Diagnostic Tests for Vision Impairment
Vision Impairment Tests: Book Excerpts
Home Diagnostic Testing
These home medical tests may be relevant to Vision Impairment:
- Vision & Eye Health: Home Testing:
Vision Impairment Diagnosis: Book Excerpts
Diagnosis of Vision Impairment: medical news summaries:
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Diagnostic Tests for Vision Impairment: Online Medical Books
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Review excerpts from medical books online, free, without registration,
for more information about the diagnostic tests for Vision Impairment.
DIPLOPIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
An expensive diagnostic workup may be avoided by referring the patient to an ophthalmologist or a neurologist at the outset. If the diplopia is intermittent, a Tensilon test would be indicated. If there are fever and chills, one should do a CBC, sedimentation rate, possibly blood cultures, skull x-ray, and x-rays of the sinuses. However, under these circumstances, it will usually be necessary to perform a CT scan of the brain, sinuses, and orbits. If there is chemosis or ecchymosis, a cavernous sinus thrombosis is likely, and immediate admission to the hospital and administration of antibiotics after blood culture has been drawn are indicated. MRI of the brain may be necessary to diagnose multiple sclerosis and some of the brain stem infarcts.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
EYE PAIN:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
The primary care specialist may want to treat cases of obvious conjunctivitis without a culture and sensitivity. However, a smear and culture is useful especially if
Neisseria
is suspected. A smear may also reveal eosinophils suggesting allergic conjunctivitis. The primary care specialist may also use fluorescein dye to diagnose a foreign body. Most primary care physicians feel competent to use tonometry to diagnose glaucoma and may feel competent to use a slit lamp. However, when there is any doubt about the diagnosis, the most cost-effective approach is to refer the patient to an ophthalmologist.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
HEMIANOPSIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Referral to an ophthalmologist for a thorough visual field examination is suggested at the outset. A neurology consultation also needs to be obtained. The neurologist will probably order a CT scan of the brain to rule out a space-occupying lesion unless multiple sclerosis is suspected.
If multiple sclerosis is suspected, MRI would be the study of choice, even though it is more expensive. In addition, VEP studies and spinal fluid analysis may be ordered to rule out multiple sclerosis.
A carotid duplex scan will help diagnose carotid vascular insufficiency, but four-vessel cerebral angiography will most likely be done so that both carotid and vertebral basilar artery disease can be evaluated. If there are endocrine changes, an endocrinologist should be consulted.
If a cerebral embolism is suspected, a source for the embolism should be sought. A cardiologist can best determine what tests to order to search for an embolic source.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
PAPILLEDEMA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Regardless of whether there are focal neurologic signs or hypertension, a CT scan or MRI should be done, and a consultation with a neurologist should be made when papilledema is suspected.
If there is significant hypertension and the CT scan or MRI are negative, a hypertensive workup should be done
.
With a normal CT scan or MRI and no focal neurologic signs or hypertension, a spinal tap and visual field examination will assist in the diagnosis of pseudotumor cerebri. However, a blood lead level should be done to rule out lead poisoning. Also, the visual field exam may show optic neuritis when the clinical examination was inconclusive.
An ophthalmologist will help diagnose optic neuritis and pseudopapilledema.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
SCOTOMA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
This should include a careful eye examination with slit lamp, tonometry, and visual field examinations. If the initial findings suggest an ocular disorder, referral to an ophthalmologist should be made. If the neurologic examination is abnormal, the patient should be referred to a neurologist, rather than ordering expensive tests such as a CT scan, MRI scan, VEP studies, angiography, and spinal fluid examinations.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Diplopia:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient complains of double vision, first check his neurologic status. Evaluate his level of consciousness (LOC); pupil size, equality, and response to light; and motor and sensory function. Then take his vital signs. Briefly ask about associated symptoms, especially a severe headache. Find out about associated neurologic symptoms first because diplopia can accompany serious disorders.
Next, continue with a more detailed examination. Find out when the patient first noticed diplopia. Are the images side-by-side (horizontal), one above the other (vertical), or a combination? Does diplopia affect near or far vision? Does it affect certain directions of gaze? Ask if diplopia has worsened, remained the same, or subsided. Does its severity change throughout the day? Diplopia that worsens or appears in the evening may indicate myasthenia gravis. Find out if the patient can correct diplopia by tilting his head. If so, ask him to show you. (If the patient has a fourth nerve lesion, tilting of the head toward the opposite shoulder causes compensatory tilting of the unaffected eye. If he has incomplete sixth nerve palsy, tilting of the head toward the side of the paralyzed muscle may relax the affected lateral rectus muscle.)
