OPHTHALMOLOGICAL ASSESSMENTS

Red flags in neuro-ophthalmology

Some diseases of the brain

Olufunmilola presenting with Ogun Lecturer and visual symptoms Honorary Consultant, are life threatening Department of and need urgent Ophthalmology, College of Medicine, management. This University of Ibadan and University article discusses College Hospital Ibadan, Nigeria. possible causes of double vision, vision loss with headache,

and non-ocular ICEH Papilloedema in a 23-year-old woman. Headache for two months. Worse on vision loss. waking. Vision 6/6 in both eyes.

he three most important ‘red flag’ symptoms First exclude monocular diplopia by asking the patient that indicate that a patient may need neuro- to cover each eye in turn. If the double vision persists Tophthalmological assessment are: when looking with just one eye, then this is usually due to an ocular problem (e.g. cataract) and does not have a 1 Sudden onset of double vision (diplopia) neurological cause. 2 Headache accompanied by vision loss (without an ocular cause) Oculomotor Figure 1. 3 Visual loss after ocular causes have been excluded nucleus The three Superior oblique If a patient presents with any of the symptoms above, you (4th cranial nerve) cranial nerves must take a detailed history (Table 1). Superior rectus 1 Sudden onset of double vision (3rd cranial nerve) Each eye is moved by six muscles which are innervated by Medial rectus three “cranial” nerves (the 3rd, 4th and 6th nerve) (Figure 1). (3rd cranial nerve) If the nerves are affected then the eye cannot move ORBIS normally, which results in double vision. The 3rd nerve Inferior rectus Lateral rectus (3rd cranial nerve) also innervates the upper eyelid (Table 2). (6th cranial nerve) Inferior oblique (3rd cranial nerve) Table 1 Taking a history Table 2 Examination

Questions to ask Clinical interpretation Questions to ask Clinical interpretation

Is the double vision The direction of gaze in which the double Is the upper eyelid Ptosis may be due to myasthenia gravis or a third worse in any direction vision is worst signifies the most likely eye drooping? nerve palsy, or may be congenital. of gaze? muscle involved. How do the eyes Assess the position of the eyes looking straight Are the images side by In 6th nerve palsies the images are side by move (each eye ahead (check for squint), and the movements of side; or is one image tilted side; alone and both each eye alone and together in all 9 positions of and above the other? In 4th nerve palsies one image is tilted. eyes together)? gaze (Figure 3 on page 67). Limitation of movement in a certain direction indicates disease Has there been a Trauma to the brain or orbit can affect the of the affected muscle or the cranial nerve which recent head injury? nerves which control eye muscle innervates it. movements. 6th nerve palsy: eye cannot look out (abduction). 3rd nerve palsy: ptosis and eye cannot look up and in. Does the double vision If the condition gets worse with use of the get worse as the day muscle then this is typical for myasthenia Are the pupils of If one pupil is larger than the other, this suggests progresses or after gravis; there may be eyelid drooping (ptosis) equal size? 3rd nerve palsy relating to the eye with the larger exercise? or diplopia as the day proceeds. pupil.

Is there any head or Pain is an important clue: it usually indicates Does the pupil react A non-reactive pupil indicates a damaged optic eye pain? infection or inflammation. Tumours are less normally to light? nerve or prior use of dilating drops. likely to be painful. What should I do? Are there any systemic Hypertension and diabetes can both cause Refer all patients with double vision for further investigation. Some symptoms or diseases? loss of vision and diplopia. may have life-threatening conditions.

