Taking a Case History

Written By Orthoptic Corner

A Structured Guide for Orthoptic students

Collecting a thorough case history from your patient is one of the most valuable parts of an orthoptic assessment. A well-gathered history:

  1. Supports accurate diagnosis

  2. Guides management decisions

  3. Helps determine likely outcomes

  4. Builds trust with patients and families

  5. Gives insight into cooperation and understanding

Sometimes, the history alone will strongly point toward the diagnosis before you even begin your assessment.

Begin with the Presenting Concern

Start by clarifying: ‘what brought you in today?’ or ‘do you have any concerns about your eyes?’

This will help you streamline your line of questioning. Often patients are referred to the Orthoptic clinic for one reason but their main concern is something completely different. By opening with these questions, it allows you to gather what their main problem is. 

Questioning adults and children is different. You will need to tailor your questions depending on the age of your patient. We will talk about this further below. 

Assessing Children

When it comes to assessing children, it is important to include the child in the conversation whenever possible. Even very young children can contribute meaningful information, and their responses help you judge their developmental level and communication ability. This will help you later on as it means you can better tailor which tests to choose to get the best information. It also helps you build a rapport with the child, which will put them at ease and also means you will gain more clinical information when it comes to testing them. 

It is also important to note who the child attended with. You can ask this by directing the child (if they are old enough) with ‘who did you bring with you today?’. You never want to assume the relationship of the adult that accompanied them. If they disclose any safeguarding information (eg if the child is in care or has a foster/adoptive parent) this is important to note down. 

Past medical history

Here you are interested in:

  1. Previous or recent illnesses 

  2. Chronic conditions

  3. If they are under any other healthcare professional and why (eg paediatricians, dermatology, speech and language)

  4. Any head or facial injuries

  5. Any current medications

  6. Any known allergies 


You can phrase this as: ‘do they have any general health issues? Are they seeing any other healthcare professionals for any reason? Do they take any regular medications? Do they have any allergies?’ 

Visual disorders in children can often coexist with systemic or developmental issues, so this context is important.


Birth History

In children under the age of 8, you want to ask about their birth history if it is known. 

Here you are interested in:

  1. Gestational age and birth weight

  2. Type of delivery (normal vaginal, assisted, caesarean (planned/emergency), forceps)

  3. Admission to neonatal or special care units

  4. Any oxygen given at birth 


Prematurity and perinatal complications are particularly associated with neurological and ocular motility disorders so it is important to ask and establish this. 

You can phrase this as: ‘was (patient) a full term or premature baby? Was that a normal delivery? What was their birth weight? Did they have to stay in a special care baby unit? Were they given any oxygen at birth?’ 


Family history

A strong family history increases suspicion, even if a deviation is not obvious at the first visit. It may also influence follow-up planning as you may want to keep children with a strong family history under review for longer.


Here you are interested in:

  1. Any relatives with a squint

  2. Any relatives that wore glasses from childhood

  3. Any relatives that needed ocular surgery 


You can phrase this as: ‘is there a family history of squints? Where an eye turns in or out? Did anyone in the family were glasses from a young age? Has anyone needed surgery on their eyes?? 


If a child is attending due to parents noticing a squint, it is important to establish:

  1. If they actually mean that the eye is drifting or if the child is screwing their eyes (which in some areas people refer to as squinting their eyes. This is different to an orthoptic squint) 

  2. Direction (inward, outward, vertical)

  3. Age at first observation

  4. Whether onset appeared sudden or gradual

  5. Whether it is constant or comes and goes

  6. Situations where it is most noticeable

  7. Whether it has changed over time

  8. Presence of head tilt or face turn

For all children want to establish what the parents/carers feel about the child’s visual ability. Do they think the child is alert? Do they make eye contact? Do they engage with their toys or tv? If the child is school aged, you can also ask if school has raised any concerns about their vision. 

