The Yield of Neuroimaging in Patients Presenting to the Emergency Department with Isolated Neuro-ophthalmological Complaints

The Yield of Neuroimaging in Patients Presenting to the Emergency Department with Isolated Neuro-ophthalmological Complaints | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Yield of Neuroimaging in Patients Presenting to the Emergency Department with Isolated Neuro-ophthalmological Complaints Tharwat El Zahran, Dalia El Hadi, Hala Mostafa, Hana Mansour, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-630811/v2 This work is licensed under a CC BY 4.0 License Status: Posted Version 2 posted You are reading this latest preprint version Show more versions Abstract Background: Neuro-ophthalmological emergencies require prompt assessment and management to avoid vision or life-threatening sequelae. The decision to perform a neuroimaging procedure is currently based on the clinical judgement of the medical team, without defined indications. This study aims to identify presenting symptoms and physical exam findings associated with relative positive findings on neuroimaging studies, Methods: This study was conducted by reviewing the electronic medical records of patients presenting to the Emergency Department (ED) with isolated neuro-ophthalmologic complaints between January 1 st , 2013 and September 30 th 2019. We collected data on the clinical presentation, neuroimaging procedures and results, consults, and diagnoses. Results: We reviewed the charts of 211 patients of whom 50.7% were females and had a mean age of 41.2 ±21.4 years. Most presented with unilateral eye complaints (53.6%), and the most common symptoms were blurred vision (77.3%) and headaches (42.2%). A total of 126 imaging procedures were performed of which 74.6% were normal, while 25.4% showed relevant abnormal findings. Complaining of blurry vision (p=0.038) or visual field changes (p=0.014) at presentation were associated with having positive findings on imaging. Physical exam findings of a visual field defect (p=0.016), abnormal pupil reactivity (p=0.028), afferent pupillary defect (p=0.018), or abnormal optic disc exam (p=0.009) were also associated with positive findings on imaging. Conclusion: Neuroimaging is more likely to yield positive findings in patients presenting to the ED with blurred vision or changes in visual field and in those found to have visual field irregularities, afferent pupillary defects or abnormal optic discs on physical exam. These findings - when combined with the proper clinical setting - should lower the threshold to proceed with neuroimaging in the emergency department. Based on our results, larger-scale studies might lead to a well-structured algorithm to be followed by ED physicians in decision making. Neuroophthalmology Neuroimaging Emergency Department Yield of Imaging Emergency Predictors Key Messages • What is already known about this subject? The advancements in neuroimaging is allowing physicians to distinguish brain lesions. The most commonly used imaging modalities by neuro-ophthalmologists would be the Brain Computed tomography (CT) and Magnetic resonance imaging (MRI). There is overuse of such imaging especially in non-indicated cases. There are however, some findings on history and physical exam that would suggest positive findings on imaging. Multiple studies previously commented on those findings separately. • What are the new findings? Our study presents grouping of risk indicators in both history and physical exam (mainly ophthalmological) that would suggest an abnormal neuroimaging in the setting of neuro-ophthalmological emergencies. They are blurred vision, or changes in visual field on history taking. While visual field irregularities, abnormal pupil reactivity with or without afferent pupillary defect or abnormal optic discs, on physical exam. We finally suggest an algorithm to follow by the ED team in approaching neuro-ophthalmological emergencies as well as a tabulation of different scenarios that could be faced. Adding to that, information on appropriate imaging, urgency as well as feared conditions. • How might these results change the focus of research or clinical practice? The mentioned risk factors are important to guide the ED physician towards neuroimaging while individualizing each case to prevent time-consuming, resource-draining, and sometimes unnecessary workup/imaging. Background Eye complaints are some of the common presenting chief complaints to the Emergency Department (ED). According to the nationally representative data from the United States Nationwide Emergency Department Sample (NEDS) between 2006-2011, an estimated 11 929 955 visits to EDs occurred in the United States for ophthalmic conditions, a mean of nearly 2 million visits per year. Out of those visits, 41.2% are for emergent conditions 1 . Neuro-ophthalmological emergencies are one of the most challenging presentations that require urgent evaluation and management to avoid vision or life-threatening sequelae 2 – 4 . The differential diagnosis is often broad, and the presenting chief complaints include eye pain, blurred vision, vision loss, diplopia, ptosis, and positive visual phenomena (flashes, dots, lights, or colors). Hence, emergency physicians are often faced with the challenge and need for prompt imaging and consultations. The increased speed of testing and wider availability has made Computed Tomography (CT) scans the most commonly used imaging modality in the ED. However, they are less sensitive than Magnetic Resonance Imaging (MRI) in assessing soft tissue. This makes MRI the modality of choice for most neuro-ophthalmological presentations, but MRIs are not readily available in ED settings 5 . Over the past several years, the use of CT and magnetic resonance imaging (MRI) has increased dramatically, but with an increased financial burden where the cost per clinically significant and relevant finding was $ 1,764.19 6 . Additionally, the use of imaging is abused and in some cases, history and physical exam are enough for proper diagnosis and management 7 . In their study, Mehta et al found that only 28.9% of neuroimaging tests requested by neuro-ophthalmologists resulted in an abnormal finding relevant to the patient’s neuro-ophthalmic condition 6 . In this study, we aim to identify the most common chief complaints and physical exam findings that are more likely to be associated with significant and clinically relevant findings on neuroimaging in the ED. These findings will guide the emergency physician in selectively choosing patients that require neuroimaging and in choosing the appropriate imaging modality in order to prevent time-consuming, resource-draining, and often unnecessary radiation exposure. Materials And Methods Study Design and Selection of Participants: This is a retrospective cross-sectional study that was conducted by reviewing the electronic medical records of all patients presenting to the Emergency Department (ED) at the American University of Beirut Medical Center in Lebanon, the largest tertiary care center in the country, between January 1st, 2013 and September 30th, 2019 with isolated neuro-ophthalmologic complaints. We assessed the demographics, presentations, physical exam findings, consultations, imaging studies and findings, and diagnoses of these patients. The described research adhered to the tenets of the Declaration of Helsinki. Data collection and management: We reviewed the electronic health records (patient charts, imaging reports, physicians’ notes) of all patients presenting to the ED with neuro-ophthalmological complaints including vision change, blurriness, vision difficulty, visual disturbance, vision loss, decrease in vision, double vision, orbital pain, eye drooping, floaters, disturbance in the visual field. Patients whose discharge diagnosis was not related to neuro-ophthalmology (e.g. retinal detachment, abrasion, cataracts… etc.) were excluded from the study. Abnormality in imaging was defined as a lesion documented by a radiologist in a report to be matched to the patient’s presentation by a neuro-ophthalmologist who excluded abnormalities in imaging that did not contribute to the possible neuro-ophthalmological disease, such as chronic abnormal findings, and findings anatomically not related to the visual pathway or to any neuro-ophthalmic pathology. That way, the significance in the results is true significance to neuro-ophthalmological imaging findings and not just any irregularity reported by radiology. The relevant abnormal findings on imaging that we considered as positive findings included space occupying pathologies like subarachnoid bleed, intracranial bleed, and intracranial masses, vascular pathologies, mainly thrombosis and aneurysm, and inflammatory pathologies like active demyelinating disease and optic neuritis. Data Analysis: Data was analyzed using the statistical package for the social sciences (IBM SPSS) version 25. Continuous variables were described using the mean and standard deviation, while categorical variables were presented as frequencies and percentages. Statistical differences across the categories of the outcome variables for categorical covariates were determined using Pearson’s Chi-square and Fisher’s exact tests. The Institutional Review Board (IRB) at the American University of Beirut approved this study for meeting ethical standards. Results We identified a total of 1298 patients who presented with ophthalmologic complaints between January 1st, 2013 and September 30th 2019. After excluding those who were found to have purely ophthalmologic diagnoses as described in the methods section, 211 patients were included in the study ( Table 1 ) . Our sample included 107 (50.7%) females and the patients’ age ranged between 5 and 94 years with a mean of 41.2 ±21.4 years. Most patients (53.6%) had unilateral eye complaints while 98 (46.4%) had bilateral complaints. The most commonly reported symptom at presentation was blurry vision (77.3%), followed by headaches (42.2%), change in visual field (20.4%), transient vision loss (24.6%), double vision (23.2%), eye pain (21.8%), floaters (11.4%), dizziness (10.9%), and eyelid droop (5.2%). In addition, 40.3% had associated nausea/vomiting ( Table 1 ). The ophthalmology and neurology teams were both consulted in 20.4% of the cases, while 26.5% received only ophthalmology consults and 28.9% received only neurology consults. Physical exam findings were documented by the ED team as well as by the consultants. On physical examination, the presence of decreased visual acuity was the most common finding (33.6%), followed by abnormal extraocular movements (9.5%) and abnormal optic disc exam (9.0%) (Table 1 ). Table 1 The Characteristics of Patients Presenting to the Emergency Department with Isolated Neuro-ophthalmological Complaints Age in years – Mean (Standard deviation) 41.2 (21.4) Characteristics Count (Percentage) Gender Female Male 107 (50.7) 104 (49.3) Laterality Unilateral Bilateral 113 (53.6) 98 (46.4) Symptoms at Presentation CT in ED (% out of the patients with the symptom) Abnormal CT in ED (% out of CTs performed) MRI in ED (% out of the patients with the symptom) Abnormal MRI in ED (% out of MRIs performed) Total number of patients with a given symptom at presentation Blurred vision 73 (44.8) 11 (15.1) 18 (11.0) 11 (61.1) 163 (77.3) Headache 36 (40.4) 3 (8.3) 10 (11.2) 6 (60.0) 89 (42.2) Change in visual field 23 (53.5) 5 (21.7) 8 (18.6) 5 (62.5) 43 (20.4) Transient vision loss 21 (40.4) 4 (19.0) 6 (11.5) 2 (33.3) 52 (24.6) Double vision 25 (51.0) 5 (20.0) 6 (12.2) 5 (83.3) 49 (23.2) Eye pain 9 (19.6) 1 (11.1) 8 (17.4) 4 (50.0) 46 (21.8) Floaters 7 (29.2) 1 (14.3) 5 (20.8) 2 (40.0) 24 (11.4) Dizziness 15 (65.2) 1 (6.7) 3 (13.0) 2 (66.7) 23 (10.9) Eye droop 6 (54.5) 0 (0.0) 3 (27.3) 2 (66.7) 11 (5.2) Associated Nausea/ vomiting 36 (42.4) 4 (11.1) 15 (17.6) 7 (46.7) 85 (40.3) Physical Exam Findings