The Ophthalmic Case Historian PDF

6 The Ophthalmic Case Historian Charles l. Haine ost clinicians know that providing patient care is clinician. Again, this is due to the experienced clinician's M a combination of art and science. During the eye exam...

6 The Ophthalmic Case Historian ost clinicians know that providing patient care is M a combination of art and science. During examination-and particularly during clinical refrac- tion-there appears to be more science than art. Most of the clinical data that the clinician collects can be quantified, and the clinical procedures used to gain the information are grounded in visual science. Case history is one example in which art is more at play. During the taking of the case history, the clinician must listen to the patient and attempt to understand exactly what the patient is trying to convey. The taking of a case history from a patient is very much a problem-solving exercise; in this exercise, the patient is the one who knows what is bothering him or her, and the physician must first elicit the complaint and then follow that with more questions to determine the nature of and reason for the complaint. The physician must ask the correct questions to obtain the crucial details about that complaint. It is this social interchange between patient and physician that makes or breaks a clinician in his or her quest to understand the patient's problems. With experience, the clinician learns to do what is known as "pattern matching."! During this process, a patient presents with a set of complaints, and the clini- cian listens to and records them. The experienced prac- titioner then compares the signs and symptoms to similar sets of complaints from past patient encounters. As the clinician sees more and more patients, his or her accuracy of recognition of clinical entities improves to the point at which valid provisional diagnoses are made in the vast majority of case histories that he or she takes. For student clinicians, the process is slightly different, because they have not yet built a base of clinical pat- terns; the student must collect information from the patient and then form conditional hypotheses that can be tested. These hypotheses can be tested by gathering additional information from the patient about the com- plaint and by beginning to collect objective data during the commencement of the clinical examination. There is a difference in the type and amount of hypotheses (differential diagnoses) formed by the two groups. The experienced practitioner forms fewer hypotheses, which usually are more specific than those of the student 196 BENJAMIN Borishs Clinical Figure 6-1 Comprehensive model of clinical decision Therapeutic. history be recorded at the top of the clinical record. However, much of the history can be-and, in fact, is- obtained during the examination process. It would be an interesting experiment to record case history on the examination record form at the point at which it is actu- ally obtained during the examination process. In other words, if a clinical finding stimulates the clinician to ask a question, the patient's response would be recorded immediately following the results of the clinical finding that provoked that line of questioning. This would produce a case history that was continuous, which began at the onset of the patient encounter and ended after the last clinical finding was determined. As an aca- demic exercise alone, it is likely that a clinician would gain significant new insights into the clinical decision- making process that he or she uses. It is the patient's complaints and supporting infor- mation that provide the road map for the clinical exam- ination. Although it is difficult to imagine examining a patient without ascertaining his or her clinical history, without such information, the clinical examination would drift aimlessly to a faulty conclusion, or the clinician would have to perform every examination shocked by the brevity of ophthalmic record keeping when they visit an established ophthalmic practitioner's office. It mattered not whether it was an optometrist or ophthalmologist they were visiting; the record of the examination was not as robust nor was it as well docu- mented as they were taught it should be during their professional education. In particular, the case history has been an area in which practitioners have recorded little beyond the details surrounding the patient's visual problem. However, this situation can no longer be tolerated, because medicolegal considerations have changed the practitioner's responsibility to document. "If it is not recorded, it was not done" a clinician should carry into the examination room. Furthermore, as the move to managed care increases, eye care practitioners are going to be practicing in health-maintenance organizations, hospitals, and gov- ernment medical programs; credentialing and privi- leging will become paramount issues for these practitioners. In these arenas, there is both internal and external review of medical records for quality assurance purposes. The internal review is one of the means of documentation of care rendered" that a hospital exe- cutive committee will use to establish credentials and privileges." The Joint Commission on Hospital Accredi- tation Organization (JCAHO) makes periodic external reviews of most civilian and government health-care facilities. As part of that review, record perusal for com- pleteness and relevance is a standard procedure. Here again, the eye care practitioners must have high-quali records.' including case history, about they have treated to help the hospital gain JCAHO accreditation status. Finally, ophthalmic practice patterns are changing, and, with that change, clinicians need to alter the infor- mation that they elicit during the case history. As recently as 1972, by law, only ophthalmologists (in the eye care field) could use pharmaceutical agents in their practice; today nearly all optometrists have the same or similar opportunities to treat ocular disease. With this shift in the scope of practice, it is no longer acceptable to query the patient only about the visual system and to then begin examining the patient. It is necessary to know something about the patient's general health, both past and present, because that may alter the for- mation of the diagnostic hypothesis. The concept of "standard of care" has placed further emphasis on the importance of case history in the delivery of quality health care by vision-care providers. CONTENT Demographic Data The case history is opened with some introductory information about the patient. 198 BENJAMIN" Borishs Clinical Refraction question been asked in an open-ended manner. Lastly, the terminology used should come as close as possible to that of the patient. If a patient is asked if he or she has ever had iritis, he or she will likely give a different response than if he or she had been asked about a pre- vious episode of sensitivity to light and a red eye. History of Present Complaint The history of the present complaint is that point at which the clinician details or characterizes the chief complaint of the patient. It is here that the philosophi- cal difference in the clinician's approach between vision problems and disease is noted. With ocular disease, the standard medical model works with ease, but vision problems are not quite the same; the differences are examined below. With the medical model, there are several areas of pursuit that work for most signs and symptoms. The complaint is specified using the follow- ing categories. Location. Where is the sign or symptom mani- fested? If the complaint is pain, can the patient localize it? Sometimes it is good to have the patient point to the location. For internal symptoms, the patient can still localize the area of the symptom by pointing with his or her fingers in two planes of reference. With a blurred vision complaint, the location is logically a point in space at which the images are blurred. Severity. How extreme is the symptom? This is usually thought to be limited to pain, but it can apply to most signs and symptoms. It can even apply to blurred vision, although it is hard to get patients to characterize blur in terms of severity. When the symptom is pain, the adjectives used to describe it would be sharp, dull, lancing, piercing, radiating, and excruciating. Pain sever- ity is best measured on a I-to-It) scale by asking the patient, "How severe is the pain that you experienced on a scale of 1 to 10, with 1 being minimal discomfort and 10 being unbearable pain?" The response is then recorded using this scale. Character of the Sign or Symptom. What type of pain is it? Is it boring, sharp, or dull? Does it radiate? If blur when reading is the complaint, is the blur constant at a fixed distance, or does it come on after reading for a while? Is the blur from the letters splitting into two or just a constant sustained blur at the reading distance? Does it occur when going from the end of one line to the beginning of the next? All of these characteristics have differing etiologies and require differing treatment strategies. Nature of Onset. Did the sign or symptoms come on suddenly, or was the onset so slow as to leave the patient with an unclear knowledge of the onset? Sudden painless loss of vision in one eye might have a vascular etiology, whereas gradual loss of vision might be the result of a space-occupying lesion in the cranium. A For example, diabetic patients may note that their dis- tance vision is blurred on some days and on not others. If asked, they may be able to further explain blood sugars are usually elevated during the same day that they noticed the blurred vision. Migraine is diagnosed only after determining that the appropriate antecedent components are present and that they are followed by an appropriate type of headache. In other words, a headache without accom- panying signs and symptoms may be a migraine, but the diagnosis is much more certain with the requisite company. Most of the preceding could apply to a vision problem, but the language does not readily adapt. When there is a vision-related complaint, the patients often do not know at what point their vision became blurred. Alternatively, the problem may not wax and wane. What does frequency mean when applied to blurred vision? Furthermore, the visual system is meas- urable without invasive procedures, and the patients unable to quantify their complaints in precise terms. This discussion brings to mind a 55-year-old over- the-road truck driver who noticed blur at near during his hospitalization for