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Exam Curriculum 3/3/2018 https://novel.utah.edu/examcurriculum NOVEL: Exam Curriculum 1. Home 2. Exam Curriculum I. Overview of the neuro-ophthalmology examination II. Evaluation of visual function a. Visual acuity i. Distance acuity 1. Pinhole examination ii. Near acuity iii. Refraction b. Color vision i. Red desaturation ii. Pseudo-isochromatic testing iii. Color sorting/Hue discrimination tests c. Contrast sensitivity d. Confrontation visual fields e. Amsler grid f. Stereopsis III. Pupillary examination a. Pupillary size measurement in light and dark i. Anisocoria b. Pupillary reflexes i. Light reflex ii. Near reflex iii. Direct and consensual response iv. Dilation lag v. Light near dissociation vi. Swinging flashlight test 1. Neutral density filter test c. Pharmacological examination of anisocoria i. 0.1% or 1% pilocarpine ii. 1% hydroxyamphetamine iii. 0.5% or 1% apraclonidine iv. 10% cocaine IV. Slit lamp examination a. Lids b. Conjunctivae c. Cornea i. Corneal staining ii. Tear film breakup time iii. Schirmer's test iv. Systemic diseases with corneal findings d. Anterior chamber e. Iris/Ciliary Body f. Lens g. Vitreous V. Intraocular pressure testing a. Applanation (Goldmann) tonometry b. TonoPen c. Palpation https://novel.utah.edu/examcurriculum 1/5 3/3/2018 https://novel.utah.edu/examcurriculum d. Other methods (Icare; Schiotz tonometry) VI. Funduscopic examination a. Direct ophthalmoscopy i. Traditional direct ophthalmoscopy ii. Panoptic ophthalmoscopy b. Indirect ophthalmoscopy c. Slit lamp biomicroscopy d. Digital fundus camera (also see section XI.d.i) i. Smart phone based device ii. Non mydriatic digital fundus camera 1. Handheld device 2. Tabletop device VII. Examination of the orbit and extraocular structures a. External examination i. Facial symmetry 1. Inter-pupillary and inter-canthal distance 2. Abnormal movements ii. Skin examination a. Blepharospasm and hemifacial spasm b. Orbit i. Palpation of lids and orbit 1. Retropulsion ii. Globe position in orbit 1. Exophthalmometry a. Hertel measurement c. Examination of the lacrimal system d. Eyelids i. Marginal reflex distance 1 (MRD1) and palpebral fissure ii. Levator palpebrae superioris function iii. Eyelid and eye lash position 1. Eyelid ptosis a. Fatigable ptosis b. Ice-pack test 2. Eye lid retraction 3. Entropion and ectropion 4. Lid lag 5. Lagophthalmos 6. Other eye lid signs a. Lid twitch iv. Pharmacological tests: 1. Tensilon test 2. Prostigmine testing e. Examination of lymph nodes VIII. Examination of eye movements and alignment: a. Normal eye movements b. Examination of ocular alignment i. Hirschberg (corneal light reflex) ii. Cover/Uncover test) iii. Alternate cover test iv. Prism (bar) cover test v. Red glass test vi. Maddox rod testing vii. Double Maddox rod testing viii. Three step test https://novel.utah.edu/examcurriculum 2/5 3/3/2018 https://novel.utah.edu/examcurriculum c. Examination of eye movements: i. Visual fixation ii. Range of eye movements 1. Versions 2. Ductions iii. Optokinetic nystagmus iv. Saccades v. Smooth pursuit vi. Vestibulo-ocular reflex (VOR) test 1. Rapid VOR assessment (head impulse test) 2. Slow VOR assessment vii. Convergence and accommodation 1. Amplitude 2. Near point viii. Divergence amplitude IX. Examination of the Vestibular system a. Hearing assessment and otoscopy b. Dynamic visual acuity c. Methods to elicit nystagmus i. Removal of fixation ii. Valsalva iii. Tragal compression iv. Vibration v. Head-shaking 1. Acuity vi. Hyperventilation vii. Positional testing X. Neurological examination a. Overview of neurological examination b. Examination of mental status including cognitive assessment i. Screening tools 1. Montreal