Intensive Care Idiosyncrasies

  • Testing of the visual pathways requires the presence of both eyes intact, and the absence of trauma to the iris.
  • Formal visual field and acuity testing requires a conscious cooperative patient.
  • In the unconscious patient, afferent optic nerve function can be tested using the light reflex

Examination

  • Each eye is tested individually.
  • Visual acuity in the conscious extubated patient:
    • "How many fingers am I holding up?"
    • Ask the patient to identify an object in the room.
  • Visual acuity in the unconscious patient:
    • Move an object in the patient's field of vision; look for sustained visual tracking.
    • Rapidly confront the patient's pupil with an object; look for a startle "flinch" response
    • Test the light reflex (see the chapter on CN III)
  • Visual fields
  • Fundoscopy:
    • Dilate the pupils, and inspect the optic disc and retina with an ophthalmoscope

A discussion of the lesions of the visual pathways takes place elsewhere.

Similarly, pupillary abnormalities deserve their own page.

Here, the focus is primarily on the optic nerve itself.

Visual acuity in the conscious patient

In order to accurately assess visual acuity, one requires a conscious and cooperative patient. One does not routinely see the Snellen chart waved around in the ICU. However, this is the better method of testing the visual acuity. "How many fingers am I holding up" and looking at the bedside clock are rather crude methods, but certainly enough for a rapid bedside identification of major deficits. Other crude methods (eg. the identification of routine objects) can also be employed, but ultimately, nothing beats the Snellen chart in terms of reproduceability and accuracy.

However, generally speaking, rather than focusing on subtle deficits of long and short distance vision, the pragmatic intensivist usually just wants to know whether the patient is blind or not.

Visual acuity in the unconscious patient

One does not need the patient to be either conscious or cooperative in order to establish whether they are blind. There are several tests one can perform to assess the unilateral retina:

Sustained visual pursuit

Close one of the patient's eyes. The other eye, remaining open, gets an object moved in front of it.

If one can convince oneself that the patient's eyes track that object, at the very least the optic nerve must be intact (as well as most of the rest of the visual pathway). The patient in a minimally conscious state may demonstrate the capacity for visual tracking, as one of the features of their slow recovery.

The tracking of objects is a reflex mediated by the superior colliculus, in the tectum of the midbrain.

Startle response

Provided they have not recently received a dose of muscle relaxant, one can rely on the "startle" response to establish whether the patient's optic nerve is still working.

Close one of the patient;s eyes. Rapidly confront the other eye with your finger. A patient with intact optic nerve function up to the level of the optic tract will blink. This reflex is also mediated by the superior colliculus

Light reflex

The other two tests in this section are fairly unreliable. Is the patient tracking the object, or are their eyes roaming uselessly? On the other hand, the light reflex is fairly unequivocal. if the pupil constricts briskly in reponse to light, the optic nerve is intact. The light reflex is discussed in greater detail elsewhere.

Interpretation of lost visual acuity

Causes of Bilateral Blindness
  • Bilateral occipital lobe infarction
  • Bilateral occipital lobe trauma
  • Bilateral optic nerve damage
  • Bilateral retinal damage, eg. methanol toxicity or retinal haemorrhage
Causes of Unilateral Blindness

Gradual onset

  • Cataract
  • Glaucoma
  • Macular degeneration
  • Diabetic retinopathy
  • Retroorbital or pituitary tumour

Sudden onset

  • Retinal artery or vein occlusion
  • Temporal arteritis
  • Ischaemic optic neuropathy
  • Optic neuritis
  • Migraine

References

A splendid resource for digital artwork exists at Cranial Nerves Illustrated, courtesy of the University of Toronto. The authors of the book and images - L. Wilson-Pauwels, P. Stewart, E.J. Akesson and S.D. Spacey - have made the images available for free, provided they are exploited as a teaching resource.

The best textbook for an intimately detailed clinical examination of the cranial nerves is Walker, Hall and Hurst's "Clinical Methods: The History, Physical, and Laboratory Examinations" 3rd edition. It is all the more amazing for its free online availability.

The most detailed discussion for the causes of disorders of taste and smell comes from Chapter 20 (Pasquale and Mair), cited in Bradley's "Neurology in Clinical Practice: Principles of Diagnosis and Management" The 2012 2-volume 2nd edition will set you back $519.

Favre, J. J., et al. "Blood supply of the olfactory nerve." Surgical and Radiologic Anatomy 17.2 (1995): 133-138.

Cereda, C., et al. "Strokes restricted to the insular cortex." Neurology 59.12 (2002): 1950-1955.

Price, Joseph L. "Beyond the primary olfactory cortex: olfactory-related areas in the neocortex, thalamus and hypothalamus." Chemical Senses 10.2 (1985): 239-258.

Zusho, Hiroyuki. "Posttraumatic anosmia." Archives of Otolaryngology 108.2 (1982): 90-92.

Lieblich, Jeffrey M., et al. "Syndrome of anosmia with hypogonadotropic hypogonadism (Kallmann syndrome): clinical and laboratory studies in 23 cases." The American journal of medicine 73.4 (1982): 506-519.

Kuo, Yu-Heng, et al. "Sertraline alleviated osmophobia caused by partial hypopituitarism with isolated ACTH deficiency." General hospital psychiatry35.5 (2013): 574-e9.

Amoore, John E. "Olfactory genetics and anosmia." Olfaction. Springer Berlin Heidelberg, 1971. 245-256.

Schurr, P. H. "Aberrations of the sense of smell in head injury and cerebral tumours." Proceedings of the Royal Society of Medicine 68.8 (1975): 470.

Sherman, A. H., J. E. Amoore, and V. Weigel. "The pyridine scale for clinical measurement of olfactory threshold: a quantitative reevaluation."Otolaryngology and head and neck surgery 87.6 (1978): 717-733.

Royall, Donald R., et al. "Severe dysosmia is specifically associated with Alzheimer-like memory deficits in nondemented elderly retirees."Neuroepidemiology 21.2 (2002): 68-73.

Jones, Barbara P., Howard R. Moskowitz, and Nelson Butters. "Olfactory discrimination in alcoholic Korsakoff patients." Neuropsychologia 13.2 (1975): 173-179.

Moberg, Paul J., et al. "Olfactory recognition: Differential impairments in early and late Huntington's and Alzheimer's diseases." Journal of clinical and experimental neuropsychology 9.6 (1987): 650-664.

PENG, Rong, Jin-hong ZHANG, and Yan WU. "RESEARCH ON DYSOSMIA IN PATIENTS WITH PARKINSON'S DISEASE." Modern Preventive Medicine 1 (2007): 087.

Wolberg, Faith L., and Dewey K. Ziegler. "Olfactory hallucination in migraine."Archives of neurology 39.6 (1982): 382-382.

Kopala, L. C., K. P. Good, and W. G. Honer. "Olfactory hallucinations and olfactory identification ability in patients with schizophrenia and other psychiatric disorders." Schizophrenia research 12.3 (1994): 205-211.

Gloor, Pierre, et al. "The role of the limbic system in experiential phenomena of temporal lobe epilepsy." Annals of neurology 12.2 (1982): 129-144.