When you come across a suspected neuro-ophthalmic patient, set aside atleast 15–20 minutes of the clinic time for a detailed history and examination.
Record the patient's age, gender and occupation. Optic neuritis is generally seen in women between 20 and 40 years of age. Ischemic optic neuropathy is mostly seen after the age of 40 years. Traumatic optic neuropathy is more common in young males riding two wheelers.
Thyroid eye disease, myasthenia gravis, benign intracranial hypertension, meningiomas and multiple sclerosis are more common in females. Craniopharyn-gioma, optic nerve glioma and rhabdomyosarcoma are most commonly seen in the pediatric population.
Traumatic optic neuropathy, intracranial and orbital foreign bodies, subdural hematoma, intracerebral hemorrhage and ophthalmoplegia are more common in the armed forces and police due to the high incidence of trauma.
CHIEF COMPLAINT
It helps to ask the patient—‘Tell me in one sentence what your problem is.’ Record the chief complaint in the patient's own words. Document the onset, severity, side, progression and associated features of the patient's visual symptoms. If the patient is unreliable, family members, medication lists, past neuroimaging and discharge summaries can be very useful.5
Some of the differential neuro-ophthalmic entities related to history:
Decreased Vision
Transient visual loss (vision returns to normal within 24 hours, usually within one hour):
- Few seconds: Papilledema
- Few minutes: Amaurosis fugax, vertebrobasilar insufficiency
- 10–60 minutes: Migraine (with or without subsequent headache), Impending central retinal vein occlusion, ischemic optic neuropathy, carotid occlusive disease, CNS lesion, optic disc drusen, giant cell arteritis.
Visual loss lasting more than 24 hours
- Sudden painless: Retinal artery or vein occlusion, ischemic optic neuropathy, vitreous hemorrhage, retinal detachment
- Gradual painless loss: open angle glaucoma, diabetic retinopathy, and compressive optic neuropathy
- Painful loss: acute angle closure glaucoma, optic neuritis, uveitis
Loss of Color Vision
Optic neuritis, other optic neuropathies.
Loss of Side Vision
Right or left hemifield—stroke, pituitary tumor, glioma, subdural hematoma, migraine
Upper or lower hemifield—AION, optic neuritis
Central—optic neuritis, toxic neuropathy.
Loss of Contrast of Vision
Optic neuritis.
Shaking of Objects (oscillopsia) or Eyes
Acquired nystagmus (vertical or horizontal).
Eye Pain (Orbital)
Sinusitis, orbital pseudotumor, optic neuritis, diabetic nerve palsy.
Headache
Malignant hypertension, increased intracranial pressure, infectious CNS disorder, giant cell arteritis, cerebral tumor, aneurysm, subarachnoid hemorrhage, epidural or subdural hematoma, migraine, cluster headache, tension, trigeminal neuralgia, Tolosa Hunt disease, cervical spine disease.
Double Vision
- Typically intermittent: myasthenia gravis, intermittent decompensation of existing phoria
- Constant: Isolated sixth, third or fourth nerve palsy, thyroid eye disease, inflammatory pseudotumor, cavernous sinus superior orbital fissure syndrome, post-trauma-blowout fracture, internuclear ophthal-moplegia, vertebrobasilar insufficiency.
Deviation of the Eye (Squint)
Isolated third, fourth or sixth nerve palsy, multiple oculomotor nerve palsies, cavernous sinus/superior orbital fissure syndrome, myasthenia gravis, chronic progressive external ophthalmoplegia, blowout fracture.
Drooping of Eyelid (Ptosis)
Aging, myasthenia gravis, Horner's syndrome, third nerve palsy, chronic progressive external ophthal-moplegia.
Lid Retraction
Thyroid eye disease, midbrain syndrome.
Prominence of Eye (Proptosis)
Thyroid eye disease, orbital cellulitis, pseudotumor, orbital tumors, trauma, varix, mucormycosis.