Disclosure
Ophthalmology is a specialty in which diagnoses are most often made by using visual clues. Ophthalmology residents are typically trained to concentrate on their observational skills and to spend relatively less time obtaining the detailed histories that are characteristic of other medical specialties. In contrast, thorough history taking is the cornerstone of diagnosis in neuro-ophthalmology. Without conversation with the patient, many details about would be missed. The neuro-ophthalmic history is not isolated from the rest of the patient's history or physical examination. While conversing with the patient, note the following: gait, visage, eyes, ocular adnexa, hands, clothing, and mannerisms. Findings on physical examination often direct further questions. After one obtains the patient's history and physical findings, the neuro-ophthalmic diagnosis is usually apparent. This article is not an all-inclusive review of the neuro-ophthalmic history. Instead, it emphasizes selected points.
Identifying data Document the patient's age, sex, race, and occupation in the first sentence of the chief complaint. Although staff other than the physician usually document the patient's birthday usually is documented on the chart, the present author routinely asks older patients, "How young are you?" This polite question helps the clinician ascertain the patient's ability to understand English, which can help in predicting or assessing the accuracy of the history. In neurologic histories, patient's hand dominance is usually noted in the first sentence of the chief complaint. Hand dominance may be important in some patients with stroke affecting the visual pathway. Chief complaint When possible, document the chief complaint in the patient's own words. The patient's conception of the problem may differ markedly from the referring physician's diagnosis. Patients commonly are referred for a specific neuro-ophthalmic problem, yet they may be unable to relate this to the physician. Note the duration of the patient's symptoms and the lateralization or binocularity of visual deficits. In patients who present with multiple seemingly unrelated complaints, it may be necessary to redirect the interview by asking the following questions: (1) If I could solve 1 problem for you today, what would it be? (2) Tell me about your problem in 1 sentence. If a third-party payer audits the notes from the patient consultation, it may be useful to preface the chief complaint with statements such as, "Patient referred for evaluation and opinion of symptoms of _____.”
Document the onset, quality, severity, lateralization, temporal characteristics, and associated features of the patient's visual symptoms. If the patient is unreliable, family members, his or her medication list and past neuroimages, and results of gestalt examination can guide the inquiry into the history of the present illness. In patients who seem cognitively intact but do not or cannot provide details of their visual problem, suspect functional visual loss. When questioned, patients with functional visual loss often repeatedly state, "I don't know." Vital diagnostic elements are discussed below.
Lateralization, location, duration, tempo, and presence or absence of pain
Determine if the patient's visual loss is monocular or bilateral by if they occlude 1 eye or the other. Patients frequently mistake homonymous visual loss as a deficit confined to the eye that is ipsilateral to the field loss. Confirm that the patient does not have a right homonymous hemianopsia.
If the visual loss is monocular, ascertain if horizontal respect to the visual loss is present. If the visual loss is bilateral, exclude a homonymous or heteronymous defect.
Document if the perceived vision loss is at distance fixation, near, or both. Patients often present to the neuro-ophthalmologist's office with complaints of presbyopia.
Degree of recovery
The degree of recovery and the time until recovery after visual loss are other important elements. Transient visual obscurations that last for seconds may be due to increased intracranial pressure. Dry eyes can also cause transient visual phenomena.
Painless unilateral visual loss that lasts several minutes may be embolic (amaurosis fugax), especially if it respects the horizontal midline. Gaze-evoked amaurosis may be due to a meningioma of the optic nerve sheath or another tumor of the orbital apex.
Transient visual loss with scintillations, fortification spectra, and movement that lasts 20-30 minutes then completely resolves suggests migraine. Migraine is a diagnosis of exclusion, but it is the most common cause of transient visual loss in young patients. Transient visual obscurations last only seconds. Amaurosis fugax usually lasts seconds to minutes at the most.
Sudden-onset visual loss with little recovery suggests an ischemic event. Subacute visual loss with almost complete recovery of vision after several weeks or months is characteristic of optic neuritis. Slowly progressive visual loss may be due to a compressive optic neuropathy. Painful visual loss may indicate optic neuritis. Visual loss with headache in an elderly patient may be due to giant cell arteritis.
