Inspect and palpate the skull for lumps, such as a meningioma or a sarcoma.

Auscultate the skull by placing the diaphragm of the stethoscope on the frontal bone, and then on the lateral occipital bones, and then the bell over each eye (with the opposite eye open). Ask the patient to hold his or her breath each time. Bruits heard over the skull may be due to an arteriovenous malformation, advanced Paget's disease or a vascular meningioma, or they may be conducted from the carotids. Then auscultate over the carotid arteries for a carotid bruit.

Medical examination of the eyes: a summary Method The patient should sit at the edge of the bed facing the examiner while the examination begins with inspection (Figure 10.38). Ptosis is best detected at this stage while standing well back from the patient. Look then for any corneal abnormalities, such as band keratopathy (page 185) or Kayser-Fleischer rings (Wilson's disease, page 142). Corneal ulceration may be obvious if severe. Look at the colour of the sclerae: yellow (jaundice), blue (in osteogenesis imperfecta, because the thin sclerae allow the choroidal pigment to show through), or red (Tables 10.10 and 10.11). Note scleral pallor or telangiectasia. Table 10-11. Causes of uveitis Iritis (anterior uveitis) Idiopathic Generalised disease Seronegative spondyloarthropathies Inflammatory bowel disease Diabetes mellitus Granulomatous disease-e.g. sarcoidosis Infections-e.g. gonococcal, syphilis, toxoplasmosis, brucellosis, tuberculosis Choroiditis (posterior uveitis) Idiopathic Generalised disease Diabetes mellitus Granulomatous disease-e.g. sarcoidosis Infections-e.g. toxoplasmosis, syphilis, tuberculosis, toxocaral infection

The uveal tract consists of the anterior uvea (iris) and posterior uvea (ciliary body and choroid). page 318 page 319

Figure 10.38 The medical eye examination

Figure 10.39 Bilateral ptosis after upward gaze in myasthenia gravis Look from behind and above the patient for exophthalmos (page 263). Proceed then as for the cranial nerve examination-that is, testing visual acuity, visual fields and pupillary responses to light and accommodation, and then performing ophthalmoscopy. Begin ophthalmoscopy by examining the cornea and lens, and then the retina. Look for retinal changes of diabetes mellitus and hypertension. Also inspect carefully for optic atrophy, papilloedema, angioid streaks, retinal detachment, central vein or artery thrombosis, and retinitis pigmentosa. Test the eye movements. Look also for fatiguability of eye muscles by asking the patient to look up (Figure 10.39) at the finger for about half a minute. In myasthenia gravis (page 356) the muscles tire and the eyelids begin to droop. Test for lid lag if hyperthyroidism seems a possibility. Test the corneal reflex. Palpate the orbits for tenderness. Auscultate the eyes with the bell of the stethoscope-the eye being tested is shut while the other is open and the patient is asked to stop breathing. page 319 page 320 Figure 10.40 Oculosympathetic pathway involved in Horner's syndrome Figure 10.40 This three-neurone pathway projects from the hypothalamus to the intermediolateral column of the cervical spinal cord, then to the superior cervical ganglion and finally to the pupil, the levator palpebrae and the sweat glands of the face. A lesion at any site along the pathway can produce Horner's syndrome.

Figure 10.40 (Adapted from Simon RP, Aminoff MJ, Greenberg DA, Clinical neurology 1989. Appleton & Lange, 1989.) Consider the possibility that the patient may have a glass eye. This should be suspected if visual acuity is zero in one eye and no pupillary reaction is apparent. Attempts to examine and interpret the fundus of a glass eye are always unsuccessful and embarrassing. Diplopia Most cases of diplopia (about 60%) are not due to a cranial nerve abnormality. It is important to have an approach to the problem that will help work out the cause. First find out whether the diplopia is monocular (25%) or binocular. Monocular diplopia persists when one eye is covered. It is usually due to an eye problem such as astigmatism, dislocated lens, uneven contact lens surface or thick spectacles. It disappears if the patient looks through a pin hole. Although it is said commonly to be due to hysteria, this is a very rare cause. If the diplopia is binocular, consider the common causes:

1 Cranial nerve palsy (III, IV or VI)-look for ptosis, pupil changes (III), abnormal eye movements. 2 Eye muscle disease (myasthenia gravis)-worse later in day, worse after prolonged upward gaze and associated with bilateral ptosis. 3 Thyroid ophthalmopathy-proptosis, lid lag, chemosis.

4 Trauma to the orbit-history or signs of trauma. 5 Internuclear ophthalmoplegia-associated neurological signs.

Horner's syndrome Interruption of the sympathetic innervation of the eye at any point (Figure 10.40) results in Horner's syndromehh (Table 10.12). This is the presence of partial ptosis (as sympathetic fibres supply the smooth muscle of both eyelids) and a constricted pupil (unbalanced parasympathetic action) which reacts normally to light (Figure 10.41). Test for a difference (decrease) in the sweating over each eyebrow with the back of the finger (absence of this sign does not exclude the diagnosis).ii page 320 page 321

Figure 10.41 Left Horner's syndrome, with partial ptosis and miosis. Horner's syndrome may be part of the lateral medullary syndrome, so that the other signs to be looked for include: nystagmus to the side of the lesion; ipsilateral fifth (pain and temperature), ninth and tenth cranial nerve lesions; ipsilateral cerebellar signs (page 357); and contralateral pain and temperature loss over the trunk and limbs (page 354). Next ask the patient to speak and note any hoarseness of the voice, which may be due to a recurrent laryngeal nerve palsy from lung carcinoma or from a lower cranial nerve lesion. Go on now to look at the hands for clubbing and test for weakness of finger abduction (page 99). If any of these signs is present, perform a respiratory examination, concentrating on the apices of the lungs for signs of lung carcinoma. Examine the neck for lymphadenopathy, thyroid carcinoma and a carotid aneurysm or bruit. Syringomyelia may rarely be a cause of this syndrome, so the examination should be completed by testing for dissociated sensory loss (page 353). Remember, syringomyelia may cause a bilateral Horner's syndrome. Table 10-12. Causes of Horner's syndrome 1 Carcinoma of the apex of the lung (usually squamous cell carcinoma) 2 Neck o Malignancy-e.g. thyroid o Trauma or surgery 3 Lower trunk brachial plexus lesions o Trauma o Tumour 4 Carotid arterial lesion o Carotid aneurysm or dissection o Pericarotid tumours (Raeder's syndrome)* o Cluster headache 5 Brainstem lesions o Vascular disease (especially the lateral medullary syndrome) o Tumour o Syringobulbia

6 Syringomyelia (rare)