DOI: 10.1097/01.icu.0000188706.61977.ba
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PMID: 16264341
Issn Print: 1040-8738
Publication Date: 2005/12/01
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Excerpt
We have a different view of the situation. The simple argument attempting to negate neuro-ophthalmology's role in patient care, clinical, and basic research centers on the belief that advances in magnetic resonance and scanning, automated visual fields, and nerve fiber layer imaging are making the field a footnote to technology.
At the advent of computed and magnetic resonance imaging scanning, Professor William H Hoyt, the dean of world neuro-ophthalmology and professor at the University of California at San Francisco, predicted that neuroimaging technology would make the clinical neuro-ophthalmologist more important in patient care.
Actually, the whole field of retinal nerve fiber layer imaging was launched with the direct ophthalmoscope by Professors Hoyt and Frisen (see accompanying article on optical coherence tomography, multiple sclerosis, and optic neuritis). Automated visual fields have had the same practice-building effect, magnifying the demand for clinicians who can take a history, examine the entire eye, and then integrate the visual field results into the entire clinical picture.
Our waiting room is filled 5 days a week with patients who haul, tow, and drag literally pounds of magnetic resonance imaging and computed scans, containing precious little useful information. Most of these images reiterate that neuroimaging studies are normal in nonarteritic ischemic optic neuropathy, giant cell arteritis, optic disc anomalies, myasthenia, cranial mononeuropathies, many types of nystagmus, and other neuro-ophthalmologic disorders.
These transported images also prove again and again the point that: ‘If you image the brain, you will frequently never see the orbits well enough to diagnose the cause of the patient's proptosis.
Additional testimony (unfortunately, in the literal sense of the word ‘testimony’) for the necessity of high-quality neuro-ophthalmology is offered by the medical-legal fact that giant cell arteritis and its destruction of the optic nerve is one of the most common nonsurgical reasons for litigation against ophthalmologists in America.
The articles in this volume are linked by the common theme that good clinical observations are the basis for making rational decisions about the management of each individual patient; without the proper clinical diagnosis, cursory general ophthalmology examinations linked with poorly conceived imaging studies become a very expensive odyssey in medical physics. One of the first patients that I saw with retinal nerve fiber layer loss caused by optic neuritis and multiple sclerosis had been diagnosed with ‘low tension glaucoma’ at yet another ‘name-brand medical center’. Her multiple sclerosis and optic neuritis were by no means a secret but a well-established diagnosis for 5 years. Those neuro-ophthalmologic facts, however, did not prevent treatment with topical glaucoma drops for 3 years.
Specifically, as the focus of multiple sclerosis treatment moves to treating earlier to prevent axonal loss, neuro-ophthalmology will become an even more integral and crucial part of the care of these patients. Therefore, I am confident that neuro-ophthalmology's place is secure and will continue to grow and prosper, notwithstanding the uncorrected myopia of some other ophthalmologists.