Consider mucormycosis in patients with new-onset visual loss and a history of diabetic ketoacidosis (without vitreous hemorrhage) or immunocompromise.
Reading-related visual loss in older patients
When older patients complain of visual loss when reading, presbyopia is not always the cause. Determine if the patient has difficulty seeing whole words, finding the next line (possible left homonymous field loss), or reading the next word (possible right homonymous field loss).
Diplopia
Diplopia is a common neuro-ophthalmic complaint. Document the following features: monocular or binocular nature, relative orientation of the separated images, frequency of the diplopia, activities that enhance the diplopia, and associated ptosis or known dysthyroidism.
Double vision that persists despite closing either eye but improves with pinhole suggests (1) monocular diplopia from uncorrected refractive error, (2) optical aberrations of the ocular media, or (3) (on occasion) retinal disorders that distort the fovea.
Monocular diplopia that improves with blinking often is due to the irregular astigmatism from dry eyes. Monocular diplopia that does not resolve despite pinhole may be due to palinopsia (perseverance of visual images) from an evolving cerebral lesion, often in the nondominant hemisphere.
Binocular diplopia with vertical or diagonal separation of objects, worse when the patient is reading or climbing stairs and better with head tilt to 1 side, suggests palsy of cranial nerve (CN) IV.
Binocular diplopia with horizontal separation that is worse in the distance suggests CN VI palsy.
Patients who develop complete CN III palsy initially may complain of diplopia. They later indicate that the diplopia resolves, because ptosis occludes the visual axis.
Variability or worsening of the diplopia as the day progresses with associated ptosis suggests myasthenia gravis.
Table 1. Relatively Uncommon Visual Complaints of Neuro-ophthalmic Interest
*Many neoplasms have been associated with paraneoplastic retinopathy. Carcinoma of the lung is a common cause of cancer-associated retinopathy. The retinal arterioles are typically narrowed, the field is constricted, and the electroretinogram is depressed. The cancer-associated retinopathy autoantibody test is commercially available (from Athena Diagnostics, phone 1-800-394-4493, cost = $215.00).
When patients present to the neuro-ophthalmologist, they frequently complain of periocular pain or headache.
Always consider giant cell arteritis in older patients who present with headache, scalp tenderness, or occipital tenderness.
Burning discomfort in a unilateral segment of the trigeminal nerve distribution occasionally precedes the appearance of herpetic vesicles; at times, early herpes zoster can be mistaken for temporal arteritis.
Migraine headaches, which often consist of several hours of throbbing hemicranial and retro-orbital discomfort, are common. Migraine may be accompanied by visual scintillations and fortification spectra, which resolve over 15-30 minutes. A family history of migraine is common, and trigger factors, such as certain foods, may be noted.
Cluster headache is characterized by early morning awakening with unilateral periocular pain, accompanied by lacrimation and ipsilateral Horner syndrome.
Eye pain has several differential diagnoses. The number of patients with keratitis sicca who are referred for neuro-ophthalmic opinion is surprising. Dry eye is the likely diagnosis in patients who complain of sandy eyes or sharp eye pain that is worse in the evening than at other times. Corneal abrasions, iritis, and angle-closure glaucoma are best differentiated on slit-lamp examination, but clues from the patient's may also help.
Patients with corneal abrasion usually report trauma, contact lens wear, or prior recurrent corneal erosions usually are reported by patients with corneal abrasion. Patients with iritis usually complain of intense photophobia, and they may have an underlying autoimmune disease. In rare cases, patients with persistent photophobia unexplained by ocular abnormalities may have a chiasmal tumor. Angle-closure glaucoma may be misdiagnosed as an intracranial process (eg, aneurysm) because of the prominent headache, nausea and vomiting, and middilated pupil. |
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Medications Systemic or topical steroids may predispose patients to glaucomatous cupping of the optic nerve. Tetracycline, vitamin A, and other medications have been linked to pseudotumor cerebri. The antituberculosis agents ethambutol, rifampin, and isoniazid can cause a toxic optic neuropathy. Amiodarone-induced optic neuropathy has been reported. Chronic hydroxychloroquine use may result in maculopathy. Procainamide, penicillamine, and other drugs have been implicated in drug-induced myasthenia gravis. Digoxin, even at therapeutic levels, may cause visual disturbances, typically xanthopsia. Sildenafil (Viagra) may cause blue-tinged vision, and at least one report exists of oculomotor nerve palsy 36 hours following ingestion. Long-term use of the antiepileptic vigabatrin has been associated with peripheral field loss. Topiramate is used in patients with seizures and in some patients with headaches. Topiramate can cause acute myopia and bilateral angle closure glaucoma. Desferrioxamine, an iron-chelating agent, increases the risk of mucormycosis. Maternal use of Dilantin or alcohol during pregnancy may result in a predisposition to optic nerve hypoplasia. Patients often do not mention that they are taking aspirin. Over-the-counter medications such as ginkgo biloba may promote bleeding. Consider this point, if surgery of the optic nerve, strabismus, or orbit is planned. Allergies Sulfonamide allergy may preclude the use of acetazolamide (Diamox) in patients with pseudotumor cerebri. Allergies to shellfish may contraindicate the use of iodine-based dyes used in CT.
