I am delighted to welcome a guest post from my respected colleague, Andy Millington. In this piece, Andy breaks down the difference between simply recalling the LOFTSEA mnemonic and using it as a sophisticated framework for clinical processing. Andy builds on some of the key aspects described in History and Symptoms: The Eye Examination, building the LOFTSEA approach further.
Despite having worked as an optometrist for many years, I’ve recently seen a couple of patients with conditions I had never encountered before. It got me thinking about how we approach the clinically unfamiliar.
At university, we’re taught the LOFTSEA approach (Location, Onset, Frequency, Type, Self-treatment, Effect on life, Associated symptoms), but it’s more than just a memory aid. It gives us a framework not just for identifying and diagnosing, but for classifying and processing—a more realistic description of what frontline clinicians actually do.
When a presentation is completely new to us, as rarer conditions may be, we need to judge its significance, categorise it, and decide who should see it and how urgently. We know LOFTSEA works well for common issues like headaches, but how well does it function as a framework for investigating unfamiliar conditions?
Location: The Importance of the Diagram
Location is the natural starting point: where is it, and what does it look like? This is arguably the most important step, not only for decision-making but for documentation.
I’m going to be honest about this bit. A photograph is not an alternative to a good physical description and a diagram. Photography is valuable and definitely should be included, but it doesn’t explain why you found something suspicious in the first place. A drawing, however, can highlight the specific features that raised your concern.
The key difference is that a photograph records everything, while our visual system presents a filtered and interpreted version of what we see. Even when we try to be objective, the eye captures an image and the brain processes it into a curated perception. Preferential vision tests demonstrate this well, as our eyes automatically track the most interesting or relevant parts of a scene—a behaviour confirmed repeatedly through eye-tracking studies.
We also naturally filter out distractions—the litter bin in front of a beautiful mountain view, or the dirt on a car windscreen when we’re admiring a rainbow. At the same time, we are hardwired to recognise patterns. When examining an eye, we notice groups of signs that stand out to us, and those patterns become part of our interpretation.
This means that our diagrams and written descriptions contain analysed information. They contain the meaningful details our brain selected and processed—information that a photograph alone cannot provide.
Onset, Frequency, and The Patient’s Story
Once you’ve described the appearance, location, and relationship to surrounding structures, the next part of LOFTSEA moves you on to Onset and Frequency. Has it appeared suddenly or slowly? Is it recent or long-term? Does it change? A lesion that bleeds, scabs, heals, and recurs tells a different story from one that is static or episodic.
Type brings us to the patient’s own “explanatory model”—their beliefs and interpretations about what is happening. This model is often the very reason they seek help.
An example from my clinic
An example I often use is a patient who came in with a very red, painful eye. Instead of describing the eye problem straight away, they began telling me, in great detail. This included referencing their summer holiday in a gîte in rural France. It sounded idyllic: a peaceful location, a private swimming pool, and fresh produce from the garden. But as they continued, I found myself becoming frustrated. After all, they were here because of a sore red eye, and I wanted to focus on helping them.
However, their story was actually part of their explanatory model—the way they understood what might have caused the problem. They were worried that swimming daily in a pool filled with water drawn from a borehole might be responsible, or that they had eaten or touched a plant in the garden and then rubbed their eye. Their concerns made sense once I understood what they were trying to explain.
“Their concerns made sense once I understood what they were trying to explain.”
Andy Millington
Their explanatory model links closely to Self-treatment and Effect on life. It’s essential to know what they’ve already tried. Recommending something they’ve already failed with affects compliance and your credibility. Understanding what improves or worsens the condition is a powerful diagnostic tool.
Finally, Associated Symptoms include what the patient notices and what you recognise as clinically linked. Patients with autoimmune conditions, for example, may detect subtle patterns (such as fatigue, skin sensitivity, gastrointestinal irritation) long before a clinician connects the dots. Their associations may differ from yours, but both perspectives are valuable and part of the diagnostic process.
The Decision: What Do We Do After LOFTSEA?
So after all this: what is it, and what do we do next?
Experienced clinicians lean heavily on pattern recognition, while newer clinicians tend to rely on step-by-step comparison. When faced with the unknown, trust your gut, but with a healthy dose of cautious pessimism. When in doubt, assume the worst-case scenario.
By the time you’ve worked through LOFTSEA, you’ll know whether the condition is acute or chronic, stable or changing, and what the patient expects. Often, a well-documented period of watchful waiting is appropriate, perhaps alongside a second opinion. Group practice makes this easier; if no colleague is available immediately, a rapid rebooking usually is.
The other option is to refer the patient for further opinion or treatment. This should not be seen as the final solution, but rather the default course of action. This is unless you can confidently demonstrate that referral is unnecessary.
And a final word on second opinions: having given and received countless ones, I can say that the person offering the second opinion often has the easier job. They’re handed a short list of possibilities and choose between them. The first clinician did all the difficult groundwork, assessing and sorting signs and symptoms. It’s easy to forget that, but it’s worth remembering: you’ve already done the heavy lifting.
I again would just like to say thank you to Andy for taking the time to write this piece. His experiences in optometry are incredibly valuable. I have constructed some Frequently Asked Questions below; based on the questions I often get asked in regards to LOFTSEA.
Frquently Asked Questions – LOFTSEA
If you enjoyed this article and found it useful for your studies, please consider sharing it with your peers. If you are a lecturer and wish to link to this article to aid in explaining LOFTSEA, please feel free to do so.
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