 So, I'm Judith Warner, Neurolophthalmology at the Moran Ice Center, University of Utah. I'm Neurology-trained Neurolophthalmologist. And so the first thing we're going to do is check your vision. And I know that this has been shown in a variety of ways, but this is how we do it in Neurolophthalmology. So if you hold that and cover up your left eye so you're looking just out of your right eye and read the lowest line that you could read. And the top line is V-L-N-E. Anything on the next line? D-A-O-F. And the next line down? E-G-N-D-H. And the next one? F-Z-B-D-E. Excellent. All right, how about the top line now? O-F-L-C-T. Okay, anything on the next line? A-P-E-O-T-F. Great. Can you make anything out on the last line there or the second, the next line down now? T-Z-V-E-C-L. Excellent, well that's 2020. Yeah. That's better than it seemed to start. All right, then you switch around to the other eye. And can you read that same line? O-F-L-C-T. And the next? A-P-E-O-T-F. And the next one down? T-Z-V-E-C-L. Okay, and then you can actually switch it to reading numbers, which some people with aphasia can read numbers but not letters. And if people are having a lot of trouble with reading, you can also just move to a single letter. And a lot of people who are having trouble concentrating or even who just have amblyopia, people have small areas of field of vision or scatomata can see single letters and single numbers better. So can you read that? Nine. And we can just kind of move it down. Six. And the next one down? Nine. And the next one down? Five. Fantastic, 2015. Great, well done. So when we're checking as people's central vision, one of the other things we want to do is check an amza grid. And so this is an amza grid and we look at it in each eye individually. So I want you to hold that up again and look at the dot in the middle. And while you're looking at that dot in the center, see if you can see the whole grid. Is there anything missing or wavy or distorted? No. No? And normally we would do this, of course, with the near correction. Why don't you switch around to the other eye? Same thing here while you're looking at the dot. Anything missing, wavy, distorted? No. It's all good? Absolutely wonderful. All right, so the next thing we move to is color vision testing. Some people use the Ishiihara color plate. Some people use the HRR color plate. There are a variety of other ones. I happen to prefer the Ishiihara's. You stick with what you're trained with. So why don't you hold that up again so you're looking with your right eye. The first plate is a control plate. It does not actually require color vision. And as you can see, it's really, really large. So people with even extremely impaired vision, 2,100, 2,400 even, can see this gigantic number. So you just read through them. 12, 8, 29, 5, 3, 15, 74, 6, 45, 5, 7, 16, 17, 18. OK. And those are the plates there we use routinely for checking for optic nerve dysfunction. Of course, we would normally check the other eye. It is important, if a technician is doing it, that they note that the patient can see the control, even if they can't see any of the other plates, or if they can't see the control. If somebody's got really good vision, they can't see the control plate, that might tell us something about how they're seeing. The other thing is they might be able to see all of the plates in both eyes, but they might really struggle in one eye and do pretty well in the other eye. And that is something that needs to be documented as well. This set of plates can be used for checking what kind of color vision deficit somebody has if it's a protan-dutan. So once you check the color vision, we routinely check stereopsis again. And so for that, you need these special glasses that are polarized lenses. They can be used for other interesting purposes as well. So this one here, you ask the patient whether or not they can see the fly is looking three-dimensional. And I ask you to, can you pinch the wing of the fly? That's a classic answer. Then there's a little more detailed testing. That's gross stereopsis. This is a little more detailed. I usually do the animals first. In each row, there's one animal that's sticking up off the page. Can you point to or tell me which one? Excellent. Fast and accurate. Very good. OK, now in each set of four circles, there's one that's sticking up off the page. I want you to tell me or point to each one, and you can hold it yourself. The last one's really hard. Give it a whirl. Excellent. Very well done. I think that one of the things that I like to see is that somebody who's really trying is they're doing this movement of the plates, because that's what somebody who has depth perception does when they're trying to see three dimensions. May I have the glasses back? All righty. Now I'm going to check your pupils. It's kind of a bright light, and I'm going to be shining in your two eyes. I want you to just look right straight ahead. So the first thing I do when I'm checking some of these pupils is look at their pupils in the room light, and I'm illuminating from below just so that I can see the pupils really nicely. Now we're going to turn the lights off, and I want you to keep looking right straight ahead, and we can look at both of the pupils, again, illuminating from below so that we can see the pupils, but not actually putting light in them. So then I shine the light in both eyes at the same time, and then take away the light from both eyes at the same time. And