16 yr old female with (?) iih points to be asked in history and negative history
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IIH idiopathic intracranial hypertension history taking clinical points adolescent female
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History Taking in a 16-Year-Old Female with Suspected IIH
IIH (Idiopathic Intracranial Hypertension / Pseudotumor Cerebri) in a post-pubertal adolescent female closely mirrors the adult pattern - obese female of childbearing age with raised ICP and no structural cause. A thorough history is central to both diagnosis and ruling out secondary causes.
PRESENTING COMPLAINTS - Points to Elicit
1. Headache (Most Common Symptom - 84%)
- Onset, duration, frequency - constant/daily/intermittent?
- Character - typically diffuse, often retro-orbital; can be migraine-like (52%) or tension-type (22%)
- Severity - progressive worsening?
- Aggravating factors - Valsalva (coughing, sneezing, straining), positional change (bending forward), Valsalva-induced worsening suggests raised ICP
- Relieving factors
- Morning headache - worsening on waking (raised ICP)
- Associated nausea/vomiting
- Whether it wakes from sleep
2. Visual Symptoms (directly from papilledema/raised ICP)
- Transient visual obscurations (TVOs) - 68%: brief dimming/"graying out" lasting up to 30 seconds, precipitated by standing up, bending over, bright light, or eye movement
- Diplopia / double vision - horizontal diplopia (18%) from 6th nerve palsy (false localizing sign)
- Blurred vision or decreased visual acuity - 32%
- Progressive peripheral visual field loss - typically starts nasal inferior quadrant
- Photophobia - 48%
3. Pulsatile Tinnitus (52%)
- "Whooshing" or pulse-synchronous sound in ears
- This is a highly specific symptom for raised ICP - ask specifically
4. Other Symptoms
- Dizziness - 51%
- Neck/back pain - 42-53%
- Radicular pain - 19%
- Cognitive difficulties / poor school performance - particularly noted in adolescent IIH
- Irritability
HISTORY OF PRESENT ILLNESS - Systematic Questions
Weight History (Most Important Risk Factor in Adolescents)
- Current weight and height (calculate BMI)
- Recent weight gain - rapid weight gain is strongly associated; ask for timeline
- Prior body weight, any recent change
Menstrual History (Critical in Female)
- Menarche - age of onset (post-pubertal adolescent IIH resembles adult pattern)
- Menstrual regularity - irregular cycles can suggest hormonal issues
- Polycystic ovary syndrome (PCOS) - associated with obesity and IIH
- Recent hormonal changes
Drug/Medication History (Extremely Important - Secondary Causes)
Ask specifically about ALL of the following:
| Drug | Relevance |
|---|---|
| Tetracyclines (doxycycline, minocycline) | Common in acne treatment - strongly associated with IIH |
| Vitamin A / Retinoids (isotretinoin/Roaccutane) | Very common in adolescents for acne - major cause |
| Oral contraceptive pills (OCPs) | Hormonal association |
| Corticosteroids | Especially withdrawal after prolonged use |
| Growth hormone | Used in short stature/GH deficiency |
| Thyroid hormone replacement | Excess LT4 can cause IIH in children |
| Lithium | Psychiatric medications |
| Nalidixic acid | Antibiotics |
| Iron supplements (excess) | In high doses |
| Anabolic steroids |
In a 16-year-old female, isotretinoin and doxycycline for acne are the single most common drug-related triggers to ask about.
Dietary History
- Excessive Vitamin A intake - supplements, liver consumption
- Diet and eating habits
- Weight-gain history
PAST MEDICAL HISTORY
- Prior episodes of similar headache or raised ICP
- Thyroid disease - hypothyroidism is associated
- Renal disease - hypertension
- Obstructive sleep apnea - associated with IIH
- Addison's disease (steroid withdrawal)
- SLE or other autoimmune conditions - can cause raised ICP
- Anemia - particularly iron deficiency
- Hypercoagulable states - relevant to rule out cerebral venous sinus thrombosis (CVST)
- Any known intracranial pathology, head trauma, infection
Surgical/Procedure History
- Any prior lumbar punctures
- Any prior eye surgeries or optic nerve issues
FAMILY HISTORY
- Migraine (common differential)
- Intracranial tumors
- Hypercoagulable disorders (DVT, CVST in young relatives)
SOCIAL HISTORY
- Diet (high vitamin A? High calorie?)