Decreased visual acuity Abnormal extraocular movements Abnormal optic disc exam Abnormal anterior chamber exam Abnormal posterior chamber exam Afferent pupillary defect Visual field defect Abnormal pupil reactivity 71 (33.6) 20 (9.5) 19 (9.0) 17 (8.1) 14 (6.6) 14 (6.6) 10 (4.7) 7 (3.3) Of the 211 patients, 176 (83.4%) received their final diagnosis in the ED, while the rest required further workup either on outside basis or upon admission. The most common diagnoses were migraine (20.4%) followed by ocular migraine (19.9%), isolated cranial nerve palsy (8.5%) and ischemic stroke (8.1%) (Table 2 ). Most patients (67.3%) were treated and discharged home while 32.7% required hospital admission. Table 2 The Final Diagnoses Reached in the Emergency Department for Patients Presenting with Isolated Neuro-ophthalmological Complaints Final Diagnosis Reached in ED (N= 176) Number of patients with diagnosis (%) Migraine Ocular migraine Isolated cranial nerve palsy Ischemic stroke Retinal vein/ Retinal artery occlusion Psychosomatic Optic neuritis Demyelinating lesion other than optic neuritis Intracranial mass Myasthenia gravis Intracranial bleed Ischemic optic neuropathy Other 43 (20.4) 42 (19.9) 18 (8.5) 17 (8.1) 10 (4.7) 10 (4.7) 8 (3.8) 8 (3.8) 5 (2.4) 4 (1.9) 3 (1.4) 3 (1.4) 5 (2.4 A total of 126 imaging procedures were performed in the ED (Table 3 ). Ninety-four of them (74.6) were head CTs of different modalities, with only 14 (14.9% of the CT scans) showing relevant abnormal findings. Six of the patients with normal CT scans proceeded to do an MRI, with 3 (50%) yielding positive findings on the MRI. Three of the patients with abnormal CT scans proceeded to do a subsequent MRI, with 2 (67.7%) showing abnormal results. Thirty-two brain MRIs (25.4%) of different modalities were performed, with 18 (56.3% of the MRIs) showing relevant abnormal findings. Table 3 The Imaging Procedures Performed in the Emergency Department for Patients Presenting with Isolated Neuro-ophthalmological Complaints Type of Imaging Procedures Performed in the ED Normal Abnormal Total CT Head with contrast 8 (72.7) 3 (27.3) 11 (8.7) CT Head without contrast 65 (85.5) 11 (14.5) 76 (60.3) CT Angiography Head/ Neck 7 (100) 0 (0) 7 (5.5) MRI Brain with gadolinium 3 (25.0) 9 (75.0) 12 (9.5) MRI Brain without gadolinium 3 (42.9) 4 (57.1) 7 (5.5) MR Angiography Brain 7 (70.0) 3 (30.0) 10 (7.9) MRI Orbit 1 (33.3) 2 (66.7) 3 (2.4) Total 94 (74.6) 32 (25.4) 126 (100) Multiple patients underwent follow up imaging studies (Table 4 ). A total of 93 follow up imaging procedures were performed, of which 6 (6.3%) were CT scans and 87 (93.7%) were MRIs. Most of the follow up images were normal (62.4%) while 35 (37.6%) showed relevant abnormal findings. Table 4 The Imaging Procedures Performed on Follow-up* for Patients Presenting with Isolated Neuro-ophthalmological Complaints Count (%) Type of Imaging Procedures Performed on Follow Up Normal Abnormal Total Number of Imaging Procedures CT Head with contrast 2 (100) 0 (0) 2 (2.1) CT Head without contrast 3 (75.0) 1 (25.0) 4 (4.2) CT Angiography Head/ Neck 0 (0) 0 (0) 0 (0) MRI Brain with gadolinium 27 (69.2) 12 (5.7) 39 (41.9) MRI Brain without gadolinium 7 (70.0) 3 (30.0) 10 (10.8) MR Angiography Brain 16 (57.1) 12 (42.9) 28 (30.1) MRI Orbit 3 (3.2) 7 (7.5) 10 (10.8) Total 58 (62.4) 35 (37.6) 93 (100) *Imaging ordered upon following up in the outpatient clinics or later during admission. Having a presenting symptom of blurry vision (p-value= 0.038) or complaining of a change in visual field (p-value= 0.014) was significantly associated with having positive findings on neuroimaging. Moreover, physical exam findings of a visual field defect (p-value= 0.016), abnormal pupil reactivity (p-value= 0.028), afferent pupillary defect (p-value= 0.018), or abnormal optic disc exam (p-value= 0.009) was also significantly associated with having positive findings on neuroimaging. Age, gender, laterality of the chief complaint, the team recommending the imaging procedure (ED, ophthalmology, or neurology), other presenting symptoms, and other physical exam findings did not have any statistically significant association with having positive findings on neuroimaging (Table 5 ). Table 5 The Association Between Selected Covariates and Obtaining a Positive Finding on Imaging Procedures Performed on Patients Presenting with Isolated Neuro-ophthalmological Complaints Total Imaging Findings P-Value Characteristics 96 (100) Normal Abnormal Gender Female Male 49 (51.0) 47 (49.0) 38 (77.6) 38 (80.9) 11 (22.4) 9 (19.1) 0.691 Laterality Unilateral Bilateral 41 (42.7) 55 (57.3) 31 (75.6) 45 (81.8) 10 (24.4) 10 (18.2) 0.459 Symptoms Present at Presentation Blurred vision Yes No 82 (83.3) 14 (14.6) 62 (75.6) 14 (100) 20 (24.4) 0 (0.0) 0.038 Transient vision loss Yes No 24 (25.0) 72 (75.0) 18 (75.0) 58 (80.6) 6 (25.0) 14 (19.4) 0.562 Change in visual field Yes No 27 (28.1) 69 (71.9) 17 (63.0) 59 (85.5) 10 (27.0) 10 (14.5) 0.014 Floaters Yes No 9 (9.4) 87 (90.6) 6 (66.7) 70 (80.5) 3 (33.3) 17 (19.5) 0.389 Double vision Yes No 29 (30.2) 67 (69.8) 21 (72.4) 55 (82.1) 8 (27.6) 12 (17.9) 0.284 Eye pain Yes No 14 (14.6) 82 (83.3) 9 (64.3) 67 (81.7) 5 (35.7) 15 (18.3) 0.160 Eye droop Yes No 8 (8.3) 88 (91.7) 6 (75.0) 70 (79.5) 2 (25.0) 18 (20.5) 0.670 Headache Yes No 42 (43.8) 54 (56.3) 34 (81.0) 42 (77.8) 8 (19.0) 12 (22.2) 0.704 Dizziness Yes No 17 (17.7) 79 (82.3) 14 (82.4) 62 (78.5) 3 (17.6) 17 (21.5) 1.000 Nausea/Vomiting Yes No 44 (45.8) 52 (54.2) 35 (79.5) 41 (78.8) 9 (20.5) 11 (21.2) 0.933 Physical Exam Findings Decreased visual acuity Yes No 28 (29.2) 68 (70.8) 19 (67.9) 57 (83.8) 9 (32.1) 11 (16.2) 0.080 Visual Field Defect Yes No 10 (10.4) 86 (89.5) 5 (50.0( 71 (82.6) 5 (50.0) 15 (17.4) 0.016 Abnormal extraocular movements Yes No 12 (12.5) 84 (87.5) 8 (66.7) 68 (81.0) 4 (33.3) 16 (19.0) 0.266 Abnormal pupil reactivity Yes No 4 (4.2) 92 (95.8) 1 (25.0) 75 (81.5) 3 (75.0) 17 (17.7) 0.028 Afferent pupillary defect Yes No 9 (9.4) 87 (90.6) 4 (44.4) 72 (82.8) 5 (55.6) 15 (15.6) 0.018 Abnormal optic disc exam Yes No 8 (8.3) 88 (91.7) 3 (37.5) 73 (83.0) 5 (62.5) 15 (17.0) 0.009 Abnormal anterior chamber exam Yes No 3 (3.1) 93 (96.9) 3 (100) 73 (78.5) 0 (0.0) 20 (21.5) 1.000 Abnormal posterior chamber exam Yes No 5 (5.2) 91 (94.8) 5 (100) 71 (78.0) 0 (0.0) 20 (22.0) 0.580 Sub-analysis was done based on the type of imaging done (CT versus MRI). The associations aforementioned were lost except for visual field defect on physical exam that was found to be associated with abnormal CT brain imaging (p=0.049) Discussion Our study focused on the neuro-ophthalmological presentations in the Emergency Department (ED) of one of the largest tertiary care centers in the country. To our knowledge there is no other study that looked at neuroophthalmological complaints in the ED, but there are studies that looked at general eye complaints among which neuroophthalmological complaints constituted around 30 percent of the consults. This was the highest subspecialty requiring consultation 8 . In our study, more than three quarters of the presentations required consults and they were almost equally divided between ophthalmology, neurology, and both. No specific consults were made to the neuroophthalmologist, as the medical center is an academic institute and the first line of consult would be the resident on call. When it comes to chief complaints, blurry vision was by far the most frequent followed by headaches, while ocular traumas and red eyes were the most common non-neuroophthalmological eye emergencies in other studies 1 , 9 . Around half of the neuroophthalmological presentations to the emergency department were nonemergent such as migraine, ocular migraine and psycho- somatization which constituted around 50% of the diagnoses. This was in accordance to what Chana et al found when assessing all eye related ED visits in The United States but was more than what Kang found in Taiwan (Only 20% had nonemergent eye conditions) 1 , 10 . We focused in this study on the various neuroimaging modalities used in the emergency department when faced with neuroophthalmological complaint. Although few studies before looked at neuroimaging use in neuroophthalmological diseases, none of them tackled this issue in the ED setting 6 , 7 . We found that 57.8% of our patients underwent neuroimaging. Brain CT scans were more commonly done (74.65%), compared to Brain MRIs (25.4%). Around three quarters of the images were read as normal or with findings unrelated to the chief complaints. Of all the CT images done, only 14.9% had clinically relevant abnormal findings compared to 56.3% with MRIs. Along the same lines, a study found no increased diagnostic value in Brain CTs done for patients with isolated double vision without other neurologic signs 11 . This shows that brain imaging is overused partly because most ED physicians as well as some ophthalmologists and neurologists are uncomfortable and inexperienced in diagnosing neuro-ophthalmological conditions. In this tertiary care center, an MRI would usually require hospital admission to be performed sometimes the following day, hence, the number of MRIs done in the ED was too little to draw conclusions from. The two symptomatic presentations that were significantly more likely to yield a clinically relevant positive finding on imaging were blurred vision and changes in the visual field. It is important, however, to note that a significant percentage of patients had blurred vision (77%) which might reduce the importance of this symptom in predicting positive findings on neuroimaging. As for the signs, visual field defects, abnormal pupil reactivity, APD and abnormal optic disc exam were predictors of relevant abnormal brain imaging. This was consistent with other similar studies that showed highest diagnostic yield in patients with an abnormal pupil reactivity (with an ARPD) 6 , 12 or with a visual field defect 13 . All those physical exam parameters could be assessed by the ED physician at the bedside. Abnormal findings on brain imaging that were considered related to the neuro-ophthalmological presentation included hemorrhage or hypodensity suggestive of stroke, acute lacunar infarcts, inflammation, metastatic lesions involving the visual or ocular motor pathways, and demyelinating diseases. A sub-analysis separating the abnormal findings on CT versus MRI was performed. The only association that remained significant was visual field defect on physical exam. This finding predicted an abnormality on CT scan but not on MRI. The lack of significance in the latter is probably attributed to the small sample size of MRI images done in the ED and it paves the way for future studies with a larger population and a higher number of imaging performed (especially MRI) to possibly achieve significance. While using a CT scan in the ED for its speed and low cost 5 is a quick and sometimes necessary way to rule out certain entities, like bleeding or small orbital fractures 14 , it is rarely helpful in diagnosing neuro-ophthalmological conditions. Therefore, one should be careful when ordering CT scans as some pathologies warrant an MRI, the gold standard diagnostic tool for most neuro-ophthalmic conditions 12 , while others can be diagnosed using proper history and physical exam without the need for any image. One example of an unnecessary CT scan is for a patient aged in the 60ies, who is diabetic and with new onset diplopia. Assessment of the patient showed abducens nerve palsy with no other significant findings. This is most likely microvascular and brain imaging initially is not warranted. Another example is for an adolescent patient also presenting with new onset double vision, after a period of headaches, nausea and vomiting. Eye exam is significant for papilledema. Such a patient will need an MRI and MRV of the brain and CT scan alone is not sufficient. Table 1 summarizes the most common neuroophthalmologic conditions and the need for imaging in various scenarios. As front liners, ED physicians and consultants have the responsibility to make such decisions while considering the cost-effectiveness of the resources, and the additional information the image would add to the working diagnosis. The ED physician should be attentive to both the presentation and physical exam to assess urgency, the need for consultation (ophthalmology or neurology) and threat to sight or life (Table 6 ). Table 6 Steps to follow by the ED team when encountering a patient with a neuro-ophthalmological complaint 1. Obtain a full history, including questions on blurred vision, visual field defects and diplopia. 