Cranial Nerve & Eye Exam

CRANIAL NERVE & EYE EXAM

I: Olfactory II: Optic III-IV-VI: extraocculars V: Trigeminal VII: Facial VIII: Vestibulocochlear IX-X: Glossopharyngeal, Vagus XI: Accessory XII: Hypoglossal

CN I: Olfactory
? Usually not tested.
? Rash, deformity of nose.
? Test each nostril with essence bottles of coffee, vanilla, peppermint.

CN II: Optic
? With patient wearing glasses, test each eye separately on eye chart/ card using an eye cover.
? Examine visual fields by confrontation by wiggling fingers 1 foot from pt’s ears, asking which they see move.
? Keep examiner’s head level with patient’s head.
? If poor visual acuity, map fields using fingers and a quadrant-covering card.
? Look into fundi.

CN III, IV, VI: Occulomotor, Trochlear, Abducens
? Shine light in from the side to gauge pupil’s light reaction.
? Assess both direct and consensual responses.
? Assess afferent pupillary defect by moving light in arc from pupil to pupil. unne). Optionally: as do arc test, have pt place a flat hand extending vertically from his face, between his eyes, to act as a blinder so light can only go into one eye at a time.
? “Follow finger with eyes without moving head”: test the 6 cardinal points in an H pattern.
? Look for failure of movement, nystagmus [pause to check it during upward/ lateral gaze].
? Convergence by moving finger towards bridge of pt’s nose.
? Test accommodation by pt looking into distance, then a hat pin 30cm from nose.
? If MG suspected: pt. gazes upward at Dr’s finger to show worsening ptosis.

CN V: Trigeminal
? Corneal reflex: patient looks up and away.
? Touch cotton wool to other side.
? Look for blink in both eyes, ask if can sense it.
? Repeat other side [tests V sensory, VII motor].
? Facial sensation: sterile sharp item on forehead, cheek, jaw.
? Repeat with dull object. Ask to report sharp or dull.
? If abnormal, then temperature (heated/ water-cooled tuning fork), light touch (cotton).
? Motor: pt opens mouth, clenches teeth (pterygoids).
? Palpate temporal, masseter muscles as they clench.
? Test jaw jerk (pseudobulbar palsy).

CN VII: Facial
? Inspect facial droop or asymmetry.
? Facial expression muscles: pt looks up and wrinkles forehead.
? Examine wrinkling loss.
? Feel muscle strength by pushing down on each side because of bilateral innervation.
? Pt shuts eyes tightly: compare each side.
? Pt grins: compare nasolabial grooves.
? Also: frown, show teeth, puff out cheeks.
? Corneal reflex already done.

VIII: Vestibulocochlear (Hearing, Vestibular rarely)
? Dr’s hands arms length by each ear of pt.
? Rub one hand’s fingers with noise on one side, other hand noiselessly.
? Ask pt. which ear they hear you rubbing.
? Repeat with louder intensity, watching for abnormality.
? Weber’s test: Lateralization
? 512/ 1024 Hz [256 if deaf] vibrating fork on top of patients head/ forehead.
? “Where do you hear sound coming from?”
? Normal reply is midline.
? Rinne’s test: Air vs. Bone Conduction
? 512/ 1024 Hz [256 if deaf] vibrating fork on mastoid behind ear. Ask when stop hearing it.
? When stop hearing it, move to the patients ear so can hear it.
? Normal: air conduction [ear] better than bone conduction [mastoid].
? If indicated, look at external auditory canals, eardrums.

CN IX, X: Glossopharyngeal, Vagus
? Voice: hoarse or nasal.
? Pt. swallows, coughs (bovine cough: recurrent laryngeal).
? Examine palate for uvular displacement. (unilateral lesion: uvula drawn to normal side).
? Pt says “Ah”: symmetrical soft palate movement.
? Gag reflex [sensory IX, motor X]:
? Stimulate back of throat each side.
? Normal to gag each time.

CN XI: Accessory
? From behind, examine for trapezius atrophy, asymmetry.
? Pt. shrugs shoulders (trapezius).
? Pt. turns head against resistance: watch, palpate SCM on opposite side.

CN XII: Hypoglossal
? Listen to articulation.
? Inspect tongue in mouth for wasting, fasciculations.
? Protrude tongue: unilateral deviates to affected side.

