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Chapter 1: Neuro-Ophthalmic History and Examination

CHAPTER OUTLINE

  • INTRODUTION

  • CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS

    • Visual loss

    • Positive visual and hallucinations

    • Diplopia

    • Ptosis Anisocoria

    • Pain and Photophobia

  • REVIEW OF SYSTEMS AND OTHER HISTORY

  • EXAMINATION OVERVIEW

    • Function

    • Structure

    • Putting it all together

  • EXAMINING THE EYE AND ORBIT

  • CLINICAL ANCILLARY TESTS

    • Photography

    • Intravenous fluorescein angiography

    • Optical coherence tomography

    • Ultrasonography

  • NEUROIMAGING

    • Computed tomography

    • Magnetic resonance imaging

    • Imaging the orbit

    • Imaging the brain

    • Cerebral angiography

    • Functional neuroimaging

  • KEY POINTS

INTRODUCTION

The art and science of obtaining a meaningful history is the keystone of neuroophthalmology. Some may doubt the importance of the history in ophthalmology—because the examiner has the unique ability to actually see the organ of interest inside and out in vivo (unlike the cardiologist or nephrologist)—but a single day in a busy neuroophthalmology clinic will put that notion to rest.

We do not wish to imply that neuro-ophthalmic history-taking should be a lengthy, memorized barrage of questions relating to every system in the body. Instead, the effective examiner is similar to a mechanic with a large chest of tools, carefully selecting the correct instruments for the task at hand. Because effective history-taking depends on a thorough knowledge of the many manifestations of disease in the visual system, it is truly the most complex “procedure” a physician can perform on a patient. A guide, outlining the components of the neuro-ophthalmic history, is provided in Table 1–1.

TABLE 1–1.

ELEMENTS AND RATIONALE OF THE HISTORY

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TABLE 1–1.

ELEMENTS AND RATIONALE OF THE HISTORY
Components of History Comments
Chief complaint(s) List the patient's current concerns in order of importance.
History of present illness Explore details of each complaint.
Review of systems Inquire about specific symptoms. Include pertinent ophthalmic, neurological, and medical system reviews.
Past history Identify known ophthalmic, neurological, and medical disorders; previous surgeries; and medical or radiation therapies.
Medications List all prescription medicines, eye drops, vitamins, over-the-counter drugs, birth control pills, injections, and home remedies.
Other drugs Inquire about the use of illegal drugs, alcohol, and tobacco.
Allergies Note drug or environmental allergies. Try to distinguish true allergic reactions from side effects.
Social/sexual Assess risks of HIV and other sexually transmitted diseases.
Occupational/recreational Evaluate potential exposure to toxins, trauma, as well as the affect of the disorder on the patient's ability to work safely.
Family history Explore ophthalmic, neurological, and medical disorders that may be hereditary.

Abbreviation: HIV, human immunodeficiency virus.

CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS

Neuro-ophthalmic chief complaints usually concern visual loss, positive visual phenomena, diplopia, ptosis, anisocoria, pain, and photophobia. Vision complaints are often difficult for patients to articulate. In addition, neuro-ophthalmic patients commonly present with an array of seemingly disjointed complaints, offering a considerable challenge to even to the most determined historian. For this reason, crystallizing the patient's concerns into a list of individual complaints, ...

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