Using the stethoscope to auscultate the eye and head Using the stethoscope to auscultate the eye and head. The stethoscope is particularly helpful in the neuro-ophthalmic evaluation in two situations: listening for vascular bruits (embolic and vascular occlusive diseases, and carotid cavernous fistula) and detecting the flutter of superior oblique myokymia. Auscultation over the temporalis muscle (with the bell or diaphragm) should be performed in patients with amaurosis fugax for possible ophthalmic carotid bruits or bruits transmitted from more proximal sources. When auscultating over the temple (where the squamosal bone is the thinnest), the patient should be instructed to open the mouth to inhibit noise from temporalis muscle contraction (A). Both the eyeball and temple should be auscultated when a carotid-cavernous fistula is suspected. When auscultating over the eye, its best to use the diaphragm rather than the bell, as the hole in the bottom of the bell is easily occluded by loose eyelid skin that muffles the sound. When listening over the eye, have the patient close both eyes and then place the diaphragm over the globe (B). Then instruct the patient to open the opposite eye (which will inhibit orbicularis muscle contraction noise in the auscultated eye (C). In superior oblique myokymia, the sound of the fluttering superior oblique muscle can sometimes be heard with auscultation over the globe—sounding like a motorcycle revving up—due to the abrupt starting and stopping of the rapid contractions. Source: Examination of the Visual Motor System, Practical Neuroophthalmology Citation: Martin TJ, Corbett JJ. Practical Neuroophthalmology; 2013 Available at: https://neurology.mhmedical.com/DownloadImage.aspx?image=/data/books/1041/martin_ch7_fig13.jpeg&sec=59023195&BookID=1041&ChapterSecID=59021904&imagename= Accessed: October 17, 2017 Copyright © 2017 McGraw-Hill Education. All rights reserved