A good history is critical

Disorders of the brain and nervous system that affect the eye and vision are often complex to diagnose – most neuro-ophthalmic disorders are not ‘spot’ diagnoses. Consequently, much information can be gleaned when obtaining a thorough from the patient.

While you should have some structure or regularity to the way you take a history, be flexible enough to explore potential flags as you come across them in the course of speaking to the patient.

1. Information about the presenting complaint

• The problem (symptoms)
• The time course*
• The speed of onset and development over time
• Any variability during the day
• ‘Warning signs’ prior to symptom onset
• Any previous episodes (how often and how long)
• Triggering factors

*Remember to distinguish between time of onset vs when the patient first noticed the symptoms (e.g. a patient who rubs one eye when ‘irritated’ and notices that the other eye has no vision will not be able to determine the time of onset).

2. Subsequent questioning

• Pain
• Vision loss
• Diplopia
• Past ocular history
  • Glasses or contact lenses
  • Eye drops, surgery or laser
  • Eye patching or surgery as a child
• Past medical history
  • Cancer
  • Autoimmune disease
  • Diabetes, hypertension, high cholesterol
  • Smoking
  • Trauma
  • Surgery
• Medications (including recreational substances)
  • Provides clues to systemic diseases forgotten by the patient
  • Can manifest or exacerbate neuro-ophthalmic disorders
    • Optic neuropathy – ethambutol, isoniazid, amiodarone, drugs for erectile dysfunction
    • Raised intracranial pressure – corticosteroids, oral contraceptive pill, tetracyclines, vitamin A derivatives for acne
    • Retinopathy – tamoxifen, hydroxychloroquine
    • Double vision – penicillamine, aminoglycoside-induced myasthenia gravis
    • Nystagmus – phenytoin, lithium
• Family history of ophthalmic or neurologic disease
• Social history
• Diet/nutrition

Importantly, remember to ask open-ended questions rather than direct questions, as this will provide you with much more detailed answers that can help to guide your subsequent line of questioning.

Ask: ‘how have you been lately?’, ‘any trouble combing your hair?’ or ‘any trouble eating?’

Not: ‘do you have a headache?’ or ‘have you lost weight?’

Follow with a thorough clinical examination

When you suspect a neuro-ophthalmic condition, always assess:

• VA
• Colour vision
• VF by confrontation (before dilation)
• Eye movements
• Pupils
  • Direct
  • Indirect
  • Relative afferent pupillary defect (RAPD) to check for optic nerve lesion
• Lid position
• Corneal sensation
• Slit lamp examination (including dilation)
• Optic disc 3Cs – colour, cup, contour
• Take photos

Refer as appropriate

By this stage, you may or may not have a list of differential diagnoses. If referral is appropriate, choose an ophthalmologist with neuro-ophthalmic training to allow further investigations and intervention (if appropriate) in a timely manner.