Explore associated symptoms such as eye pain. Ask about hypertension, diabetes mellitus, allergies, and thyroid, neurologic, or muscular disorders. Also, note a history of extraocular muscle disorders, trauma, or eye surgery.
Observe the patient for ocular deviation, ptosis, proptosis, lid edema, and conjunctival injection. Distinguish monocular from binocular diplopia by asking the patient to occlude one eye at a time. If he still sees double out of one eye, he has monocular diplopia. Test his visual acuity and extraocular muscles. Check his vital signs.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Eye pain:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient's eye pain doesn't result from a chemical burn, take a complete history. Have the patient describe the pain fully. Is it an ache or a sharp pain? How long does it last? Is it accompanied by burning, itching, or discharge? Find out when it began. Is it worse in the morning or late in the evening? Ask about recent trauma or surgery, especially if the patient complains of sudden, severe pain. Does he have headaches? If so, find out how often and at what time of day they occur.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Hemianopsia:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Suspect a visual field defect if the patient seems startled when you approach him from one side or if he fails to see objects placed directly in front of him. To help determine the type of defect, compare the patient’s visual fields with your own — assuming that yours are normal. First, ask the patient to cover his right eye while you cover your left eye. Then move a pen or similarly shaped object from the periphery of his (and your) uncovered eye into his field of vision. Ask the patient to indicate when he first sees the object. Does he see it at the same time you do? After you do? Repeat this test in each quadrant of both eyes. Then, for each eye, plot the defect by shading the area of a circle that corresponds to the area of vision loss.
Next, evaluate the patient’s level of consciousness (LOC), take his vital signs, and check his pupillary reaction and motor response. Ask if he has recently experienced a headache, dysarthria, or seizures. Does he have ptosis or facial or extremity weakness? Hallucinations or loss of color vision? When did neurologic symptoms start? Obtain a medical history, noting especially eye disorders, hypertension, diabetes mellitus, and recent head trauma.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Scotoma:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
First, identify and characterize the scotoma, using such visual field tests as the tangent screen examination, the Goldmann perimeter test, and the automated perimetry test. Two other visual field tests — confrontation testing and the Amsler grid — may also help in identifying a scotoma.
Next, test the patient’s visual acuity and inspect his pupils for size, equality, and reaction to light. An ophthalmoscopic examination and measurement of intraocular pressure are necessary.
Explore the patient’s medical history, noting especially eye disorders, vision problems, or chronic systemic disorders. Find out if he takes medications or uses eyedrops.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Vision loss:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Sudden vision loss can signal an ocular emergency. (See Managing sudden vision loss.) Don’t touch the eye if the patient has perforating or penetrating ocular trauma.
If the patient’s vision loss occurred gradually, ask him if the vision loss affects one eye or both and all or only part of the visual field. Is the visual loss transient or persistent? Did the visual loss occur abruptly, or did it develop over hours, days, or weeks? What is the patient’s age? Ask the patient if he has experienced photosensitivity, and ask him about the location, intensity, and duration of any eye pain. You should also obtain an ocular history and a family history of eye problems or systemic diseases that may lead to eye problems, such as hypertension; diabetes mellitus; thyroid, rheumatic, or vascular disease; infections; and cancer.
The first step in performing the eye examination is to assess visual acuity, with best available correction in each eye. (See Testing visual acuity, page 630.)
Carefully inspect both eyes, noting edema, foreign bodies, drainage, or conjunctival or scleral redness. Observe whether lid closure is complete or incomplete, and check for ptosis. Using a flashlight, examine the cornea and iris for scars, irregularities, and foreign bodies. Observe the size, shape, and color of the pupils, and test the direct and consensual light reflex (See “Pupils, nonreactive,” page 521.) and the effect of accommodation. Evaluate extraocular muscle function by testing the six cardinal fields of gaze. (See Testing extraocular muscles, page 206.)
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Diplopia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient complains of double vision, first check his neurologic status. Evaluate his level of consciousness (LOC); pupil size, equality, and response to light; and motor and sensory function. Then take his vital signs. Briefly ask about associated symptoms. First find out about associated neurologic symptoms, especially a severe headache, because diplopia can accompany serious disorders.
Next, continue with a more detailed examination. Find out when the patient first noticed diplopia. Are the images side by side (horizontal), one above the other (vertical), or a combination? Does diplopia affect near or far vision? Does it affect certain directions of gaze? Ask if diplopia has worsened, remained the same, or subsided. Does its severity change throughout the day? Diplopia that worsens or appears in the evening may indicate myasthenia gravis. Find out if the patient can correct diplopia by tilting his head. If so, ask him to show you. (If the patient has a fourth cranial nerve lesion, tilting the head toward the opposite shoulder causes compensatory tilting of the unaffected eye. If he has incomplete sixth cranial nerve palsy, tilting the head toward the side of the paralyzed muscle may relax the affected lateral rectus muscle.)
