THE ROUTINE EXAMINATION OF AN OPHTHALMIC PATIENT

‘My method in such cases.’ SIR A. CONAN Doyle, The Musgrave Ritual

IN a work that aims at giving a bird’s eye view of the whole of ophthalmology in a small volume, space prevents detailed description of the theory and technique of ophthalmoscopy, retinoscopy, etc. The author has, therefore, decided to assume some knowledge on the part of the student of the elementary use of such instruments and to concentrate instead on the various practical points of the routine examination which are frequently forgotten or neglected.

Every good physician has a systematic routine for the examination of every patient, and it is only by carrying this out in the same order that errors and omissions are avoided. The ophthalmologist should be just as precise and businesslike and form his own routine procedure. There is, however, one danger of a routine that must be avoided at all costs: the danger of regarding the patient as a ‘case”. He is not. He is a human being, and often a very scared and timid one, and should always be treated accordingly. Kindness and politeness cost nothing and are rewarded by a responsiveness and co-operation that is rarely given to the impatient brow-beating type of surgeon. The patient should never be given the impression that he is regarded as a case. Routine is necessary, but it should not be so inflexible that the patient is aware of it.

Order of Examination: The authors adopt the following order of examination as a routine in almost every case and recognize it as in their experience the best. They in no sense wish to condemn the methods of others who follow a different practice. The important thing for every prospective ophthalmic surgeon to do is to form his own routine order and to stick to it.

History.

Visual acuity.

External examination of:

History: The ophthalmologist will soon find that a careful record of the patient’s history is abundantly worth while. In every case the age and occupation should be noted, for very often the power or type of glasses to be ordered will depend upon this. After ascertaining these elementary factors the question: ‘What are you complaining of?’ should be put to the patient and the answer noted. Care should be taken over these notes. It is not sufficient to write the bald word ‘headaches’. Their location, severity, frequency, relationship to close work, whether associated with vomiting or not, should be noted. Lengthy notes are unnecessary, but something trite such as ‘pains at the back of the eye after close work’ or ‘severe right-sided headache with dazzling lights and ending with a bilious attack’ is always helpful. Furthermore, on subsequent consultations it is a good plan to inquire about previous symptoms and, rightly or wrongly, it gives the oculist the reputation of having a good memory and therefore of ‘taking an interest in my case’. Notes should be taken also of the general health, illnesses, operations and indeed anything else that seems important to the patient and might have a bearing on the case. The oculist who is curt, abrupt and too busy to listen to the patient’s history will be a bad oculist and had better give up ophthalmology and try his hand at pathology. He may be quite good at post-mortem examinations, for his patients will be dead!

FAMILY HISTORY: This can be of great importance, as such common complaints as glaucoma, senile cataract, astigmatism, amblyopia, etc. often ‘run in families’.

Visual Acuity: Each eye must be taken separately as an invariable routine in every case. This is of fundamental importance and is often most important of all in cases where it seems most superfluous. A record of this is of utmost value in subsequent consultations. More than once the author has come across patients who make claims for compensation for very trivial injuries such as corneal foreign bodies, etc., and who have grossly exaggerated their symptoms. A record of the visual acuity at the time the injury was treated is of obvious value in such cases.

In Britain, the visual acuity is always tested by Snellen’s types (Fig. 1), which are based upon the assumption that the minimum visual angle is 1 minute. Each letter is shaped so that it subtends 5 minutes of arc at a given distance, while the width of each constituent arm of the letter subtends 1 minute. This type is placed 6 m from the patient’s eyes (or 3 m if a reverse type is used and it is viewed in a mirror).

The normal patient should be able to read the seventh line at a distance of 6 m, the sixth line at 9 m, the fifth at 12, the fourth at 18, the third at 24, the second at 36 and the top at 60 m, because from each of these distances the respective lines subtend 5 minutes. Normal vision is expressed by the fraction 6/6; if a patient can only read the sixth line his vision is 6/9, and so on, 6/12, 6/18, 6/24, 6/36 and if he can read the top only it is 6/60. If the patient can only read some letters of a certain line this should be recorded, e.g. 6/18 partly or 6/12–2. If a patient cannot see the top letter he should be asked to count fingers at 1 m, and if he cannot do this he should be tested as to his ability to see a hand moving at the same distance. If the vision is too poor even for this, tests should be made as to whether he can perceive light. These last three measures of visual acuity are recorded as CF, HM and PL, respectively. Time will be saved in vision taking if a 1-cm strip of red cellophane or passe-partout is stuck on the test type to underline the 6/12 line (A H X N T) and the patient is asked to read below the red line. If the visual acuity is not good enough for this, the patient should be asked to start at the top and read downwards.

In America and some Continental countries, vision is recorded in terms of the 20-ft table. The following is the conversion table:

External Examinations: All examinations of the external eye should be made in the first instance without a magnifier but with a good light. Two methods of illumination are excellent:

After examination without magnification, the use of a binocular loupe may be very helpful. The monocular loupe has been somewhat outdated by the slit-lamp, which gives a much greater magnification and the additional advantage of stereoscopic vision. Nevertheless, the monocular loupe still plays a useful part in that it gives a fairly high magnification without elaborate apparatus and in a time-saving manner.

LIDS: These should be examined for blepharitis, ectropion, entropion, trichiasis, meibomian cysts and other abnormalities.

CONJUNCTIVA: Both bulbar and palpebral conjunctivae should then be examined and note should be taken as to whether the former is injected or oedematous and the latter red or velvety. In such cases the upper lid should be everted, for quite often a case of chronic conjunctivitis that fails to...