For patients who cannot remember their medical history, document the following features: past surgery, hospital admissions, previous medications, reasons for seeing a physician, results of past neuroimaging or blood tests, and trauma (eg, motor vehicle accidents). Whenever feasible, personally review the patient's CT scans or MRIs. A history of cancer must be carefully excluded in all patients. The present authors have encountered women with new-onset orbital disease who denied their past history of breast cancer. Patients may not mention a history of lymphoma because they do not believe that lymphoma is related to cancer. Patients with a remote history of cutaneous melanoma may overlook this fact. When neoplasia is suspected, refresh the patient's memory by specifically asking about past biopsy procedures and courses of chemotherapy or radiation therapy.
Amaurosis fugax with contralateral extremity weakness may indicate ipsilateral internal carotid artery disease. Ambulatory difficulties, bowel or bladder dysfunction, paresthesias, and weakness may accompany optic neuritis in patients with multiple sclerosis. Headache may be associated with neuro-ophthalmic problems, such as increased intracranial pressure, giant cell arteritis, migraine, and other neuro-ophthalmic entities. Headaches associated with increased intracranial-pressure are often associated with nausea and vomiting and usually worse in the morning, in the supine position, or during a Valsalva maneuver than in other conditions. Ophthalmologists must maintain a high index of suspicion for giant cell arteritis in all elderly patients. In addition to headache, scalp tenderness, vision loss, or diplopia, inquire about symptoms of polymyalgia rheumatica, jaw claudication (pain with mastication that resolves with rest but returns after a period of chewing), chills or fevers, weight loss, and malaise. Tongue claudication is a variant of jaw claudication. Erythrocyte sedimentation rate (ESR results may be normal in about 10% of patients. Determine if the ESR was determined by means of a Wintrobe test or a Westergren test because results are lower with the former than with the latter. Diabetes mellitus and hypertension are common diseases in patients with neuro-ophthalmic problems. Be aware that many patients do not consider that they have diabetes if they their condition is controlled with diet or oral hypoglycemics. Likewise, some patients with hypertension consider themselves cured, denying that they have high blood pressure because they take antihypertensives. Dysthyroidism is a common disorder that can cause neuro-ophthalmic, problems such as proptosis, diplopia, or vision loss. Subtle cases of thyroid-related ophthalmopathy and confirmatory symptoms of systemic dysthyroidism may be overlooked unless patients are carefully examined for lid retraction. Atrial fibrillation increases the risk of embolic disease. Conduct careful cardiopulmonary inquiry before attempting edrophonium (Tensilon) tests. Pacemakers preclude the use of MRI. In all patients with ocular myasthenia, inquire about the following symptoms that may have systemic generalization: dyspnea, dysphagia, and difficulty getting out of chairs or climbing stairs (proximal weakness). Skin rashes may accompany numerous conditions such as syphilis, Lyme disease, sarcoidosis, and collagen vascular disease. Results of previous skin biopsy may suggest basal cell carcinoma, squamous cell carcinoma, and melanoma. If phakomatosis is suspected in a child, querying the mother about skin lesions is often helpful. Determining a history kidney disease is important. Hypertensive nephropathy is not uncommon, and hypertensive or diabetic nephropathy may be a relative contraindication for contrast-enhanced CT scanning. Collagen vascular diseases may be associated with nephritis or hematuria. Patients with pseudotumor cerebri and kidney stones have a relative contraindication for acetazolamide. Acetazolamide is a sulfa medication; patients with an allergy to sulfa should not take acetazolamide. Rheumatologic and collagen vascular disease, which may be associated with joint disease, can cause vasculitis that affects the visual pathway. Lupus has far-ranging systemic manifestations. Shoulder pain that is worse in the morning than at other times, especially when the patients reaches for top cupboards or puts on pullover clothing, may suggest polymyalgia rheumatica. Polymyalgia rheumatica is associated with giant cell arteritis. Chiropractic manipulation has been associated with vertebral artery dissections or carotid artery dissections. Acquired hearing loss may be important in various neuro-ophthalmic conditions (eg, acoustic schwannoma, Harada disease, retinocochlear cerebral vasculitis). A history of psychiatric problems may increase the index of suspicion for functional visual loss. However, the clinician must be wary to exclude an accompanying component of organic disease in patients with such findings. Claustrophobic patients may require sedation or benefit from open-field MRI.
