Neuro-ophthalmology: examination and investigation

The detail to which a neuro-ophthalmological examination can be undertaken clearly depends on the facilities available to the examiner. Examination in a fully furnished ophthalmology suite is entirely different to bedside examination with nothing but a Snellen chart, a red pin, and an ophthalmoscope. In this article we will try to provide a balance between the “ideal” and what is practically possible to the “jobbing neurologist”. There are certain techniques and tools which are particularly related to the assessment of children (for example, in relation to amblyopia or squint). These will not be dealt with here as the focus of this article is the assessment of the adult. The interested reader is referred elsewhere.1

THE NEURO-OPHTHALMOLOGICAL EXAMINATION

General examination

The neuro-ophthalmological examination should not be seen as an independent process, but complementary to both full general examination and full neurological examination. For example, it may be that general problems such as symptoms and signs of acromegaly prompt a neuro-ophthalmological assessment. Alternatively, it may be the other way round as in the case of a patient presenting with amaurosis fugax who will need a full neurological examination as well as a cardiovascular assessment.

Examination of head and neck

Examination of the neck is important with respect to mass lesions and more commonly extracranial vascular occlusive disease. Leaving this aside, of particular importance is the examination of the cranial nerves which may help to localise the neurological lesion. For example, a sixth nerve palsy which is accompanied by ipsilateral numbness of the face, facial weakness, and hearing loss is likely to be caused by a lesion in the cerebello-pontine angle. Other physical signs in the head and neck are occasionally useful, and a few specific examples are listed in box 1.