2. Bedside ophthalmological exam: vision, color vision, confrontational visual field of each eye separately, pupillary reflex testing looking for an APD, cranial nerves assessment including ocular motor, trigeminal, facial and vestibulocochlear nerves, and finally an initial assessment of the optic disc with a direct ophthalmoscope. 3. Based on this initial survey, the ED physician would have the appropriate information to proceed with imaging, to be followed/ or done in parallel with a specialist’s consultation: Neurology or Ophthalmology. 4. The consulted party would then assess its need for further imaging based on their own assessment. We conclude that risk indicators for abnormal neuroimaging in the setting of neuro-ophthalmological emergencies are blurred vision, or changes in visual field on history taking. While visual field irregularities, abnormal pupil reactivity with or without afferent pupillary defect or abnormal optic discs, are risk factors related to physical testing. Although those factors are important and -if present- should sway the ED physician towards neuroimaging (Table 7 ) but still individualizing each case is of utmost importance to prevent time-consuming, resource-draining, and sometimes unnecessary workup/imaging. Table 7 Various neuroophthalmological scenarios in the Emergency Department, with appropriate imaging. Urgency 0-3. 0: imaging not needed, 1: imaging can be done on an outside basis, 2: imaging is needed in ED or after admission, 3: imaging needed urgently for possible life-threatening conditions Symptom/ sign Condition Brain Imaging in ED Urgency Type of image Gadolinium Feared condition Diplopia +/- ptosis History and Exam (H and E) suggestive of microvascular nerve palsy (4th, 6th or complete, pupil sparing 3rd ) No 0 Diplopia/ ptosis Third nerve palsy - otherwise yes 3 MRI brain + MRA / CTA with Cerebral Aneurysm Diplopia Not suggestive of microvascular nerve palsy yes 2 MRI brain/ brainstem with and without Cranial nerve inflammation, infiltration, compression, demyelination Diplopia After orbital trauma yes 2 CT orbit without Orbital fracture with entrapment Diplopia +/-Ptosis History and exam suggestive of Myasthenia Gravis No 1 CT chest with Thymoma Isolated Ptosis Isolated Depends on history 1 Oscillopsia/ nystagmus New onset yes 2 MRI brain/ brainstem with and without Demyelination tumor, Inflammation, Infiltration Anisocoria with ptosis Horner’s Yes 3 MRI/ MRA/ CTA brain and neck up to the thoracic vertebra with Carotid dissection Anisocoria Tonic Pupil No 0 Decrease in vision/ optic nerve swelling H and E suggestive of Non Arteritic Ischemic optic neuropathy No 0 Decrease in vision/ optic nerve swelling H and E suggestive of Arteritic Ischemic optic neuropathy No 1 Visual Field Defect Bitemporal hemianopsia/ Junctional Scotoma Yes 3 CT/ MRI brain/ Sella with and without Pituitary apoplexy/ optic chiasmal compression Visual field defect Homonymous hemianopsia Yes 3 CT/ MRI brain with and without Intracranial bleed/ Cerebrovascular accident (CVA)/ tumor Transient vision loss Lasting seconds to minutes yes 3 CT/ MRI with Transient ischemic attack, embolism MRA/ CTA Of brain and neck Transient blurry vision Lasting 20-60 minutes followed by headaches no 1 Bilateral Optic nerve swelling + headaches Papilledema Yes 2 MRI with Tumor, cerebral venous thrombosis MRV Scintillating scotoma Followed by headaches no 0 Positive visual disturbances Flashes, visual snow, palinopsia No 1 Epilepsy Optic nerve swelling H and E suggestive of drusen No 0 Decrease vision, eye pain +/- optic nerve swelling H and E suggestive of optic neuritis yes 2 MRI brain and orbit with fat suppression with and without demyelinating disease Decrease vision with optic nerve swelling or pallor Not suggestive of optic neuritis or ischemic optic neuropathy yes 2 MRI brain and orbit with fat suppression with and without Compressive/ infiltrative Multiple cranial nerve palsies combination of 2,3,4,5 and 6 yes 3 MRI/ MRA/ MRV or CT/ CTA/ CTV with Orbital apex or cavernous pathologies including aneurysm, thrombosis and carotid cavernous fistulas Optic ataxia, simultagnosia ocular motor apraxia Ballint's Triad yes 2 MRI/ CT with and without Intracranial bleed/ Cerebrovascular accident (CVA)/ tumor/ posterior cortical atrophy Abbreviations ED: Emergency Department CT: Computed Tomography CTA: Computed Tomography Angiography MRI: Magnetic Resonance Imaging MRA: Magnetic Resonance Angiography MRV: Magnetic Resonance Venography H and E: History and Physical Exam APD: Afferent Pupillary Defect IRB: Institutional Review Board Declarations Patients or the public WERE NOT involved in the design, or conduct, or reporting, or dissemination plans of our research. Ethics approval : This study and its protocol was approved by the Institutional Review Board (IRB) at the American University of Beirut (AUBMC). The IRB has waived the need for obtaining informed consent. The data collection, analysis and manuscript hold no Personal Identifiable Data of patients or their charts. Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research. Consent to participate : Not applicable Consent for Publication: Not applicable Competing interests : No conflicting relationship exists for any author Funding: None Availability of Data and Material: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. The data are not publicly available because they contain information that might compromise the privacy of the participants in the study. Acknowledgements : None Authors Contributions: Tharwat El Zahran M.D. Conception of the work, Design of the work, Drafting the work and Revising the work critically for important intellectual content, Final approval of the version to be published, and Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Dalia El Hadi M.D. Conception of the work, Design of the work, Drafting the work and Revising the work critically for important intellectual content, Final approval of the version to be published, and Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Hala Mostafa M.D. Conception of the work, Design of the work, Drafting the work and Revising the work critically for important intellectual content, Final approval of the version to be published, and Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Hana Mansour M.D. Conception of the work, Design of the work, Drafting the work and Revising the work critically for important intellectual content, Final approval of the version to be published, and Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Ibrahim Hashim M.D. Conception of the work, Design of the work, Drafting the work and Revising the work critically for important intellectual content, Final approval of the version to be published, and Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Soubhi Tahhan Conception of the work, Design of the work, Drafting the work and Revising the work critically for important intellectual content, Final approval of the version to be published, and Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Alaa Bou Ghannam M.D. Conception of the work, Design of the work, Drafting the work and Revising the work critically for important intellectual content, Final approval of the version to be published, and Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. References Channa R, Zafar SN, Canner JK, Haring RS, Schneider EB, Friedman DS. Epidemiology of Eye-Related Emergency Department Visits. JAMA ophthalmology. 2016;134(3):312–319. Huff JS, Austin EW. Neuro-Ophthalmology in Emergency Medicine. Emergency medicine clinics of North America. 2016;34(4):967–986. Joa ̃o Lemos EE. Neuro-Ophthalmological Emergencies. The Neurohospitalist. 2015;5:223–233. Turgut BTFCaKFA. Neuro-ophthalmological emergency disorders: A general view. International Journal of Clinical and Experimental Ophthalmology. 2017;1(1):060–066. Paramdeep Singh RK. A review of imaging techniques in Neuro-ophthalmology Biological and Biomedical Reports. 2012;2(2):99–107. Mehta S, Loevner LA, Mikityansky I, et al. The diagnostic and economic yield of neuroimaging in neuro-ophthalmology. J Neuroophthalmol. 2012;32(2):139–144. Joshua M. Kruger DMC, and Mary Beth Cunnane. Systematic approaches for reviewing neuro-imaging scans in ophthalmology. Digit Journal of Ophthalmology. 2017;23(3):50–59. Daniel J Oh LNK, Judy L Chen, Ahmad A Aref, William F Mieler, Peter W MacIntosh Inpatient and Emergency Room Ophthalmology Consultations at a Tertiary Care Center. Journal of Ophthalmology. 2019. Baig R, Ahmad, K., Zafar, S., Khan, N., Ashfaq. Frequency of ocular emergencies in a tertiary care setting in Karachi, Pakistan - It is time to reduce unnecessary visits. Journal of the Pakistan Medical Association. 2018;68(10):1493–1495. Kang EY TW, Lin JY, Huang CJ, Yeh PH, Wu WC, Wang FL, Liu L, Lai CC, Chen KJ. Eye-related Emergency Department Visits with Ophthalmology Consultation in Taiwan: Visual Acuity as an Indicator of Ocular Emergency. Nature Scientific Reports 2020;10(1). Nazerian P, Vanni S, Tarocchi C, et al. Causes of diplopia in the emergency department: diagnostic accuracy of clinical assessment and of head computed tomography. European Journal of Emergency Medicine. 2014;21(2):118–124. Jeong-Yong Lee, Jung-Heon Kim, Hyung-Rae Cho, et al. Requirement for Head Magnetic Resonance Imaging in Children Who Present to the Emergency Department With Acute Nontraumatic Visual Disturbance. Pediatric Emergency Care. 2019;35(5). Margolin E. CT only useful for selected patients presenting with primary eye complaints in the emergency department. American Journal of Emergency Medicine. 2016;36(1):134. Tahira Nishtar TA, Nosheen Noor, and Fayaz Muhammad. Rational use of Computed Tomography Scan head in the Emergency Department of a high volume tertiary care public sector hospital. Pakistan Journal of Medical Sciences. 2019;35(2). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 2 posted You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-630811","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":84976231,"identity":"6a425a25-afa1-4a2b-a778-0d42a40b9c15","order_by":0,"name":"Tharwat El Zahran","email":"","orcid":"","institution":"American University of Beirut Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tharwat","middleName":"El","lastName":"Zahran","suffix":""},{"id":84976232,"identity":"f595401e-e6ff-4fc5-876d-66dfce8cf3a1","order_by":1,"name":"Dalia El Hadi","email":"","orcid":"","institution":"American University of Beirut Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dalia","middleName":"El","lastName":"Hadi","suffix":""},{"id":84976233,"identity":"bac433ba-f039-453f-9a78-f33038caeb7c","order_by":2,"name":"Hala Mostafa","email":"","orcid":"","institution":"American University of Beirut Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hala","middleName":"","lastName":"Mostafa","suffix":""},{"id":84976234,"identity":"9f44658f-f58c-4cc0-a2ea-6c58c518c9f1","order_by":3,"name":"Hana Mansour","email":"","orcid":"","institution":"American University of Beirut Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hana","middleName":"","lastName":"Mansour","suffix":""},{"id":84976235,"identity":"a1a7d1a6-c8fe-448f-b89d-90eceaa2fd1e","order_by":4,"name":"Ibrahim Hashim","email":"","orcid":"","institution":"American University of Beirut Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ibrahim","middleName":"","lastName":"Hashim","suffix":""},{"id":84976236,"identity":"ef4c4068-f29f-410a-a61f-1d3611efe794","order_by":5,"name":"Soubhi Tahhan","email":"","orcid":"","institution":"American University of Beirut Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Soubhi","middleName":"","lastName":"Tahhan","suffix":""},{"id":84976237,"identity":"1af69356-c81c-4799-a495-74b79174ca2c","order_by":6,"name":"Alaa Bou Ghannam","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuUlEQVRIiWNgGAWjYDACCf6HDz4wMCQAmQYMDAUHiNHCw2w4A67FgDgtbNI8JGnhn9172Nim5nAeA3vzNgkGgztEWHLnXOLjnGOHixl4jpUBtTwjwmE3EoyNc9gOJzZI5JgBtRwmrEP+RoKZtMU/oBb5N0RqMbiRYybN2AayhYdILYZ3jiUb9valF7PxpBVbJBDjF7nbzQcf/PhmncfPfnjjjQ8VRIQYHLCBiAQSNIyCUTAKRsEowAMAdx86iYzR3W0AAAAASUVORK5CYII=","orcid":"","institution":"American University of Beirut Medical Center","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Alaa","middleName":"Bou","lastName":"Ghannam","suffix":""}],"badges":[],"createdAt":"2021-06-16 18:59:04","currentVersionCode":2,"declarations":"","doi":"10.21203/rs.3.rs-630811/v2","doiUrl":"https://doi.org/10.21203/rs.3.rs-630811/v2","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":19317381,"identity":"9a924abc-dd0f-4ef9-bba3-49cbbe83464f","added_by":"auto","created_at":"2022-03-17 05:44:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":567354,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-630811/v2/5dc6f399-4bac-4ad9-af65-f15ef58a4696.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Yield of Neuroimaging in Patients Presenting to the Emergency Department with Isolated Neuro-ophthalmological Complaints","fulltext":[{"header":"Key Messages","content":"\u003cp\u003e\u003cu\u003e\u0026bull; What is already known about this subject?\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe advancements in neuroimaging is allowing physicians to distinguish brain lesions. The most commonly used imaging modalities by neuro-ophthalmologists would be the Brain Computed tomography (CT) and Magnetic resonance imaging (MRI). There is overuse of such imaging especially in non-indicated cases. There are however, some findings on history and physical exam that would suggest positive findings on imaging. Multiple studies previously commented on those findings separately. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u0026bull; What are the new findings?\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eOur study presents grouping of risk indicators in both history and physical exam (mainly ophthalmological) that would suggest an abnormal neuroimaging in the setting of neuro-ophthalmological emergencies. They are blurred vision, or changes in visual field on history taking. While visual field irregularities, abnormal pupil reactivity with or without afferent pupillary defect or abnormal optic discs, on physical exam. We finally suggest an algorithm to follow by the ED team in approaching neuro-ophthalmological emergencies as well as a tabulation of different scenarios that could be faced. Adding to that, information on appropriate imaging, urgency as well as feared conditions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u0026bull; How might these results change the focus of research or clinical practice?\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe mentioned risk factors are important to guide the ED physician towards neuroimaging while individualizing each case to prevent time-consuming, resource-draining, and sometimes unnecessary workup/imaging. \u0026nbsp;\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eEye complaints are some of the common presenting chief complaints to the Emergency Department (ED). According to the nationally representative data from the United States Nationwide Emergency Department Sample (NEDS) between 2006-2011, an estimated 11 929 955 visits to EDs occurred in the United States for ophthalmic conditions, a mean of nearly 2 million visits per year. Out of those visits, 41.2% are for emergent conditions \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Neuro-ophthalmological emergencies are one of the most challenging presentations that require urgent evaluation and management to avoid vision or life-threatening sequelae \u003csup\u003e\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. The differential diagnosis is often broad, and the presenting chief complaints include eye pain, blurred vision, vision loss, diplopia, ptosis, and positive visual phenomena (flashes, dots, lights, or colors). Hence, emergency physicians are often faced with the challenge and need for prompt imaging and consultations.\u003c/p\u003e \u003cp\u003eThe increased speed of testing and wider availability has made Computed Tomography (CT) scans the most commonly used imaging modality in the ED. However, they are less sensitive than Magnetic Resonance Imaging (MRI) in assessing soft tissue. This makes MRI the modality of choice for most neuro-ophthalmological presentations, but MRIs are not readily available in ED settings \u003csup\u003e \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e \u003c/sup\u003e. Over the past several years, the use of CT and magnetic resonance imaging (MRI) has increased dramatically, but with an increased financial burden where the cost per clinically significant and relevant finding was \u003cspan\u003e$\u003c/span\u003e1,764.19 \u003csup\u003e6\u003c/sup\u003e. Additionally, the use of imaging is abused and in some cases, history and physical exam are enough for proper diagnosis and management \u003csup\u003e \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e \u003c/sup\u003e. In their study, Mehta et al found that only 28.9% of neuroimaging tests requested by neuro-ophthalmologists resulted in an abnormal finding relevant to the patient\u0026rsquo;s neuro-ophthalmic condition \u003csup\u003e \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e \u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn this study, we aim to identify the most common chief complaints and physical exam findings that are more likely to be associated with significant and clinically relevant findings on neuroimaging in the ED. These findings will guide the emergency physician in selectively choosing patients that require neuroimaging and in choosing the appropriate imaging modality in order to prevent time-consuming, resource-draining, and often unnecessary radiation exposure.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Selection of Participants:\u003c/h2\u003e \u003cp\u003e This is a retrospective cross-sectional study that was conducted by reviewing the electronic medical records of all patients presenting to the Emergency Department (ED) at the American University of Beirut Medical Center in Lebanon, the largest tertiary care center in the country, between January 1st, 2013 and September 30th, 2019 with isolated neuro-ophthalmologic complaints. We assessed the demographics, presentations, physical exam findings, consultations, imaging studies and findings, and diagnoses of these patients. The described research adhered to the tenets of the Declaration of Helsinki.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection and management:\u003c/h2\u003e \u003cp\u003eWe reviewed the electronic health records (patient charts, imaging reports, physicians\u0026rsquo; notes) of all patients presenting to the ED with neuro-ophthalmological complaints including vision change, blurriness, vision difficulty, visual disturbance, vision loss, decrease in vision, double vision, orbital pain, eye drooping, floaters, disturbance in the visual field. Patients whose discharge diagnosis was not related to neuro-ophthalmology (e.g. retinal detachment, abrasion, cataracts\u0026hellip; etc.) were excluded from the study.\u003c/p\u003e \u003cp\u003eAbnormality in imaging was defined as a lesion documented by a radiologist in a report to be matched to the patient\u0026rsquo;s presentation by a neuro-ophthalmologist who excluded abnormalities in imaging that did not contribute to the possible neuro-ophthalmological disease, such as chronic abnormal findings, and findings anatomically not related to the visual pathway or to any neuro-ophthalmic pathology. That way, the significance in the results is true significance to neuro-ophthalmological imaging findings and not just any irregularity reported by radiology.\u003c/p\u003e \u003cp\u003eThe relevant abnormal findings on imaging that we considered as positive findings included space occupying pathologies like subarachnoid bleed, intracranial bleed, and intracranial masses, vascular pathologies, mainly thrombosis and aneurysm, and inflammatory pathologies like active demyelinating disease and optic neuritis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis:\u003c/h2\u003e \u003cp\u003eData was analyzed using the statistical package for the social sciences (IBM SPSS) version 25. Continuous variables were described using the mean and standard deviation, while categorical variables were presented as frequencies and percentages. Statistical differences across the categories of the outcome variables for categorical covariates were determined using Pearson\u0026rsquo;s Chi-square and Fisher\u0026rsquo;s exact tests.\u003c/p\u003e \u003cp\u003e The Institutional Review Board (IRB) at the American University of Beirut approved this study for meeting ethical standards.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eWe identified a total of 1298 patients who presented with ophthalmologic complaints between January 1st, 2013 and September 30th 2019. After excluding those who were found to have purely ophthalmologic diagnoses as described in the methods section, 211 patients were included in the study \u003cb\u003e(\u003c/b\u003eTable \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Our sample included 107 (50.7%) females and the patients\u0026rsquo; age ranged between 5 and 94 years with a mean of 41.2 \u0026plusmn;21.4 years.\u003c/p\u003e \u003cp\u003eMost patients (53.6%) had unilateral eye complaints while 98 (46.4%) had bilateral complaints. The most commonly reported symptom at presentation was blurry vision (77.3%), followed by headaches (42.2%), change in visual field (20.4%), transient vision loss (24.6%), double vision (23.2%), eye pain (21.8%), floaters (11.4%), dizziness (10.9%), and eyelid droop (5.2%). In addition, 40.3% had associated nausea/vomiting \u003cb\u003e(\u003c/b\u003eTable \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe ophthalmology and neurology teams were both consulted in 20.4% of the cases, while 26.5% received only ophthalmology consults and 28.9% received only neurology consults. Physical exam findings were documented by the ED team as well as by the consultants. On physical examination, the presence of decreased visual acuity was the most common finding (33.6%), followed by abnormal extraocular movements (9.5%) and abnormal optic disc exam (9.0%) (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe Characteristics of Patients Presenting to the Emergency Department with Isolated Neuro-ophthalmological Complaints\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eAge in years \u0026ndash; Mean (Standard deviation)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41.2 (21.4)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCharacteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCount (Percentage)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e107 (50.7)\u003c/p\u003e \u003cp\u003e104 (49.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLaterality\u003c/b\u003e\u003c/p\u003e \u003cp\u003eUnilateral\u003c/p\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e113 (53.6)\u003c/p\u003e \u003cp\u003e98 (46.