- Physical activity
- Smoking, alcohol
- Any recreational drug use
- Stress, sleep quality (OSA symptoms - snoring, daytime somnolence)
NEGATIVE HISTORY (Important to Specifically Ask and Document as Absent)
These help fulfill the diagnostic criteria and rule out secondary causes:
Symptoms to Rule Out Other Diagnoses
| Symptom | Rules Out |
|---|---|
| No fever, meningism (neck stiffness, photophobia, phonophobia in context of fever) | Meningitis / encephalitis |
| No focal neurological deficits (limb weakness, sensory loss, ataxia) | Intracranial mass, stroke |
| No seizures | Structural lesion, CNS infection |
| No altered consciousness, confusion | Mass lesion, metabolic cause |
| No thunderclap headache | SAH (subarachnoid hemorrhage) |
| No progressive ascending weakness | GBS (raised CSF protein can occasionally raise ICP) |
| No history of head trauma | Post-traumatic CSF issues |
| No orthostatic component (worse lying, better standing) | Low pressure headache / CSF leak |
Risk Factor Negatives
| Negative History | Significance |
|---|---|
| No use of tetracyclines / isotretinoin / vitamin A supplements | Excludes drug-induced |
| No corticosteroid use or recent withdrawal | Excludes steroid-related |
| No OCP use | Reduces hormonal cause |
| No family history of thrombosis | Reduces CVST risk |
| No recent viral illness, vaccinations | Can precede IIH in children |
| Not pregnant | CVST, eclampsia, IIH of pregnancy |
| No symptoms of hypothyroidism (cold intolerance, weight gain, constipation) | Hypothyroidism-associated IIH |
| No symptoms of adrenal insufficiency | Steroid withdrawal |
| No history of anemia symptoms | Iron deficiency anemia-related IIH |
DIAGNOSTIC CRITERIA REMINDER (Modified Dandy / Friedman 2013)
For context when structuring history:
- A. Papilledema present
- B. Normal neurological exam (except 6th nerve palsy allowed)
- C. Neuroimaging: normal parenchyma, venous thrombosis excluded
- D. Normal CSF constituents
- E. LP opening pressure > 25 cm H2O
History should systematically address each of these criteria and provide evidence against all secondary causes.
Summary Table for Quick Reference
| Domain | Key Points to Ask |
|---|---|
| Headache | Character, timing, Valsalva aggravation, morning worsening |
| Vision | TVOs, diplopia, blurred vision, visual field loss |
| Pulsatile tinnitus | Pulse-synchronous whooshing |
| Drug history | Isotretinoin, doxycycline, Vit A supplements, OCP, steroids, GH |
| Weight | BMI, recent rapid weight gain |
| Menstrual | Menarche, regularity, PCOS |
| Negative history | No fever, no focal deficits, no seizures, no trauma, no thrombosis risk |
| Exclude CVST | No prior DVT, hypercoagulable history, combined OCP |
Sources: Bradley and Daroff's Neurology in Clinical Practice; Cummings Otolaryngology; Medscape IIH Clinical Presentation; MDPI Pediatric IIH Obesity Review 2025; Springer Pediatric IIH study
Decrease vision with blurring of vision history for neurology
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History Taking: Decreased Vision / Blurring of Vision (Neurology)
The single most important first step in any neurological history for visual loss is localization along the visual pathway - this determines the entire differential diagnosis. History is the primary tool for localization.
STEP 1 - THE MASTER QUESTION: Monocular or Binocular?