Family history The patients' family history helps delineate optic neuropathies. A family history of glaucoma is helpful in patients with cupping of the optic nerve that is not disproportionate to pallor. Likewise, a family history of multiple sclerosis is a risk factor for optic neuritis. Patients with dominant optic atrophy may have a supportive family history. Blindness in a patient's brother or maternal uncles may indicate Leber hereditary optic neuropathy. Asymptomatic inferior field defects and the appearance of superior segmental dysplasia may be explained by maternal diabetes. Many of the phakomatoses (with the exception of Sturge-Weber syndrome and ataxia telangiectasia) are autosomal dominant. Social history The social history is important, as it reveals the patients' social situation, as well as details of the disease. The patient's vocation indicates their understanding of medical language and expectations. The patient's occupation may determine his or her work restrictions and ability to continue work, and the need for vocational rehabilitation. Visual dysfunction may have grave implications for patients who have jobs that involve commercial driving, working at heights, or discharging firearms. The confabulation of alcoholism may thwart the validity of the history. A history of alcoholism raises the possibilities of nutritional amblyopia and Wernicke alcoholic ophthalmoplegia. Patients with a military history may have increased risk for Treponema infection. Because military recruits usually undergo screening of their color vision, the current review is often a good opportunity to determine the chronicity or progression of dyschromatopsia. Previous transfusions, the patient's sexual habits and sexual orientation, and the use of intravenous recreational drugs may raise the possibility of HIV-related disease.
When booking appointments, the secretary should remind patients to bring their medication list, medical history, CT scans and/or MRIs, and photographs, if applicable. When appropriate, organize the charts 1 day before the patient arrives; this ensures that the referring physician has faxed or sent the notes, fields, and neuroimaging results, Have patients complete a screening inventory of questions while they are in the waiting room. As an alternative, the screening inventory can be posted on the Webs site for the practice, and the patient can complete it online and bring the completed form to the office. A standardized history form may save time and help organize dictations. Some physicians may find an inquiry checklist helpful in the workup of common neuro-ophthalmic problems; for an example, see the Sample Neuro-ophthalmologic Functional Inquiry Checklist below. To save writing, this checklist organized items so that positive findings can be circled and negative findings crossed out. A question inventory may help the chart documentation comply with the appropriate coding levels for Medicare audits. In some practices, patient's history is obtained by residents or healthcare professions. Unfortunately, ophthalmic technicians and novice trainees may miss the significance of certain comments from the patient. Although standardized history forms may be useful in neuro-ophthalmology practice, the senior physician should personally review the neuro-ophthalmic history with the patient. If the physician does not specifically hear the chief complaint, a patient might leave the office without the primary concern being addressed. The patient's compliant or history often changes when questioned a second time. Patients often seek second or third opinions from neuro-ophthalmologists. In such cases, telephone consultation with the patient's previous caregiver may be invaluable. Although knowledge of the previous clinician's working diagnoses may bias clinical judgment, it may prevent unnecessary repetition of tests. The second clinician can also avoid repeating the conditions of the initial examiner that led to the patient's dissatisfaction.
Table 2. Sample Neuro-ophthalmologic Functional Inquiry Checklist
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
){kind=small}