a myocardial infarction. He was positive that the blurred vision was caused by his myocardial infarction. In reality, his lifestyle changed radically when he was hospitalized, and it is probable that changes in the way he used his visual system were the cause of the apparent sudden change in vision (rather than the heart attack). In this case, the onset would be reported as sudden when, in fact, the onset was gradual. It is best to be wary of the history of patients without being disbelieving. Secondary Complaints The clinician wants to characterize these complaints much as he or she did the chief complaint. Hence, most of the preceding information will be included for these complaints as well. Often these complaints are part of the same problem that is causing the chief complaint, but not always. In fact, it is in this area of the history that the clinician should always try to invoke the "law of parsimony." This law, simply stated, holds that, if one diagnosis fits a group of signs and symptoms, best choice of a working diagnosis or hypothesis. Let us examine this in more detail. If Condition 1 has a and b for symptoms, Condition 2 has a, c, and d for symp- toms, Condition 3 has a, b, c, and d, for symptoms and the patient has symptoms a, c, and d, it is more parsi- monious to make the diagnosis of Condition 2 for this patient. Condition 2 has all three symptoms that the patient manifests and is the most likely choice, but Con- dition 3 cannot be ruled out, because symptom b may be silent in this patient. The clinician needs to investi- 200 BENJAMIN Borishs Clinical History of Any Ocular Surgery This history may be significant for the present com- plaint, even though the patient may not connect the present complaint with the previous surgery. For example, when one is trying to ascertain the etiology of diplopia, knowledge of childhood squint surgery or refractive surgery as an adult can be beneficial. It would certainly complicate the physician's diagnostic evaluation if he or she were unaware of such a history. History of Any Ocular Disease or Trauma If for no other reason than the fact that history is bound to repeat itself, a complete history of ocular disease and trauma is necessary. This would include not only the type of episode but also the type of treatment rendered and any sequelae. Often the patient is not aware of the significance of prior trauma on the current condition for which they have sought care. A history of blunt trauma to the eye is crucial when a patient has monocular glaucoma or is about to undergo cataract extraction with intraocular lens implantation; the patient would not be aware that such a history has any significance. Medical History Here the clinician wants to describe significant past ill- nesses or injuries and any sequelae from those In addition, previous surgical procedures could be helpful. A young adult male patient with chronic back pain and recurrent red eye would lead a clinician to con- sider ankylosing spondylitis. The same patient without the back pain complaint would pose a more vexing diagnostic problem. Drugs and Medications Prescription medications should include the name of the drug, the reason that it is being taken, the dosage, and the duration that it has been used. The rela- tionship between systemic conditions and ocular prob- lems is legendary. Medications taken by the patient can indicate the nature, course, and ocular complications of certain conditions. Diabetes is one such condition. The type of diabetes can be surmised from the type of medication used to treat it. From the type of diabetes, the course, prognosis, and ocular complications can be estimated. Over-the-counter medications should include the drug name, why it is being taken, the dosage, and the duration of use. These drugs are often ignored during history taking, but they are important to the astute cli- nician. Antihistamines used to treat hay fever may be important for the narrow-angle glaucoma patient and for the patient with chronic allergic conjunctivitis. Conditions that Might Be Transmitted from One Family Member to Another A good example of this type of condition is tuberculo- sis. Public health officials thought that they had tuber- culosis in check until the mid-1980s; it is now reaching epidemic proportions in the urban population as a con- current rise in the number of new cases of AIDS is seen. It would be a significant finding that the patient's father has tuberculosis and has had it for 10 years, during which time the patient lived with his or her father. A large percentage of tuberculosis cases in the population are recurrent inflammatory reactions or reactivation of the mycobacterium. Social History Information here is related to the patient's habits and vocation. Occupation It is well established that certain visual needs ciated with certain occupations. For instance, pilots have rigorous standards for their visual status. Other voca- tions might demand normal color vision. However, beyond the vision system, some occupations involve enormous health hazards. The health care worker and the implementation of "universal precautions" Occupational Safety and Health Administration is a classic example. Furthermore, this area has obvious ramifications for the eye care practitioner, because working distance is critical for the presbyopic patient. In fact, there are special occupational bifocals for persons whose work area might be at or above eye level and, more recently, for persons who work with computer monitors during a significant portion of the work day. Marital Status Single young adults live a different lifestyle than do married young adults. Although this may seem irrele- vant, the potential for exposure to sexually transmitted disease is vastly different for the two groups. There are differences in the life expectancies for single males versus married males, even when ignoring the potential ually transmitted disease. It seems that married males consume a better diet than singles males and, therefore, have a longer life expectancy than do single males. Avocational Interests Like occupation, this information is critical for the cli- nician. Knowledge of hobbies and avocations is a major area in which the astute practitioner will pursue details to assist the patient with correcting his or her vision. Alcohol Use Here the clinician may obtain information about the patient's ability to comply with treatment regimens; he 202 BENJAMIN Boristrs Clinical area can lead to better diagnosis. A good example is atopic dermatitis, which can be manifested in the palpe- bral conjunctiva. Gastrointestinal Not many diseases affect the gastrointestinal tract and the eye, but there are a few. Hermansky-Pudlak syn- drome is a hereditary condition with gastrointestinal symptoms and ocular albinism as an eye manifestation. There is increasing evidence that diet and ocular condi- tions may be linked; gyrate atrophy is but one example. Genitourinary Reiter's syndrome is a condition of young males with sterile urethritis, arthritis, and conjunctivitis as the ocular involvement. The clinician must also remember that a history of sexually transmitted disease should place the clinician on alert for ocular problems. The ocular problems might be interstitial keratitis in patients with syphilis, iritis in those with disseminated gonorrhea, or cytomegalovirus retinitis in patients with AIDS. Also, the clinician should be highly suspicious of other forms of sexually transmitted disease when faced with a diagnosis of sexually transmitted disease. Psychiatric The first condition that a practitioner might list in this area is hysterical reaction, with tunnel vision as its classic symptom. Although startling, hysterical ambly- opia is not the most common form of psychogenic visual problems of which the eye care clinician must be aware; rather, stress-related illnesses are the most common form of this type of condition. The alert clini- cian should be vigilant for this, because it can save con- A Simulated Case History Although it would not be appropriate to use an actual case history, the following illustrates the form and content of a case history for a first-time patient. important to see a whole, intact case history so that the new physician has a concept on which to build his or her own case histories. History of Present Complaint This 22-year-old white female presents with a chief com- plaint of blur at distance. This blur has developed grad- ually over the last year. It is constant in nature and slowly progressive. It is not related to bodily function or activity. The blur seems to be worse at night, when she is driving. She does not notice an increase in blur when she is watching television at night. The blur is now causing problems reading road signs in time to make so to the point that the patient may get nauseated and vomit. During the headache, the patient is hyper- sensitive to light and sound and usually seeks a quiet, dark room in which to lie down. The actual headache may last from 1 to 6 hours. Sleep is possible during this phase and often brings relief. patient has not noticed any association with any bodily activities and has not noticed any relationship to foods that she has eaten during the 24 hours prior to the headache. Past Ocular History The patient has worn glasses since she was 12 years old to correct nearsightedness. Her last eye examination was 2 years ago, when she was given a new spectacle cor- rection that she has worn constantly. Her optometrist had no other recommendations for her at last visit. She denies any ocular surgery or significant trauma. She did have an episode of "pink eye" when had it about 14 years ago, which healed without seque- lae. Past Medical History The patient had mumps and chickenpox as a child with no sequelae. She has had no other significant diseases or surgeries. HOW TO APPROACH THE PATIENT Open-Ended Ouestion To obtain a clear case history, it is necessary to ask ques- tions that the patient can respond to with more than a yes or no. These questions should be of the type that allows the patient to tell about his or her problems without the physician interrupting the storytelling. What is desired is to gain information about the patient's problems with the patient doing most of the talking. Judgmental statements or comments should be avoided. The clinician is acting as a recorder of the history and a guide to the patient on this journey. The clinician's moral and ethical beliefs have no place in the process. Some examples may be, "Why did you make your appointment?," "Tellme about your visual "Have you had problems