Cognitive Assessment (MoCA) 2. Mini-Mental State Examination (MMSE) 3. Other screening tools: Saint Louis University Mental Status Examination ii. Clinic based assessment of visual and spatial disorders 1. Subjective visual vertical assessment a. Bucket test 2. Line bisection test 3. Face recognition 4. Reading and writing 5. Boston cookie theft picture 6. Pulfrich effect iii. Comprehensive neuro-psychological evaluation of visual and spatial disorders c. Cranial nerve examination i. Examination of trigeminal nerve 1. Corneal sensation a. Von Frey hair assessment ii. Examination of facial nerve d. Motor examination e. Sensory examination f. Reflexes g. Coordination i. Finger to nose ii. Heel to shin https://novel.utah.edu/examcurriculum 3/5 3/3/2018 https://novel.utah.edu/examcurriculum h. Gait including tandem i. Romberg testing XI. Diagnostic tests a. Visual field testing i. Automated static perimetry ii. Kinetic perimetry 1. Goldmann perimetry iii. Tangent screen b. Electrophysiology i. Visual evoked potential ii. Electroretinogram (ERG) 1. Full field ERG 2. Multifocal ERG 3. Pattern ERG iii. Electro-oculogram (EOG) iv. Nerve conduction study and electromyography (NCS/EMG) c. Pupillometry i. Infrared photography ii. Digital pupilometry d. Ophthalmic imaging i. Digital fundus photography ii. Fundus fluorescein angiography iii. Fundus autofluorescence iv. Optical coherence tomography (OCT) 1. Imaging the optic nerve a. Retinal nerve fiber layer (RNFL) b. Ganglion cell layer (GCL) c. Enhanced depth imaging (EDI) 2. Imaging the macula 3. OCT-angiography v. Ultrasonography i. Ocular ii. Orbital vi. External photography e. Neurological imaging i. Computed tomography (CT) 1. Head 2. Orbit ii. Magnetic resonance imaging (MRI) 1. Brain 2. Orbits iii. Vascular imaging 1. Color Doppler ultrasonography 2. Computed tomography angiography (CTA) of head and neck 3. Magnetic resonance angiography (MRA) of head and neck 4. Computed tomography venography (CTV) 5. Magnetic resonance (MRV) 6. Conventional angiogram of head and neck iv. Functional magnetic resonance imaging (fMRI) v. Diffusion tensor imaging (DTI) vi. Positron emission tomography (PET) f. Lumbar puncture with opening pressure i. Fluoroscopically guided g. Audio-vestibular testing https://novel.utah.edu/examcurriculum 4/5 3/3/2018 https://novel.utah.edu/examcurriculum i. Caloric testing ii. Vestibular evoked myogenic potentials iii. Rotational chair testing iv. Video head impulse testing v. Audiogram vi. Video nystagmography vii. Electronystagmography viii. Video oculography XII. Special situations a. Examination of the comatose patient b. Pediatric patient i. Visual acuity strategies ii. Visual field examination iii. Hirschberg testing iv. Krimsky testing v. Vestibular occular reflex (VOR) testing vi. Rotational testing c. Nonorganic vision loss patient i. Severe monocular vision loss 1. Fogging using phoropter 2. Prism shift test and the vertical prism test 3. Stereoacuity 4. Polarized lens acuity testing ii. Severe binocular vision loss 1. Blink to threat 2. Optokinetic nystagmus 3. Tilt mirror test 4. Simple tests of proprioception 5. Mimicking the examiner (Simon says) iii. Non organic visual field loss 1. Tunnel vision on tangent screen test 2. Spiral and stellate visual field on Goldman 3. Monocular hemianopia 4. Clover leaf pattern on automated perimetry A collaboration of the Spencer S. Eccles Health Sciences Library, University of Utah, and the North American Neuro-Ophthalmology Society. Initially funded by the National Library of Medicine Grant #G08 LM07919-02. All work herein is licensed under a Creative Commons License. https://novel.utah.edu/examcurriculum 5/5.
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