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSymptoms at Presentation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCT in ED (% out of the patients with the symptom)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eAbnormal CT in ED (% out of CTs performed)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMRI in ED (% out of the patients with the symptom)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eAbnormal MRI in ED (% out of MRIs performed)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eTotal number of patients with a given symptom at presentation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlurred vision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73 (44.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (15.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (61.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e163 (77.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeadache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (40.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (11.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e89 (42.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChange in visual field\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (53.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (18.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e43 (20.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransient vision loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (40.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e52 (24.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDouble vision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (51.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e49 (23.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEye pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (17.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e46 (21.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFloaters\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (29.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24 (11.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDizziness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (65.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23 (10.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEye droop\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (54.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11 (5.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssociated Nausea/ vomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (42.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (17.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e85 (40.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysical Exam Findings\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eDecreased visual acuity\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eAbnormal extraocular movements\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eAbnormal optic disc exam\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eAbnormal anterior chamber exam\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eAbnormal posterior chamber exam\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eAfferent pupillary defect\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eVisual field defect\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eAbnormal pupil reactivity\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e71 (33.6)\u003c/p\u003e \u003cp\u003e20 (9.5)\u003c/p\u003e \u003cp\u003e19 (9.0)\u003c/p\u003e \u003cp\u003e17 (8.1)\u003c/p\u003e \u003cp\u003e14 (6.6)\u003c/p\u003e \u003cp\u003e14 (6.6)\u003c/p\u003e \u003cp\u003e10 (4.7)\u003c/p\u003e \u003cp\u003e7 (3.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOf the 211 patients, 176 (83.4%) received their final diagnosis in the ED, while the rest required further workup either on outside basis or upon admission. The most common diagnoses were migraine (20.4%) followed by ocular migraine (19.9%), isolated cranial nerve palsy (8.5%) and ischemic stroke (8.1%) (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Most patients (67.3%) were treated and discharged home while 32.7% required hospital admission.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe Final Diagnoses Reached in the Emergency Department for Patients Presenting with Isolated Neuro-ophthalmological Complaints\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal Diagnosis Reached in ED (N= 176)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of patients with diagnosis (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMigraine\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eOcular migraine\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eIsolated cranial nerve palsy\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eIschemic stroke\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eRetinal vein/ Retinal artery occlusion\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003ePsychosomatic\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eOptic neuritis\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eDemyelinating lesion other than optic neuritis\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eIntracranial mass\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eMyasthenia gravis\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eIntracranial bleed\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eIschemic optic neuropathy\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eOther\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (20.4)\u003c/p\u003e \u003cp\u003e42 (19.9)\u003c/p\u003e \u003cp\u003e18 (8.5)\u003c/p\u003e \u003cp\u003e17 (8.1)\u003c/p\u003e \u003cp\u003e10 (4.7)\u003c/p\u003e \u003cp\u003e10 (4.7)\u003c/p\u003e \u003cp\u003e8 (3.8)\u003c/p\u003e \u003cp\u003e8 (3.8)\u003c/p\u003e \u003cp\u003e5 (2.4)\u003c/p\u003e \u003cp\u003e4 (1.9)\u003c/p\u003e \u003cp\u003e3 (1.4)\u003c/p\u003e \u003cp\u003e3 (1.4)\u003c/p\u003e \u003cp\u003e5 (2.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA total of 126 imaging procedures were performed in the ED (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Ninety-four of them (74.6) were head CTs of different modalities, with only 14 (14.9% of the CT scans) showing relevant abnormal findings. Six of the patients with normal CT scans proceeded to do an MRI, with 3 (50%) yielding positive findings on the MRI. Three of the patients with abnormal CT scans proceeded to do a subsequent MRI, with 2 (67.7%) showing abnormal results. Thirty-two brain MRIs (25.4%) of different modalities were performed, with 18 (56.3% of the MRIs) showing relevant abnormal findings.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe Imaging Procedures Performed in the Emergency Department for Patients Presenting with Isolated Neuro-ophthalmological Complaints\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of Imaging Procedures Performed in the ED\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbnormal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCT Head with contrast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (72.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (8.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCT Head without contrast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (85.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76 (60.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCT Angiography Head/ Neck\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (5.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMRI Brain with gadolinium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (9.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMRI Brain without gadolinium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (5.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMR Angiography Brain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (70.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (7.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMRI Orbit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94 (74.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (25.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e126 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMultiple patients underwent follow up imaging studies (Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). A total of 93 follow up imaging procedures were performed, of which 6 (6.3%) were CT scans and 87 (93.7%) were MRIs. Most of the follow up images were normal (62.4%) while 35 (37.6%) showed relevant abnormal findings.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe Imaging Procedures Performed on Follow-up* for Patients Presenting with Isolated Neuro-ophthalmological Complaints\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eCount (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of Imaging Procedures Performed on Follow Up\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNormal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eAbnormal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eTotal Number of Imaging Procedures\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCT Head with contrast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (2.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCT Head without contrast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (4.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCT Angiography Head/ Neck\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMRI Brain with gadolinium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (41.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMRI Brain without gadolinium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (70.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (10.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMR Angiography Brain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (30.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMRI Orbit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (10.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (62.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (37.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Imaging ordered upon following up in the outpatient clinics or later during admission.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHaving a presenting symptom of blurry vision (p-value= 0.038) or complaining of a change in visual field (p-value= 0.014) was significantly associated with having positive findings on neuroimaging. Moreover, physical exam findings of a visual field defect (p-value= 0.016), abnormal pupil reactivity (p-value= 0.028), afferent pupillary defect (p-value= 0.018), or abnormal optic disc exam (p-value= 0.009) was also significantly associated with having positive findings on neuroimaging. Age, gender, laterality of the chief complaint, the team recommending the imaging procedure (ED, ophthalmology, or neurology), other presenting symptoms, and other physical exam findings did not have any statistically significant association with having positive findings on neuroimaging (Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe Association Between Selected Covariates and Obtaining a Positive Finding on Imaging Procedures Performed on Patients Presenting with Isolated Neuro-ophthalmological Complaints\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eImaging Findings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCharacteristics\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e96 (100)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eNormal\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eAbnormal\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (51.0)\u003c/p\u003e \u003cp\u003e47 (49.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (77.6)\u003c/p\u003e \u003cp\u003e38 (80.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (22.4)\u003c/p\u003e \u003cp\u003e9 (19.