what I'm looking here for is a nice brisk reaction to the light, and a nice brisk reaction to the dark. Both pupils actively dilate in the dark. Light and dark. Now I'm going to do the swinging flashlight sign, where I'm going to shine the light in one eye, and then the other, one eye, and the other. And I'm looking for the pupil to dilate when I'm going from one eye to the other. The other thing I'm going to check is at near. I want you to look right at my light here, and see how nicely her pupils constrict, and look in the distance again, and up close. Excellent. And in the distance again. Very nice. The next thing I'm going to do is confrontation visual fields. There are many, many ways of checking the visual fields. Confrontation fields are nice, because you have all the equipment right here. The first thing I want you to do is cover one of your eyes. That's right, you can just use your hand. And then I want you to look right at my nose. And while you're looking at my nose, tell me how many fingers I'm holding. Two, one, one, two. Total. Three, four. Good job. And then we do the other eye. Switch around, OK? How many fingers am I holding up? Two, one, one, two, three, two, three. Very good. Thought I was going to fool you. All righty. The other thing you can do is you can check for red desaturation. So you can check for red desaturation between the two eyes, holding up a nice bright red object. A lot of people use the top of the dilating drops. I want you to look right at this red. And I want you to tell me if it looks the same in both eyes. Looking right at it. It looks the same with this eye. And the same with this eye. Look right at it. Look the same? Look the same? Same? And if the patient says it looks different between the two eyes, try and get them to describe it. And if they can, quantify the difference. And they may say that the red is half as bright. 50% is bright. And that's something you can actually are documenting optic nerve dysfunction over time. The other thing you can use these little red balls for is checking visual field. It's a little more subtle. It can be very handy for picking up pituitary tumors. So again, cover one eye and look right here at my nose. And tell me why you're looking at my nose. Both of these little red balls look like they're nice and bright red. Look the same as each other? They look the same as each other? Look the same as each other? Excellent. Switch around to the other eye? Same thing. Look the same as each other? Same? And same? Excellent. Nicely done. Now we're going to check some of the other cranial nerves. We've already checked two through visual acuity and color vision. We've checked three, four, and six by checking eye movements. The next thing we're going to do is check seven by checking facial movement. So what you want to do is ask the patient to give a nice big smile. Show me all your teeth. Now relax. Raise up your eyebrows and relax. And squeeze your eyes really, really tight shut. And for this, you can actually see if you can open the patient's eyes. If you've ever tried to put drops in a kid's eyes, you know that you can't open somebody's eyes if they don't want you to. You can see this with request movement, but also just observe as a patient is sitting in front of you. You want to look at blink speed for very subtle facial weakness. Somebody with a subtle facial nerve palsy can have a slower blink on one side or the other, even if they don't have inability to close the eyes. The other thing you're going to check is the trigeminal nerve. Trigeminal nerve does facial sensation and also the muscle domestication. So when you're going to check facial sensation, you're going to use a little teeny cotton swab to check corneal sensation. That checks the reflex arc not only of the cornea, but also of the facial nerve itself with the blink. So what you do is you warn the patient what's going to be happening. Have them look right straight ahead and come from the side and with a tiny little wisp of cotton, just very gently touch the cornea and that will induce a blink. And you can do the same thing on the other side, tiny little blink, very good. And you can see that you had a nice blink response in both sides. Then now I've got this little cotton swab ready to go and I can tickle on the forehead, tickle on the cheek and tickle on the jaw. Those are the three different divisions of the trigeminal nerve. The next thing you can do is you can break your little cotton swab and create a little scratchy device and you can check more of a pinprick type of sensation with a scratch and you ask the patient, do you feel that all over? Does it feel the same all over? The other thing you can do with the trigeminal nerve is a muscle domestication. And so I want you to bite down and you can feel the masseters equally on both side and I want you to open your mouth and you can keep your mouth open. I don't ever try to do mouth closure because that would be foolhardy. There's not that much role for the tuning fork, for facial sensation, but it is nice and cold. So we use it to check the sensation of cold in all three divisions of the trigeminal nerve. Is it the same all over? Yes. Very good. And if you're suspecting that there could be some sort of factitious sensation loss, you can actually check vibration sensation on each side of the forehead. And the patient says that they can feel the vibration on one side but not the other that may raise some suspicion. You can also check for