Explore associated symptoms such as eye pain. Ask about hypertension, diabetes mellitus, allergies, and thyroid, neurologic, or muscular disorders. Also, note a history of extraocular muscle disorders, trauma, or eye surgery.
Observe the patient for ocular deviation, ptosis, exophthalmos, eyelid edema, and conjunctival injection. Distinguish monocular from binocular diplopia by asking the patient to occlude one eye at a time. If he still sees double out of one eye, he has monocular diplopia. Test visual acuity and extraocular muscles. Also, check vital signs.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Hemianopsia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Suspect a visual field defect if the patient seems startled when you approach him from one side or if he fails to see objects placed directly in front of him. To help determine the type of defect, compare the patient’s visual fields with your own—assuming that yours are normal. First, ask the patient to cover his right eye while you cover your left eye. Then move a pen or similarly shaped object from the periphery of his (and your) uncovered eye into his field of vision. Ask the patient to indicate when he first sees the object. Does he see it at the same time you do? After you do? Repeat this test in each quadrant of both eyes. Then, for each eye, plot the defect by shading the area of a circle that corresponds to the area of vision loss.
Next, evaluate the patient’s level of consciousness (LOC), take his vital signs, and check his pupillary reaction and motor response. Ask if he has recently experienced headache, dysarthria, or seizures. Does he have ptosis or facial or extremity weakness? Hallucinations or loss of color vision? When did his neurologic symptoms start? Obtain a medical history, noting especially eye disorders, hypertension, diabetes mellitus, and recent head trauma.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Scotoma:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
First, identify and characterize the scotoma, using such visual field tests as the tangent screen examination, the Goldmann perimeter test, and the automated perimetry test. Two other visual field tests—confrontation testing and the Amsler grid—may also help in identifying a scotoma.
Next, test the patient’s visual acuity and inspect his pupils for size, equality, and reaction to light. An ophthalmoscopic examination and measurement of intraocular pressure (IOP) are necessary.
Explore the patient’s medical history, noting especially any eye disorders, vision problems, or chronic systemic disorders. Find out if he takes medications or uses eyedrops.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Vision loss:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Sudden vision loss can signal an ocular emergency. Don’t touch the eye if the patient has a perforating or penetrating ocular trauma. (See Managing sudden vision loss, page 802.)
If the patient’s vision loss occurred gradually, ask him if it affects one eye or both and all or only part of the visual field. Is the vision loss transient or persistent? Did it occur abruptly or develop over hours, days, or weeks? What is the patient’s age? Ask the patient if he has experienced photosensitivity, and ask about the location, intensity, and duration of any eye pain. Also, obtain an ocular history and a family history of eye problems or systemic diseases that may lead to eye problems, such as hypertension; diabetes mellitus; thyroid, rheumatic, or vascular disease; infections; and cancer.
The first step in performing the eye examination is to assess visual acuity with the best available correction in each eye. (See Testing visual acuity, page 803.)
Carefully inspect both eyes, noting edema, foreign bodies, drainage, or conjunctival or scleral redness. Observe whether lid closure is complete or incomplete, and check for ptosis. Using a flashlight, examine the cornea and iris for scars, irregularities, and foreign bodies. Observe the size, shape, and color of the pupils, and test the direct and consensual light reflex (see “Pupils, nonreactive,” page 654) and the effect of accommodation. Evaluate extraocular muscle function by testing the six cardinal fields of gaze. (See Testing extraocular muscles, page 246.)
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Eye pain [Ophthalmalgia]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient’s eye pain doesn’t result from a chemical burn or from acute angle-closure glaucoma, take a complete history. Have the patient describe the pain fully. Is it an ache or a sharp pain? How long does it last? Is it accompanied by burning, itching, or a discharge? Find out when it began. Is it worse in the morning or late in the evening? Ask about recent trauma or surgery, especially if the patient complains of severe pain that developed suddenly. Does he have headaches? If so, find out how often and at what time of day they occur.
During the physical examination, don’t manipulate the eye if you suspect trauma. Carefully assess the eyelids and conjunctivae for redness, inflammation, and swelling. Then examine the eyes for ptosis or exophthalmos. Finally, test visual acuity with and without correction, and assess extraocular movements. Characterize any discharge. (See Examining the external eye, page 322.)