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.691\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLaterality\u003c/b\u003e\u003c/p\u003e \u003cp\u003eUnilateral\u003c/p\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (42.7)\u003c/p\u003e \u003cp\u003e55 (57.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (75.6)\u003c/p\u003e \u003cp\u003e45 (81.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (24.4)\u003c/p\u003e \u003cp\u003e10 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.459\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSymptoms Present at Presentation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlurred vision\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82 (83.3)\u003c/p\u003e \u003cp\u003e14 (14.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (75.6)\u003c/p\u003e \u003cp\u003e14 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (24.4)\u003c/p\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.038\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransient vision loss\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (25.0)\u003c/p\u003e \u003cp\u003e72 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (75.0)\u003c/p\u003e \u003cp\u003e58 (80.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (25.0)\u003c/p\u003e \u003cp\u003e14 (19.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.562\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChange in visual field\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (28.1)\u003c/p\u003e \u003cp\u003e69 (71.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (63.0)\u003c/p\u003e \u003cp\u003e59 (85.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (27.0)\u003c/p\u003e \u003cp\u003e10 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.014\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFloaters\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (9.4)\u003c/p\u003e \u003cp\u003e87 (90.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (66.7)\u003c/p\u003e \u003cp\u003e70 (80.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (33.3)\u003c/p\u003e \u003cp\u003e17 (19.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.389\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDouble vision\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (30.2)\u003c/p\u003e \u003cp\u003e67 (69.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (72.4)\u003c/p\u003e \u003cp\u003e55 (82.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (27.6)\u003c/p\u003e \u003cp\u003e12 (17.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.284\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEye pain\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (14.6)\u003c/p\u003e \u003cp\u003e82 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (64.3)\u003c/p\u003e \u003cp\u003e67 (81.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (35.7)\u003c/p\u003e \u003cp\u003e15 (18.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.160\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEye droop\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (8.3)\u003c/p\u003e \u003cp\u003e88 (91.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (75.0)\u003c/p\u003e \u003cp\u003e70 (79.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (25.0)\u003c/p\u003e \u003cp\u003e18 (20.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.670\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeadache\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (43.8)\u003c/p\u003e \u003cp\u003e54 (56.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (81.0)\u003c/p\u003e \u003cp\u003e42 (77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (19.0)\u003c/p\u003e \u003cp\u003e12 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.704\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDizziness\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (17.7)\u003c/p\u003e \u003cp\u003e79 (82.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (82.4)\u003c/p\u003e \u003cp\u003e62 (78.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (17.6)\u003c/p\u003e \u003cp\u003e17 (21.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNausea/Vomiting\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (45.8)\u003c/p\u003e \u003cp\u003e52 (54.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (79.5)\u003c/p\u003e \u003cp\u003e41 (78.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (20.5)\u003c/p\u003e \u003cp\u003e11 (21.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.933\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysical Exam Findings\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecreased visual acuity\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (29.2)\u003c/p\u003e \u003cp\u003e68 (70.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (67.9)\u003c/p\u003e \u003cp\u003e57 (83.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (32.1)\u003c/p\u003e \u003cp\u003e11 (16.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.080\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisual Field Defect\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (10.4)\u003c/p\u003e \u003cp\u003e86 (89.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (50.0(\u003c/p\u003e \u003cp\u003e71 (82.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (50.0)\u003c/p\u003e \u003cp\u003e15 (17.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.016\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbnormal extraocular movements\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (12.5)\u003c/p\u003e \u003cp\u003e84 (87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (66.7)\u003c/p\u003e \u003cp\u003e68 (81.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (33.3)\u003c/p\u003e \u003cp\u003e16 (19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.266\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbnormal pupil reactivity\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (4.2)\u003c/p\u003e \u003cp\u003e92 (95.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (25.0)\u003c/p\u003e \u003cp\u003e75 (81.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (75.0)\u003c/p\u003e \u003cp\u003e17 (17.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.028\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfferent pupillary defect\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (9.4)\u003c/p\u003e \u003cp\u003e87 (90.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (44.4)\u003c/p\u003e \u003cp\u003e72 (82.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (55.6)\u003c/p\u003e \u003cp\u003e15 (15.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.018\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbnormal optic disc exam\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (8.3)\u003c/p\u003e \u003cp\u003e88 (91.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (37.5)\u003c/p\u003e \u003cp\u003e73 (83.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (62.5)\u003c/p\u003e \u003cp\u003e15 (17.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbnormal anterior chamber exam\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (3.1)\u003c/p\u003e \u003cp\u003e93 (96.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (100)\u003c/p\u003e \u003cp\u003e73 (78.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003cp\u003e20 (21.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbnormal posterior chamber exam\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (5.2)\u003c/p\u003e \u003cp\u003e91 (94.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (100)\u003c/p\u003e \u003cp\u003e71 (78.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003cp\u003e20 (22.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.580\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSub-analysis was done based on the type of imaging done (CT versus MRI). The associations aforementioned were lost except for visual field defect on physical exam that was found to be associated with abnormal CT brain imaging (p=0.049)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e Our study focused on the neuro-ophthalmological presentations in the Emergency Department (ED) of one of the largest tertiary care centers in the country. To our knowledge there is no other study that looked at neuroophthalmological complaints in the ED, but there are studies that looked at general eye complaints among which neuroophthalmological complaints constituted around 30 percent of the consults. This was the highest subspecialty requiring consultation \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. In our study, more than three quarters of the presentations required consults and they were almost equally divided between ophthalmology, neurology, and both. No specific consults were made to the neuroophthalmologist, as the medical center is an academic institute and the first line of consult would be the resident on call.\u003c/p\u003e \u003cp\u003eWhen it comes to chief complaints, blurry vision was by far the most frequent followed by headaches, while ocular traumas and red eyes were the most common non-neuroophthalmological eye emergencies in other studies \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Around half of the neuroophthalmological presentations to the emergency department were nonemergent such as migraine, ocular migraine and psycho- somatization which constituted around 50% of the diagnoses. This was in accordance to what Chana et al found when assessing all eye related ED visits in The United States but was more than what Kang found in Taiwan (Only 20% had nonemergent eye conditions) \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWe focused in this study on the various neuroimaging modalities used in the emergency department when faced with neuroophthalmological complaint. Although few studies before looked at neuroimaging use in neuroophthalmological diseases, none of them tackled this issue in the ED setting \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWe found that 57.8% of our patients underwent neuroimaging. Brain CT scans were more commonly done (74.65%), compared to Brain MRIs (25.4%). Around three quarters of the images were read as normal or with findings unrelated to the chief complaints. Of all the CT images done, only 14.9% had clinically relevant abnormal findings compared to 56.3% with MRIs. Along the same lines, a study found no increased diagnostic value in Brain CTs done for patients with isolated double vision without other neurologic signs \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. This shows that brain imaging is overused partly because most ED physicians as well as some ophthalmologists and neurologists are uncomfortable and inexperienced in diagnosing neuro-ophthalmological conditions. In this tertiary care center, an MRI would usually require hospital admission to be performed sometimes the following day, hence, the number of MRIs done in the ED was too little to draw conclusions from.\u003c/p\u003e \u003cp\u003eThe two symptomatic presentations that were significantly more likely to yield a clinically relevant positive finding on imaging were blurred vision and changes in the visual field. It is important, however, to note that a significant percentage of patients had blurred vision (77%) which might reduce the importance of this symptom in predicting positive findings on neuroimaging. As for the signs, visual field defects, abnormal pupil reactivity, APD and abnormal optic disc exam were predictors of relevant abnormal brain imaging. This was consistent with other similar studies that showed highest diagnostic yield in patients with an abnormal pupil reactivity (with an ARPD) \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e or with a visual field defect \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. All those physical exam parameters could be assessed by the ED physician at the bedside.