Chapter 25: Approach to Acute Visual Changes, Abnormal Eye Movements, and Double Vision

PART 1—GENERAL APPROACH TO ACUTE VISUAL CHANGES

WHAT ARE THE KEY PORTIONS OF THE NEUROLOGICAL HISTORY SPECIFIC TO THE VISUAL SYSTEM?¹

Patients can present with a myriad of ocular complaints. Key questions include:

• History of previous ophthalmologic problems

• Temporal onset of vision loss

• Is there vision loss? If so,

  • Monocular or binocular vision loss

  • Pattern (scotoma, field, etc)

• Does the patient have double vision? If so,

  • Are the images duplicated in a horizontal, vertical, or skew pattern?

  • Any exacerbating factors?

    • Is the double vision worse when looking at a near or far object?

    • Does turning the head make the double vision worse?

  • Does the double vision resolve with covering one eye?

• Is pain associated with the vision loss?

  • Retro-orbital?

  • Pain with eye movements?

  • Other painful symptoms?

• When should ophthalmology be consulted urgently?

  • Monocular double vision

  • Inability to perform a good funduscopic examination without a dilated examination, and an ophthalmologic or vascular central retinal artery occlusion (CRAO) or central retinal vein occlusion (CRVO) cause is suspected

  • Suspicion of temporal arteritis

  • Monocular vision loss with a normal funduscopic examination by a neurologist when a primary neurological disorder such as migraines or multiple sclerosis (MS) is not suspected.

WHAT ARE THE KEY PORTIONS OF THE NEUROLOGICAL EXAMINATION SPECIFIC TO THE VISUAL SYSTEM?¹

Visual acuity

Visual acuity should be measured on each patient. Different types of charts exist, and use is dependent on provider preference. Chart types include the following:

• Snellen eye chart is used at 20 feet or 6 feet distance, depending on the size of the chart.

• Rosenbaum vision chart is used at a distance of 14–16 inches.

• For patients who do not speak English, a tumbling E chart may be helpful. The patient identifies the direction of the E, that is, upward, downward, left, or right.

Using a pinhole can help to determine if vision correction can be helpful to improve the acuity, especially if the patient’s glasses are not available. Commercial pinholes are available or one can be made with a piece of paper. Simply create a hole with a needle or safety pin that is just large enough to see the images.

Eye movement and pupillary examination

• H test: patients with visual complaints or double vision should have extraocular movements tested in all directions.

• Pupil examination: light response with direct and indirect testing

• Indirect testing: swinging flashlight:

• Alternating shining a light between the eyes can be helpful in determining if an afferent pupillary defect (APD) is present.

• In an APD, the normal eye constricts, but when the flashlight is shined in the ...