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Diplopia:
Physical examination. Focused physical examination (PE)
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
This should include a visual acuity test for each eye. Ask the patient about diplopia being present when covering each eye. If double vision is still present while having one or the other eye covered, by definition, this is monocular diplopia. A rare patient will complain of triplopia, or triple vision. This usually is malingering, but occasionally can be caused by corneal surface irregularity. Other parts of the examination are important: check the ocular rotations; lack of abduction or external rotation of the eye would suggest a sixth nerve palsy. Check for monocular ptosis; if it is present, then a third nerve palsy is suggested. Pupillary responses, if fixed and dilated, suggest an acute pupillary-involving third nerve palsy. An optic nerve where papilledema is present suggests an intracranial-involving process. A red fundus reflex test showing an opacity in the red reflex suggests an ocular cause, such as cataracts or corneal opacity.
Testing
A. Clinical laboratory tests. For most diplopia workups, no blood, urine, or clinical laboratory tests are needed. The only tests that might be suggested would be a glucose and hemoglobin A1c for those cases in which a suspicion of diabetes exists. An elevated erythrocyte sedimentation rate with temporal tenderness present would suggest temporal arteritis.
B. Diagnostic imaging. In monocular diplopia, no diagnostic imaging is necessary. However, with binocular diplopia, diagnostic imaging with a computed tomography scan with and without contrast should be done. With a third nerve palsy present with pupillary involvement, then a magnetic resonance imaging scan would be preferred to look for an aneurysm of the posterior communicating artery. All cases of untreated diplopia should be referred to an ophthalmologist for evaluation. If the diplopia is binocular, the patient needs to be seen on the same day. If monocular, the evaluation should be undertaken within 1 to 3 days.
Diagnostic assessment
It is critical in the evaluation to determine whether the problem is monocular or binocular diplopia. In monocular diplopia, there is usually a more vague history; blurred vision is often present, or occasional floaters or lines are noted in the vision. More chronicity is expected of weeks to months with an intermittent presentation. The patient is often more vague about the description of the condition. In true binocular diplopia, the patient classically notes the problem suddenly, is definitely noting two images, which are either vertically or horizontally separated; when covering one and then the other eye, it goes away in each occlusion state. The level of seriousness is markedly increased in binocular diplopia. An ophthalmologic examination is mandated in either scenario (3).
References
1. Brazis PW, Lee AG. Binocular vertical diplopia. Mayo Clin Proc 1998:73:55–66.
2. Richardson LD, Joyce DM. Diplopia in the emergency department. Emerg Med Clin North Am 1997;15(3):649–664.
3. Spector RH. Vertical diplopia. Surv Ophthalmol 1993;38(1):31–62.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Papilledema:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A focused physical examination should include vital signs, such as blood pressure. Examine the head: check for neck stiffness, temporal artery tenderness, pain in and around the eyes, and pain on ocular rotations, such as occurs in optic neuritis. Afferent pupillary defect is another red flag that almost always signifies an ocular cause of disc edema, retinal vein occlusion, anterior ischemic optic neuropathy, or optic neuritis. Always examine both eyes. Normally papilledema is bilateral, but can be present asymmetrically. In true disc edema, nerve fiber layer swelling is seen, which obscures the margins of the blood vessels. Tiny splinter hemorrhages will be seen in and around the optic nerve. If the other eye has no disc swelling, look for spontaneous venous pulsations (SVP). If these SVPs are present, there is normal intracranial pressure, therefore, no true papilledema. Very prominent retinal hemorrhages suggest malignant hypertension or central retinal vein occlusion, rather than papilledema. Disc elevation can be measured using the diopteric overcorrection in the direct ophthalmoscope. Basically, focus on the retina and add in plus (red) power until the optic nerve blurs. Three diopters equals 1 mm of elevation. Ocular rotations are limited in both third and sixth nerve palsy. Sixth nerve palsies show limited lateral gaze and third nerve palsies have limitation in medial gaze, elevation, and depression. When ptosis and a dilated pupil are seen, suspect an aneurysm at the posterior communicating artery in the circle of Willis as the underlying cause. Decreased visual acuity is another red flag and normally is only mildly depressed in true papilledema. If the vision is decreased severely, look for other causes that are not related to increased intracranial pressure.
Testing
A. Laboratory studies. If disc edema is found, suggested laboratory tests include sedimentation rate and C-reactive protein for temporal arteritis; white blood count to rule out underlying infection and leukemic infiltration of the optic nerve; a computed tomography (CT) or magnetic resonance imaging (MRI) scan to rule out a compressive lesion; cerebrospinal fluid (CSF) examination for signs of meningitis, tumor, or hemorrhage only after ruling out a compressive lesion with a scan.
