Neuro-ophthalmology Conditions and appropriate referral pathway
- Third nerve palsy
- Fourth nerve palsy
- Sixth nerve palsy
- Seventh nerve palsy
- Horner's Syndrome or pupil anisocoria
- Neurological fields defect
- Swollen optic discs
- Migraine with visual aura
1. Third Nerve Palsy
Cranial nerve palsies may indicate intracranial pathology so the patient should have a full neurological assessment to look for any other localised signs and have imaging of the brain (ideally a CT venogram) as part of the initial workup.
Acute onset, painful third nerve palsy with headache or neck-ache: please refer immediately to a local Emergency Department.
Sudden onset third nerve palsy with minimal headache and a history of microvascular disease may be referred to our eye casualty for urgent assessment.
2. Fourth Nerve Palsy
Fourth nerve cranial nerve palsies are less commonly acute. More often it is a decompensation of a congenital palsy, traumatic or microvascular. These can be referred to casualty if sudden-onset or to clinic routinely (up to 18 weeks) if longstanding or minimally symptomatic.
3. Sixth Nerve Palsy
Acute onset sixth cranial nerve palsy should be referred to the eye casualty service.
4. Seventh Nerve Palsy
Patients with Bell’s palsy or lower motor neuron facial nerve palsies are more susceptible to corneal exposure and dry eyes. Rarely this can lead to severe infection of the ocular surface. These patients can be usually managed in the community with topical lubricant 4-8 times per day and a lubricating ointment at night-time with horizontal lid taping to prevent exposure.
Please refer if the eye becomes uncontrollably dry or red. Corneal ulceration (which can be seen as an acute opacity of the cornea) requires urgent same day referral.
Myasthenia gravis may present with eye symptoms alone in 70% of cases, peaking at the ages of 20 and 60. It should be suspected when symptoms (diplopia, ptosis) are intermittent or variable, and become significantly worse towards the end of the day or after exertion.
The patient’s GP may consider testing for Anti-Acetylcholine Receptor and Anti-Muscarine Receptor antibody prior to referral.
This can most commonly be referred routinely, although on occasions, the systemic manifestations may be rather significant, such as swallowing, chewing or breathing difficulties. This must be immediately referred to the medical or neurology team as an emergency.
6. Horner Syndrome or pupil anisocoria
Patients with new onset anisocoria with significant neck/headache or neurological signs (i.e. painful 3rd nerve palsy or Horners’ syndrome) should be sent immediately to the nearest A&E department for urgent assessment and imaging (CT venogram or MRI).
Longstanding asymptomatic anisocoria may be referred routinely and the patient advised to attend casualty if symptoms develop.
Before referring please consider whether the patient may have had contact with any medications affecting the autonomic nervous system.
7. Neurological field defect
A patient with an acute onset and symptomatic homonymous visual field defect requires immediate referral to the stroke or medical on call team. Symptoms might include weakness in the face, arm or leg, confusion, headaches, slurred speech, difficulty walking, or difficulty swallowing.
If this is an incidental finding and the patient is asymptomatic, referral to the ophthalmology unit may be made routinely.
Referral to the eye casualty is recommended for new onset bi-temporal visual field defects once imaging (CT venogram or MRI) has been conducted.
8. Swollen discs
Asymptomatic patients where unclear disc margins are found on routine examination may be considered for advice and guidance and the patient advised to attend A&E if neurological symptoms develop in the interim.
When referring patients, or simply asking for advice, please include in your email: an OCT of the disc; visual acuity; colour (Ishihara) acuity. This is helpful to our consultants in determining urgency.
Patients with increasing headache or neurological red flags should be referred to our casualty service.
9. Migraine with visual aura
Migraine aura (jagged lines of light across one or both eyes) in a young, known migraineur is rarely of concern and can be referred routinely if there is no other neurological symptoms.
New onset migraines with aura in older patients or aura that increases in frequency always in the same area of the vision should be referred to neuro-ophthalmology/ neurology on a semi-urgent basis.