Cranial Nerve Examination

Question patient about diplopia; the patient is more likely to notice this before the examiner can detect impairment of eye movement. If present:

- note the direction of maximum displacement of the images and determine the pair of muscles involved

- identify the source of the outer image (from the defective eye) using a transparent coloured lens.

diplopia is maximal when eyes deviate to the right and downwards


Right ^ inferior rectus or

superior oblique

Left IV nerve palsy

A pair of glasses with different coloured lenses show outer image arising from left eye

Conjugate movement: Note the ability of the eyes to move together (conjugately) in horizontal or vertical direction or tendency for gaze to fix in one particular direction.

Nystagmus: This is an upset in the normal balance of eye control. A slow drift in one direction is followed by a fast corrective movement. Nystagmus is maximal when the eyes are turned in the direction of the fast phase. Nystagmus 'direction' is usually described in terms of the fast phase and may be horizontal or vertical. Test as for other eye movements, but remember that 'physiological' nystagmus can occur when the eyes deviate to the endpoint of gaze.


direction (fast phase)

gaze direction where nystagmus Is maximal

Slow Fast Slow Fast e.g. Nystagmus to the left maximal on left lateral gaze.

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