Curriculum standards

Knowledge guides

LG20: Disorders of vision and other senses

Key presentations and conditions

Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.

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Epidemiology, pathophysiology, and clinical sciences

Advanced Trainees will have a comprehensive depth of knowledge of the principles of the foundational sciences.

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Investigations, procedures, and clinical assessment tools

Advanced Trainees will know the scientific foundation of each investigation and procedure, including relevant anatomy and physiology. They will be able to interpret the reported results of each investigation or procedure.

Advanced Trainees will know how to explain the investigation or procedure to patients, families, and carers, and be able to explain procedural risk and obtain informed consent where applicable.

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Important specific issues

Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management and integrate these into care.

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Presentations – hearing and balance

Ataxia
Auditory hallucinations / Aura
Hearing loss
Loss of balance and/or coordination
Nausea and/or vomiting
Tinnitus

Presentations – smell and taste

Behavioural / Mood / Personality changes
Difficulties with vision and/or speech
Gustatory / Olfactory aura
Loss of smell
Loss of taste
Memory loss

Presentations – vision

Anisocoria
Binocular visual loss
Bi-temporal hemianopia
Blurry vision
Difficulty reading
Diplopia / Double vision
Headache
Hemianopia
Jaw claudication
Light sensitivity
Loss of depth perception
Monocular visual loss
Muscular difficulties:
- coordination problems
- stiffness
- weakness and/or paralysis
Myalgia
Nausea and/or vomiting
Nystagmus
Pain
Partial visual loss
Photopsia
Ptosis and/or exotropia
Quadrantinopia
Red eye
Seizures
Transient visual loss
Visual hallucinations

Conditions – double vision

Internuclear ophthalmoplegia
Myasthenia gravis
Ocular motor nerve palsies

Conditions – hearing

Acoustic neuroma
Raised intracranial pressure
Seizures
Stroke

Conditions – papilloedema / optic disc swelling

Cerebral venous thrombosis
Idiopathic intracranial hypertension
Intracranial space-occupying lesions

Conditions – positive visual phenomena

Charles Bonnet syndrome
Dementia with Lewy bodies
Migraine
Occipital epilepsy
Parkinson disease

Conditions – smell / taste

Neurodegenerative conditions
Orbitofrontal tumours
Seizures

Conditions – vision loss

Anterior pathway:
- anterior ischaemic optic neuropathy
- giant cell arteritis
- optic neuritis
Chiasmal compression
Demyelinating disease, such as:
- multiple sclerosis (MS)
- neuromyelitis optica spectrum disorder (NMOSD)
Diabetes with microvascular ischaemic complications
Posterior pathway:
- migraine
- occipital seizures
- posterior cortical atrophy
- stroke

For each presentation and condition, Advanced Trainees will know how to:

Synthesise

recognise the clinical presentation
identify relevant epidemiology, prevalence, pathophysiology, and clinical science
take a comprehensive clinical history
conduct an appropriate examination
establish a differential diagnosis
plan and arrange appropriate investigations
consider the impact of illness and disease on patients and their quality of life when developing a management plan

Manage

provide evidence-based management
prescribe therapies tailored to patients’ needs and conditions
recognise potential complications of disease and its management, and initiate preventative strategies
involve multidisciplinary teams

Consider other factors

identify individual and social factors and the impact of these on diagnosis and management

Acute, chronic, common, and rare diseases that cause:
- disorders of the special senses
- double vision
- papilledema
- visual loss
Methods of assessing automated and confrontation perimetry, pupillary function, visual acuity, and visual fields, and performing a direct ophthalmoscopy
Neuroanatomy and neurophysiology of the auditory, oculomotor, olfactory, pupillary, and visual systems

Cerebrospinal fluid (CSF) procedures and investigations

Lumbar puncture (LP) and interpretation of investigation results, such as:
- basic CSF analysis:
  - cell count
  - cytology
  - immunological tests
  - microbiological tests
  - protein level
  - sugar level
  - xanthochromia
- opening pressure
- special tests:
  - 14-3-3 protein
  - oligoclonal bands
  - spectrophotometry

Clinical neurophysiology investigations

EEG:
- sleep-deprived EEG
- standard EEG
- video EEG
Electromyography (EMG):
- needle EMG
- single-fibre EMG
Evoked potentials:
- repetitive nerve stimulation
- visual
Vestibular function tests

Neurogenetic investigations

Genetic testing, including, but not limited to:
- chromosomal testing, such as:
  - karyotype
  - microarray
- genomic testing, including whole exome or genome sequencing
- mitochondrial genome sequencing
- targeted panel testing
Referral to a neurogeneticist

Neuroimaging investigations

CT, including:
- CT angiography
- perfusion
- venography
MRI, including:
- functional (fMRI)
- magnetic resonance:
  - angiography (MRA)
  - spectroscopy (MRS)
  - venogram (MRV)
- with contrast
PET
Single photon emission computed tomography (SPECT)
Vascular imaging:
- catheter angiography
- Doppler ultrasound

Neuroimmmunology investigations

Autoantibody measurement:
- anti-aquaporin 4 antibodies
- autoantibodies associated with myasthenia gravis, such as anti-acetylcholine receptor antibodies
- paraneoplastic antibodies
Referral to a neuroimmunologist

Neuropathology investigations

Biopsy:
- brain
- temporal artery

Neuropsychological investigations

Cognitive screening:
- Mini-Mental State Examination
- Montreal Cognitive Assessment

Other investigations

Cardiac investigations:
- 24-hour electrocardiogram monitoring
- ECG
- echocardiography
Other laboratory tests:
- C-reactive protein (CRP)
- B12 level
- erythrocyte sedimentation rate (ESR)
- fasting lipids
- HbA1c
- serum angiotensin converting enzyme
- thrombophilia screen

Overlap with other medical specialties, such as ophthalmology and otolaryngology / ear, nose, and throat (ENT) surgery, and when it is appropriate to refer
Prognosis and implications of these disorders