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.

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