Ask the patient: "Have you checked by covering each eye separately?" This is non-trivial - patients often misidentify binocular hemianopia as monocular loss.
| Monocular | Binocular | |
|---|---|---|
| Localizes to | Ipsilateral eye or optic nerve (pre-chiasmal) | Chiasm or retrochiasmal |
| Examples | Optic neuritis, NAION, retinal artery occlusion | Bitemporal hemianopia (chiasm), homonymous hemianopia (optic tract/radiation/cortex) |
STEP 2 - ONSET AND TIME COURSE (Most Critical Localizing Feature)
A. Sudden onset (seconds to minutes) - Vascular
- Transient + monocular (amaurosis fugax): embolic, carotid artery disease - "curtain descending over the eye," lasts minutes, altitudinal
- Retinal migraine: transient monocular loss with headache, vasospastic
- TVO (Transient Visual Obscurations): seconds-long, postural (standing up), from raised ICP / papilledema
- Sudden persistent monocular: CRAO (central retinal artery occlusion), AION - maximal at onset, minimal recovery
B. Subacute onset (hours to days) - Inflammatory / Demyelinating
- Optic neuritis - worsens over hours to a few days, then improves
- Hours-to-days onset with painful eye movements = optic neuritis until proven otherwise
C. Slowly progressive (weeks to months) - Compressive / Infiltrative
- Pituitary tumor (bitemporal), meningioma, glioma
- Toxic/nutritional optic neuropathy
- Hereditary optic neuropathies (Leber's - subacute but typically young male)
D. Stepwise / Stuttering - Vascular
- MS relapses, vascular TIA
STEP 3 - DETAILED CHARACTERIZATION OF VISION LOSS
Nature of loss - ask specifically:
- Decreased acuity - can't read / see far? (central field affected)
- Field loss - "missing piece of vision" - which quadrant/side?
- Color vision affected? - red desaturation (optic nerve sign; "does red look washed out or faded compared to other eye?")
- Contrast sensitivity - things look "washed out" or dim despite normal acuity (optic neuritis)
- Positive symptoms - flashing lights (photopsia - migraine, retinal detachment), floaters, zigzag (scintillating scotoma of migraine aura)
- Negative symptoms - simply missing area of vision (ischemia, optic nerve)
Pattern of field loss - key localizing clues:
| Field Defect | Localization |
|---|---|
| Central scotoma | Optic nerve (optic neuritis, NAION, toxic) |
| Altitudinal (superior or inferior half) | Optic nerve (NAION - inferior altitudinal loss) |
| Bitemporal hemianopia | Optic chiasm (pituitary lesion) |
| Homonymous hemianopia | Optic tract / LGN / optic radiation / cortex (ipsilateral side to defect) |
| Congruous homonymous | More posterior (occipital cortex) |
| Incongruous homonymous | More anterior (optic tract) |
| Quadrantanopia (pie in sky) | Temporal lobe (Meyer's loop) |
| Quadrantanopia (pie on floor) | Parietal lobe |
STEP 4 - ASSOCIATED SYMPTOMS (Localizing + Etiological)
Pain with vision loss - key discriminator:
| Pain | No Pain | |
|---|---|---|
| Optic neuritis | Yes - eye pain on movement (90%), precedes loss by hours | |
| NAION | No | Yes |
| Retinal artery occlusion | No | Yes |
| Arteritic AION (GCA) | Jaw claudication, scalp tenderness, temporal headache | |
| Uveitis / scleritis | Deep aching pain | |
| Angle closure glaucoma | Severe periocular pain + halos, nausea |
Headache - ask character, onset, location:
- ICP-related: morning headache, positional, with nausea/vomiting + TVOs = papilledema/IIH
- Thunderclap = SAH (acute visual loss from SAH)
- GCA: temporal headache + jaw claudication + > 50 years
Diplopia (double vision):
