Approach to Common Visual Complaints Presenting to the Outpatient Neurologist

Abstract

Visual complaints are commonly encountered by the practicing neurologist. We review assessment of vision loss, diplopia, and positive visual phenomena, all of which require a thoughtful evaluation to localize disease and refine management. While many causative entities are unlikely to cause poor visual outcomes, including dry eyes, migraine, and congenital strabismus, others may threaten vision, life, or both, such as posterior communicating artery aneurysms, pituitary apoplexy, or temporal arteritis. A systematic approach to vision loss and diplopia is reviewed along with focused differential diagnoses.

Keywords

diplopia - vision loss - positive visual phenomena - neuro-ophthalmology

Publication History

Article published online:
26 November 2021

• References

• 1 Zhao J, Fliotsos MJ, Ighani M, Eghrari AO. Comparison of a smartphone application with Ishihara pseudoisochromatic plate for testing colour vision. Neuroophthalmology 2018; 43 (04) 235-239
• 2 Young WB, Heros DO, Ehrenberg BL, Hedges III TR. Metamorphopsia and palinopsia. Association with periodic lateralized epileptiform discharges in a patient with malignant astrocytoma. Arch Neurol 1989; 46 (07) 820-822
• 3 Chodnicki KD, Pulido JS, Hodge DO, Klaas JP, Chen JJ. Stroke risk before and after central retinal artery occlusion in a US cohort. Mayo Clin Proc 2019; 94 (02) 236-241
• 4 Hayreh SS, Podhajsky PA, Zimmerman B. Occult giant cell arteritis: ocular manifestations. Am J Ophthalmol 1998; 125 (04) 521-526
• 5 Stone JH, Tuckwell K, Dimonaco S. et al. Trial of tocilizumab in giant-cell arteritis. N Engl J Med 2017; 377 (04) 317-328
• 6 Hayreh SS, Zimmerman MB. Non-arteritic anterior ischemic optic neuropathy: role of systemic corticosteroid therapy. Graefes Arch Clin Exp Ophthalmol 2008; 246 (07) 1029-1046
• 7 Saxena R, Singh D, Sharma M, James M, Sharma P, Menon V. Steroids versus no steroids in nonarteritic anterior ischemic optic neuropathy: a randomized controlled trial. Ophthalmology 2018; 125 (10) 1623-1627
• 8 Optic Neuritis Study Group. The clinical profile of optic neuritis. Experience of the optic neuritis treatment trial. Arch Ophthalmol 1991; 109 (12) 1673-1678
• 9 Beck RW, Cleary PA, Backlund JC. The course of visual recovery after optic neuritis. Experience of the Optic Neuritis Treatment Trial. Ophthalmology 1994; 101 (11) 1771-1778
• 10 Rizzo III JF, Andreoli CM, Rabinov JD. Use of magnetic resonance imaging to differentiate optic neuritis and nonarteritic anterior ischemic optic neuropathy. Ophthalmology 2002; 109 (09) 1679-1684
• 11 Beck RW, Trobe JD, Moke PS. et al; Optic Neuritis Study Group. High- and low-risk profiles for the development of multiple sclerosis within 10 years after optic neuritis: experience of the optic neuritis treatment trial. Arch Ophthalmol 2003; 121 (07) 944-949
• 12 Jacobs LD, Beck RW, Simon JH. et al; CHAMPS Study Group. Intramuscular interferon beta-1a therapy initiated during a first demyelinating event in multiple sclerosis. N Engl J Med 2000; 343 (13) 898-904
• 13 Wingerchuk DM, Banwell B, Bennett JL. et al; International Panel for NMO Diagnosis. International consensus diagnostic criteria for neuromyelitis optica spectrum disorders. Neurology 2015; 85 (02) 177-189
• 14 Mandler RN, Davis LE, Jeffery DR, Kornfeld M. Devic's neuromyelitis optica: a clinicopathological study of 8 patients. Ann Neurol 1993; 34 (02) 162-168
• 15 Lennon VA, Wingerchuk DM, Kryzer TJ. et al. A serum autoantibody marker of neuromyelitis optica: distinction from multiple sclerosis. Lancet 2004; 364 (9451): 2106-2112
• 16 Hamid SHM, Whittam D, Mutch K. et al. What proportion of AQP4-IgG-negative NMO spectrum disorder patients are MOG-IgG positive? A cross sectional study of 132 patients. J Neurol 2017; 264 (10) 2088-2094
• 17 Chen JJ, Flanagan EP, Jitprapaikulsan J. et al. Myelin oligodendrocyte glycoprotein antibody (MOG-IgG)-positive optic neuritis: clinical characteristics, radiologic clues and outcome. Am J Ophthalmol 2018; 195: 8-15
• 18 Beck RW, Cleary PA, Anderson Jr MM. et al; The Optic Neuritis Study Group. A randomized, controlled trial of corticosteroids in the treatment of acute optic neuritis. N Engl J Med 1992; 326 (09) 581-588
• 19 Kleiter I, Gahlen A, Borisow N. et al; Neuromyelitis Optica Study Group. Neuromyelitis optica: evaluation of 871 attacks and 1,153 treatment courses. Ann Neurol 2016; 79 (02) 206-216
• 20 Merle H, Olindo S, Jeannin S. et al. Treatment of optic neuritis by plasma exchange (add-on) in neuromyelitis optica. Arch Ophthalmol 2012; 130 (07) 858-862
