Ophthalmic Education:

Principles and Guidelines of a Curriculum for Ophthalmic Education of Medical Students: Chapter V: Neuro-Ophthalmology

On this page:

• Educational Goal
  
  
• Anatomy
  
  
• Neuroimaging
  
  
• How to examine the patient
  
  
• How to interpret findings
  
  
• Clinical Competencies

Educational Goal: 

Students should understand the relationship of the eye and visual system within the context of the central nervous system.

Students should also know how to test pupillary reactions and how to assess peripheral visual fields, and should understand conditions which require immediate ophthalmic evaluation, such as sudden vision loss, papilledema, and anterior ischemic optic neuropathy with giant cell arteritis in the elderly patient, III nerve palsy with pupillary involvement, IV and VI nerve palsies.

A. Anatomy.*

1. Bony anatomy.**

2. Vascular anatomy.**

3. Afferent visual pathways.* (REF. 4 Fig. 7.12)

4. Ocular motor pathways.*

5. Facial motor and sensory anatomy.*  

a. Trigeminal nerve.*             

b. Facial nerve.*  

6. Ocular autonomic pathways.*

a. Sympathetic pathways (REF. 24 Slide 13-15) (REF. 4 Fig. 7.4)

b. Parasympathetic pathways.*

7. Pupillary pathways.* (REF. 4 Fig. 7.1)

B. Neuroimaging.**

1. Glossary.**

2. History.**

3. Basics of magnetic resonance imaging (MRI) and computerized tomography (CT) scanning.**

4. Fundamental concepts in localization.**

C. How to examine the patient.*  

1. Visual acuity testing.*  

2. Visual field testing – confrontation.*  

3. Extraocular motility – appearance of eyes in primary position and normal motility in six cardinal positions of gaze.*  

a. Strabismus – ocular alignment in primary position.*

b. Limitation of eye movement.*

c. Limitation of gaze (both eyes affected similarly).*

d. Nystagmus (spontaneous jerking eye movements).*

4. Position of the eyelids.*  

a. Normal lid position.*

b. Upper eyelid retraction.* (REF. 4 Fig. 8.9)

c. Upper eyelid ptosis.*

5. Pupillary reflexes.* (REF. 4 Fig. 7.2)

6. Direct ophthalmoscopy.*  

D.  How to interpret findings.

1. Pupillary disorders.* (REF. 24 Slide 09, 11) (REF. 4 Fig. 7.2)

a. Dilated pupil.*  (REF. 24 Slide 10)

  i. Unilateral.*

  ii. Bilateral.*

b. Adie’s tonic pupil.** (REF. 24 Slide 16)

c. Relative afferent pupillary defect.* (REF. 4 Fig. 7.2)

d. Unilateral small pupil.** (REF. 24 Slide 12, 15) (REF. 4 Fig. 7.3) (REF. 10 Fig. 26-3 Right Horner syndrome, the first sign of localized intrathoracic neuroblastoma in a 6-month-old boy)

2. Neuro-motility abnormalities.*

a. Cranial nerve palsies.*  (REF. 2B Slide 70) (REF. 24 Slides 17-19)

  i.    III nerve.* (REF. 2B Slide 71) (REF. 2F Slide 61) (REF. 24 Slide 18) (REF. 4  Fig. 7.5); Pupil not involved vasculopathic, not urgent.* (REF. 22 Fig. H19); Pupil involved, compressive lesion, urgent referral.* (REF. 9 Figs. 14-16) (REF. 24 Slide 19)

  ii. IV nerve.* (REF. 4 Fig. 7.6) (REF. 22 Fig. E01, E02)

  iii. VI nerve.* (REF. 2B Slide 72) (REF. 4 Fig. 7.7) (REF. 22 Fig. H20, H21, H22, E03, E04, E05)

b. Other cranial nerve palsies.**

  i. V cranial nerve.**

  ii. VII cranial nerve.**

c. Myasthenia gravis.** (REF. 2F Slide 75) (REF. 24 Slide 21, 22)

d. Intranuclear ophthalmoplegia.** (REF. 24 Slide 20) (REF. 4 FIG 7.8 and 7.9)

e. Nystagmus.**

3. Optic nerve disease.*

a. Optic disc elevation (REF. 24 Slide 04).*

  i. Congenital anomalous disc elevation.**

  ii. Papilledema.*  (REF. 2F Slide 10-12) (REF. 24 Slide 8) (REF. 3 Case 14, Papilledema, p.28) (REF. 22 Fig. E16)

  iii. Papillitis.** (REF. 24 Slide 5)   

  iv. Ischemic optic neuropathy.** (REF. 2B Slide 73) (REF. 2F Slide 58, 59) (REF. 3 Case 11, Anterior Ischemic Optic Neuropathy, p.22) (REF. 22 Fig. E09) (REF. 29 Giant cell arteritis)

b. Amaurosis fugax.** (REF. 2F Slide 16-20)

c. Optic atrophy.** (REF. 3 Case 3, Optic Atrophy, p.6)

d. Visual field defect.** (REF. 4 Fig. 7.12)

4. Visual field defects.* (REF. 24 Slide 23-25) (REF. 22 Fig. E28)

a.  Scotoma.***

b. Hemianopia.* (REF. 4 Fig. 7.12) (REF. 22 Fig. E25)

c. Homonymous hemianopia.* (REF. 4 Fig. 7.12)

d. Bitemporal hemianopia.* (REF. 4 Fig. 7.12) (REF. 22 Fig. E26, E27)

Clinical Competencies

Students should:

• Measure visual acuity with near card.*
• Perform confrontation visual field testing in four quadrants for each eye.*
• Test pupillary function and recognize a relative afferent pupillary defect.*
• Perform test of ductions and versions and recognize acute onset cranial nerve palsies III, IV, VI which require immediate referral.*
• Recognize and diagnose nystagmus.*
• Examine the optic disc with the direct ophthalmoscope and recognize optic nerve pallor and papilledema.*

* Basic Level: Necessary in the education of medical students worldwide.

** Standard Level: A higher level of ophthalmic understanding than the basic curriculum of most international medical students.

*** Advanced Level: Advanced cognitive and clinical skills more appropriate for students who seek further training in ophthalmology, which may be covered in an ophthalmology elective in medical school.

(Also see: More on Educational Priorities)

Next: VI. Vitreoretinal Diseases

Also see:

• Table of Contents of the "Principles and Guidelines of a Curriculum for Ophthalmic Education of Medical Students"
  
  
• Education of Medical Students in Ophthalmology
  
  
• Resources for Ophthalmic Education of Medical Students