Walsh and Hoyts
Clinical Neuro-Ophthalmology
The Essentials
Third Edition
Neil R. Miller, MD
Professor of Ophthalmology, Neurology, and Neurosurgery
Frank B. Walsh Professor of Neuro-Ophthalmology
Director, Neuro-Ophthalmology and Orbit Units
Wilmer Eye Institute
Johns Hopkins Hospital
Baltimore, Maryland
Prem S. Subramanian, MD
Associate Professor of Neuro-Ophthalmology
Wilmer Eye Institute
Johns Hopkins Hospital
Baltimore, Maryland
Vivek R. Patel, MD
Wilmer Eye Institute
Johns Hopkins Hospital
Baltimore, Maryland
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3rd edition
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To Our Patients: Past, Present, and Future
PREFACE
This third edition of Walsh and Hoyts Clinical Neuro- Ophthalmology: The Essentials, is borne from the same need that motivated the development of its 1st edition 15 years agoto provide a thorough, yet much more concise complement to the 3-volume sixth edition of the comprehensive parent text, Walsh and Hoyts Clinical Neuro-Ophthalmology. We are encouraged by the extent to which our readers have embraced the first two editions; however, we felt that given the tremendous advances that have occurred over the past decade, it was time for an updated, refined version while preserving its brevity and readability. In particular, we have emphasized the role of modern imaging techniques such as OCT, high resolution CT/MRI, and multifocal ERG in patients with known and presumed neuro-ophthalmologic disorders. Diagrams and tables have been enhanced wherever possible, and the vast majority of photos are now in color. Coverage of complex eye movement disorders has been greatly enriched by the inclusion of videos available online.
In this new edition, we have incorporated new information, both text and illustrations, within the pre-existing organization and content of its predecessors. Five sectionsthe afferent and efferent visual systems, disorders of the pupil, disorders of the eyelids, and non-organic disordersprovide the framework for 23 chapters. As we recognize that the way in which we acquire information is constantly evolving and that the speed with which information changes also is increasing, we have not included any references but trust that the reader interested in more detailed information will find it online. Nevertheless, we believe that there continues to be a need for knowledge of the fundamentals of neuro-ophthalmology, allowing the reader to integrate more effectively this knowledge with information acquired from the multitude of sources available.
We sincerely hope we have accomplished our goal of enhancing our readers understanding and appreciation of the fascinating world of neuro-ophthalmology.
CONTENTS
SECTION I
THE AFFERENT VISUAL SYSTEM
1 Examination of the Visual Sensory System
Despite continuous advances in neuroimaging and other new techniques, the examination of the afferent visual sensory system is still the core of the neuro-ophthalmologic examination. This chapter describes the most common subjective and objective testing parameters used in the afferent visual system examination.
Evaluation of the afferent system begins with a thorough medical history, followed by an ophthalmologic examination, including assessment of best-corrected or at least pinhole visual acuity at distance and near, color vision, visual fields, anterior segments (including the media), vitreous, intraocular pressure (IOP), and appearance of the optic discs, retinas (especially the macula), and retinal vessels. At the completion of the examination, one should have an idea as to the structure involved in the patients visual sensory difficulties or at least have a differential diagnosis. If the diagnosis remains unclear, a number of ancillary tests are available, including ocular imaging and electrophysiologic procedures, that should lead to the correct diagnosis.