This document outlines the steps and important considerations for taking a patient history for subjective refraction. It discusses gathering information on the chief complaint, past ocular and medical history, family history, current medications, and allergies. It also provides guidance on special considerations for taking histories for pediatric cases, strabismus, neuro-ophthalmic conditions, glaucoma, uveitis, and ocular trauma. Key elements to document include symptoms, previous treatments, and systemic health factors that could influence eye health or treatment options. The goal is to obtain a thorough history to guide the examination and refractive procedure.

1. SUBJECTIVE REFRACTION-I
OPTOM.ASKAR P K

2. STEP BY STEP OF
SUBJECTIVE REFRACTION
 HISTORY TAKING
 VISION RECORDING
 LENSOMETRY
 SUBJECTIVE REFRACTION
 AXIS REFINING
 NV ADDITION
 BINOCULAR BALANCING
 COUNSELING

4. HISTORY TAKING IN ……..
 GENERAL
 PAEDIATRIC CASES
 SQUINT CASES
 NEURO OPHTHALMOLOGY CASES
 GLAUCOMA CASES
 UVEA CASES
 TRAUMA CASES

5. The history must include:
 [1] The patient’s chief and secondary ocular
complaints,
 [2] Previous ocular and health history,
 [3] Family ocular and health history,
 [4] Recent medical investigations,
 [5] Medications used by the patient for both
systemic and ocular pathologies,
 [6] Allergies to medications (if any).

6. The chief complaint
 Always begin with an open-ended question
 secondary complaints
 If the chief complaint pertains to loss of vision
then the nature of vision loss should be noted i.e.,
is it associated with pain or not, whether the
vision loss is gradual or sudden etc.,

7.  E.g.:- Sudden painful loss of vision (OD)
 defective vision for distance (OD>OS) since birth
 Frontal Headache & eyestrain associated with
near work more at evening-2 months

8. Past ocular history
 Previous eye examinations and treatments,
injuries to the eye, surgeries to the eye and any
other medical procedures involving the eye like
the laser treatments etc.

9.  Cataract surgery done (OD)-3 years back from al
salama eye hospital
 Yag cap done on left eye -5 years back from
Aravind eye hospital
 H/O injury with football (OS)- 3 months back

10. Past medical history
 Diabetes, Hypertension,
 Arteriosclerosis, Heart disease,
 Migraine and other headache problems
 Thyroid disorders, multiple sclerosis…..

11.  DM -10 yrs on insulin RX
 HT -4 yrs on Ayurvedic RX
 Migraine on RX

12. Family ocular/health history
 This becomes more important in ocular
pathologies like glaucoma, retinal degenerative
conditions like retinitis pigmentosa, diabetic
hypertensive retinopathies and squint etc.,

13. Medications used by the patient
 This includes the name of the drugs used for both
the systemic and ocular pathologies, their
concentration, dosage & the time of last
application must all be noted and updated at
subsequent visits.

14. Allergies
 Allergies to drugs like Sulpha groups, penicillin,
steroids might help in planning the treatment
modality for many ocular diseases
 Because the above mentioned drugs might have
been included in a drug which is used to treat
certain ocular conditions.

15. HISTORY AND PRELIMINARY
WORKUP IN PAEDIATRIC CASES
 How the problem was detected and what?
 Decreased vision
 Squint
 White reflex
 Nystagmus

16. Birth history
 Pre-natal factors
 Maternal age at the time of delivery
 H/o maternal infections
/medications/Radiation therapy
 H/o premature delivery

17. Peri-natal factors
 Normal / caesarian/ forceps /traumatic
delivery

18. Post-natal factors
 Systemic ailments
 Trauma
 Milestones
 H/o Incubation
 H/o Oxygenation / phototherapy
 H/o vaccinations & booster doses
 Genetic factors
 Family history
 H/o consanguinity parentage
 H/o siblings having similar problems

19. HISTORY AND PRELIMINARY WORK UP
IN SQUINT CASES
 Direction of deviation
 Age of onset
 Deviation constant or intermittent
 If sudden then ask for any associated
neurologic signs like dizziness
/vertigo/weakness /any tingling in arms or
legs etc….
 head tilt/ turn, chin up/down position

20. Past history
 H/o any treatment for amblyopia associated
with squinting
 Patching
 Any glasses prescribed previously
 H/o any surgery done

21. HISTORY AND PRELIMINARY WORK UP
IN
NEURO OPHTHALMOLOGY CASES
 A careful history can often lead to the
diagnosis of a neuro -ophthalmic disorder
prior to examination

22. The common complaints that
patients often come are
 Decreased vision
 Headache
 Ptosis
 Diplopia
 Peri ocular pain
 Proptosis

23. Systemic history
 Hypertension
 Diabetes mellitus
 Collagen vascular diseases
 Tuberculosis
 Urinary incontinence
 Vasculitis
 Viral fever
 Neurological deficits
 Stroke
 Weight loss
 Hypercholesteremia

24. HISTORY AND PRELIMINARY WORK UP
IN GLAUCOMA CASES
 Present complaints and the reason for
which the patient has come to the clinic.
 See for any specific instructions by the
consultant from the previous visit.

25.  E.g. Vision, AT means apart from a very
brief history on new complaints and
medication history, the patient has to undergo
Vision with PGP and PH for distance and
near along with AT.

26. Dilatation
 No dilatation is required for new patients
with glaucoma (since gonioscopy is needed)

27. HISTORY AND PRELIMINARY WORK UP
IN UVEITIS CASES
 Patient Details
 Age
 Young Patients – Congenital Toxoplasmosis, Toxocariasis,
Peripheral Uveitis.
 Elderly Patients – Toxoplasmosis, Herpes Zoster, Aphakic
Uveitis.
 Sex
 Male – prone to Ankylosing Spondylitis, Reiter’s syndrome.
 Women—Toxoplasmosis, chronic anterior Uveitis of
Unknown Cause

28. Past Investigations
 Any recent Investigations.
 Rheumatoid factor, Anti nuclear Anti bodies,
ESR, Mantoux, Chest X-ray.
 Above details should be noted with date of the
tests.

29.  Medications
 Current medications (both topical and systemic)
 If Patient has discontinued the medications for the
last few days it is useful to record when the patient
last used the medications & what was the last dose
at which the medication was stopped.

30. Other Details
 Contact with pets (Toxoplasma, Toxocara)
 Oral and genital ulceration (Behcet’s disease)
 Fever, Weight loss, cough (Tuberculosis)
 H/o Immunosuppressive usage.

31. HISTORY AND PRELIMINARY WORK UP
IN TRAUMA CASES
 Details of the Accident
 Date and Time.
 Location.
 Whether incident was
accidental/intentional/self-inflicted.

32.  Whether it occurred in the work place
 If it occurred at the work place was
protective eye- wear being worn at the time
of the accident – if worn what kind of
protection.
 Name and Addresses of Witnesses

33. Details of Agent causing the Injury
 Blunt Trauma:
 Description of Object.
 Penetrating Trauma:
 Single/ Multiple Penetration.
 Composition of the Object.
 Chemical Injury:
 Nature of Chemical – Acid/Alkali.
I got hit with that
ball

34. Documentation for near vision
correction
 When patient has been prescribed with
higher add then please note it down in EMR
that patient require higher add and note down
the working distance range for that add given.
 Example : +2.50Ds @ 30-40cms
 Preference of new glasses also to be
mentioned.