Neuro-ophthalmology for beginners

Many ophthalmologists think that NO is a subject for experts which is very untrue
If you want to approach this tough subject you have to follow the same guidelines i always
stressed; what am i looking for?
The interaction of ophthalmology and neurology is inevitable and can be divided into:
1)helping the neurologist and neurosurgeon gauge the effect of CNS disease on the eye
2)ophthalmic presentation of CNS disease
As you can see both are very important but the approach is different
In the first situation; Every ophthalmologist should ask himself why am i examining this referred
patient? To what purpose?
1)because of the effect on vision and field (optic nerve)?
2)because of the effect on muscles and diplopia?
3)other miscellaneous situations as corneal exposure in coma or 7th nerve palsy, loss of corneal
sensation in the context of a cerebellopontine tumor or after injecting the trigeminal neuralgia, a
field defect from a compressive lesion along the higher visual pathway etc.?
All severely affect the QoL so my response to the referral must stress and clarify these issues of
concern in clear specific words
Yes the patient has papilledema or no the disc is normal or we need further investigation as the
findings are inconclusive
Yes there is partial 6th nerve palsy or 3rd nerve palsy or INO confirming the diagnosis of MS etc
The neurosurgeon is not concerned with the patients refraction or that his vision is low because
he is myope; or that he has a cataract, he is more concerned that the pituitary adenoma he is
going to remove is causing a drop in vision or a field defect and to what level and to document
this loss so that any postoperative change is not attributed to his surgery and to know if his
surgery could severely compromise the patient's vision or field. The neurologist wants to know in
clear words is this papilledema or not (pseudopapilledema) is this a recent 6th nerve palsy or an
old or restrictive esotropia; are the fundus findings supporting the diagnosis of MS or NMO, is the
field conclusive of pituitary adenoma or temporal lobe affection etc
Everyday we read responses that mention everything in the examined eyes except what the
neurologist, the neurosurgeon or the internist want to help him assessing his situation, be
SPECIFIC
The other situation is when a CNS disease presents to the ophthalmologist; here the job is a bit
more tough
We need to know what are the common groups of presentation of neurologic diseases
1)optic nerve; vision and color
2)field; esp. hemianopias
3)pupil; anisocoria
4)EOM; ptosis, strabismus, diplopia and nystagmus
5)corneal sensation; central corneal ulcers
The correct response here is that
-every optic nerve condition not associated with uveitis
-every bilateral field affection whether glaucoma is suspected or not
-every pupil affection
-every recent deviation of EOM or ptosis
-every central non infiltrated corneal ulcer
I should put a neurological disease as a dd in my algorithm and exclude it by sound clinical signs
Sometimes we forget simple clinical facts; early and moderate glaucomatous cupping are
associated with 6/6 vision; when you find a 6/18 vision with a 0.6 cup this is not glaucoma
Glaucomatous field defects rarely respect the vertical meridian
Recent diplopia or EOM deviation is neurologic in 75% of cases
Just keep the neuro-ophthalmology in your mind and you will start diagnosing neurologic
diseases.
Books have to be systematic; they classify neuro-ophthalmology into chapters like afferent
pathway, efferent pathway unfortunately this is not how we meet patients but it is necessary for a
complete text.