- Horizontal diplopia = 6th nerve palsy (false localizing sign of raised ICP, or brainstem)
- Vertical diplopia = 4th nerve palsy
- Variable diplopia - worse at end of day / after sustained gaze = Myasthenia Gravis
Other neurological symptoms:
- Limb weakness/sensory loss, ataxia, dysarthria, dysphagia - MS, stroke, brainstem lesion
- Facial numbness, hemibody sensory loss - optic tract to cortex lesion
- Uhthoff's phenomenon - vision worsens with heat or exercise → highly specific for demyelinating disease (optic neuritis / MS)
- Seizures - cortical lesion (posterior cortex - visual cortex involvement)
- Cognitive decline, personality change - diffuse cortical disease
STEP 5 - PAST HISTORY (Etiological Clues)
| History | Suggests |
|---|---|
| Prior episode in same or other eye with recovery | MS / optic neuritis recurrence |
| Known MS | Optic neuritis relapse |
| Hypertension, diabetes, hyperlipidemia, smoking, AF, carotid disease | Vascular (NAION, CRAO, stroke) |
| Autoimmune disease (SLE, Sjögren, sarcoidosis) | Optic neuropathy from systemic disease |
| Raised ICP features (prior headache, papilledema) | IIH, mass lesion |
| Pituitary/brain tumor history | Compressive visual loss |
| Thyroid disease (Graves') | Dysthyroid orbitopathy |
| Amblyopia ("lazy eye"), ocular trauma | Non-neurological cause |
| Family history of visual loss, premature deaths | Leber's hereditary optic neuropathy (LHON), glaucoma |
| Diabetes insipidus, polyuria | Neurosarcoidosis, craniopharyngioma |
STEP 6 - DRUG AND TOXIC HISTORY
Toxic optic neuropathy = bilateral, painless, slowly progressive, central/cecocentral scotoma, red desaturation
- Ethambutol - TB treatment, dose-dependent bilateral optic neuropathy
- Methanol - ingestion, rapid severe bilateral visual loss
- Hydroxychloroquine - macular toxicity (bull's eye maculopathy)
- Tobacco / alcohol - nutritional/tobacco amblyopia
- Amiodarone - bilateral optic neuropathy
- Vigabatrin - bilateral visual field constriction
- Sildenafil - NAION risk
- Vitamin B12 deficiency - nutritional optic neuropathy
- Isotretinoin, tetracyclines - IIH/raised ICP
STEP 7 - SYSTEMIC/CONSTITUTIONAL HISTORY
| Symptom | Suggests |
|---|---|
| Weight loss, fatigue, night sweats | Malignancy (infiltrative optic neuropathy), lymphoma |
| Jaw claudication, scalp tenderness, temporal artery tenderness, fatigue, polymyalgia | GCA (arteritic ISCHEMIC optic neuropathy) - emergency |
| Fever, rash, lymphadenopathy | Sarcoidosis, Lyme, viral |
| Oral/genital ulcers | Behcet's disease |
| Skin rash (butterfly rash, photosensitivity) | SLE |
| Dry eyes/mouth | Sjögren's |
| Symptoms of raised ICP: headache, vomiting, diplopia, TVOs | Papilledema from any cause |
| Obesity, recent weight gain | IIH |
| Pregnancy | IIH, CVST, eclampsia |
STEP 8 - NEGATIVE HISTORY (Important to Elicit and Document)
| Negative | Significance |
|---|---|
| No pain on eye movement | Against optic neuritis |
| No improvement after first episode | Against typical optic neuritis |
| No Uhthoff's phenomenon | Against demyelination |
| No jaw claudication, scalp tenderness, fever, raised ESR | Against GCA |
| No prior episodes | Against MS relapse |
| No drug exposure (ethambutol etc.) | Against toxic optic neuropathy |
| No fever/meningism | Against infective/inflammatory meningitis |
| No limb weakness/sensory symptoms | Against posterior stroke if isolated visual loss |
| No trauma | Against traumatic optic neuropathy |
| No family history of visual loss in young men | Against LHON |
Quick Reference - Key Differential Clues by Pattern
