Pseudophakia History Taking - Optha Long Case For Practical Exam

Pseudophakia is the clinical condition wherein the patients eye have artificial lens implanted instead of natural crystalline lens.

Pseudophakia History Taking.

History taking of pseudophakia for practical examination includes:

1. Patient particulars.
2. Chief complaints of the patient related to pseudophakia.
3. History of present illness.
4. Past ocular illness history.
5. History of systemic diseases.
6. Family history.
7. Personal history.
8. General physical and systemic examination.
9. Ocular examination.
10. Visual acuity.
11. Eyelid and Eyelashes, Conjunctiva, Sclera, Anterior chamber depth, Iris, pupil, etc.
12. Digital tonometry.
13. Extraocular muscle movements.
14. Lacrimal apparatus.
15. Provisional diagnosis.

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(Tips: No need to enumerate these steps separately. Don't write it in the copy)

The above is the perfect format for taking history of long case of Pseudophakia in the practical examination. Be it in the opthalmology or ENT or any other subjects, the format for history taking is more or less same.

So, let's discuss one by one in brief.

(Start writing in your practical copy from here)

Patient particulars.

Name: Mr./Mrs. X (Patient name).
Age: 65yrs
Sex: Male/Female
Address: Darjeeling, Bengal
Religion: Muslim/Hindu 
Occupation: Farmer
Socioeconomic Status: Poor economic condition.

Chief Complaints.

Patient has as such no complaints in his Right eye (affected eye). He has come for routine check-up.

History of present illness.

Patient was operated in his right eye (RE) 3 months back in North Bengal Medical College and Hospitial. He was operated as he developed gradual onset of dimness of vision in his both eye for last 10 months and the problem was more in RE.

He consulted eye surgeon in this hospital; Who after examination told that he has cataract in his both eye and decided to operate RE first.

According to the the patient, he has undergone cataract surgery along with intraocular lens implantation in his RE. 2-3 days after operation he was able to see everything in distance with his RE but there was difficulty during near work. One and half month after operation doctor prescribed him glass and he uses glass only during near work. At present he has come for routine check up only.

History of Past Ocular illness: Nothing Significant.

History Of Systemic illness.

Patient has no history of diabetes, hypertension, thyroid disorder, tuberculosis or any other systemic disorder and he never had any type of operation.

Family History: Nothing significant.

Personal History: He is a smoker but not addicted to alcohol.No history of any allergic disorder.

General Physical and Systemic Examination: Reveals no abnormality.

Ocular Examination.

Visual Acuity: 

RE 6/6 without glass and 6/6 with his own glass. 

RE near- N6 with own glass.

Eyelid and Eye lashes: Normal in position and there is no entropion, ectroopion, blepharitis or trichiasis.

Conjunctiva: No congestion.

Sclera: No congestion.Scar mark seen superiorly near limbus. (Scar mark according to the type of surgeries done)*

Cornea: Rest of the cornea except near the incision is clear. 

Pupil: Round, regular, reacts briskly. Shiny glassy reflex found behind the iris plane. All the Purkinje images are present.

Digital Tonometry: Normal

Extraocular muscle movement: Normal

Lacrimal Apparatus: Appears to be normal.

(Tips: Don't comment on the internal structures of the eye which you can't normally inspect with torch light only.)

Provisional Diagnosis.

Mr. X, 65yrs male patient, who is a smoker, underwent cataract surgery with intraocular lens implantation in his Right eye 3 months back. On examination scar mark found in the sclera superiorly. Shiny reflex found behind the iris plane and all the Purkinje images present. So from the above points, my provisional diagnosis is that this is a case of Pseudophakia.