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Clinical decisions in neuro-ophthalmology
SURVEY OF OPHTHALMOLOGY
BOOK
VOLUME 31 . NUMBER 2
REVIEWS
l
SEPTEMBER-OCTOBER
1986
STEVEN M. PODOS, EDITOR
Clinical Decisions in Neuro-Ophthalmology, by Ronald M. Burde, M.D., Peter J. Savino, M.D. and Jonathan D. Trobe, M.D., St. Louis, Missouri, C.V. Mosby Company, 1985, 338 pp., illus. Price: $62.95
diagnosis of papilledema (page 123); Isolated internal ophthalmoplegia is not a sign of 3rd nerve paresis (page 183); Invasive neuroradiologic investigation is not usually helpful therapeutically in chronic stable 6th nerve palsy (page 190). There are a few points on careful scrutiny which might merit clarification. Legend F of color plate 9, facing page 117, implies that in papillophlebitis hemorrhages do not extend to the periphery, although they may. As the authors indicate on page 182, an ischemic type lesion was indeed present in the pathologic studies of diabetic pupil-sparing 3rd nerve palsy, although vessel occlusion was not actually demonstrated. Acquired pendular (jelly) nystagmus might be included in the list of monocular or dissociated oscillations present in the primary position in the top righthand box in chart 6-l on page 196. The statement on page 211 that physiologic nystagmus tends to be more prominent “in one eye” would be more specific if changed to “in the abducting eye.” In the description of rebound nystagmus on page 212, I believe the word “alcoholic” may have been substituted by error for “chronic” cerebellar degeneration. On page 214 the authors might mention the frequent induction of voluntary nystagmus by convergence, and on page 2 15 they might repeat the use of “sequential saccades” in the definition of ocular flutter. The definition of square wave jerks on page 215 might be clarified by indicating that instead of a “break in fixation” there are “unwanted saccades that take the eyes off the target” (Leigh and Zee, The Neurology ofEye Movements, 1983, p. 61). On page 216 the authors state that ocular bobbing is “indicative of brain stem dysfunction and is not precisely localizeable,” although the reference offered does indicate pontine compression. The authors generally present views alternative to their own, particularly when widely held, with a few exceptions. The finding of relative afferent pupillary defect in at least rare cases of amblyopia might be mentioned on page 18, particularly in view
The authors are experienced clinicians, investigators and teachers in neuro-ophthalmology and have combined to produce an excellent book - comprehensive, well organized, well written and well illustrated. It serves both as a basic text in neuro-ophof sophisticated thalmology and as a source discussion (with valuable up-to-date references) of fine points in differential diagnosis and in management well beyond the level of a basic text. The novel feature, a Decision Tree approach to the various clinical problems faced in neuro-ophthalmology, provides a successful organizational framework for the book and serves as an excellent guide in the management of these clinical problems. There are particularly valuable discussions of temporal arteritis, nutritional amblyopia, amaurosis fugax, practical management of vertebrobasilar insufficiency, benign intracranial hypertension, the technique and significance of tensilon testing, Horner’s syndrome, the management of thyroid ophthalmopathy as well as carotid cavernous fistula and meningioma, and headache including migraine. The book is replete with “pearls” reflecting the experienced clinical judgment of the authors. A few examples from areas other than those cited above are the following: Frequent ophthalmic check of patients on Ethambutol is not essential since the visual impairment is generally reversible (page 49); The advisability of CT scan in evaluation of optic atrophy if the clinical course is unclear, unless there is clear arteriolar narrowing (page 52); The value of early visual examination following surgery for optic nerve/chiasm compressive lesions (page 63); Fluorescein angiography is not of great value in the 136
137
BOOK REVIEWS of the recent report by Portnoy, Thompson, Lennarson and Corbett (AJO 96: 609, 1983) indicating the finding of such a defect in a surprising number of amblyopic patients. Although most neuro-ophthalmologists do not consider corticosteroid therapy of value in anterior ischemic optic neuropathy as stated on page 41, it might be mentioned that Hayreh, who has extensive investigative experience in this disorder, believes it of value during the period of disc swellin,g to lessen visual loss, and that some of us do use it in desperate cases, such as an only eye. In the discussion of therapy ofocular myasthenia on page 176, it might be mentioned that there are those who do not favor the use of corticosteroid in purely ocular myasthenia (although it is indeed likely to help) unless extremely important, e.g., occupationally. I believe that the statement (page 181) that “pupillary sparing is rarely found (
tive Decision Tree approach. It is invaluable for the ophthalmologist or neurologist in training or in practice and is highly recommended for the neuroophthalmologist as well. MW.I:S M. BEHKENS, M.D. NE\\. YORK,
An Outline Coakes
land, John
Price:
of Ophthalmology,
and Patrick
J. Holmes
Wright and Sons Ltd.,
Sellers, 1985:
NI:\V YORK
by
Roger
Bristol,
L. Eng-
195 pp., illus.
