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Neuro-Ophthalmology
 
   Neuro-Ophthalmology

Neuro-ophthalmology is the specialty that is concerned with visual symptoms resulting from brain diseases. The visual symptoms can be divided into visual loss, or problems with eye movements. Visual loss may result from problems within the optic nerve or its connections to the visual portions of the brain. The eye is like a camera, and images are focused on the retina. The optic nerve is the cable that takes these images to the brain. There are several parts of the brain that are involved with precise control of eye movements. Difficulty within these regions often produces misalignment of the eyes with resultant double vision. Any of several processes may affect the optic nerve or its connections, including strokes, inflammation, multiple sclerosis or tumors.

Neuro-ophthalmologists are physicians involved in the field of neuro-ophthalmology. Neuro-ophthalmologists have completed medical school, and either a neurology or ophthalmology residency, followed by a neuro-ophthalmology fellowship.

Causes of Vision Loss

Visual loss may result from a problem within the eye or its connections to the brain. Blurred vision in one eye may be the result of a lens problem (glasses), cataract or other opacities blocking light’s entrance, a retinal problem, optic nerve disease or a lazy eye (amblyopia).

Causes of Double Vision (diplopia)

Double vision may be divided into two general categories: monocular or binocular. Monocular double vision affects one eye at a time. If the unaffected eye is closed, the double vision persists. Monocular double vision results from eye disease, usually a lens problem or cataract changes. Binocular double vision is only present when both eyes are open and goes away when either eye is closed. Binocular double vision results from misalignment of the eyes. When the eyes are pointed in different directions, the brain perceives two separate images (one from each eye).

The eyes are kept aligned by the muscles that control eye movements, which in turn are controlled by three nerves from the brain. Misalignment (causing binocular double vision) is most commonly due to a problem with one of three areas: the nerves that connect to the eye muscles, the connection between the nerves and the eye muscles, or the eye muscles themselves. There are several things that can affect the nerves going to the eye muscles including strokes or tumors pressing on the nerves. The most common disease to affect the connection between the nerves and eye muscles is myasthenia gravis. There are several muscle diseases that may affect the eye muscles.

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Diseases Treated by a Neuro-Ophthalmologist

Pseudotumor cerebri
Pseudotumor cerebri (PTC) is a disease primarily of young females. For reasons that are not understood, obesity appears to play a role in the disease. PTC results in elevated pressure inside the head (elevated intracranial pressure). This pressure typically produces headaches and swelling of the optic nerve heads. The swelling of the optic nerve heads may result in visual loss, and this is the most feared complication of the disease. The disease is diagnosed by excluding other causes of elevated pressure within the head through imaging (CAT/CT scan or magnetic resonance imaging) and lumbar puncture (spinal tap). Treatment begins with weight loss when appropriate, and may also include diuretics or surgery if medical means fail.

Optic neuritis
Optic neuritis refers to inflammation of the optic nerve. Optic neuritis typically produces blurred vision in one eye with pain or discomfort around the eye. The visual blur progresses over the first week, then stabilizes for several weeks before spontaneous improvement in most cases. Most patients regain vision of 20/40 (within three lines of 20/20 vision) by six months. The exam can help localize the blur to the optic nerve. Optic neuritis may occur without other disease, or can be associated with systemic diseases, such as multiple sclerosis (MS). Evaluation often includes an MRI scan to rule out other causes of optic nerve dysfunction, and to look for other evidence of MS. Treatment may include steroids (intravenous Solu-Medrol followed by oral prednisone), which increases the rate of recovery of vision.

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What to expect from your first visit to a neuro-ophthalmologist

When your referring physician contacts our office, an appointment will be set up for you with the appropriate provider in our office. If the appointment day/time that we have set for you does not fit with your schedule, you may contact our office directly and change the appointment, but please understand that a cancellation may result in a substantial delay in your being seen and treated (we are often booking three months or more in advance)

We will mail to your home a set of directions, instructions and a questionnaire. We ask that you review all of these materials and complete the questionnaire and bring it with you to your office visit. If you do not receive these materials, please contact our office and we will get the packet to you. You will need to be certain that all relevant medical records have been forwarded to us directly or you may hand carry them when you come to your appointment. We will need to see the films of any MRI's or CT scans you have had done as well as reports in order to properly evaluate you, so please bring the films with you or arrange to have them sent prior to your appointment.

If you are new to the Clinical Center, you will be asked to arrive 30 minutes prior to your appointment in order to register at New Patient Registration on the first floor of the Clinical Center. There you will be asked to provide your insurance information and identification, and a clinical chart will be made for you. You can then come up to our office in Suite A217 and check in at the registration window. We will collect your chart, questionnaire and medical records and confirm your insurance information.

Please note that the patient is ultimately responsible for obtaining the proper insurance authorizations prior to arrival at the appointment. If your visit is not authorized appropriately your appointment may be rescheduled (resulting in long delays in being seen) or you will be asked to pay for your visit, and then you can seek reimbursement from your insurance carrier.

You will be seen initially by a clinical fellow or staff member who will obtain a medical history with you, confirm the questionnaire and evaluate your visual function. Your pupils will be dilated at your first and perhaps subsequent visits. If you are unable to drive safely while dilated, please bring a driver with you. As you will probably still be dilated when you leave our office, you may be more comfortable if you bring with you a pair of sunglasses. If corrective lenses have been prescribed for you, whether or not you typically wear them, please bring them to your visit. If you wear contact lenses, please bring your contacts case with you and a pair of glasses if you have them.

Your examination will be tailored to your specific complaint but will likely include a visual field evaluation, examination of the structures of the eye itself, evaluation of your visual function, and inspection of your retina and optic nerve.

After your examination, the examiner will leave the room to discuss your case with the attending physician (Dr. Kaufman, Dr. Eggenberger or Dr. Yedavally). Your doctor will then come into the room and confirm certain aspects of your exam and history and will discuss with you his/her impressions and recommendations for your condition. You will have the opportunity to ask questions and together you and he/she will develop a treatment strategy. After your discussion with the doctor, you will be directed to the reception desk where the tests/evaluations your doctor has suggested will be scheduled. If your insurance prohibits our office from scheduling these evaluations, we will contact your primary care physician and request that he/she carry out the "plan" which may include MRI, lab work, Dopplers, cardiac testing and/or evaluation with other specialists.

Our evaluations are very extensive and thorough. If this is your first evaluation, please plan to be here at least 3 hours (perhaps as long as 4 hours) so that we may properly assess your problem.

Additional information can be found on these websites:

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