B. Diagnostic imaging. If true papilledema is suspected, diagnostic imagining is mandatory. A CT scan with and without contrast should be ordered, possibly followed by MRI and MRI angiography, if the CT scan is inconclusive. MRI will be particularly helpful in imaging brainstem and cerebellar lesions, which can obstruct CSF flow. Despite the greater cost of the MRI and the greater specificity of intracranial pathology, the CT scan still is the preferred technique to image acute bleeding intracranially.
Diagnostic assessment
The critical workup in papilledema includes an accurate history and assessment of the visual system. Vision is often not significantly impaired in true papilledema; if present, it would suggest seeking other causes. An afferent pupillary defect indicates a localized optic nerve or retinal condition as the cause. A detailed examination of the optic nerve to look for optic nerve drusen or pseudopapilledema is also important. The finding of spontaneous venous pulsation indicates normal intracranial pressure and no imaging is mandatory. However, if absent, this does not rule out normal intracranial pressure. No imaging is mandatory; however, if needed, a lumbar puncture should be performed following imaging. Treatment should be directed toward the underlying cause of the elevated intracranial pressure.
References
1. Gordon RN, Burde RM, Slamovits T. Asymptomatic optic disc edema. J Neuroophthalmol 1997;17(1):29–32.
2. Hedges TR. Bilateral visual loss in a child with disc swelling. Surv Ophthalmol 1992;
36(6):424–428.
3. Moster ML. Unilateral disk edema in a young woman. Surv Ophthalmol 1995;39(5):
409–416.
4. Wall M. Optic disc edema with cotton-wool spots. Surv Ophthalmol 1995;39(6):
502–508.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Scotoma:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Visual acuity. The vision of each eye should be assessed with spectacles or contact lenses in each eye independently. Central scotomas are seen with optic nerve, macular disease, or (rarely) an occipital tip lesion; and Snellen visual acuity will be decreased.
B. Visual fields. Confrontation field test is performed with each eye independently. Briefly flash several fingers in each of the four quadrants. Bilateral field loss in the same field of vision in each eye indicates injury posterior to the chiasm. Bitemporal field defects are seen with chiasmal lesions (pituitary masses, craniopharyngiomas, and others). Monocular field defects are seen in retina and optic nerve disease.
C. Pupil examination. The presence of a prominent APD, which implies optic nerve injury, will help to differentiate central scotomas caused by macular disease. An APD is commonly seen with optic neuritis, optic neuropathy (ischemic and traumatic), asymmetric glaucomatous damage, optic nerve tumors, and central retinal artery or vein occlusion. An APD is not seen in early papilledema and minimally with macular degeneration, macular holes, or choroidopathy.
D. Fundus examination. Direct ophthalmoscopy can give a quick assessment of the red reflex (i.e., a dim red reflex in a diabetic with vitreous hemorrhage). Vitreous floaters can occasionally be seen as shadows in the red reflex. Examine the nerve for edema, pallor, or glaucomatous cupping. Macular scarring or pigmentary change is most commonly seen with macular degeneration.
E. Other examinations. A neurologic assessment is needed for a patient with bilateral field loss, screening for contralateral paresis and other focal deficits, palpation of the temporal artery for tenderness or diminished pulse if the history suggests giant cell arteritis, as is auscultation of the carotids for bruits and the heart for a murmur in a patient with amaurosis fugax or stroke. Glaucoma can be screened with tonometry. Check arms and legs for signs of intravenous drug abuse.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Memory Impairment:
Physical examination (PE)
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Normal physical findings are reported in most patients with AD, AAMI, and depression.
B. Specific abnormalities that help classify dementias include resting tremor (LBD, PDWD), myoclonus (CJD, LBD), glabellar reflex (AD), palmomental reflex (AD, PD), cogwheel rigidity (LBD, PDWD), stooped shuffling gait (LBD, PDWD), asterixis (alcoholism), chorea (HD), focal motor or sensory deficits (MID), asymmetric reflexes (MID, CJD), apraxic gait-wide based, feet stuck to floor or magnetic (normal pressure hydrocephalus, NPH), diffuse muscle wasting early in clinical course (CJD, HIV, dementia), and gaze paresis especially downward (progressive supranuclear palsy, PSNP).
Testing
A. Tests useful in clinical practice are presented in Table 4.1.
B. Clinical laboratory tests can rule out treatable dementias. Check complete blood count, electrolytes, calcium, phosphorous, magnesium, glucose, blood urea nitrogen, creatinine, liver and thyroid function tests, vitamin B12 level, and syphilis test (VDRL). If indicated, test for HIV and heavy metals.
C. Cerebral spinal fluid (CSF) examination is indicated in patients with early onset dementia, metastatic cancer, reactive VDRL, fever, or rapidly progressive dementia. If NPH is suspected, the withdrawal of 30 ml CSF with subsequent clinical improvement may predict therapeutic ventriculoperitoneal shunt success.