with your eyes in the past?" If previous issues are indicated, the physician could ask, "What might those have been?" Alternatively, cian may inquire, "What type of eye problems had in the past?" Minimal Direction The above implies that the physician needs to direct the patient without leading him or her into responses that he or she thinks the physician wants to hear. It is an interac- 204 BENJAMIN Borishs Clinical addressed is headache, because it is a common com- plaint. The worst thing that any practitioner can do to a patient is to tell a patient that the complaint is "all in the head"; this goes double for headache. Not only is it a bad pun, but it is also bad practice. Most patients over the age of 8 years have had a headache at some point during their lives. In the major- ity of practices, more than 90% of these complaints are not related to the patient's eyes or visual system. It is the patient, thorough clinician who can differentiate between the types of headaches and their causes. A headache is pain that occurs in the cranium, the nape of the neck, or the forehead. Most patients do not include ear, tooth, jaw, or eye pain in this complaint. Headache can originate from the musculature sur- rounding the cranium, pressure in the paranasal sinuses, or stretching of or traction on the intracranial or extracranial vasculature or pia mater. The substance of the brain (gray and white matter) is, for all intents and purposes, not pain sensitive. Most of the pathophysiol- ogy associated with headache helps with localizing the site of the cause of the headache. However, when it is traction or displacement of the associated structure, it is not possible to localize from the site of the pain to the site of the lesion; this is because space-occupying masses are the major source of traction or displacement, and the traction or displacement may be distant to the site of the lesion. Therefore, the site of the pain may be and usually is remote from the location of the mass. Stress Headache Almost everyone, at one time or another, has experi- enced a headache caused by stress, anxiety, or tension; this is the most common headache that a clinician encounters in practice. These headaches are much more common in adults. Patients complain of pain in the occipital region or the nape of the neck. Sometimes the patient presents with frontal pain, which is related to the same mechanism as the pain at the base of the occiput but which is transferred to the frontal region through the aponeurotica. The headache is often accom- panied by a feeling of tightness that leads to a band headache. Classic stress headaches usually happen at work or school and occur during the late afternoon or toward the end of the work period. Also, these headaches may be related to vision problems. It has been demonstrated that a three-dimensional prism with a vertical orientation placed before the eye can produce a muscle tension headache after about half an hour of wear. The pain is usually constant, comes on gradually, and can build for hours. The pain is usually dull in the beginning and may proceed to a moderate degree. The patient is not disabled, and he or she may continue to function normally. Nausea and vomiting are not com- monly associated with the pain. On palpation, the mus- culature of the back of the neck is taut and may be in Migraine Headache Migraine is known by many names: migram, nia, and sick headache, to name a few. It is character- ized by pain on one side of the head, although simultaneous bilateral pain may occur. It is a familial disorder in which the child has a pattern of headache similar to that experienced by the parent. Migraine syn- drome usually starts during the second or third decade of life. The attacks seem to appear fairly regularly; then, during the fourth decade of life, they subside for a period of 10 to 15 years, only to recur during the fifth and sixth decades of life. Although the mechanism was alluded to earlier, the trigger for the migraine incident is not known. It has been related to the menstrual cycle in females, the phases of the moon, stress, and other obscure causes. The classic model of migraine involves four phases: (1) the prodrome, (2) the aura, (3) the headache, and (4) post headache. The Prodrome. This phase is the least well defined of the four. The astute patient notes that he or she may feel euphoric or depressed during the hours preceding the headache. The sensation may be less well defined, and the patient just has a "feeling" that the headache is going to happen. Some patients evidently do not experience this phase in their syndrome or, if they do, they cannot or have not linked the feelings with the migraine. Some patients note that they "retain on the day preceding the headache. Again, this the most difficult to document. The Aura. This phase is the eye care practitioner's friend, because a significant number of patients report the symptoms to the eye care practitioner first. The aura is usually visual, with something that Helmholtz named a fortification scotoma being the most common present- ation. The fortification scotoma is a jagged, bright, margined visual phenomena that starts in the center of vision and gets progressively larger over a 5- to lO-minute period; it then collapses in the reverse order of progression. The name fortification is derived from the design of towers in European castles and the resem- blance of the margins of the scotoma to that The margins are usually reported to be colored, bright lights that have a shimmering quality. The aura is often called a scintillating scotoma. The visual image is usually bilateral, which indicates occipital origin, and it is most likely the result of ischemia from the vasoconstriction of early migraine. The pattern of the aura is usually con- sistent from episode to episode for a given patient. The aura lasts from 15 to 30 minutes, with most patients reporting that it lasts about 20 minutes. The aura is com- plete before the headache commences. If a patient should report that the aura persists into the headache, the headache is not a migraine. The Headache. Unilateral pain in the cranium is the most typical complaint. This is severe, throbbing, boring pain on one side of the head. The pain can be so intense 206 BENJAMIN Borlshs Clinical Hemianopic Migraine Here the patient notes that he or she has a hemianopic visual field defect during the aura. It usually does not have the shimmering borders of the classic aura, but, in all other characteristics, it is the same as the classic pres- entation. The clinician is again encouraged to perform a thorough case history and then proceed to a neuro- logical evaluation the first time that the patient presents with such symptoms. Hemiplegic Migraine This variant of migraine is rare, and it usually occurs in young females. They exhibit frank hemiplegia for a period of a few minutes and up to 3 days. This is more a form of paraesthesia than paralysis, and it is associ- ated with an increased Babinski reflex on the affected side. This condition tends to get the "million workup" because of the gravity of the symptoms in a young patient. It can be isolated in later episodes, for the primary care provider, the first episode is a con- dition of great concern and urgency. Hypertensive Headache This condition is basically a nonentity. Although much has been made of headache occurring in patients with hypertension, it is not a valuable symptom for nician. There is little to no predictive value headaches that result from hypertension. The headaches that occur in hypertension appear to be due to dilata- tion of branches of the external carotid artery, because occlusion of the external carotid artery alleviates the pain. However, the attributes of this headache do little to differentiate it from other headaches, and it has little diagnostic value. Cluster Headache These headaches are also known as histamine headaches. This headache is named for the pattern of presentation Episodes tend to cluster together over days or weeks with long, irregular intervals between the clusters of headaches. The typical patient is male, in the fifth decade of life, and a "type A" personality. The headache is unilateral in the frontal region with conjunctival engorgement, lacrimation, and nasal congestion on the affected side. The attack can last from 15 minutes to 1 hour, and it may recur several times a day. The pain is similar to migraine in that it is severe, deep, and boring. In recent years, propanolol has been used to reduce the frequency and severity of this type of headache. The headache is brought on by dilatation of the internal carotid artery on the affected side. This phenomenon can be simulated by the injection of histamine into the internal carotid artery, but the existence of histamine in the clinical presentation of cluster headache has not been demonstrated. near to distant. The blur at both distances is fleeting in that it clears within seconds of the shift in gaze. These symptoms are usually noted at about 40 years of age, when the patient still has sufficient accommodative reserve to read without a reading addition at near and when he or she is probably due for a decrease in accom- modative facility. During the subsequent 5 years, the patient begins to notice that, the further away from the body that he or she holds the material, the clearer the material is. The classic complaint of an early presbyopic patient is that his or her "arms are getting these cases, it is best to refer the patient to an orthope- dic surgeon or to prescribe a first pair of multifocals. When a complaint of blur at near is the principal reason for the patient visit in a child or adolescent, the clinician should strongly suspect binocular rather than refractive problems. The patient could have refractive problems (e.g., high hyperopia, astigmatism), but, in terms of incidence and the patient's age, tions are certainly less common reasons for presenta- tion. In these patients, the clinician should aware of any symptom that might be related to ocular discomfort or fatigue during the case history. Question- ing the patient about the type of blur may be particu- larly fruitful in this situation. The patient with binocular motor problems may confuse diplopia with blur during the case history. The clinician can differentiate between the blur and diplopia by having the patient describe exactly what is seen when working at near. When reading, the patient may have trouble finding his or her place when going from the end of one line to the begin- ning of another, or he or she may notice that the letters begin