64 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 | NUMBER 96 | 2016 2 Headache accompanied by vision loss Table 4 Examination (without an ocular cause) Questions to ask Clinical interpretation The brain is encased by the skull and meninges and Are the pupils of See Table 2. is bathed in cerebrospinal fluid. If the flow of fluid equal size and is blocked, by a tumour for example, this raises the do they react pressure inside the head (intracranial pressure), normally to light? causing headache, sometimes with nausea or vomiting. Is there optic disc Swelling of the optic disc can be due to Raised intracranial pressure can lead to swelling of the swelling or raised intracranial pressure optic nerve head (papilloedema), usually in both eyes. atrophy? (papilloedema) or inflammation (papilitis). If the raised pressure persists, the optic nerves become Optic atrophy may be due to longstanding atrophic; i.e. they become paler then normal. compression of the optic nerve or vascular or toxic damage to the nerve. Both headaches and visual loss are common. Before What should I do? suspecting a neurological cause, examine the patient to Refer all patients with headache and persistent visual exclude eye conditions which might be responsible for loss for further investigation. The referral must be the visual loss (Table 4). urgent if they have papilloedema. Some may have Taking a history life-threatening conditions. Ask questions about any aches or pain using the mnemonic ‘SOCRATES’ (Table 3). 3 Visual loss after ocular causes have been excluded Table 3 Structured history Most causes of visual loss are due to diseases of Questions to ask Clinical interpretation the eye. Ocular conditions must be excluded by Site: Where is the Pain overlying the sinuses may careful examination of the eye before considering a headache? The suggest sinusitis, whereas periorbital neurological cause of poor vision (Table 5). patient may pain suggests orbital pathology. describe or point Progressive vision loss with no ocular cause must be to the location taken seriously. Onset: How long Migraine is a common cause of Table 5 Visual loss have they had the recurrent severe headache which headache? may last hours or even days. Questions to ask Clinical interpretation Is it worse at any Pain which is worse in the morning on Is the vision loss Unilateral vision loss indicates a time of the day? waking up may be due to raised in one or both problem within the eyeball or optic intracranial pressure. The headache eyes? nerve in the orbit. may be associated with nausea and vomiting. Has there been Vision loss that is progressively any change in the worsening may suggest a space- haracter: Can Dull, constant, unrelieved pain over C vision since onset? occupying lesion. they describe the days or weeks may suggest a quality or type of space-occupying lesion. Are there any Vomiting, seizures, and changes in pain? A sudden, throbbing pain is more other mood or mental state may indicate typical of vascular problems like symptoms? increased intracranial pressure. © The author/s and migraine or an aneurysm. Calll for URGENT referral. Community Eye Health Journal 2016. This is an Open Access Radiation: does Pain that starts in one place and Is there a fever? Fever indicates infection, check the article distributed under the the pain start in seems to move or ‘radiate’ to sinuses, ears, orbit, and for neck stiffness. Creative Commons Attribution one place and another suggests that is generated Non-Commercial License. then extend/ by the irritation of a nerve. spread to another? More red flags

Associated vision Severe constant headache with Proptosis loss gradual visual loss suggests either Proptosis is anterior displacement of the globe. It may be due to space- compression of the optic nerve, or longstanding raised intracranial occupying lesions in the orbit. Adults with acquired proptosis need to be pressure. evaluated for thyroid disorder. Pulsatile proptosis, painful proptosis and all cases of proptosis associated with vision loss should be referred for urgent Time course: have Symptoms which are constant and evaluation. the symptoms getting more severe may indicate a changed over serious progressive condition e.g. a Ptosis time? tumour. Drooping of the upper lid is called ptosis. All cases of acquired ptosis Intermittent headaches are more typical of vascular or inflammatory should be evaluated by an ophthalmologist. Marked unilateral ptosis conditions. with ocular deviation down and out are signs of a 3rd cranial nerve palsy. If associated with severe sudden onset of unilateral headache this Exacerbating A headache which is worse when can be due to a intracranial aneurysm (dilated artery). Patients must be factors: What lying down or bending down may be makes the due to raised intracranial pressure. referred for immediate neuro-ophthalmological review. headache worse Bilateral ptosis which gets worse as the day progresses may be due to or better? myasthenia gravis. Severity: Ask the Any headache that interferes with patient to rate the the patient’s daily activities should Partial ptosis with a smaller (constricted) pupil on the same side is due to severity on a scale not be ignored. damage to the sympathetic nerves which supply the muscles in the eyelid and from 1 (mild) to 10 iris – this is called Horners syndrome and the cause needs to be investigated. (very severe)

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