Neuro-Ophthalmology

Neuro-ophthalmologists are teachers. They spend a tremendous amount of time teaching neurologists and neurosurgeons about the eye, and teaching ophthalmologists about the brain. They often act as facilitators, helping these physicians communicate with each other. Neuro-ophthalmologists attempt to “lump” these complex specialties into something called neuro-ophthalmology, which deals with every aspect of the eye and the brain, approached anatomically via the afferent and efferent visual systems.

Our service at Emory University is filled with neurology-trained and ophthalmology-trained fellows, and with neurology, ophthalmology, and neurosurgery residents. They come to our service having cared for the same patients from completely different perspectives. One of the most challenging tasks for neuro-ophthalmologists is to teach and stimulate the interest of all residents from different specialties. Our neuro-ophthalmology fellows learn how to teach during their fellowship years, and many have already surpassed their mentors.

When I was asked to edit a Seminars in Neurology edition devoted to neuro-ophthalmology, I decided to ask only our current and former fellows to be contributing authors. Some are neurologists, others are ophthalmologists, and they all have become accomplished neuro-ophthalmologists. This issue of Seminars in Neurology is a contribution from the Emory University neuro-ophthalmology teaching tradition created by Dr. Nancy J. Newman. A big thank you to Ted Atkins, Tariq Bhatti, Beau Bruce, John Kerrison, Paul Phillips, Janet Rucker, and Greg Van Stavern who wrote superb articles!

This issue presents up-to-date articles on some of the most important and commonly seen neuro-ophthalmic disorders. This is not a textbook, and not everything could be covered. These articles were specifically written for the neurologist. We try to emphasize the “thinking process” used by neuro-ophthalmologists, in addition to providing the most updated information on each topic. The article on vision loss reminds the neurologist that not all patients with loss of vision have an optic neuropathy, and it provides specific guidelines for the diagnosis of optic neuropathies. The two most common acute optic neuropathies are optic neuritis in the young and ischemic optic neuropathies in older patients. The diagnosis of disc edema remains difficult for neurologists, who tend to only think of papilledema (i.e., disc edema caused by raised intracranial pressure). Indeed, disc edema is a nonspecific finding that results from any insult involving the optic nerve head. Systematic examination of the fundus is important in all neurological patients presenting with headache or a known intracranial process. Patients with papilledema can develop irreversible loss of vision and may even become blind. Detection of papilledema and prevention of vision loss is one of the neurologist's tasks.

Oculomotor disorders and diplopia are commonly encountered in neurology. Of the numerous causes of diplopia reviewed in the oculomotor disorders article, third nerve palsies generate the most questions and the most anxiety, so we have provided a detailed discussion of these disorders in a separate contribution. Orbital syndromes traditionally belong to the ophthalmologist. The orbital syndrome article, however, emphasizes that often a neurologist may be the specialist who makes the diagnosis and even follows the patient. Finally, although often accused of being therapeutic nihilists, neurologists can be active participants in the management of patients with diplopia. The article on treatment of diplopia covers the various approaches for correcting the problem.

I hope you enjoy this issue of Seminars in Neurology and that you will use it to teach your students and colleagues a little more neuro-ophthalmology.