| Condition | Eye | Onset | Pain | Recovery | Key Feature |
|---|---|---|---|---|---|
| Optic neuritis | Monocular | Days | Yes (on movement) | Yes (weeks) | Uhthoff, young woman, MS risk |
| NAION | Monocular | Sudden | No | Minimal | Vascular risk, altitudinal loss, crowded disc |
| Arteritic AION (GCA) | Monocular | Sudden | Yes (headache, jaw) | Minimal | >50 yr, raised ESR, emergency |
| CRAO | Monocular | Sudden | No | Minimal | Embolic, AF, carotid disease |
| Amaurosis fugax | Monocular | Transient (mins) | No | Full | Curtain, carotid stenosis |
| Retinal migraine | Monocular | Transient | Headache | Full | Vasospasm, migraine history |
| TVOs (papilledema) | Bilateral | Seconds, postural | Headache | Full | IIH, seconds-brief, Valsalva |
| Pituitary tumor | Bitemporal field | Weeks-months | Headache | Variable | Bitemporal hemianopia, endocrine sx |
| Occipital stroke | Homonymous | Sudden | Headache | Variable | Vascular risk, macular sparing |
| Toxic optic neuropathy | Bilateral | Weeks | No | Variable | Drug/nutritional history |
| Uhthoff MS | Monocular | With heat/exercise | No | Yes | Demyelination |
Sources: Bradley and Daroff's Neurology in Clinical Practice; Continuum: Diagnostic Approach to Vision Loss (PMC10564074); Stroke Manual; Wills Eye Manual
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Decrease vision with blurring of vision history for neurology
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Here is a complete, ready-to-use History-Taking Proforma for Decreased Vision / Blurring of Vision from a neurology perspective:
HISTORY-TAKING PROFORMA
Chief Complaint: Decreased Vision / Blurring of Vision
1. PATIENT IDENTIFICATION
- Name | Age | Sex | Occupation | Handedness
- Referred by: self / ophthalmologist / GP / neurologist
2. PRESENTING COMPLAINT
"Decreased vision / blurring of vision since ___"
3. HISTORY OF PRESENTING COMPLAINT
A. LATERALITY - (First and Most Important Question)
- Right eye only
- Left eye only
- Both eyes
- "Did you check by covering each eye separately?"
Monocular = pre-chiasmal (eye or optic nerve) Binocular = chiasmal or retrochiasmal
B. ONSET
- Sudden (seconds) - vascular: embolism, ischemia
- Subacute (hours to days) - inflammatory: optic neuritis
- Gradual (weeks to months) - compressive, toxic, hereditary
- Episodic / Recurrent - MS, migraine, IIH (TVOs)
- Exact date and time of onset: ___
C. DURATION & COURSE
- Duration since onset: ___
- Transient - lasted ___ minutes/hours, fully recovered
- Persistent - still present
- Progressive - worsening over time
- Improving - spontaneous recovery (optic neuritis)
- Stepwise / Fluctuating - vascular / MS relapse
- Stable / Nonprogressive
D. NATURE OF VISION LOSS
(Ask each one specifically)
| Feature | Present | Absent | Details |
|---|---|---|---|
| Reduced visual acuity (near / far) | |||
| Blurring of vision | |||
| Visual field loss - missing area | Which side/quadrant? | ||
| Central scotoma - central black spot | |||
| Altitudinal loss - upper/lower half | |||
| Peripheral field loss - tunnel vision | |||
| Color vision affected - red looks faded | |||
| Contrast sensitivity reduced - washed out | |||
| Diplopia - double vision | Horizontal / vertical? | ||
| Positive symptoms - flashes, zigzags | |||
| Floaters | |||
| Halos around lights | |||
| Night blindness |
E. ASSOCIATED PAIN
- Pain on eye movement - cardinal sign of optic neuritis (present in ~90%)
- Duration of pain: ___
- Precedes vision loss? Y / N
- Resolved within 7 days? Y / N (>7 days argues against ON)
