An accurate history is crucial for triage of referrals over the phone – so please be thorough.

Some tips for common presentations;

• Visual loss: Which eye, rate of onset, intermittent or not, which part of visual field affected (central/peripheral/all), floaters or flashes, headaches, any giant cell arteritis symptoms (if age >50)
• Red eye: duration, discharge, visual disturbance, pain, trauma, photophobia, surrounding cellulitis
• Pain: which eye, where, type of pain (FB sensation vs ache etc), pain on eye movements, relieved with topical anaesthetic?
• Diplopia: clarify if monocular or binocular (does it go away when either eye is covered)
• Flashes/floaters: previous retinal tear/detachment or FHx of this, myopia, previous eye surgery, recent trauma/falls
• POHx: ‘lazy eye’, contact lens use, past diagnoses, who they see (consultant/ known to) trauma or surgery, current eye drops
• PMHx: common co-morbidities that we need to know about include diabetes, hypertension, cerebrovascular disease, connective tissue/inflammatory disease, immunosuppression, or recent hospitalisation

• Visual acuity: first with distance glasses (or no glasses if doesn’t use them), and then with pinhole if VA less than 6/6 – this step is very helpful in our triaging DO NOT SKIP IT. If no pinhole is available in clinic, you can create your own with an 18G needle (or Pen) and any piece of paper or cardboard
• Pupil check (check if equal, then direct and consensual responses, and RAPD)
• Eye movements (ask the patient if diplopia is horizontal, diagonal, or vertical. Try to elicit in which direction of gaze it improves or worsens, worse on distance or close up) plus nystagmus
• Slit lamp exam – look at: lids/lashes/periorbital tissue, conjunctiva and sclera, cornea (can stain with 25% fluorescein and use a blue light to look for corneal abrasions), anterior chamber, iris/lens. You must evert the eyelid if any corneal abrasions or foreign bodies on the surface of the eye
  • Full strength 2% fluorescein is only useful for Seidel’s when looking for penetrating eye injury or ruptured globe
• Intraocular pressure measurement (do not check if suspicions of a ruptured globe)
• Confrontational fields if visual loss a symptom (just because a patient says it’s their right eye, doesn’t exclude a right sided homonymous hemianopia
• Do not dilate the eye unless discussed first with ophthalmology

• Outcome of most recent ophthalmology visit with a baseline visual acuity if available. Recent letters are very helpful
• Potential thoughts on differentials?
• If you can master the above in a concise and clear manner, with clear thought into your question and what assessment you have made – you have impressed already

• Failing to check vision with pinhole – even if you check the vision with glasses on, you must always also then check using the pinhole if vision less than 6/6. This is commonly forgotten
• When checking vision using a standard Snellen chart at 6m – you report the vision with the 6 on top e.g. 6/9
• Do not use a hand held phone or ipad screen as a substitute for a Snellen chart. Patients will need to accommodate if they are looking at a near target; their performance will be impeded if they are presbyopic without their reading glasses
• Using a tonopen in suspected globe ruptures can expel globe contents so do not use if suspecting rupture