$12.50
This short text is intended by the authors to serve as a guide to help medical students understand how to approach common eye complaints. The material is organized by the ocular complaint which the patient might present with to the emergency department. The differential diagnosis of these symptoms is stressed, with therapy being mentioned more to provide an overview than to recommend specific modes of treatment. The seven main chapters touch on problems such as loss of vision, ocular pain, abnormal external appearance of the eyes, abnormal eye movements, trauma, the eye in systemic disease, and basic ophthalmic investigations and treatment. The authors are consultants at King’s College and St. George’s Hospital in London. Some of the British terminology and medications are somewhat foreign to an American readership. The text is accompanied by good quality black and white photos which demonstrate pathology as it would be seen without the aid of the slit-lamp. The book serves as a good introduction for the medical student seeking to develop an approach to basic ophthalmic differential diagnosis. MARC J. SIEC;EI., M.D. NEW’ YORK Nk:\V YORK
BOOK
VOLUME 31 . NUMBER 2
REVIEWS
l
SEPTEMBER-OCTOBER
1986
STEVEN M. PODOS, EDITOR
Clinical Decisions in Neuro-Ophthalmology, by Ronald M. Burde, M.D., Peter J. Savino, M.D. and Jonathan D. Trobe, M.D., St. Louis, Missouri, C.V. Mosby Company, 1985, 338 pp., illus. Price: $62.95
diagnosis of papilledema (page 123); Isolated internal ophthalmoplegia is not a sign of 3rd nerve paresis (page 183); Invasive neuroradiologic investigation is not usually helpful therapeutically in chronic stable 6th nerve palsy (page 190). There are a few points on careful scrutiny which might merit clarification. Legend F of color plate 9, facing page 117, implies that in papillophlebitis hemorrhages do not extend to the periphery, although they may. As the authors indicate on page 182, an ischemic type lesion was indeed present in the pathologic studies of diabetic pupil-sparing 3rd nerve palsy, although vessel occlusion was not actually demonstrated. Acquired pendular (jelly) nystagmus might be included in the list of monocular or dissociated oscillations present in the primary position in the top righthand box in chart 6-l on page 196. The statement on page 211 that physiologic nystagmus tends to be more prominent “in one eye” would be more specific if changed to “in the abducting eye.” In the description of rebound nystagmus on page 212, I believe the word “alcoholic” may have been substituted by error for “chronic” cerebellar degeneration. On page 214 the authors might mention the frequent induction of voluntary nystagmus by convergence, and on page 2 15 they might repeat the use of “sequential saccades” in the definition of ocular flutter. The definition of square wave jerks on page 215 might be clarified by indicating that instead of a “break in fixation” there are “unwanted saccades that take the eyes off the target” (Leigh and Zee, The Neurology ofEye Movements, 1983, p. 61). On page 216 the authors state that ocular bobbing is “indicative of brain stem dysfunction and is not precisely localizeable,” although the reference offered does indicate pontine compression. The authors generally present views alternative to their own, particularly when widely held, with a few exceptions. The finding of relative afferent pupillary defect in at least rare cases of amblyopia might be mentioned on page 18, particularly in view