hyperactivity of some of the reflexes of the face. You can check the jaw jerk. I want you to open your mouth just a little teeny bit and a little bit less. I'm gonna just tap on your jaw and you can look at the jaw jerk. So you've checked five and seven. You can check hearing by rubbing your fingers on either side and asking the patient if they can hear it and if it's the same. You can also do vestibular testing and there's a variety of ways of checking this. Already you've done your eye movement exam and you've looked for nice stagnants which often indicates a vestibular problem. But one of the things that's very helpful is the head thrust. So when you're looking at the head thrust, what you wanna do is ask the patient to look right at your nose and then you gently grab the patient's head and move it a little bit from side to side like this. And you ask the patient to keep looking right at your nose. And then with warning, you need to say I'm gonna move your head abruptly, okay? But you keep looking right at my nose. Just like that. And one more time. Just like that. And the patient's eyes should be able to remain exactly on your nose with the vestibular ocular reflex. Hers was perfect, of course. And the other thing you can do when you're looking for vestibular problems is look at vestibular ocular reflex suppression. And so for that, it's a little bit more of an active job. What I want you to do is hold your thumb out in front of you like that and I want you to look right at your thumb. Keep your head pointed straight ahead and then I can move your chair around while you keep looking right at your thumb. So I want you to look right at your thumb and here we go. Keep looking right at it and you can give it a nice little vigorous push and she's able to maintain fixation on her thumb at all times. So you can relax. So the next part of the testing would be your gag reflex which tests nine and 10. And so I want you to open your mouth real wide and say ah. So the first thing you can do is you can see that her palate is elevating symmetrically. And then if you have a tongue depressor, you can actually create a gag. I'm not sure that that's absolutely necessary if somebody doesn't have specific sensation loss in their throat or if they haven't been having trouble swallowing or if they're not actually having elevation of their palate appropriately. Then you can move down to 11 which is the spinal accessory nerve and I want you to push your face against my hand, turn your head. There you go. Just like that and over here and then shrug your shoulders up and then H hypoglossal stick your tongue all the way out and you can ask the person to put your tongue back in. Now put your tongue in your cheek here and good and over here. Excellent. And even just looking at the tongue often if there's trouble with hypoglossal nerve you can see atrophy of the tongue. The next thing I'm going to do is the fundus examination which you can do with a handheld direct ophthalmoscope which is falling somewhat out of favor but is hugely helpful for almost all incidents. So what you want to do is get everything set up so that you can do this as comfortably as possible. So what you're going to ask the patient to do is look right straight ahead off of the distance. If they're focused up close their pupil will get smaller and that's not what you need. You choose a smallish for an undeadly pupil you want to choose a smallish light, not too bright. And then it's all about feedback, sensory feedback. So you're going to be having very poor vision for what's going on around you when this is happening so you need to be able to know where the patient is relative to you because in essence you're looking through a little keyhole and if you've ever looked through a keyhole which I know nobody ever does but if you did look through a keyhole you'd know that you have to get right up close. The closer you are to the keyhole the better you can see through it. And she's got pretty small pupils so we're going to need to really get ourselves coordinated to be able to see here. So once you look right straight ahead then you get yourself set so you can see the red reflex and you can see my little pinkies out here because I want to be able to stop myself before I actually bash foreheads with her. So here we go, we're going to come forward. I am looking at the red reflex coming forward, coming forward. I just touch her cheek with my finger here and I'm right on the optic nerve and I can see beautiful venous pulsations and a nice healthy looking optic nerve and I can pop over here and just take a quick look at her phobia. Then you want to do it on the other side. And again, I'm using my hand on her shoulder or I can use it on her head to make sure that I have good sense of where she is once my eyes are covered up. Again, looking right straight ahead and then come in and right in there on her optic nerve and she's the world's most cooperative patient so it works really well. We've covered the remainder of the cranial nerves two through 12. You could check one if you wanted to if you're concerned about a orbital frontal meningioma for instance and somebody who's got foster Kennedy syndrome. You can check somebody's sensation of smell with coffee, try not to use alcohol swabs because they are doing more checking nasal pain rather than smell. So we have checked the remainder of the cranial nerves two through 12 and we've done the funds examination. I hope that you have found this helpful.