the case, you have to determine whether the source of the anomaly is purely a refractive error or stress-related.

Furthermore, it is ideal to address all complaints for patient satisfaction. But sometimes the solutions can be counterproductive to each other, so the best approach is to at least address the chief complaint from a different approach.


A 45-year old female patient consulted for blurring of vision at near, she despises the use of spectacles and was suggested for contact lens use. Contact lens exam determined that she was not qualified for contact lenses due to severe dry eye. Her nature of work included sitting in an enclosed space with air-conditioning on, it was also observed that she was not organized and hygienic with her personal belongings.

Now, if this were your patient, you could probably convince her to wear reading glasses in your clinic but there's no guarantee that she would use them for reading (kasi nga ayaw sa glasses). On the other hand, she may not qualify for contact lens use because her hygiene and sanitary habits may cause further problems in the near future.

SOLUTION: Suggest the use of magnifying lenses for viewing near objects.

2. Understand how the complaints affect the quality of life. Is the patient's productivity reduced due to his affected vision? Is he able to socialize well? Does he have difficulty recognizing friends and family? How difficult can he perform on his daily activities?

While it is ideal to restore the patient's quality of life before having to experience visual anomalies, this is not always the case. Especially if the solution can be hazardous in the patient's occupation. (i.e. a professional basketball player wearing spectacles in-game is not advised.)

3. Determine if the patient requires additional tests to address the visual problem. To be able to see comfortably clear is an optometrist's main goal in every patient's visual needs, a secondary goal would be to maximize vision.

There will be cases where there would be other tests to perform according to the patient's needs, this includes:

  • contact lens examination
  • color blind test
  • sports vision assessment
  • low vision assessment

4. Determine if the patient needs a referral. You should identify your stand in addressing the patient's problem in terms of learning, support, care, or correction?

Does the patient have learning problems or has difficulty in communicating?

He could probably be referred to a speech therapist after the eye exam.

Does the patient require support as a human being?

A patient who has lost his vision in one eye could be due to evisceration or enucleation may regain his confidence outdoors with the help of a prosthetic eye

Does the patient require a more sophisticated care due to presence of eye diseases such as cataracts, glaucoma, or retinopathy?

Addressing any form of anomalies is a must before prescribing any correction lenses to the patient. A referral to an ophthalmologist is the most appropriate step in this case before consulting an optometrist.

Does the patient simply require correction for his visual needs?

If the above areas are at optimum, then the patient may only need intervention in terms of correction or therapy through lenses and ocular exercises. By default, an optometrist should be able to provide these solutions.

The minimum information to obtain in taking the case history:

  • reason for consultation
  • chief complaint and associated complaints
  • hours of sleep
  • age
  • occupation
  • social life (alcohol, smoking)
  • daily activities that require vision (driving, reading)
  • comorbidities and medical history


Case history taking is one of the most underrated portions of an eye exam, if you do this well you're doing yourself and your patient a huge favor.

With experience, the practitioner gets better with creativity and critical thinking.

A consequence of a sincere taking of the case history is the building of rapport between the optometrist and the patient. Not only does this develop trust but also a high chance of having a recurring patient for periodical check-ups.