to split apart when reading for longer time periods. Asthenopia or headache is a frequent compan- ions to these motor problems, particularly on school days and, more particularly, toward the end of the day. Nonspecific Ocular Discomfort and Fatigue (Asthenopia) Asthenopia is pain, discomfort, or fatigue in or around the eyes. The causes of asthenopia are refractive error, motor anomalies, and integrative problems. A combi- national etiology of asthenopia is probable, in which accommodation and convergence are both at play in the development of these symptoms. Whenever there is imbalance between the eyes (e.g., anisometropia, ani- seikonia, high phoria), eyestrain is highly likely. The cli- nician should document the nature of the complaint as thoroughly as possible with the patient in an effort to isolate the underlying etiology as nearly as possible. A child with near blur must be questioned about accom- panying signs and symptoms so that causal hypotheses may be formed. Small to moderate refractive errors cause most of the symptoms in patients complaining of asthenopia. With 208 BENJAMIN Borlshs Clinical males and females equally. It is often associated with a condition in which the lids do not fully close during sleep, called lagophthalmos. Because of Bell's phenome- non, the lower portion of the cornea dries, and there is a semilunar area of desiccation at the limbus and across the exposed inferior cornea and conjunctiva. The patient awakens and is fine until he or she opens the eyes. When the eyes open, pain, burning, and tearing occur. This is almost always more severe in one eye, but both eyes are generally involved. In more extreme recurrent corneal erosion may become a part of the syn- drome. Patients sleeping under ceiling fans or where there are nocturnal drafts are more prone to this condi- tion. In temperate climates, it is also worse in the winter, when the humidity is lower inside the home. Blurred Vision at the Far Point This complaint is most commonly associated with myopia, although it may occur in decompensated phorias in older adults, certain cranial nerve palsies, some oculomotor imbalances, and high astigmatic refractive errors. "Blur" reported by the patient can be the result of lateral binocular diplopia and monocular diplopia, in addition to refractive or accommodative causes. The vast majority of patients with blur at dis- tance are uncorrected or undercorrected myopes. The classic complaint in the child is the inability to read what is written on the board at the front of the room. The child may have a history of being moved to the front of the class to compensate for the blurred vision. In some elderly patients, vertical phorias become tropias with certain conditions. Because the vertical phoria is usually smaller in magnitude than are hori- zontal phorias, the complaint may be one of blur at dis- tance rather than frank diplopia. The classic complaint of this type of patient is that they see blurred taillights on the cars in front of them. The complaint is actually diplopia, but the magnitude is so small that the tail- lights look blurred rather than doubled. The reason tail- lights have this appearance and headlights do not is that, at night, peripheral cues for binocular lock are significantly reduced. Oncoming headlights produce more binocular lock cues for the driver, and, therefore, the tendency is to notice problems when viewing tail- lights. It is believed that these patients are patients who break into tropic responses when "fatigue ductions" are performed on them during their earlier years. Diabetes mellitus is a common cause of intermittent blur that should not be ignored. These patients complain of blurred vision that lasts for a day or so. When questioned further, they can link the blurred vision to an increase in blood sugar levels. Although this is a complaint that is usually elicited from an estab- lished diabetic, it is possible that the ophthalmic prac- tive problems or convergence excess. The causes of occipital headaches are not as clearly defined, with con- vergence insufficiency and vertical imbalance being the primary causes. However, refractive deviations and presbyopia have been noted to cause these headaches. Furthermore, it is sometimes difficult to determine if the occipital headache is actually visual in nature as opposed to being related to stress. The third location of which the clinician should be aware is the temporal area, where uncorrected oblique astigmatism is the primary cause. Although uncommon, this is a clinical pearl worth remembering. With vision-related headaches, the patient usually notices that the pain begins after reading or use of the eyes and that it is preceded by eyestrain. At times, the headache comes on toward the end of a work period, much like the classic tension headache. In fact, tension- like headache can be induced by the introduction of loose prisms in front of one eye for a period of 15 minutes. The character of the ocular-induced headache is usually dull, steady pain. Severe pain or other associ- ated symptoms should lead the clinician to seek etiology for the headache. The pain can wax and wane with use of the visual system. Resting the visual system generally relieves the pain. If the underlying etiology is the binocular system, patching one eye will relieve the symptoms. Conjunctivitis and Blepharitis (Crusting and Flaking) Patients rarely complain of conjunctivitis or blepharitis, but they do complain of crusting and flaking of the eye- lashes. Sometimes this is normal drying of ocular secre- tions in the inner canthus overnight, but at times it may be the harbinger of impending, full-blown, acute conjunctivitis. The best way to differentiate between the two is a good inspection of the conjunctiva. The most common problem involving crusting and flaking that an ophthalmic practitioner sees is chronic ble- pharitis. Patients are sometimes oblivious or resigned to the condition and do not mention it during the case history, but it is during that time that the observant cli- nician first notices it. The base of the lashes have col- larettes, and the lid margins are reddened. These patients have usually had the problem since childhood, with the condition varying in severity. This caused by chronic staphylococcal infection, and treated with lid scrubs. Left untreated, this condition can progress to marginal corneal ulcers and ulcerative blepharitis. The other form of blepharitis that is known as squa- mous blepharitis is not as easily noted, but it is easier to treat. Also known as seborrheic blepharitis, this con- dition presents with flakes (scurf) on the eyelashes, mild erythema of the lid margin, flakes in the eyebrow, 210 BENJAMIN Borishs Clinical the amount of pain is usually consistent with the degree of inflammation. Herpetic keratitis is an exception to this rule because of the decreased corneal sensitivity associated with this viral infection. Episcleritis and scle- ritis can produce anything from a burning pain to a deep boring pain; again, the amount of pain parallels the disease process. One of the more common and intense ocular pains is that induced by the trapping of a foreign body under a rigid contact lens on the eye. Frank pain in the globe is an uncommon complaint. One of the most commonly cited types of ocular pain in textbooks is that found on rotation of the globe, which is associated with retrobulbar optic neuritis. Although it is true that this is a complaint in patients with acute optic neuritis and therefore multiple sclero- sis (MS), it is not commonly encountered in practice. Furthermore, it is unusual for that particular complaint to be the chief complaint in a patient with MS; it is much more likely that the patient will complain of vision loss associated with heat (Uhthoffs sign) and other neurological deficits. It is probably the critical nature of the diagnosis that leads authors to give such attention to the symptom. Retrobulbar pain is also associated with tension headache. However, tension headache involves no pain on rotation or loss of vision. Many patients complain of a sharp, stabbing pain in the eye that can stun the patient. The pain comes on unexpectedly and suddenly. It is short in duration, lasting for 1 to 2 seconds. This pain does not recur fre- quently, but it does recur. Most patients can remember the episodes with vivid detail, stating where they were and what they were doing at the time of attack. The cause is unknown, and there is no known treatment. Fortunately, the pain is fleeting, and the episodes leave no sequelae. Acute narrow-angle glaucoma is another source of deep ocular pain. When present, the pain is excruciat- ing and debilitating, and it can produce nausea and vomiting. The pain subsides as the attack is broken. Pain may be absent in patients with longstanding glaucoma or in those with absolute glaucoma, even in the face of significant intraocular pressure rises. The clinician should be aware that a carotid aneurysm may produce similar unilateral pain to that found in acute The differential here is the lack of redness and normal intraocular pressure in the carotid aneurysm. Intraocular inflammation can cause pain on accom- modation in cases of anterior uveitis. This pain is dull, and it is similar to the photophobic pain experienced by these patients. This pain may also be described as an ache. The pain decreases with the withdrawal of the near-point stimulus. Many patients with iritis who do not manifest photophobia do have pain on accommo- dation; the mechanism of both pain with reading and pain with bright light is probably the miosis induced by both stimuli. TABLE 6-1 Causes of loss of Vision and Duration of Symptom Cause of Vision Loss Duration of Scotoma Transient ischemic attacks Few seconds Migraine headache 20 minutes Multiple sclerosis Hours to days Retinal detachment Until repaired or permanent Tumor Permanent Nonarteritic ischemic Months to permanent optic neuropathy Central retinal vein Months with residual occlusion loss Central retinal artery Permanent occlusion Cerebral vascular accident Weeks to permanent most important. Those other symptoms and how they help with the making ofthe tentative diagnosis will now be addressed. Transient ischemic attacks are a common complaint among males who are 50 years old and older. It is a complaint that is frequently missed unless the clinician is looking for the appropriate history. TIAs are mani- fested almost exclusively as symptoms, which are often visual and fleeting. The classic sign is a graying out of vision, which then returns to normal in 5 to 10 seconds. Depending