Ophthalmic Evaluation &

Approaches to The Patient

Muhammad Asroruddin
Ophthalmology Department
UNTAN

Modul of Foundation of Clinical Practice

 Overview
The purpose of ophthalmic evaluation is to
document objective and subjective
measurements of visual function and
ocular health

Modul of Foundation of Clinical Practice

 Overview
The specific objectives of the comprehensive ophthalmic evaluation
are to:
• Obtain an ocular and systemic history
• Determine the optical and health status of the eye, visual system,
and related structures
• Identify risk factors for ocular and systemic disease
• Detect and diagnose ocular abnormalities and disease
• Establish and document the presence or absence of ocular signs
and symptoms of systemic disease
• Discuss the nature of the findings and implications with the patient
• Initiate an appropriate response (further diagnostic tests.
Treatment, or referral when indicated)

Modul of Foundation of Clinical Practice

 Overview
A successful evaluation relies in part also on the
physician approaching the patient
appropriately and with a certain professional
demeanor (attitude), and is supported by the
keeping of adequate records

Modul of Foundation of Clinical Practice

 History
• Important first step in an ophthalmic evaluation
• Demographic data
• Identity of other pertinent health care providers utilized by the patient
• Chief complaint and history of present illness
• Present status of vision, including the patient’s perception of his/her own
visual status, visual needs, and any ocular symptoms
• Past ocular history, incl prior eye diseases, injuries, diagnoses, treatments,
surgeries, and ocular medications
• Past systemic history, including allergies, adverse reactions to medication,
medication use, and pertinent medical problems and hospitalizations
• Family history, including poor vision (and cause, if known), and other
pertinent familial ocular and systemic disease

Modul of Foundation of Clinical Practice

 Goals of The History
• Identifying the patient
• Identifying other practitioners who have cared
for the patient
• Obtaining a diagnosis
• Selecting therapy
• Socioeconomic and medicolegal
considerations

Modul of Foundation of Clinical Practice

 Examination
• Analysis of the physiologic function and anatomic status of the eye,
visual system, and related structures.
• Visual acuity examination, with and without correction (if any) at
distance and at near.
• Determination of best-corrected visual acuity utilizing refraction
• Ocular alignment and motility examination
• Pupillary examination
• Visual field examination (confrontation testing)
• External eye and ocular adnexa examination
• Anterior segment examination
• Tonometry to determine intraocular pressure
• Posterior segment examination

Modul of Foundation of Clinical Practice

 Ophthalmic Equipment (for GP)
• Snellen acuity chart
• Near visual acuity chart
• Slit-lamp biomicroscope
• Tonometer
• Trial frame and trial lens
• Penlight
• Direct and indirect ophthalmoscope
• Color vision

Modul of Foundation of Clinical Practice

 Physician Demeanor & Approach to
the Patient
• Compassion and professionalism
• Listen to patient’s concern carefully and with undevided
intention
• Ask if the patient has any additional questions or concerns
and address them, after completing evaluation and
counseling
• Maintain the confidentiality of all patient information and
interactions.
• Use the appropriate language, use translator if needed
• Creating an atmosphere of trust, respect, and openness, so
that the patient will communicate freely, and effective
patient-physician communication can be achieved

Modul of Foundation of Clinical Practice

 Ethical Consideration
• Provide care with compassion, honesty, integrity, and respect for
human dignity
• Do not refer to a patient as the retinal detachment. Instead, always
refer to patients by their names
• Seek a healthy personal lifestyle
• Understand the psychology of illness
• Maintain clinical and moral competence to avoid doing harm and to
ensure provision of excellent care
• Communicate openly and honestly with patients
• Do not allow fees for ophthalmologic services to exploit patients or
third-party payers
• Always strive to preserve, to protect, and to advance the best
interests of the patients.

Modul of Foundation of Clinical Practice

Modul of Foundation of Clinical Practice