The Three Pillars of Patient History
A complete patient history in ophthalmology extends well beyond the eyes. Medical history, ocular history, and family history form three interconnected pillars that reveal a patient's risk profile, explain current findings, and guide future monitoring. As an ophthalmic assistant, gathering this information accurately and completely is one of your most valuable contributions to patient care.
Medical History
Systemic conditions frequently affect ocular health. Documenting medical history helps the ophthalmologist anticipate which ocular complications to screen for:
High-Impact Systemic Conditions
| Condition | Ocular Manifestation |
|---|---|
| Diabetes mellitus | Diabetic retinopathy, macular edema, cataracts |
| Hypertension | Hypertensive retinopathy, vein occlusions |
| Autoimmune diseases (RA, lupus) | Dry eye, scleritis, uveitis |
| Thyroid disease (Graves') | Proptosis, lid retraction, exposure keratopathy |
| Multiple sclerosis | Optic neuritis, nystagmus |
| Sickle cell disease | Proliferative retinopathy, vitreous hemorrhage |
What to Document
- All current and past medical diagnoses
- Surgical history (including non-ocular surgeries)
- Hospitalizations and their reasons
- Current health status and disease control (e.g., most recent HbA1c for diabetic patients)
Ocular History
The ocular history documents everything related to the patient's eye health and prior eye care:
- Previous ocular diagnoses: Glaucoma, cataracts, macular degeneration, amblyopia, strabismus
- Ocular surgeries and procedures: Cataract extraction, LASIK, retinal detachment repair, intravitreal injections, laser treatments
- Ocular injuries: Corneal foreign bodies, chemical burns, blunt or penetrating trauma
- Contact lens history: Type, wear schedule, complications
- Current eyewear: Glasses prescription, age of current glasses
- Eye drop use: Current ophthalmic medications, artificial tears
Always ask about both eyes individually when documenting ocular history. A patient may have very different histories for each eye (surgery on one, healthy other). Document OD and OS separately for all ocular history elements.
Family History
Many ocular conditions have a genetic component that increases risk for the patient:
- Glaucoma: First-degree relatives with glaucoma significantly increase the patient's risk
- Age-related macular degeneration: Strong familial association
- Diabetes: Family history increases the patient's risk of developing diabetic eye disease
- Retinal detachment: Some predisposition is heritable
- Strabismus and amblyopia: Familial patterns are common
- Keratoconus: Increased incidence in families
What to Ask
- Do any immediate family members (parents, siblings, children) have eye diseases?
- Has anyone in the family gone blind or had significant vision loss?
- Is there a family history of diabetes, hypertension, or autoimmune disease?
- Any family history of glaucoma specifically? (Particularly important for African American patients, who have higher prevalence)
Asking only about eye disease in the family history. Systemic conditions like diabetes, hypertension, and autoimmune diseases run in families and carry significant ocular implications. The family history should cover both ocular and systemic conditions.
When a patient reports a family history of glaucoma, document which relative was affected (parent, sibling, grandparent) and the type if known (open-angle, angle-closure). First-degree relatives carry a much higher risk than distant relatives.
Key Takeaways
- Medical history reveals systemic conditions (diabetes, hypertension, autoimmune disease) with ocular manifestations
- Ocular history documents all prior eye conditions, surgeries, injuries, and treatments for each eye individually
- Family history identifies genetic risk factors for glaucoma, AMD, diabetes, and other heritable conditions
- Always document both eyes separately and include both ocular and systemic family history
- A thorough history helps the ophthalmologist anticipate findings and tailor the examination