D. Diagnostic imaging is indicated in all except perhaps longstanding end-stage dementia. Magnetic resonance imaging is most sensitive but computerized tomography (CT) will suffice to rule out subdural hematoma, central nervous system (CNS) tumor, hydrocephalus, cerebral atrophy, and infarction. Positron emission tomography scans promise to be most specific.
E. Electroencephalogram usually reveals nonspecific slowing, except in CJD (diagnostic high voltage bursts).
Diagnostic assessment
A. AAMI (benign forgetfulness) is a nonprogressive memory problem with recalling people’s names and relatively minor recent events in those aged more than 65 years. Other cognitive domains are intact and this does not appear to predict future acquired dementias.
B. Depression causes a pseudodementia that can be diagnosed using the Mini-Mental Status Examination (MMSE) (score >23) and the Geriatric Depression Scale Short Form (score >4).
C. AD is the leading cause of dementia (127/100,000 population). Gradual onset of a progressive memory impairment along with at least two other cognitive defects that impair social or occupational function, a normal PE and laboratory determinations, and some cerebral atrophy on CT make a probable AD diagnosis. This is substantiated on postmortem examination 85% of the time (Chapter 4.4).
D. LBD is the second leading cause of dementia with a fluctuating course, parkinsonian features, early visual hallucinations, and myoclonus developing within 1 year of the dementia. Patients with LBD are exquisitely sensitive to the extrapyramidal side effects of traditional major tranquilizers and have a two- to threefold increased mortality if on these (4).
E. MID is the third leading dementia type with its stepwise or abrupt history and focal sensor-motor defects.
F. PDWD occurs in 30/100,000 population and develops in up to one-third of Parkinson’s disease patients.
G. NPH is suspected with the triad of dementia, urinary incontinence, and an apraxic gait.
H. PSNP is a Parkinson-plus condition with paresis of downward, then later upward and horizontal gaze.
I. HD occurs in 5 to 10/100,000 population with chorea, prominent behavioral problems, dementia, and high suicide rates; onset occurs in individuals in the third and fourth decade of life. It has autosomal dominant heritance on chromosome 4.
J. CJD is a rare (1/1,000,000 population), viral prion CNS infection with rapid progression of dementia, wasting, and myoclonic jerks. Death occurs within 6 to 9 months in these patients aged 40 to 50 years.
K. HIV dementia is rare in the absence of symptoms of systemic infection. Use CSF to rule out CNS infections.
L. PD is rare with psychiatric disorders, blindness, and language defects (compared with more memory defects in AD) (5).
References
1. Gallo JJ, Reichel W, Andersen L. Handbook of geriatric assessment. Rockville, MD: Aspen Publishers, Inc., 1988:11–64.
2. Goldmacher DJ, Whitehouse PJ. Evaluation of dementia. N Engl J Med 1996;
335:330–336.
3. Robbins LJ. Dementia, delirium and depression: approach to the confused elderly patient. In: Geriatric medicine for the FP audio CME lectures and workshops. Kansas City, MO: American Academy of Family Physicians, 1997:9–36.
4. Lapalio LR, Sakala SS. Distinguishing Lewy body dementia. Hosp Prac 1998;
33:93–108.
5. Neary D, Snowden JS. Classification of the dementias. London: Churchill Livingstone, 1998:717–725.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Eye Pain:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
A foreign body sensation occurs with a foreign body, corneal abrasion, or keratoconjunctivitis sicca. Itching is associated with allergic and vernal conjunctivitis. Photophobia occurs with iritis and herpes simplex keratitis. Deep pain suggests acute glaucoma or posterior scleritis. Pain on eye movement is found with optic neuritis, sinusitis, and influenza.
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Source: Field Guide to Bedside Diagnosis, 2007
Diplopia/Nystagmus:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
The direction of gaze with the most prominent diplopia reflects the action of the paretic muscle. Binocular diplopia is due to ocular misalignment, and the patient will usually close one eye to compensate. Acute monocular diplopia can occur with corneal aberrations, cataract, or foveal traction.
CN III paresis: The lateral rectus and superior oblique are unopposed, turning the eye outward and downward. An acute lesion may be peripheral (diabetic or ischemic) or central (posterior communicating artery aneurysm or
cavernous sinus lesion). Both have ptosis, absent eye elevation, and adduction, but a peripheral lesion has normal pupil size and movement (“pupillary sparing”). A central lesion produces a pupil that is dilated and unresponsive to light or accomodation. Causes include tumor, aneurysm, or severe trauma. Unilateral third nerve palsy with contralateral superior rectus palsy and bilateral partial ptosis, and bilateral third nerve palsy always represents a central lesion. Unilateral external ophthalmoplegia with normal contralateral superior rectus function, unilateral internal ophthalmoplegia, and unilateral ptosis represents a peripheral lesion.
