Symptoms that need neurological assessment
Neuro-ophthalmology deals with vision problems caused by the optic nerve, the pathways that carry visual signals to the brain, or the brain areas that control eye movement. The eye itself may be normal on a routine examination.
Sudden painless loss of vision in one eye can be a retinal artery occlusion or stroke and is an emergency. Painful loss of vision, especially with eye movement, suggests optic neuritis. Double vision, a drooping eyelid, visual field loss, flashing lights, transient visual loss and unequal pupils all need careful evaluation.
- Sudden vision loss, especially painless loss in one eye — emergency
- Painful vision loss or pain on eye movement
- Double vision, ptosis or a pupil that is larger than the other
- Loss of part of the visual field or difficulty reading
- Transient visual loss in one eye (amaurosis fugax)
- Headache with blurred disc margins, vomiting or drowsiness
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What the assessment covers
The consultation records the timing and pattern of visual symptoms, eye pain, headache, weakness, numbness, speech change and jaw or scalp symptoms. Visual acuity, visual fields, pupils, eye movements, fundoscopy and a full neurological examination are performed.
Investigations are chosen according to the suspected cause. They may include MRI of the brain and orbits, optical coherence tomography, formal visual fields, visual evoked potentials where indicated, and blood tests such as ESR, CRP, autoimmune markers, aquaporin-4 and MOG antibodies.
- Distinguish eye disease from optic nerve or brain disease
- Look for a vascular, inflammatory, compressive or neuromuscular cause
- Review blood pressure, diabetes, smoking and clotting risk
- Coordinate with ophthalmology, rheumatology or oncology when needed
Common causes
Optic neuritis is often linked to multiple sclerosis, NMOSD or MOG antibody disease, but can also follow infection. Ischaemic optic neuropathy is associated with vascular risk factors and, in older adults, with giant cell arteritis. Papilloedema can reflect raised intracranial pressure, and compressive lesions can affect the optic nerve or chiasm.
Double vision may come from a cranial nerve palsy, myasthenia gravis, thyroid eye disease, a brainstem lesion or a stroke. Migraine aura can cause transient visual symptoms, but new or persistent visual loss should not be attributed to migraine without assessment.
Access and booking
Appointments are at Kathmandu Neurology Clinic & Cognitive Center, 117 Lal Durbar Marg, Kathmandu, opposite Yak & Yeti Hotel. Call +977-9747736624 or use /book-appointment. Bring prior reports, imaging and a medication list.