The authors are experienced clinicians, investigators and teachers in neuro-ophthalmology and have combined to produce an excellent book - comprehensive, well organized, well written and well illustrated. It serves both as a basic text in neuro-ophof sophisticated thalmology and as a source discussion (with valuable up-to-date references) of fine points in differential diagnosis and in management well beyond the level of a basic text. The novel feature, a Decision Tree approach to the various clinical problems faced in neuro-ophthalmology, provides a successful organizational framework for the book and serves as an excellent guide in the management of these clinical problems. There are particularly valuable discussions of temporal arteritis, nutritional amblyopia, amaurosis fugax, practical management of vertebrobasilar insufficiency, benign intracranial hypertension, the technique and significance of tensilon testing, Horner’s syndrome, the management of thyroid ophthalmopathy as well as carotid cavernous fistula and meningioma, and headache including migraine. The book is replete with “pearls” reflecting the experienced clinical judgment of the authors. A few examples from areas other than those cited above are the following: Frequent ophthalmic check of patients on Ethambutol is not essential since the visual impairment is generally reversible (page 49); The advisability of CT scan in evaluation of optic atrophy if the clinical course is unclear, unless there is clear arteriolar narrowing (page 52); The value of early visual examination following surgery for optic nerve/chiasm compressive lesions (page 63); Fluorescein angiography is not of great value in the 136
137
BOOK REVIEWS of the recent report by Portnoy, Thompson, Lennarson and Corbett (AJO 96: 609, 1983) indicating the finding of such a defect in a surprising number of amblyopic patients. Although most neuro-ophthalmologists do not consider corticosteroid therapy of value in anterior ischemic optic neuropathy as stated on page 41, it might be mentioned that Hayreh, who has extensive investigative experience in this disorder, believes it of value during the period of disc swellin,g to lessen visual loss, and that some of us do use it in desperate cases, such as an only eye. In the discussion of therapy ofocular myasthenia on page 176, it might be mentioned that there are those who do not favor the use of corticosteroid in purely ocular myasthenia (although it is indeed likely to help) unless extremely important, e.g., occupationally. I believe that the statement (page 181) that “pupillary sparing is rarely found (
tive Decision Tree approach. It is invaluable for the ophthalmologist or neurologist in training or in practice and is highly recommended for the neuroophthalmologist as well. MW.I:S M. BEHKENS, M.D. NE\\. YORK,
An Outline Coakes
land, John
Price:
of Ophthalmology,
and Patrick
J. Holmes
Wright and Sons Ltd.,
Sellers, 1985:
NI:\V YORK
by
Roger
Bristol,
L. Eng-
195 pp., illus.
$12.50
This short text is intended by the authors to serve as a guide to help medical students understand how to approach common eye complaints. The material is organized by the ocular complaint which the patient might present with to the emergency department. The differential diagnosis of these symptoms is stressed, with therapy being mentioned more to provide an overview than to recommend specific modes of treatment. The seven main chapters touch on problems such as loss of vision, ocular pain, abnormal external appearance of the eyes, abnormal eye movements, trauma, the eye in systemic disease, and basic ophthalmic investigations and treatment. The authors are consultants at King’s College and St. George’s Hospital in London. Some of the British terminology and medications are somewhat foreign to an American readership. The text is accompanied by good quality black and white photos which demonstrate pathology as it would be seen without the aid of the slit-lamp. The book serves as a good introduction for the medical student seeking to develop an approach to basic ophthalmic differential diagnosis. MARC J. SIEC;EI., M.D. NEW’ YORK Nk:\V YORK