Diagnostic Approach for Tremor, Numbness, and Vision Changes

Initial Neurological Evaluation

The American Academy of Ophthalmology recommends performing a detailed sensorimotor examination to assess for strabismus, ocular misalignment, and abnormal eye movements that may explain vision changes 1
Evaluate pupillary responses in both bright and dim illumination to identify potential neurological deficits, as suggested by the American Academy of Neurology 2
Complete fundus examination to check for papilledema or optic atrophy, as recommended by the American Academy of Ophthalmology 3
Test for limb ataxia using finger-to-nose and heel-to-shin tests, looking for movements out of proportion to weakness, according to the American College of Emergency Physicians 4

The American College of Radiology recommends ordering brain MRI with and without contrast as the primary imaging study to evaluate for demyelinating disease, stroke, mass lesions, or cerebellar pathology 5
Include orbital views if vision changes suggest optic neuritis or orbital pathology, as suggested by the American Academy of Ophthalmology 1
Consider MR angiography if vascular causes are suspected, according to the American College of Emergency Physicians 4

Consider testing for myelin oligodendrocyte glycoprotein (MOG) antibodies if optic neuritis or demyelinating disease is suspected, as recommended by the National Institute of Neurological Disorders and Stroke 5
Check for aquaporin-4 antibodies to rule out neuromyelitis optica spectrum disorders, according to the National Institute of Neurological Disorders and Stroke 5
If myasthenia gravis is suspected due to fluctuating symptoms, order acetylcholine receptor antibody testing, as suggested by the American Academy of Neurology 2

For vision changes with suspected optic neuritis, visual evoked potentials and optical coherence tomography may be helpful, according to the National Institute of Neurological Disorders and Stroke 5
If multiple sclerosis is suspected, consider lumbar puncture for cerebrospinal fluid analysis including oligoclonal bands, as recommended by the National Institute of Neurological Disorders and Stroke 5

Multiple sclerosis: Consider when vision changes (optic neuritis) occur with numbness and tremor, as suggested by the National Institute of Neurological Disorders and Stroke 5
Stroke or TIA: Can cause acute onset of symptoms, especially if there are vascular risk factors, according to the American College of Emergency Physicians 4

Skew deviation: May present with vertical diplopia and subjective tilting of the visual field, as described by the American Academy of Ophthalmology 3
Abducens nerve palsy: Presents with horizontal diplopia, worse at distance, according to the American Academy of Ophthalmology 1
Third nerve palsy: May present with ptosis and diplopia, as suggested by the American Academy of Neurology 2

Missing myasthenia gravis due to variable presentation, which can cause ptosis and diplopia, as warned by the American Academy of Neurology 2
Assuming microvascular etiology in cranial nerve palsies without thorough evaluation, as cautioned by the American Academy of Neurology 2

If initial testing is negative but symptoms persist, consider referral to a neurologist or neuro-ophthalmologist, as recommended by the American Academy of Ophthalmology 3