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Clinical Investigation

What to do when you suspect a neuro-ophthalmic condition


A good history is critical

Disorders of the brain and nervous system that affect the eye and vision are often complex to diagnose – most neuro-ophthalmic disorders are not ‘spot’ diagnoses. Consequently, much information can be gleaned when obtaining a thorough from the patient.

While you should have some structure or regularity to the way you take a history, be flexible enough to explore potential flags as you come across them in the course of speaking to the patient.

  1. Information about the presenting complaint

  • The problem (symptoms)
  • The time course*
  • The speed of onset and development over time
  • Any variability during the day
  • ‘Warning signs’ prior to symptom onset
  • Any previous episodes (how often and how long)
  • Triggering factors

*Remember to distinguish between time of onset vs when the patient first noticed the symptoms (e.g. a patient who rubs one eye when ‘irritated’ and notices that the other eye has no vision will not be able to determine the time of onset).

  1. Subsequent questioning

  • Pain
  • Vision loss
  • Diplopia
  • Past ocular history
    • Glasses or contact lenses
    • Eye drops, surgery or laser
    • Eye patching or surgery as a child
  • Past medical history
    • Cancer
    • Autoimmune disease
    • Diabetes, hypertension, high cholesterol
    • Smoking
    • Trauma
    • Surgery
  • Medications (including recreational substances)
    • Provides clues to systemic diseases forgotten by the patient
    • Can manifest or exacerbate neuro-ophthalmic disorders
      • Optic neuropathy – ethambutol, isoniazid, amiodarone, drugs for erectile dysfunction
      • Raised intracranial pressure – corticosteroids, oral contraceptive pill, tetracyclines, vitamin A derivatives for acne
      • Retinopathy – tamoxifen, hydroxychloroquine
      • Double vision – penicillamine, aminoglycoside-induced myasthenia gravis
      • Nystagmus – phenytoin, lithium
  • Family history of ophthalmic or neurologic disease
  • Social history
  • Diet/nutrition

Importantly, remember to ask open-ended questions rather than direct questions, as this will provide you with much more detailed answers that can help to guide your subsequent line of questioning.

Ask: ‘how have you been lately?’, ‘any trouble combing your hair?’ or ‘any trouble eating?’

Not: ‘do you have a headache?’ or ‘have you lost weight?’

Follow with a thorough clinical examination

When you suspect a neuro-ophthalmic condition, always assess:

  • VA
  • Colour vision
  • VF by confrontation (before dilation)
  • Eye movements
  • Pupils
    • Direct
    • Indirect
    • Relative afferent pupillary defect (RAPD) to check for optic nerve lesion
  • Lid position
  • Corneal sensation
  • Slit lamp examination (including dilation)
  • Optic disc 3Cs – colour, cup, contour
  • Take photos

Refer as appropriate

By this stage, you may or may not have a list of differential diagnoses. If referral is appropriate, choose an ophthalmologist with neuro-ophthalmic training to allow further investigations and intervention (if appropriate) in a timely manner.

Have a question?

IMPORTANT: If you are concerned about your eyes and require an urgent consultation, DO NOT use this form. Please call one of our clinics during office hours or contact your nearest emergency department.

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