- Periocular / orbital aching pain - scleritis, uveitis
- Temporal headache + jaw claudication + scalp tenderness - GCA / arteritic AION (EMERGENCY)
- Severe periocular pain + nausea + halos - acute angle closure glaucoma
- Headache - morning, postural, nausea/vomiting - raised ICP / papilledema
- No pain whatsoever - NAION, CRAO, toxic optic neuropathy
F. TEMPORAL PROFILE - KEY DIFFERENTIATOR
| Timing | Diagnosis to Consider |
|---|---|
| Transient - seconds, postural (standing/bending) | TVOs from papilledema / IIH |
| Transient - minutes, altitudinal, "curtain" | Amaurosis fugax - embolic |
| Transient - with migraine headache | Retinal migraine / visual aura |
| Transient - with exercise or heat, recovers | Uhthoff's phenomenon - MS/demyelination |
| Subacute - days, pain on movement, recovers | Optic neuritis |
| Sudden - maximal at onset, no pain, no recovery | NAION, CRAO |
| Gradual - weeks, bitemporal field loss | Chiasmal compression - pituitary tumor |
| Gradual - bilateral, cecocentral scotoma | Toxic / nutritional optic neuropathy |
G. AGGRAVATING / RELIEVING FACTORS
- Worse with heat / hot shower / exercise - Uhthoff's (MS)
- Worse on standing / bending - TVOs (IIH)
- Worse with eye movements - optic neuritis
- Worse at end of day - myasthenia gravis (ptosis/diplopia)
- Relieved by rest - MG
- Postural component (worse lying flat) - raised ICP
- Any specific triggers: bright light, exercise, meals, medications
H. SIMILAR EPISODES IN THE PAST
- Previous episode in the same eye - recovered? MS / ON recurrence
- Previous episode in the other eye - recovered? MS
- Prior TIAs (transient weakness, speech disturbance) - vascular
- Documented prior optic neuritis or MS diagnosis
4. ASSOCIATED NEUROLOGICAL SYMPTOMS
(Helps localize lesion beyond optic nerve)
| Symptom | Present | Absent | Details |
|---|---|---|---|
| Limb weakness - focal | Which limb(s)? | ||
| Sensory loss / tingling / numbness | Which distribution? | ||
| Facial numbness | |||
| Ataxia / balance problems / incoordination | |||
| Dysarthria / slurred speech | |||
| Dysphagia | |||
| Vertigo | |||
| Bladder/bowel dysfunction | Urgency, retention | ||
| Fatigue (disproportionate) | MS hallmark | ||
| Cognitive disturbance / memory | |||
| Seizures | |||
| Hearing loss / tinnitus | Pulsatile? | ||
| Diplopia / squint | New or old? | ||
| Ptosis | Unilateral / bilateral |
5. ASSOCIATED SYSTEMIC SYMPTOMS
| Symptom | Present | Absent | Suggests |
|---|---|---|---|
| Headache - character / timing | ICP, GCA, migraine | ||
| Nausea / vomiting | Raised ICP | ||
| Jaw claudication | GCA - EMERGENCY | ||
| Scalp tenderness (combing hair) | GCA | ||
| Fever / chills | Infective/inflammatory | ||
| Weight loss / night sweats | Malignancy, sarcoid | ||
| Dry eyes / dry mouth | Sjögren's | ||
| Oral/genital ulcers | Behcet's disease | ||
| Skin rash (butterfly, photosensitivity) | SLE | ||
| Joint pains / swelling | Autoimmune | ||
| Polyuria / polydipsia | Sarcoidosis, craniopharyngioma | ||
| Menstrual irregularity / galactorrhoea | Pituitary lesion | ||
| Recent viral illness / vaccination | Post-viral optic neuritis | ||
| Obesity / recent weight gain | IIH | ||
| Pulsatile tinnitus | IIH / raised ICP |
6. PAST MEDICAL HISTORY
- Multiple sclerosis / demyelinating disease
- Diabetes mellitus - type: ___, duration: ___, control: ___
- Hypertension
- Hyperlipidaemia
- Atrial fibrillation / cardiac disease
- Carotid artery disease / prior stroke / TIA
- Autoimmune disease: SLE / Sjögren / sarcoidosis / Behcet's / vasculitis