• 21 Dinkin M, Oliveira C. Men are from mars, idiopathic intracranial hypertension is from venous: the role of venous sinus stenosis and stenting in idiopathic intracranial hypertension. Semin Neurol 2019; 39 (06) 692-703
• 22 Kashkouli MB, Yousefi S, Nojomi M. et al. Traumatic optic neuropathy treatment trial (TONTT): open label, phase 3, multicenter, semi-experimental trial. Graefes Arch Clin Exp Ophthalmol 2018; 256 (01) 209-218
• 23 Borruat FX, Schatz NJ, Glaser JS, Matos L, Feuer W. Radiation optic neuropathy: report of cases, role of hyperbaric oxygen therapy, and literature review. Neuroophthalmology 1996; 16 (04) 255-266
• 24 Farooq O, Lincoff NS, Saikali N, Prasad D, Miletich RS, Mechtler LL. Novel treatment for radiation optic neuropathy with intravenous bevacizumab. J Neuroophthalmol 2012; 32 (04) 321-324
• 25 Hershenfeld SA, Sharpe JA. Monocular temporal hemianopia. Br J Ophthalmol 1993; 77 (07) 424-427
• 26 Saeger W, Lüdecke DK, Buchfelder M, Fahlbusch R, Quabbe HJ, Petersenn S. Pathohistological classification of pituitary tumors: 10 years of experience with the German Pituitary Tumor Registry. Eur J Endocrinol 2007; 156 (02) 203-216
• 27 Bodranghien F, Bastian A, Casali C. et al. Consensus paper: revisiting the symptoms and signs of cerebellar syndrome. Cerebellum 2016; 15 (03) 369-391
• 28 Gurel SC, Castelo-Branco M, Sack AT, Duecker F. Assessing the functional role of frontal eye fields in voluntary and reflexive saccades using continuous theta burst stimulation. Front Neurosci 2018; 12: 944
• 29 Walter E, Trobe JD. The clinical and imaging profile of skew deviation: a study of 157 cases. J Neuroophthalmol 2021; 41 (01) 69-76
• 30 Brodsky MC, Donahue SP, Vaphiades M, Brandt T. Skew deviation revisited. Surv Ophthalmol 2006; 51 (02) 105-128
• 31 Wong AM. Understanding skew deviation and a new clinical test to differentiate it from trochlear nerve palsy. J AAPOS 2010; 14 (01) 61-67
• 32 Lemos J, Subei A, Sousa M. et al. Differentiating acute and subacute vertical strabismus using different head positions during the upright-supine test. JAMA Ophthalmol 2018; 136 (04) 322-328
• 33 Bienfang DC. Crossing axons in the third nerve nucleus. Invest Ophthalmol 1975; 14 (12) 927-931
• 34 Dosunmu EO, Hatt SR, Leske DA, Hodge DO, Holmes JM. Incidence and etiology of presumed fourth cranial nerve palsy: a population-based study. Am J Ophthalmol 2018; 185: 110-114
• 35 Tamhankar MA, Biousse V, Ying GS. et al. Isolated third, fourth, and sixth cranial nerve palsies from presumed microvascular versus other causes: a prospective study. Ophthalmology 2013; 120 (11) 2264-2269
• 36 Neuro-Ophthalmology of Basic and Clinical Science Course. In: Basic and Clinical Science Course (BCSC). American Academy of Ophthalmology; San Francisco, CA: 2017
• 37 Bartley GB. The epidemiologic characteristics and clinical course of ophthalmopathy associated with autoimmune thyroid disease in Olmsted County, Minnesota. Trans Am Ophthalmol Soc 1994; 92: 477-588
• 38 Bartley GB, Fatourechi V, Kadrmas EF. et al. Clinical features of Graves' ophthalmopathy in an incidence cohort. Am J Ophthalmol 1996; 121 (03) 284-290
• 39 Gilhus NE. Myasthenia gravis. N Engl J Med 2016; 375 (26) 2570-2581
• 40 Bever Jr CT, Aquino AV, Penn AS, Lovelace RE, Rowland LP. Prognosis of ocular myasthenia. Ann Neurol 1983; 14 (05) 516-519
• 41 Benatar M. A systematic review of diagnostic studies in myasthenia gravis. Neuromuscul Disord 2006; 16 (07) 459-467
• 42 Chen AH, Aziz A. Heterophoria in young adults with emmetropia and myopia. Malays J Med Sci 2003; 10 (01) 90-94
• 43 Ali MH, Berry S, Qureshi A, Rattanalert N, Demer JL. Decompensated esophoria as a benign cause of acquired esotropia. Am J Ophthalmol 2018; 194: 95-100
• 44 Borrego-Sanz L, Gómez-Gómez A, Gurrea-Almela M. et al; Madrid Uveitis Study Group. Visual acuity loss and development of ocular complications in white dot syndromes: a longitudinal analysis of 3 centers. Graefes Arch Clin Exp Ophthalmol 2019; 257 (11) 2505-2516
• 45 Zaret BS. Lightning streaks of Moore: a cause of recurrent stereotypic visual disturbance. Neurology 1985; 35 (07) 1078-1081
• 46 Schankin CJ, Maniyar FH, Digre KB, Goadsby PJ. ‘Visual snow’ - a disorder distinct from persistent migraine aura. Brain 2014; 137 (Pt 5): 1419-1428
• 47 Yun SH, Lavin PJ, Schatz MP, Lesser RL. Topiramate-induced palinopsia: a case series and review of the literature. J Neuroophthalmol 2015; 35 (02) 148-151
• 48 Eperjesi F, Akbarali N. Rehabilitation in Charles Bonnet syndrome: a review of treatment options. Clin Exp Optom 2004; 87 (03) 149-152