on where the blockage is in the central nervous system, the nature of the scotoma varies. The scotomas are usually bilateral, and they vary from com- plete anopsia to a vague complaint that one side of the vision was blurry. The pathophysiology of TIA is prob- ably similar to that of a Hollenhorst plaque in the retinal circulation in that a small cholesterol plaque breaks off of the wall of an artery and temporarily lodges further downstream. This blockage results in ischemia of the nervous tissue and a temporary loss of function. What differentiates TIAs from cerebrovascular accidents (CVAs) or strokes is that TIAs are transient, as the name implies. Transient ischemic attacks begin as an isolated event, Charles l. Haine clinician. Again, this is due to the experienced clinician's the eye knowledge of the patterns of patient presentations. The flow diagram from Corliss" shown in Figure 6-1 is useful for conceptualizing the dynamic of clinical rea- soning. The top half of the chart is most useful with regard to the taking of a case history. Much of what follows in this chapter about the structure of the case history is represented by the menu-driven inquiry, which represents the standardized portion of the case history. Enabling conditions, symptoms, or observable signs are the facts elicited by the clinician using the menu-driven inquiry and observation. The clinician then uses evidential reasoning to make preliminary hypotheses about the causes of the conditions, symp- toms, and observable signs. Lastly, the clinician reviews the hypothesis and further refines the line of question- ing (hypothesis-driven reasoning), which the practi- tioner then uses to narrow the number of possible diagnoses. This process becomes second nature to the experienced clinician, who rarely thinks of evidential reasoning or menu-driven inquiry. However, to the new clinician, who has not been raised in a problem-solving environment, this is a new way of thinking about people and their problems. This chapter focuses on providing the clinician with the tools needed to use the upper-left-hand portions of Figure 6-1. Although this chapter cannot provide all of the facts and rules that are needed to be an excellent cli- nician, many are provided as examples; it is hoped that this will be a good basis on which to build. What can be addressed are the procedural skills and the structure of the knowledge base in memory. The procedural skills include instruction about how to conduct an interview, and the structure of the knowledge base forms the outline of the following sections of this chapter. It should be noted here that taking a case history is not limited to the early portion of the examination process; rather, it is a dynamic interaction that continues throughout the entire examination. (Note the arrows in Figure 6-1 that go to the Case History area from the lower portions and those that originate in the Case History area and point to Clinical Testing or Treat- ment/Management.) Tradition has dictated that the case 195 Refraction making. See the text for a detailed explanation of the model. Tx, procedure known so that nothing was missed. Case history is the key to an efficient, comprehensive, problem-oriented examination of the patient and resolution of the patient's problems. Since 1971, the problem-oriented medical record of Weed" has been the standard for clinical record keeping. It is based upon the SOAP format, which stands for sub- jective, objective, assessment, and plan. The subjective of SOAP is the case history or the information imparted by the patient about the reason that he or she is seeking care. The point of mentioning the problem-oriented record is that, when it is time for the practitioner to assess and plan for the management of the patient, the clinician is obliged to link the assessment and plan back to the complaints of the patient." This closes the loop: the clinician is expected to deal with the reasons that the patient presented for examination (e.g., the chief complaints and any secondary complaints that the patients presents during history taking). It matters little what type of record keeping if per- formed, because it will yield few valid results if the case history is ignored. During the recent past, new practi- tioners entering the eye care professions have been The Ophthalmic Case Historian Chapter 6 197 Age The age of the patient is the first piece of information that is recorded. It is common knowledge that certain diseases and conditions are more prevalent in certain patients of a given age range. For instance, chickenpox is a common childhood disease, and shingles is a common disease in adulthood; both are caused by the same virus, but they have different manifestations that depend on the age of the patient. Presbyopia is not a concern with an adolescent patient, but it is important for the 55-year-old adult. The age of onset of a disease is critical to the diagnosis and prognosis assigned to the is a dictum that patient. Gender From a vision-care professional's point of view, the most obvious sex-linked hereditary problem is color-vision deficiencies. There are many more differences between males and females in the distribution of disease. In addition to the obvious anatomical and physiological differences, men and women tend to lead different types of lives. Men tend to abuse their bodies more than women (substance abuse being much more common in males). Until the last 40 years, women did not smoke cigarettes at the same population rate as men. Now the health consequences from smoking for the two sexes appear to be converging to a point at which women have the same risk as men. ty The Chief Complaint the patients that The chief complaint is the reason that the patient has come to the physician for this particular examination. (Na patient thinks of history taking in these terms, but all clinicians should.) The chief complaint is usually limited to one to two sentences. When recording the chief complaint, it is best to record it in the patient's own words, without any interpretation by the examiner. The chief complaint is best elicited by asking patients what is bothering them or why they made the appoint- ment. Open-ended questions work best in all parts of the case history, but this type of questioning is crucial when detailing a complaint. Try not to use directed questions-for example, "Is your vision blurry?"- because the patient may try to help the physician too much. These questions may elicit inappropriate responses merely because the patient thinks that the physician wants a given answer. Also, it is much easier for the patient to fabricate a response to a direct ques- tion. Again, the patient is not usually trying to deceive the physician, but rather he or she is trying to be helpful. Not only does direct questioning lead to invalid responses on the part of the patient, but it is also lim- iting. There are only two responses to the question, "Is your vision blurry?": yes or no. In this case, the patient may have volunteered other information had the slow onset of blur at a distance may be associated with an increase in myopia. Duration. How long has the complaint been present? A patient with a sudden loss of vision of 1- hour's duration has a much better prognosis than does the same patient after 10 days with the same complaint. The duration can be critical to a diagnosis. For instance, the visual aura of migraine is almost always described as lasting approximately 20 minutes and disappearing before the headache commences. If the aura lasts longer than 20 to 30 minutes or extends into the headache phase, the clinician should investigate other causes for the visual symptoms besides migraine. Frequency. If the complaint is not constant, what is its periodicity of recurrence? This is the area in which to ascertain the nature of the frequency; in other words, is the periodicity of the symptom increasing, decreasing, or stable? A patient with a pattern of increasing fre- quency of transient ischemic attacks (TIAs) is of more concern than a patient with only rare TlAs. Exacerbation and Remission. It is not uncommon for a condition to have periods in which the patient has no signs or symptoms; however, the condition can still be present. At other times, the patient has signs and symptoms of the disease. It is necessary to characterize the nature and extent of periods of exacerbation and remission. A classic example of a disease of this type is multiple sclerosis, in which the symptoms wax and wane over a period of weeks to years. The signs and symptoms get progressively worse, and the patient never does return to normalcy during periods of remission. However, the disease does not produce a steady down- hill progression. A more pertinent example is recurrent herpes kerati- tis due to the herpes simplex virus. Here the exacerba- tions are followed by varying periods of remission. Each exacerbation may be marked by its own corneal opaci- fication, which is the only sign that the patient has any- thing wrong with the cornea during the periods of remission. It is not known what makes the virus become active, but, when it does, it produces signs and symp- toms in the nerve endings of the same nerve that was involved previously. Relationship to Bodily Activity or Functions. The clinician must be vigilant to ascertain if there is any rela- tionship between the complaint and bodily functions or activity. For example, does the blur increase when the patient is reading? Is there claudication on mastication? Does the headache get worse when reclining, or does the headache come on daily at the end of the work period? All of these are important clues to the etiology of the complaint, and they can be helpful to the practitioner. Accompanying Signs or Symptoms. When dis- cussing the patient's complaint, the clinician should be aware of any relationship to other signs or symptoms. The Ophthalmic Case Historian Chapter 6 199 gate more symptoms or signs before discerning between Conditions 2 and 3. that their Ocular History One should elicit information in the following cate- gories about the patient's ocular history. History of Spectacle Wear The clinician should gather information about the first time glasses were prescribed to the patient, how the patient wore those glasses, and when or if subsequent glasses were prescribed. The wearing pattern and time of first prescription may yield significant information about the type and magnitude of the visual correction of the patient. It is common to obtain a history of someone being given reading glasses during his or her school years