\u003c/p\u003e \u003cp\u003eAbnormal findings on brain imaging that were considered related to the neuro-ophthalmological presentation included hemorrhage or hypodensity suggestive of stroke, acute lacunar infarcts, inflammation, metastatic lesions involving the visual or ocular motor pathways, and demyelinating diseases. A sub-analysis separating the abnormal findings on CT versus MRI was performed. The only association that remained significant was visual field defect on physical exam. This finding predicted an abnormality on CT scan but not on MRI. The lack of significance in the latter is probably attributed to the small sample size of MRI images done in the ED and it paves the way for future studies with a larger population and a higher number of imaging performed (especially MRI) to possibly achieve significance.\u003c/p\u003e \u003cp\u003eWhile using a CT scan in the ED for its speed and low cost \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e is a quick and sometimes necessary way to rule out certain entities, like bleeding or small orbital fractures \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, it is rarely helpful in diagnosing neuro-ophthalmological conditions. Therefore, one should be careful when ordering CT scans as some pathologies warrant an MRI, the gold standard diagnostic tool for most neuro-ophthalmic conditions \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e, while others can be diagnosed using proper history and physical exam without the need for any image.\u003c/p\u003e \u003cp\u003eOne example of an unnecessary CT scan is for a patient aged in the 60ies, who is diabetic and with new onset diplopia. Assessment of the patient showed abducens nerve palsy with no other significant findings. This is most likely microvascular and brain imaging initially is not warranted. Another example is for an adolescent patient also presenting with new onset double vision, after a period of headaches, nausea and vomiting. Eye exam is significant for papilledema. Such a patient will need an MRI and MRV of the brain and CT scan alone is not sufficient. Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the most common neuroophthalmologic conditions and the need for imaging in various scenarios. As front liners, ED physicians and consultants have the responsibility to make such decisions while considering the cost-effectiveness of the resources, and the additional information the image would add to the working diagnosis. The ED physician should be attentive to both the presentation and physical exam to assess urgency, the need for consultation (ophthalmology or neurology) and threat to sight or life (Table \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSteps to follow by the ED team when encountering a patient with a neuro-ophthalmological complaint\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. \u0026nbsp; Obtain a full history, including questions on blurred vision, visual field defects and diplopia.\u003c/p\u003e \u003cp\u003e2. \u0026nbsp; \u0026nbsp;Bedside ophthalmological exam: vision, color vision, confrontational visual field of each eye separately, pupillary reflex testing looking for an APD, cranial nerves assessment including ocular motor, trigeminal, facial and vestibulocochlear nerves, and finally an initial assessment of the optic disc with a direct ophthalmoscope.\u003c/p\u003e \u003cp\u003e3. \u0026nbsp; Based on this initial survey, the ED physician would have the appropriate information to proceed with imaging, to be followed/ or done in parallel with a specialist\u0026rsquo;s consultation: Neurology or Ophthalmology.\u003c/p\u003e \u003cp\u003e4. \u0026nbsp; The consulted party would then assess its need for further imaging based on their own assessment.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWe conclude that risk indicators for abnormal neuroimaging in the setting of neuro-ophthalmological emergencies are blurred vision, or changes in visual field on history taking. While visual field irregularities, abnormal pupil reactivity with or without afferent pupillary defect or abnormal optic discs, are risk factors related to physical testing. Although those factors are important and -if present- should sway the ED physician towards neuroimaging (Table \u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e) but still individualizing each case is of utmost importance to prevent time-consuming, resource-draining, and sometimes unnecessary workup/imaging.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eVarious neuroophthalmological scenarios in the Emergency Department, with appropriate imaging. Urgency 0-3. 0: imaging not needed, 1: imaging can be done on an outside basis, 2: imaging is needed in ED or after admission, 3: imaging needed urgently for possible life-threatening conditions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptom/ sign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCondition\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBrain Imaging in ED\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUrgency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eType of image\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGadolinium\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFeared condition\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiplopia +/- ptosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHistory and Exam (H and E) suggestive of microvascular nerve palsy (4th, 6th or complete, pupil sparing 3rd )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiplopia/ ptosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThird nerve palsy - otherwise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMRI brain + MRA / CTA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ewith\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCerebral Aneurysm\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiplopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot suggestive of microvascular nerve palsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMRI brain/ brainstem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ewith and without\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCranial nerve inflammation, infiltration, compression, demyelination\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiplopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter orbital trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCT orbit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ewithout\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOrbital fracture with entrapment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiplopia +/-Ptosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHistory and exam suggestive of Myasthenia Gravis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCT chest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ewith\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThymoma\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIsolated Ptosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIsolated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDepends on history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOscillopsia/ nystagmus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNew onset\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMRI brain/ brainstem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ewith and without\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDemyelination tumor, Inflammation, Infiltration\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnisocoria with ptosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHorner\u0026rsquo;s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMRI/ MRA/ CTA brain and neck up to the thoracic vertebra\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ewith\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCarotid dissection\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnisocoria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTonic Pupil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecrease in vision/ optic nerve swelling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eH and E suggestive of Non Arteritic Ischemic optic neuropathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecrease in vision/ optic nerve swelling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eH and E suggestive of Arteritic Ischemic optic neuropathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisual Field Defect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBitemporal hemianopsia/ Junctional Scotoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCT/ MRI brain/ Sella\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ewith and without\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePituitary apoplexy/ optic chiasmal compression\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisual field defect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHomonymous hemianopsia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCT/ MRI brain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ewith and without\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIntracranial bleed/ Cerebrovascular accident (CVA)/ tumor\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eTransient vision loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eLasting seconds to\u003c/p\u003e \u003cp\u003eminutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCT/ MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ewith\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eTransient ischemic attack, embolism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMRA/ CTA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOf brain and neck\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransient blurry vision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLasting 20-60 minutes followed by headaches\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBilateral Optic nerve swelling + headaches\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePapilledema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ewith\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTumor, cerebral venous thrombosis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMRV\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScintillating scotoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFollowed by headaches\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive visual disturbances\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFlashes, visual snow, palinopsia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEpilepsy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOptic nerve swelling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eH and E suggestive of drusen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecrease vision, eye pain +/- optic nerve swelling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eH and E suggestive of optic neuritis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMRI brain and orbit with fat suppression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ewith and without\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003edemyelinating disease\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecrease vision with optic nerve swelling or pallor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot suggestive of optic neuritis or ischemic optic neuropathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMRI brain and orbit with fat suppression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ewith and without\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCompressive/ infiltrative\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiple cranial nerve palsies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecombination of 2,3,4,5 and 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMRI/ MRA/ MRV or CT/ CTA/ CTV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ewith\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOrbital apex or cavernous pathologies including aneurysm, thrombosis and carotid cavernous fistulas\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOptic ataxia, simultagnosia ocular motor apraxia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBallint's Triad\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMRI/ CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ewith and without\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIntracranial bleed/ Cerebrovascular accident (CVA)/ tumor/ posterior cortical atrophy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eED: Emergency Department\u003c/p\u003e\n\u003cp\u003eCT: Computed Tomography\u003c/p\u003e\n\u003cp\u003eCTA: Computed Tomography Angiography\u003c/p\u003e\n\u003cp\u003eMRI: Magnetic Resonance Imaging\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMRA: Magnetic Resonance Angiography\u003c/p\u003e\n\u003cp\u003eMRV: Magnetic Resonance Venography\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eH and E: History and Physical Exam\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAPD: Afferent Pupillary Defect\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIRB: Institutional Review Board\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003ePatients or the public WERE NOT involved in the design, or conduct, or reporting, or dissemination plans of our research.