CN IV paresis: Superior oblique weakness produces vertical diplopia. The patient tilts his or her head to the opposite side to lessen the displacement. Typical causes are a relatively minor head blow, and idiopathic.
CN VI paresis: Lateral rectus palsy produces weakness in abduction and horizontal diplopia that is better in near than in distant vision. When CN V is also affected (reduced facial sensation around the upper face and cornea), a cavernous sinus lesion should be suspected. Papilledema should also be looked for, as it indicates a mass lesion displacing the brainstem.
If the patient has an isolated lesion of one of the cranial nerves, pain will be localized to just above the eyebrow on the weak side. Intraorbital pathology is indicated by pain in the eye itself or on eye movement. The worst headache of the patient’s life raises concern for intracranial aneurysm.
True nystagmus is characterized by rapid regular oscillations around a fixed point not just with lateral gaze but also when the eyes are looking forward. A few beats of nystagmus at extremes of gaze are not pathologic. Nystagmus of ocular causes has a pendular motion whereas disease in the central nervous system produces fast and slow components. Irregular bursts of rapid eye movements (saccadic intrusions) almost always indicate a cerebellar lesion.
Internuclear ophthalmoplegia occurs when the oculomotor and abducens nerves (CN III and VI) are disconnected at the medial longitudinal fasciculus. When conjugate gaze is attempted, one eye will not adduct medially and the abducting eye (lateral gaze) will show nystagmus. This finding is seen in persons with multiple sclerosis and pontine vascular lesions.
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Source: Field Guide to Bedside Diagnosis, 2007
Diplopia:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Perform a neurologic examination. Evaluate the patient’s level of consciousness (LOC); pupil size, equality, and response to light; and motor and sensory function. Then take his vital signs.
Observe the patient for ocular deviation, ptosis, proptosis, lid edema, and conjunctival injection. Distinguish monocular from binocular diplopia by asking the patient to occlude one eye at a time. If he still sees double out of one eye, he has monocular diplopia. Test visual acuity and extraocular muscles.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Eye pain:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
During the physical examination, don’t manipulate the eye if you suspect trauma. Carefully assess the lids and conjunctivae for redness, inflammation, and swelling. Then examine the eyes for ptosis or exophthalmos. Finally, test visual acuity with and without correction, and assess extraocular movements. Characterize any discharge. (See Examining the external eye, page 272.)
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Hemianopsia:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Evaluate the patient’s level of consciousness (LOC), take his vital signs, and check his pupillary reaction and motor response. Does he have ptosis or facial or extremity weakness? Hallucinations or loss of color vision?
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Scotoma:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Test the patient’s visual acuity and inspect his pupils for size, equality, and reaction to light. An ophthalmoscopic examination and measurement of intraocular pressure (IOP) are necessary. Then identify and characterize the scotoma using such visual field tests as the tangent screen examination, the Goldmann perimeter test, and the automated perimetry test. Two other visual field tests — confrontation testing and the Amsler grid — may also help in identifying a scotoma.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Vision loss:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Don’t touch the patient’s eye if he has perforating or penetrating ocular trauma. The first step in performing the eye examination is to assess visual acuity, with best available correction in each eye. (See Testing visual acuity, page 691.)
Carefully inspect both eyes, noting edema, foreign bodies, drainage, or conjunctival or scleral redness. Observe whether lid closure is complete or incomplete, and check for ptosis. Using a flashlight, examine the cornea and iris for scars, irregularities, and foreign bodies. Observe the size, shape, and color of the pupils, and test the direct and consensual light reflex (see “Pupils, nonreactive,” page 551) and the effect of accommodation. Evaluate extraocular muscle function by testing the six cardinal fields of gaze.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Diplopia:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient complains of double vision, first check his neurologic status. Evaluate his level of consciousness (LOC); pupil size, equality, and response to light; and motor and sensory function. Then take his vital signs. Briefly ask about associated symptoms, especially a severe headache. Find out about associated neurologic symptoms first because diplopia can accompany serious disorders.