only to find that he or she has not worn glasses for years (these patients are usually hyperopic). are Last Eye Examination Date of Examination. The date of the last ocular examination seems to be limited in informa- tional content, but it can yield much inferential infor- mation about the importance that the patient places on visual symptoms and their impact on the patient's lifestyle. In some clinical settings, it is not unusual to have a patient who has never undergone an eye examination. The clinician must also be careful that the patient is not confusing an eye screening with an eye examina- tion. A frequent response to the question about the date of the last eye examination is, "I had my eyes examined about 1 year ago." Upon further questioning, the patient reveals that the eye test was part of the driver's licensing examination or a physical examination by his or her primary care physician. Results. The results of the last eye examination may provide useful information about conditions that are not apparent upon casual observation of the patient, and these may direct the examination of the patient in a way that was not expected. The physician might ask, "What did the physician tell you about your eyes at the completion of your last examination?" it is the Suggested Treatments In this area, is it easy to ask a question that is too lim- iting, such as "Did your last physician recommend any change in the type of spectacles or the way in which they would be used?" A better question in this area might be, "Did the physician recommend any new treatments or a change in the type of treatment for your eyes?" The first question ignores every type of treatment besides spectacle wear. Clearly, a more open-ended question yields better information. Refraction Recreational Drugs In this day and age, it is important to know if there is any type of street drug use occurring and the route of administration. Intravenous drug use is now the most common cause of acquired immunodeficiency syn- drome (AIDS) infection in the United States. Such a history should alert the clinician to be particularly vigilant for cytomegalovirus retinopathy or human immunodeficiency virus retinopathy. Family Ocular History This is the area in which the patient is likely to give more information than is really wanted. All too often, the patient will explain that both of his or her parents and all but one sibling wear glasses; this is not particularly useful information. The physician should be seeking information about ocular hereditary conditions and communicable diseases within the family or about those that are endemic to where the family lived. Hereditary Conditions Several hereditary conditions are relevant to the eyes, such as diabetes mellitus, color-vision deficiency, migraine, retinitis pigmentosa, and macular degenera- tion. The clinician's emphasis may shift with the demo- graphic characteristics of the patient, but this is vital information for proper care of the patient. episodes. Conditions that Might Be Transmitted from One Family Member to Another A toxoplasmosis infection in a mother could lead to transplacental infection of the fetus with a subsequent chorioretinal scar in the child. It is the responsibility of the clinician to make the appropriate linkages between the patient's condition and the concomitant manifesta- tion of the disease in a family member, because the link is not always evident to the patient. Conditions that Are Endemic to Where the Child Was Living with His or Her Family Histoplasmosis is one condition that comes to mind in this category. Knowing that the brother of the patient had a scar on the back of his eye and that the patient grew up in Illinois might create a high level of suspicion that the white spot on this patient's retina may be evi- dence of ocular histoplasmosis syndrome. Family Medical History Hereditary Conditions This category involves any systemic hereditary condition that could affect the health status of the patient at the time of examination. For example, connective-tissue dis- orders can have ocular effects, but they are considered primarily systemic conditions. The Ophthalmic Case Historian Chapter 6 201 or she may also gain information that has a direct bearing on the patient's overall health. A more recent concern is that of fetal alcohol syndrome and the delayed development that is common in children of mothers who drink. Tobacco Use Although many clinicians may think that smoking is not directly related to the eye, the ophthalmic practitioner does gain information that helps with understanding the patient's general health. A 42-year-old male who has smoked four packs a day for 20 years and who also has bilateral papilledema might lead the clinician to suspect a metastatic central nervous system lesion from a primary tumor in the lung. A more pertinent link may be the ocular surface problems that have been linked to smoking and that have further been associated with ker- atitis, which, among smokers, is more prevalent during the extended wear of soft contact lenses. are asso- Review of Systems Each of the following areas is an example of how the specific system might affect the ophthalmic practi- tioner's assessment of the patient. by the Ear; Nose, and Throat Because of the proximity of the nasal passages and actual connections between the two systems, ear, nose, and throat conditions can and do produce ocular signs and symptoms. The most obvious is allergic rhinitis, with its conjunctival component. Cardiovascular Hypertension and stroke have serious vision and ocular complications in addition to carotid artery disease, which is a common cause of TIAs and their associated visual symptoms. Marfan's syndrome is a hereditary anomaly with cardiac signs and symptoms and an ocular component that features sub luxated crystalline lens as a result of zonular dysgenesis. for sex- Endocrine Diabetes mellitus and its ophthalmic complications are the most obvious potential problems involving this system. It would be remiss to not mention thyrotoxico- sis, which can produce devastating visual complications, including blindness. Conjunctival hyperemia and mild proptosis may be the only signs of Grave's disease, which can lead to blindness in relatively rapid order from a compression neuropathy of the optic nerve. Dermatological The lids and lashes are often the site of more diffuse dermatological disease. Careful history taking in this Refraction siderable time, cost to the patient, and frustration to identify functional disorders early on during the patient encounter. For example, spouses of practitioners commonly have conditions that are related to the type of practice of their spouse. A case example is the wife of an optometrist who noted shimmering light in an oval shape to the temporal side of vision in her right eye during the week preceding Thanksgiving. She com- plained that this had been present for about a week and that, if she shut her left eye, she would lose the right three lanes of the highway. She underwent a workup with the appropriate ocular and neurological evalua- tions and was found to have an enlarged blind spot; all other test results were within normal limits. The symp- toms continued unabated through the end of Decem- ber and then disappeared. The symptoms reappeared during the spring of the following year, but this time they disappeared much sooner. Things were relatively quiescent until Thanksgiving of that year, when the scotoma and shimmering light reappeared and remained until the end of the year. It was then that the pattern became evident; when the spouse was to visit her mother-in-law, the condition would flare, only to resolve after the stressful situation would pass. This one was called "Mother-in-law's syndrome." A more critical situation would be a patient whose compulsion was toward self-enucleation with his hands. He eventually was successful with one eye and came close with the other eye. This is not a common problem, but it is one that vision-care providers might learn of during the taking of the case history and when assisting the psychiatrist with the management of a patient. the appropriate driving maneuvers while driving on city streets. It is Secondary Complaint The patient also complains of headache. She first noticed the headaches about 18 months ago and has seen her primary care physician about them, who told her that the headaches were migraines. These headaches occur about once a month, but they are not related to her menses. They involve unilateral, severe, boring pain (8/10) in the left temporal area. The patient can tell when the headache is coming by a feeling of euphoria that is followed by an aura of flashing lights, which expand to form a central relative scotoma. The aura lasts for 20 minutes, and then the headache begins. The pain seems to get more intense over the next 30 minutes or The Ophthalmic Case Historian Chapter 6 203 Drugs and Medications The patient takes over-the-counter multivitamins as a dietary supplement and birth-control pills for contra- ception. The birth-control pills are low dosage, and she has been taking them for 4 years. The Family Ocular History The patient's father (56) underwent cataract extraction with intraocular lens insertion in both eyes last year. Otherwise there is no relevant ocular history to report. Family Medical History The patient's father has a long history of asthma for which he uses inhalers. The inhalers are both bronchial dilators and steroids. Her mother (52) underwent lumpectomy of the left breast followed by radiation therapy of the breast about 3 years ago. No metastasis or recurrences to date. her little sister also Social History The patient is the last of three siblings, all alive and well. She is a senior majoring in psychology at the local uni- versity. She enjoys racquetball and running when not studying. She is single and plans to pursue graduate work in political science. She has never smoked, and she drinks alcoholic beverages only rarely and never to excess. tive dialog between the clinician and the patient. The physician wants to be as polite and friendly as possible so that the patient feels that he or she can express this per- sonal information to someone who will protect his or her privacy and who is vitally interested in his or her concerns. Active Listening The term active listening should apply to good history taking. The physician must be attentive to the patient while trying to record notes about what the patient is telling him or her. The physician should respond inter- mittently to what the patient is saying and then ask questions