Neil Miller - Walsh & Hoyts Clinical Neuro-Ophthalmology: The Essentials

Walsh and Hoyts

Clinical
Neuro-Ophthalmology

The Essentials

Neil R. Miller, MD

Frank B. Walsh Professor of Neuro-Ophthalmology

Professor of Ophthalmology, Neurology, and Neurosurgery

Wilmer Eye Institute

Johns Hopkins Hospital

Baltimore, Maryland

Prem S. Subramanian, MD, PhD

Professor of Ophthalmology, Neurology, and Neurosurgery

University of Colorado School of Medicine

Vice Chair for Academic Affairs

Division Head, Neuro-Ophthalmology

Sue Anschutz-Rodgers UCHealth Eye Center

Aurora, Colorado

Vivek R. Patel, MD

Associate Professor

Director, Neuro-Ophthalmology & Adult Strabismus

Director of Education

USC Roski Eye Institute, Keck School of Medicine

Los Angeles, California

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4th edition

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3rd edition Copyright 2016 Wolters Kluwer. 2nd edition Copyright 2008 Wolters Kluwer Health/Lippincott Williams & Wilkins. 1st edition Copyright 1999 Williams & Wilkins. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at (products and services).

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To Our Patients: Past, Present, and Future

This fourth edition of Walsh and Hoyts Clinical Neuro-Ophthalmology: The Essentials, is borne from the same need that motivated the development of its first edition 21 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 remain encouraged by the enthusiasm our readers have shown for the previous three editions. Given the continued advances that have occurred since the last edition was published 5 years ago, we believe it is time for an updated version that still preserves its brevity and readability. In particular, we have increased our emphasis on the role of modern imaging techniques such as OCT, high-resolution CT/MRI, and electrophysiology in patients with known and presumed neuro-ophthalmologic disorders. Diagrams and tables have been revised when appropriate and the vast majority of photos remain in color. We also have added more videos of eye movement disorders, abnormal pupillary responses to light and near stimuli, and examination techniques.

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 nonorganic disordersprovide the framework for 24 chapters including a new chapter on neuroimaging techniques. As we recognize that the way 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.

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.