You also want to be aware that children may present with double vision but not report it. As 1. If it's longstanding they may not be aware that it is not normal or 2. They may not be able to verbalise that they are seeing two of things. So you can ask about: 

  1. Any new or increased clumsiness

  2. Closing or covering one eye 

  3. Asking if they every see 2 of things (you can also do this at the beginning of your cover test - by asking if they see one or 2 of your fixation target) 


Reports of intermittent outward deviation are often reliable. Reports of occasional inward deviation require careful consideration of pseudostrabismus.

Assessing Adults

Adults are more likely to attend due to symptoms such as:

  1. Double vision

  2. Cosmetic concerns

  3. Recently developed eye movement problems


Past medical history

Here you are interested in: 

  1. Previous and current medical conditions

  2. Complete medication list

  3. Any history of trauma 

  4. Any new neurological symptoms

  5. Any unexplained weight change

  6. Changes in physical appearance


You are looking for any systemic changes that may be associated with ocular conditions. 


You can phrase this as: ‘do you have any general health issues? Are you taking any regular medications? Do you have any allergies? Have you had any recent head or eye injuries? Any other changes to your general health you have recently noticed?’ 


Previous ocular history 

Here you are interested in: 

  1. Glasses wear - even if they no longer wear glasses (eg they have had cataract surgery)

  2. High refractive errors

  3. Unequal prescriptions between eye

  4. Childhood squint

  5. Previous double vision

  6. Past strabismus surgery

  7. Previous patching 

  8. Prisms in glasses 


Taking a Diplopia History

If an adult is attending due to double vision, it is important to establish:

  • Onset

    • When did it start?

    • Did it come on suddenly or gradually?

    • Any history of trauma/illness around the time of onset?

    • Is the double vision improving, staying the same or worsening since onset?

  • Pattern

    • Is the double vision constant or intermittent?

    • Is the double vision worse at near or distance?

    • Is it worse in any particular direction of gaze?

  • Nature

    • Is the double vision side by side (horizontal)?

    • Is the double vision one above the other (vertical)? 

    • Is the double vision diagonal (mix horizontal/vertical)?

  • Associated Features

    • Any headaches? 

    • Any limb weaknesses? 

    • Any new weight loss?

    • Any speech or swallowing difficulties? 


Taking a Nystagmus History

In Infants and Children

Parents may describe “shaky” or “wobbly” eyes.

Here you are interested in: 

  • When was it first noticed?

  • Is it always present?

  • Any variations with gaze? Is the nystagmus less or more in any particular direction?

  • Any changes over time?

  • Have the parents noticed a head posture?


In Adults

Acquired nystagmus often has a neurological cause.


Here you are interested in: 

  • Do you feel like your vision is moving/wobbling (oscillopsia)?

  • Do you notice any balance problems?

  • Ensure you take a full systemic history

Some patients with nystagmus adopt a consistent head turn or tilt to improve binocular vision or dampen nystagmus.

Here you want to ask:

  • When did the head posture first begin?

  • Is it constant?

  • Whether it has changed?


Eye Strain and Headache

Patients are more frequently presenting to the Orthoptic clinic due to symptoms of visual fatigue. This may be due to:

  • Decompensating phoria

  • Convergence insufficiency

  • Refractive error

  • Accommodation problems

Here you are interested in: 

  • Symptom type - headaches, blurry vision, eye strain

  • Time of day - worse in the morning or evenings 

  • Triggers - close vision (phones, tablets) or prolonged closework 

  • Impact on work or hobbies

  • Relief strategies (painkillers, rest) 

Always remember that headache has many possible causes, some unrelated to ocular alignment, so a thorough case history can help you differentiate before even testing the patient. 

If the patient complains about zigzags, kaleidoscope effect in their vision followed by a headache lasting less than an hour, this may be indicative of a migraine rather than an ocular issue. 


Summary

When gathering a history:

  • Take a whole-patient approach

  • Listen carefully

  • Look for warning signs

  • Treat sudden changes seriously 

  • Build rapport early

A careful history is often the key that unlocks the diagnosis.


Orthoptic Corner
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Assessing Ocular Movements