that indicate that he or she is listening to and understanding of the concerns and information that the patient is conveying. Asking good follow-up questions problem," or is key to making the patient feel that the physician has not only listened but has understood what the patient has said and that he or she is interested in the patient. the physi- have you SYMPTOMS Headache Now that the structure and techniques of history taking have been outlined, the results that a careful history taking will yield need to be investigated. First to be Refraction spasm. Salicylates provide relief for most patients; massage and support of the head also provide relief. In fact, this is the only type of headache that is relieved by support of the head, and the pain is not augmented by coughing or straining at the stool. Both are good diag- nostic pearls. To summarize, stress or tension headaches are char- acterized by pain in the nape of the neck, come on late during the work period, and are relieved by support of the head; the pain is not augmented by things that raise the intracranial pressure. Vascular Headache This type of headache is often confused with migraine, and, indeed, it may be a migraine. It is thought that the mechanism of this headache is the same as that seen in patients with migraine; the difference between the two headaches is in the etiology and some of the symptoms. The mechanism of a vascular headache is related to seg- mental constriction of an intracranial artery followed by dilatation of that segment. The pain is the result of the stretch receptors responding to the increase in caliber of the affected vessel during the dilation phase. The differ- ence between this headache and migraine is that the vas- cular headache is most often due to a reaction to trigger substances. Most commonly, it is something that the patient has ingested during the prior 24 hours. The following items are most commonly linked to vascular headaches: red wine, dark chocolate, cheddar cheese, and crustaceans (e.g., shrimp, lobster). All of these items have vasoactive enzymes that produce localized vaso- constriction and rebound dilatation in sensitive persons. These headaches differ from migraine headaches in that the aura is rudimentary or absent in the vascular type. Vascular headaches are usually throbbing in nature, at least during the early phase. The pain does build for about the first hour, and it may become constant as the intensity increases. The pain is usually isolated to a given region of the head, but it may radiate as the headache progresses. The pattern of location of pain repeats from episode to episode. Nausea and vomiting may occur later in the headache as the pain becomes severe. The pain lasts for hours and is not relieved by salicylates or support of the head. The pain is worse upon reclining because of gravitational effects on the intracranial blood pressure. The pain is also worse when coughing or straining at the stool. Like migraine suffer- ers, these patients often seek a quiet, dark room and attempt sleep. It is not known if sleep ameliorates the pain or if it is just the passage of time, but it does seem that some relief is gained upon awakening. Antihista- mines relieve this headache rather promptly. Often patients relate that the headache is gone within 20 to 30 minutes after taking pseudoephedrine or a similar preparation. Unfortunately, migraines do not respond in the same manner. The Ophthalmic Case Historian Chapter 6 205 that the patient becomes nauseated and may vomit (hence the name "sick headache"). Again, the pain starts after the aura ceases. During the headache phase, the patient may be hypersensitive to visual, auditory, and olfactory input. The patient may be in so much pain that he or she is stuporous. The conjunctival blood vessels on the affected side may be engorged. The headache can last from 1 hour to 3 days. The patient usually seeks a quiet, dark room, and he or she may apply cold com- presses to the forehead. The patient is able to sleep during the headache, and sleep may ameliorate some of the pain. At one time, preparations of ergot were thought to be the treatment of choice if taken during the aura. In recent times, beta-blocking agents have been used with only partial success. Salicylates are of limited benefit. The pain eventually subsides, and the patient enters the final phase. Post Headache. At this point, the patient often feels as if he or she has done mortal combat. The patient is lethargic and listless and sometimes undergoes diuresis. This period lasts for a few hours, until the patient can regain normal strength. Now that classic migraine headaches have been addressed, there are some common variations to the classic presentations that the clinician should be able to recognize. water" phase is Ophthalmic Migraine This variant of migraine occurs in about 10% of migraine suffers. It is similar to classic migraine during the aura, but, after the aura, there is no headache. Depending on the age and physical status of the patient, this form of migraine could be confused with a TIA, but a TIA does not usually last 20 minutes, and the vision loss is not from the center out. Most other types of acute vision loss are discussed later, but they all last longer than 20 to 30 minutes. Certainly an ophthalmic migraine in someone with a history of the same is not cause for diagnostic concern. structure. Ophthalmoplegic Migraine This is a rare but spectacular variant of migraine in which the patient actually experiences the paralysis of extraocular muscles during the aura. Although rarely encountered in clinical practice, these patients deserve some careful neurological evaluation to rule out some potentially devastating diseases. The differential diag- nosis includes cavernous sinus thrombosis, leaking aneurysm in the circle of Willis, and less harmful dia- betic cranial nerve palsy. An important item to remem- ber is that family members tend to have the same symptoms in their migraine manifestations. Case history is helpful for guiding the urgency with which these patients are evaluated. Refraction EYE SIGNS AND SYMPTOMS Let us now turn to the specific complaints that are reported in clinical eye practice. The list of these com- plaints is long, but just a few are common. Box 6-1 is a list of complaints that account for the vast majority of reasons for an office visit. Although the entire list will be addressed, the following complaints are the most common reasons for a visit to the ophthalmic office: Blur at the near point Nonspecific ocular discomfort and fatigue Burning or tearing of the eyes Blur at far point No complaint: routine examination Appliance-related visit (i.e., spectacles or contact lenses) dollar Near-Point Blur but, Blur during near-point activities is a more common complaint in the adult population as a consequence of the onset of presbyopia or loss of accommodative amplitude in farsighted persons. Presbyopia is first noticed in patients as intermittent blur at near and a subsequent blur at distance when their view goes from the cli- in any of the Box 6-1 Common Ocular Complaints in Ophthalmic Private Practice in Order of Frequency therefore Blurred vision at near point Nonspecific ocular discomfort and fatigue Burning or tearing of eyes Blurred vision at far point No complaint: request for routine checkup, new . frames, etc. No complaint: broken or lost lenses or spectacles Headache (relation to eyes not specified) Headache following use of eyes Conjunctivitis or blepharitis (crusting and flaking) Twitching of lids, itching of eyes Photophobia Ocular pain Loss of vision (uniocular, binocular, and scotomas) Exophthalmos (uniocular and binocular) Diplopia Anisocoria Photopsia and halos Strabismus lumping of words and other difficulties when reading Disturbance of color vision Vertigo Foreign body in eye The Ophthalmic Case Historian Chapter 6 207 large refractive errors in which the patient cannot com- pensate, he or she usually resorts to monocularity or learns to tolerate the resultant reduced visual acuity. Questions related to the symptoms of small to moder- ate refractive errors then become appropriate. Does the patient have blurred vision (when, where, and how severe)? What is the patient's age? Are there times when the blur is worse, or is it constant? Is the patient having trouble at a particular distance (usually near point)? During reading, does the patient lose his or her place too short." In when going from the end of one line to the beginning of the next line? Do words seem to blur or double with prolonged reading? Do the symptoms occur later in the work period? Do the symptoms only occur on work or school days? Has the teacher noticed a reluctance on the patient's part to do certain activities? All of these lines of questioning lead the clinician to a better under- standing of the type of refractive error involved. these condi- Burning and Tearing of Eyes be keenly Burning and tearing are frequent complaints in the elderly population; they are most often related to dry eye in this age group. In a younger population, they are most commonly a complaint that accompanies sea- sonal allergy. Burning and tearing can also be the first symptoms of acute bacterial conjunctivitis. The way to differentiate between the many causes of burning and tearing is to ask about the circumstances that surround the complaint. In what conditions does the patient notice the symptoms? An older, dry-eyed patient may notice the tearing more in the winter, when out of doors on a windy day, when using the air conditioner in the car, or when in the presence of other drafts that desic- cate the cornea. The seasonal allergy sufferer usually can tie the symptoms to a particular time of year, usually spring or late summer. The conjunctivitis patient notes that this is a new symptom or, even if this is a second or third episode, that the complaint is not seasonal or periodic. During the fifth and sixth decades of life and after, dry eye becomes a significant problem for patients. They need reassurance that the clinician understands their problems, because the tearing and dry eye do not seem congruous. The tearing is a reflex tearing in response to irritation of the cornea. The problem is that these tears are aqueous, and they are deficient of the mucin and oils needed for proper tear-film mechanics. Many of these patients note that the tearing increases during reading. This may be due to decreased blinking from concentration on the reading material, which is a common result of near work. The dry eye is, therefore, intensified while reading, and increased