\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eEthics\u0026nbsp;approval\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e This study and its protocol was approved by the Institutional Review Board (IRB) at the American University of Beirut (AUBMC). The IRB has waived the need for obtaining informed consent. The data collection, analysis and manuscript hold no\u0026nbsp;Personal\u0026nbsp;Identifiable\u0026nbsp;Data\u0026nbsp;of patients or their charts.\u0026nbsp;Patients or the public\u0026nbsp;were not\u0026nbsp;involved in the design, or conduct, or reporting, or dissemination plans of our research.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Not applicable\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e Not applicable\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e No conflicting relationship exists for any author\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e None\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAvailability of Data and Material:\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;The data are not publicly available because they contain information that might compromise the privacy of the participants in the study.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e None\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAuthors Contributions:\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eTharwat\u0026nbsp;El Zahran M.D.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Conception of the work, Design of the work, Drafting the work and Revising the work critically for important intellectual content, Final approval of the version to be published, and Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\n\u003cp\u003eDalia El Hadi M.D.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Conception of the work, Design of the work, Drafting the work and Revising the work critically for important intellectual content, Final approval of the version to be published, and Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\n\u003cp\u003eHala Mostafa M.D.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Conception of the work, Design of the work, Drafting the work and Revising the work critically for important intellectual content, Final approval of the version to be published, and Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\n\u003cp\u003eHana Mansour M.D.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Conception of the work, Design of the work, Drafting the work and Revising the work critically for important intellectual content, Final approval of the version to be published, and Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\n\u003cp\u003eIbrahim Hashim M.D.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Conception of the work, Design of the work, Drafting the work and Revising the work critically for important intellectual content, Final approval of the version to be published, and Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\n\u003cp\u003eSoubhi Tahhan\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Conception of the work, Design of the work, Drafting the work and Revising the work critically for important intellectual content, Final approval of the version to be published, and Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\n\u003cp\u003eAlaa Bou Ghannam M.D.\u003c/p\u003e\n\u003cp\u003eConception of the work, Design of the work, Drafting the work and Revising the work critically for important intellectual content, Final approval of the version to be published, and Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eChanna R, Zafar SN, Canner JK, Haring RS, Schneider EB, Friedman DS. Epidemiology of Eye-Related Emergency Department Visits. JAMA ophthalmology. 2016;134(3):312\u0026ndash;319.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuff JS, Austin EW. Neuro-Ophthalmology in Emergency Medicine. Emergency medicine clinics of North America. 2016;34(4):967\u0026ndash;986.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoa ̃o Lemos EE. Neuro-Ophthalmological Emergencies. The Neurohospitalist. 2015;5:223\u0026ndash;233.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTurgut BTFCaKFA. Neuro-ophthalmological emergency disorders: A general view. International Journal of Clinical and Experimental Ophthalmology. 2017;1(1):060\u0026ndash;066.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParamdeep Singh RK. A review of imaging techniques in Neuro-ophthalmology Biological and Biomedical Reports. 2012;2(2):99\u0026ndash;107.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMehta S, Loevner LA, Mikityansky I, et al. The diagnostic and economic yield of neuroimaging in neuro-ophthalmology. J Neuroophthalmol. 2012;32(2):139\u0026ndash;144.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoshua M. Kruger DMC, and Mary Beth Cunnane. Systematic approaches for reviewing neuro-imaging scans in ophthalmology. Digit Journal of Ophthalmology. 2017;23(3):50\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaniel J Oh LNK, Judy L Chen, Ahmad A Aref, William F Mieler, Peter W MacIntosh Inpatient and Emergency Room Ophthalmology Consultations at a Tertiary Care Center. Journal of Ophthalmology. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaig R, Ahmad, K., Zafar, S., Khan, N., Ashfaq. Frequency of ocular emergencies in a tertiary care setting in Karachi, Pakistan - It is time to reduce unnecessary visits. Journal of the Pakistan Medical Association. 2018;68(10):1493\u0026ndash;1495.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKang EY TW, Lin JY, Huang CJ, Yeh PH, Wu WC, Wang FL, Liu L, Lai CC, Chen KJ. Eye-related Emergency Department Visits with Ophthalmology Consultation in Taiwan: Visual Acuity as an Indicator of Ocular Emergency. Nature Scientific Reports 2020;10(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNazerian P, Vanni S, Tarocchi C, et al. Causes of diplopia in the emergency department: diagnostic accuracy of clinical assessment and of head computed tomography. European Journal of Emergency Medicine. 2014;21(2):118\u0026ndash;124.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJeong-Yong Lee, Jung-Heon Kim, Hyung-Rae Cho, et al. Requirement for Head Magnetic Resonance Imaging in Children Who Present to the Emergency Department With Acute Nontraumatic Visual Disturbance. Pediatric Emergency Care. 2019;35(5).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMargolin E. CT only useful for selected patients presenting with primary eye complaints in the emergency department. American Journal of Emergency Medicine. 2016;36(1):134.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTahira Nishtar TA, Nosheen Noor, and Fayaz Muhammad. Rational use of Computed Tomography Scan head in the Emergency Department of a high volume tertiary care public sector hospital. Pakistan Journal of Medical Sciences. 2019;35(2).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Neuroophthalmology, Neuroimaging, Emergency Department, Yield of Imaging, Emergency Predictors","lastPublishedDoi":"10.21203/rs.3.rs-630811/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-630811/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eNeuro-ophthalmological emergencies require prompt assessment and management to avoid vision or life-threatening sequelae. The decision to perform a neuroimaging procedure is currently based on the clinical judgement of the medical team, without defined indications. This study aims to identify presenting symptoms and physical exam findings associated with relative positive findings on neuroimaging studies,\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis study was conducted by reviewing the electronic medical records of patients presenting to the Emergency Department (ED) with isolated neuro-ophthalmologic complaints between January 1\u003csup\u003est\u003c/sup\u003e, 2013 and September 30\u003csup\u003eth\u003c/sup\u003e 2019. We collected data on the clinical presentation, neuroimaging procedures and results, consults, and diagnoses.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eWe reviewed the charts of 211 patients of whom 50.7% were females and had a mean age of 41.2 ±21.4 years. Most presented with unilateral eye complaints (53.6%), and the most common symptoms were blurred vision (77.3%) and headaches (42.2%). A total of 126 imaging procedures were performed of which 74.6% were normal, while 25.4% showed relevant abnormal findings. Complaining of blurry vision (p=0.038) or visual field changes (p=0.014) at presentation were associated with having positive findings on imaging. Physical exam findings of a visual field defect (p=0.016), abnormal pupil reactivity (p=0.028), afferent pupillary defect (p=0.018), or abnormal optic disc exam (p=0.009) were also associated with positive findings on imaging.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eNeuroimaging is\u003cstrong\u003e \u003c/strong\u003emore\u003cstrong\u003e \u003c/strong\u003elikely to yield positive findings in patients presenting to the ED with blurred vision or changes in visual field and in those found to have visual field irregularities, afferent pupillary defects or abnormal optic discs on physical exam. These findings - when combined with the proper clinical setting - should lower the threshold to proceed with neuroimaging in the emergency department. Based on our results, larger-scale studies might lead to a well-structured algorithm to be followed by ED physicians in decision making.\u003c/p\u003e","manuscriptTitle":"The Yield of Neuroimaging in Patients Presenting to the Emergency Department with Isolated Neuro-ophthalmological Complaints","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2022-02-21 20:49:37","doi":"10.21203/rs.3.rs-630811/v2","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2021-06-24 19:08:14","doi":"10.21203/rs.3.rs-630811/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b7bd8904-9935-45db-89dd-7387e8316043","owner":[],"postedDate":"February 21st, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-03-17T05:44:20+00:00","versionOfRecord":[],"versionCreatedAt":"2022-02-21 20:49:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v2","identity":"rs-630811","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-630811","identity":"rs-630811","version":["v2"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}