- Pituitary / brain tumor - prior surgery / radiation
- Thyroid disease - hypo / hyper / Graves' orbitopathy
- Raised ICP / IIH - prior episode
- Glaucoma / other eye disease
- Amblyopia ("lazy eye") in childhood
- Migraine - with or without aura
- Obstructive sleep apnea
- HIV / immunocompromised state
- TB (ethambutol use)
- Renal / hepatic disease
7. DRUG HISTORY
(Toxic optic neuropathy - bilateral, painless, progressive, central scotoma)
| Drug | Class | Ocular Effect |
|---|---|---|
| Ethambutol | Anti-TB | Optic neuropathy - dose/duration dependent |
| Isoniazid (INH) | Anti-TB | Optic neuropathy (B6 depletion) |
| Hydroxychloroquine | Antimalarial / rheumatology | Macular toxicity - bull's eye |
| Amiodarone | Antiarrhythmic | Bilateral optic neuropathy |
| Vigabatrin | Antiepileptic | Bilateral peripheral field constriction |
| Sildenafil / PDE5 inhibitors | NAION risk | |
| Isotretinoin / tetracyclines | Acne | IIH / raised ICP |
| Oral contraceptive pill | IIH / thrombosis (CVST) | |
| Steroids (prolonged / withdrawal) | IIH, glaucoma | |
| Methanol ingestion | Toxic | Severe bilateral loss, emergency |
| Quinine / chloroquine | Macular / retinal toxicity | |
| Digoxin (toxicity) | Yellow/green tinge, halos |
- Nutritional history - tobacco / alcohol ("tobacco-alcohol amblyopia")
- Vitamin B12 / folate deficiency
- Dietary history - malnutrition, vitamin A excess
8. FAMILY HISTORY
- Visual loss in young male relatives - Leber's Hereditary Optic Neuropathy (LHON) - mitochondrial, males in their 20s-30s
- Glaucoma - family history
- MS in first-degree relatives
- Migraine
- Premature cardiovascular disease / stroke
9. PERSONAL AND SOCIAL HISTORY
- Smoking - pack years
- Alcohol - units/week (nutritional amblyopia, Wernicke's)
- Occupation (chemical / solvent exposure, methanol risk)
- Travel history (Lyme disease, tropical infections)
- Sexual history (syphilis - tabes dorsalis, Argyll Robertson pupil)
- IV drug use (HIV, infective endocarditis - embolic)
- Pregnancy / recent postpartum (IIH, CVST, eclampsia)
- BMI / obesity (IIH)
10. NEGATIVE HISTORY - MUST DOCUMENT
| Negative Point | Rules Against |
|---|---|
| No pain on eye movement | Optic neuritis |
| No Uhthoff's phenomenon | MS / demyelination |
| No prior episode with recovery | MS relapse |
| No jaw claudication / scalp tenderness | GCA (arteritic AION) |
| No fever / meningism | Infective optic neuritis / meningitis |
| No drug exposure (ethambutol, etc.) | Toxic optic neuropathy |
| No limb weakness / sensory symptoms | Stroke / posterior fossa lesion |
| No headache / raised ICP features | IIH / papilledema |
| No trauma | Traumatic optic neuropathy |
| No family history of visual loss (young males) | LHON |
| No pituitary symptoms | Compressive chiasmal lesion |
| No autoimmune symptoms | NMO, SLE-optic neuropathy |
11. SUMMARY - LOCALIZATION CHECKLIST
After taking history, complete this:
| Feature | Finding | Localizes to |
|---|---|---|
| Monocular / Binocular | ||
| Transient / Persistent | ||
| Pain on eye movement? | ||
| Uhthoff? | ||
| Field pattern | ||
| Color vision affected? | ||
| Associated neuro symptoms? | ||
| Vascular risk factors? | ||
| Drug / toxic exposure? |
Provisional Localization: ☐ Pre-chiasmal ☐ Chiasmal ☐ Retrochiasmal
Top Differential Diagnoses:
Based on: Bradley and Daroff's Neurology in Clinical Practice; Continuum: Diagnostic Approach to Vision Loss; Wills Eye Manual; Stroke Manual Visual Loss Guidelines
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