EYE EXAM

History

? Presenting complaint:
? Onset: gradual vs. sudden vs. asymptomatic.
? Duration: brief vs. continuous.
? Location: focal vs. diffuse, unilateral vs. bilateral.
? Eye Hx: squint, amblyopia, glasses, glaucoma.
? Family Hx: squint, lazy eye, glasses, glaucoma, cataract (young person).
? Past medical Hx: especially vascular (diabetes, hypertension).
? Medications: current meds, Hx of drugs affecting eye.
? Is pt on or been on eye drops.
? Social Hx: relevant post-op (to put eye drops in).

Inspection

In all, looking for asymmetry, deformities, discoloration, redness, discharge, lesions.
? Diagnostic faces.
? Orbit, rim: palpate for lumps.
? Brow: lost sweating (Horner’s).
? Eyelids: xanthelasma, ectropian, entropian.
? Eyelids: pus on lids (blepharitis).
? Ptosis.
? Exophthalmos.
? Iris: color, defects.
? Cornea: transparent vs. opaque, corneal arcus, band keratopthy, Kayser-Fleischer rings, lesion, scars.
? Ask the patient to look up and pull down both lower eyelids to inspect the conjunctiva and sclera.
? Conjunctiva: clear/infected. If conjunctivitis, wash hands immediately: viral form contagious.
? Sclera: jaundice, pallor, injection.
? Spread each eye open with Dr’s thumb, index finger. Ask pt to look to each side and downward to expose entire bulbar surface.
? Eyeball tenderness.

Visual acuity

If eye pain, injury, visual loss, check visual acuity before rest of the exam or inserting medications into eyes [so don't get sued].
? Let pt to use glasses, contacts if available.
? Put pt 20 feet from Snellen eye chart, or hold Rosenbaum pocket card 14 inches away.
? Pt. covers an eye at a time with a card, reading smaller letters till stop.
? Record smallest line read, eg. 20/40.

Visual fields

? Stand 2 feet in front of pt, who looks in Dr’s eyes at eye-level.
? Dr’s hands to side half way between Dr and pt, wiggle fingers, ask which they see move.
? Repeat 2-3 to test both temporal fields.
? If suspect abnormality, test 4 quadrants of each eye while card covers other.

Ophthalmoscope (fundi)

? Darken room, adjust scope so light is no brighter than necessary.
? Adjust aperture to a plain white circle.
? Set diopter dial to zero, unless have a preferred setting.
? Dr. uses left hand and left eye to examine the patient’s left eye.
? Dr’s free hand onto the pt’s shoulder or forehead for control.
? Tell pt to stare at wall.
? Look through scope, shine light into pt’s eye from 2 feet away at a 45? angle.
? See the retina as a “red reflex.”. Reflex: clear vs. opaque (cataract). Follow red color to move within a few inches from pt’s eye.
? Adjust diopter dial to bring the retina into focus. Find a blood vessel and follow it to the optic disk, use this as a point of reference.
? Inspect optic disk:
? Color of disc: pink vs. pale.
? Margins clear.
? State of cup.
? Inspect vessels: all 4 quadrants, veins are darker than arteries:
? Bleeding, exudate.
? Pigmentation, occlusion.
? Inspect macula, by moving the scope nasally:
? Foveal light reflex
? Bleeding, exudate.
? Edema, drusen
. Pupils

? Shape, relative size.
? Light reaction: dim lights if needed.
? Pt looks in distance; shine light in from side to gauge pupil’s light reaction. Record size, irregularity. ? Assess both direct (same eye) and consensual (other eye) responses.
? Assess afferent pupillary defect by moving light in arc from pupil to pupil, and if left eye light makes right eye dilate, not constrict (Marcus Gunne). Optionally: as do arc test, have pt place a flat hand extending vertically from his face, between his eyes, to act as a blinder so light can only go into one eye at a time.
? Accommodation: pt alternates between looking into distance, and a hat pin 30cm from nose.

Corneal reflections

? Shine a light from directly in front of the pt.
? Corneal reflections should be centered over pupils.
? Assess asymmetry (extraoccular muscle pathology).

Eye movements

? “Follow finger with eyes without moving head”: test the 6 cardinal points in an H pattern. Assess:
? Failure of movement.
? Nystagmus [pause to check it during upward, lateral gaze]).
? Convergence by moving finger towards bridge of pt’s nose.
? Gaze palsies (supranuclear lesions).
? Fatiguability (myasthenia).

Corneal reflex

? Corneal reflex: patient looks up and away.
? Touch cotton wool to other side.
? Look for blink in both eyes, ask if can sense it.