reflex lacrima- tion may result. A related syndrome is pain, burning, and tearing upon awakening. This can occur at any age and affects Refraction titioner will be the first to suspect diabetes in such a patient. The refractive error shift is usually in the minus direction, and it may have an astigmatic component. The refractive shifts are generally binocular and of approximately the same degree in each eye, but they are occasionally uniocular or more pronounced in one eye. No Complaint: Request for Routine Check-Up or New Frames cases, The patient who presents with this complaint seems to be the easiest to serve. There is no real complaint, but he or she wants an eye examination. The clinician should be on guard and ask himself or herself if this the true situation or whether the patient is stoic and hiding some underlying reason for the visit; it is the responsi- bility of the person taking the history to be alert for this possibility. Often something is bothering the patient, but it may not be revealed during the initial question- ing. The patient may not be consciously obscuring the reason for the visit, but, with adequate questioning, the reason for the visit comes to the fore. Perhaps the patient wants to see if the examination reveals an eye problem without prior notification of his or her problem. Unfortunately, some patients enjoy testing the physician while at the same time making their care harder to deliver. Alternatively, the patient actually may not have an underlying complaint, and a baseline exam- ination and updated spectacle prescription may serve this patient well. No Complaint: Broken or Lost Lenses or Spectacles This is usually a prior patient of the clinician's, but not always. In either case, the taking of the history is requi- site, because the clinician must know the circumstances surrounding the dispensing of the last pair of spectacles and when they were dispensed. With a new patient, a full history is appropriate. For an established patient, an update suffices. These patients-as opposed to those who are coming in for a new pair of glasses-generally do not have other underlying symptoms that are causing the visit, but the physician cannot assume that to be the case. the same Headache Not Related to the Use of Eyes This topic has been thoroughly covered in the previous Headache section. usually Headache Following Use of the Eyes The most common locations of headaches associated with use of the eyes are frontal and occipital. Brow aches and frontal headaches are most often ascribed to refrac- The Ophthalmic Case Historian Chapter 6 209 and seborrheic flakes in the hair of the sealp. Treatment for this malady is regular use of an antidandruff shampoo. Twitching of the Eyelids and Itching of the Eyes Myokymia, or twitching of the eyelid, is a common com- plaint for which there is no known remedy. It is thought to be related to psychological stress, but that is only a hypothetical cause. It is usually in the lower lid and is not visible to others, even though the patient is sure that it is apparent. Reassurance is the order of the day. If the cause of twitching is obscure, itching is almost pathognomonic of allergy. The only exception is the itching that is present in herpes simplex lesions before they vesiculate and rupture. The itch of allergy is often accompanied by a stringy, ropy discharge; a burning sensation; and a red conjunctiva. Depending on the stage of the disease process, it can be treated successfully with mast-cell inhibitors or antihistamines. another Photophobia Sensitivity to light is the hallmark of acute anterior uveitis. It can be seen in cases of keratoconjunctivitis and conjunctivitis as well as with corneal abrasions. The pain seems to be related to contraction of the iris sphincter and ciliary body. When a patient complains of sensitivity to light, the astute clinician immediately starts to look for the cause; the differential diagnosis includes hyperacute bacterial keratoconjunctivitis, her- petic keratoconjunctivitis, significant corneal abrasion, trapped foreign body, and iridocyclitis. Some persons claim photophobia as a chronic con- dition and subsequently want to wear sunglasses con- tinually. Many believe that this is an attempt to mask drug abuse by wearing dark glasses so that health care practitioners and others cannot judge pupil size or reactivity during casual contact. One way to ascertain whether the perpetual daylight use of sunglasses is nec- essary is with the direct ophthalmoloscope test. The test is performed during ophthalmoscopy with a halogen direct ophthalmoscope and a patient with an undilated pupil. If the patient does not lacrimate, the patient prob- ably does not need sunglasses in a normal environment. disease is Ocular Pain it is best Superficial pain of the eye can be the result of trauma or inflammation of the tissues of the corneal epithe- lium, conjunctiva, or episclera. Corneal abrasion, retained foreign body, and lid concretions are common traumatic causes of ocular pain. The pain with trauma is usually proportional to the extent of trauma. It can vary from a sandy, gritty feeling to frank, severe pain. Inflammatory causes of pain are many and, here again, Refraction Posterior uveins, endophthalmitis, orbital disease, and traction or displacement of extraocular muscles are other causes of deep ocular pain. When the physician is faced with a patient with unexplained orbital pain, some clinical pearls help in the differential diagnosis. The pain of uveitis is usually worse at night; the pain of diabetic neuropathy is followed by signs of ophthal- moplegia. In Tolosa-Hunt syndrome, the pain is accom- panied by involvement of the third, fourth, and sixth cranial nerves and diminished corneal sensitivity. Ocular pain can be present in temporal arteritis. In this condition, an elevated sedimentation rate, claudication on mastication, and a prominent temporal artery on the affected side help to differentiate it from other causes of deep ocular pain. Pain associated with the trigeminal nerve is common in the ophthalmic practice setting, particularly in the geriatric setting. Trigeminal neuralgia is common in females during the sixth decade of life. It is character- ized by paroxysms of severe pain in the distribution of one of the branches of the trigeminal nerve that are of sudden onset and brief duration. There is often a "trigger" area, which, upon stimulation, produces a paroxysm. There is a reflex spasm of the facial muscles in response to the pain from which its alternative name, tic douloureux, was derived. Herpes zoster can produce trigeminal pain as part of its clinical presentation. The pain is preceded by a vesicular eruption in the distribu- tion of one of the branches of the trigeminal nerve; these vesicles rupture to form multiple ulcers. The pain occurs at approximately the same time that the vesicles rupture, but it is not thought to be related to the open lesions on the skin. This pain can persist for months to years, particularly in the elderly. In fact, there seems to be a positive correlation between the patient's age and the duration of the postneuralgia pain. All elderly patients with herpes zoster should undergo workup by an internist to rule out coexisting cancer, because this disease is often seen in patients with depressed immune systems. Loss of Vision (Uniocular, Binocular, and Scotomas) glaucoma. When one is considering a real estate purchase, the first three criteria to study are location, location, and loca- tion. When a clinician is faced with a complaint of loss of vision, the first three characteristics that he or she should determine about the loss of vision are duration, duration, and duration. Table 6-1 lists most of the major conditions that produce loss of vision, along with the duration of loss. The preceding paragraph was not in jest: duration is the hallmark symptom of these conditions. This is not to say that other symptoms are not important in the dif- ferential diagnosis of loss of vision, but duration is the The Ophthalmic Case Historian Chapter 6 211 Vision loss attributable to MS is a central scotoma during the summer, after a hot shower, or after intense physical exertion. As noted earlier, this is known as Uhthoffs sign, and it is characteristic of vision loss in patients with MS. This vision loss usually lasts 1 to 2 days, and then vision is spontaneously recovered. This is not the same as the vision loss from retrobulbar optic neuritis, which is classically described as "the patient sees nothing and the physician sees nothing:' because there is vision loss and an absence of signs on the optic disk. Here, vision loss can be extensive and last for weeks. Smith" describes the fleeting loss of visual acuity as a sign of MS in 20- to 40-year-old women. Here the patient reports that in one instant he or she can read the 20/20 line and in the next he or she can only read 20/80. Again, the vision may be normal 2 minutes later. This is not a TIA, but rather it is probably related to impaired function of the optic nerve secondary to MS. The fleeting vision loss is subtle and difficult to docu- ment unless it occurs in the examination chair. Retinal detachment, tumor, ischemic optic neuropa- thy, central retinal artery occlusion (CRAO), central retinal vein occlusion, and CVA all have differing pre- sentations, but they share a common characteristic: the vision loss is longstanding or permanent. Retinal detachment is often perceived as a curtain falling over the visual field. Tumor produces a slow, progressive loss of vision. Ischemic optic neuropathy is a rapid-onset, usually altitudinal, visual-field defect that is associated with sectoral optic nerve head swelling. CRAO manifests itself as a sudden and complete loss of vision in the affected eye. Sometimes there is an island of vision in the centrocecal area, which is due to the presence of a patent cilioretinal artery. The fundus appearance is that of an ischemic retina (pale) and a cherry-red macula. The vision loss in central retinal vein occlusion is not as sudden as that of CRAO, but it is a vision loss that pro- gresses over 30 to 120 minutes, with the end result being very reduced vision in the affected eye. CVA, or stroke, is a rapid visual loss that is usually hemianopic and bilateral. Often the patient reports that the vision in the eye on the side of the visual field loss is the problem, without realizing that the field loss is bilateral. This field loss, if present at the time of examination by an eye care practitioner, is permanent. This q

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