Next, continue with a more detailed examination. Find out when the patient first noticed diplopia. Are the images side-by-side (horizontal), one above the other (vertical), or a combination? Does diplopia affect near or far vision? Does it affect certain directions of gaze? Ask if diplopia has worsened, remained the same, or subsided. Does its severity change throughout the day? Diplopia that worsens or appears in the evening may indicate myasthenia gravis. Find out if the patient can correct diplopia by tilting his head. If so, ask him to show you. (If the patient has a fourth nerve lesion, tilting of the head toward the opposite shoulder causes compensatory tilting of the unaffected eye. If he has incomplete sixth nerve palsy, tilting of the head toward the side of the paralyzed muscle may relax the affected lateral rectus muscle.)
Explore associated symptoms such as eye pain or limited eye movement. Ask about hypertension, diabetes mellitus, allergies, and thyroid, neurologic, or muscular disorders. Also, note a history of extraocular muscle disorders, trauma, or eye surgery.
Observe the patient for ocular deviation, ptosis, proptosis, lid edema, and conjunctival injection. Distinguish monocular from binocular diplopia by asking the patient to occlude one eye at a time. If he still sees double out of one eye, he has monocular diplopia. Test his visual acuity and extraocular muscles. Check his vital signs.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Hemianopsia:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Suspect a visual field defect if the patient seems startled when you approach him from one side or if he fails to see objects placed directly in front of him. To help determine the type of defect, compare the patient's visual fields with your own—assuming that yours are normal. First, ask the patient to cover his right eye while you cover your left eye. Then move a pen or similarly shaped object from the periphery of his (and your) uncovered eye into his field of vision. Ask the patient to indicate when he first sees the object. Does he see it at the same time you do? After you do? Repeat this test in each quadrant of both eyes. Then, for each eye, plot the defect by shading the area of a circle that corresponds to the area of vision loss.
Next, evaluate the patient's level of consciousness (LOC), take his vital signs, and check his pupillary reaction and motor response. Ask if he has recently experienced a headache, dysarthria, or seizures. Does he have ptosis or facial or extremity weakness? Hallucinations or loss of color vision? When did neurologic symptoms start? Obtain a medical history, noting especially eye disorders, hypertension, diabetes mellitus, and recent head trauma.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Scotoma:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Explore the patient's medical history, noting especially eye disorders, vision problems, or chronic systemic disorders. Find out if he takes medications or uses eyedrops.
Identify and characterize the scotoma, using such visual field tests as the tangent screen examination, the Goldmann perimeter test, and the automated perimetry test. Two other visual field tests—confrontation testing and the Amsler grid—may also help in identifying a scotoma.
Next, test the patient's visual acuity and inspect his pupils for size, equality, and reaction to light. An ophthalmoscopic examination and measurement of intraocular pressure are necessary.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Vision loss:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Sudden vision loss can signal an ocular emergency. (See Managing sudden vision loss, page 628.) Don't touch the eye if the patient has perforating or penetrating ocular trauma.
If the patient's vision loss occurred gradually, ask him if the vision loss affects one eye or both and all or only part of the visual field. Is the visual loss transient or persistent? Did the vision loss occur abruptly or did it develop over hours, days, or weeks? What's the patient's age? Ask the patient if he has experienced photosensitivity and ask him about the location, intensity, and duration of eye pain. You should also obtain an ocular history and a family history of eye problems or systemic diseases that may lead to eye problems, such as hypertension; diabetes mellitus; thyroid, rheumatic, or vascular disease; infections; and cancer.
The first step in performing an eye examination is to assess visual acuity, with best available correction in each eye. (See Testing visual acuity, page 629.)
Carefully inspect both eyes, noting edema, foreign bodies, drainage, or conjunctival or scleral redness. Observe whether lid closure is complete or incomplete and check for ptosis. Using a flashlight, examine the cornea and iris for scars, irregularities, and foreign bodies. Observe the size, shape, and color of the pupils, and test the direct and consensual light reflex (See “Pupils, nonreactive,” page 515.) and the effect of accommodation. Evaluate extraocular muscle function by testing the six cardinal fields of gaze. (See Testing extraocular muscles, page 197.)
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Eye pain [Ophthalmalgia]:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient's eye pain doesn't result from a chemical burn, take a complete history. Have the patient describe the pain fully. Is it an ache or a sharp pain? How long does it last? Is it accompanied by burning, itching, or discharge? Find out when it began. Is it worse in the morning or late in the evening? Ask about recent trauma or surgery, especially if the patient complains of sudden, severe pain. Does the patient wear contact lenses? How often are they removed or replaced if they're disposable? Does he have headaches? If so, find out how often and at what time of day they occur.
During the physical examination, don'tmanipulate the eye if you suspect trauma. Carefully assess the lids and conjunctiva for redness, inflammation, and swelling. Then examine the eyes for ptosis or exophthalmos. Finally, test visual acuity with and without correction, and assess extraocular movements. Characterize any discharge. (See Examining the external eye.)
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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