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PassPACES Ophthalmology For Station 5 of The PACESExamination
PassPACES Ophthalmology For Station 5 of The PACESExamination
Loss of vision:
Double vision
Establish whether the patient experiences horizontal or vertical diplopia and in which
direction the double vision is most noticeable.
Horizontal diplopia, which is worse in the distance, suggests a sixth nerve palsy.
Vertical diplopia that is at its worst in downgaze is likely to be due to a fourth nerve palsy.
Third nerve palsy will cause constant ptosis (unless surgically corrected).
It is crucial to determine whether the pupil is affected in a patient with a third nerve palsy as
this strongly suggests a compressive or traumatic lesion.
Ask about symptoms related to hyper/hypothyroidism if you suspect dysthyroid eye disease.
Pupil reactions
When examining the pupils it is important to check whether the pupils are equal or unequal at
the outset of the examination.
Equal pupils indicate an afferent (sensory) defect – usually in the optic nerve.
Unequal pupils indicate a motor defect
If the larger pupil reacts briskly to light the smaller pupil is probably the abnormal one.
• Physiological anisocoria
• Horner syndrome (~2mm ptosis)
• Third nerve palsy
• Adie pupil
• Argyll-Robertson pupil
• Miotics and mydriatics