Eyeworld

EW NEWS & OPINION 36 March 2017 by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer Neuro-ophthalmological pitfalls that doctors encounter in clinical practice and how to avoid them O phthalmologists are grate- ful for any guidelines that shed a light on the more confusing signs and symp- toms encountered in clin- ical practice. Neuro-ophthalmology is an area of expertise that plays an important role in everyday ophthal- mology. However, the specialty is not always given due consideration, and doctors are sometimes more comfortable referring their patients to a neurologist for a second opin- ion. Some classic pitfalls that present themselves in daily practice are directly related to neuro-ophthal- mology and may send doctors on a wild goose chase of mistaken cause and effect. "Mistakes in neuro-ophthalmol- ogy may cause unnecessary work-up, they may worry our patients, but they may also lead to huge catastro- phes endangering eyesight or even the lives of our patients," according to Helmut Wilhelm, MD, Univer- sity of Tuebingen Medical School with corticosteroids, it looked like chronic relapsing inflammatory optic neuropathy until the visual field exam revealed normal vision in her second eye. Because the binoc- ular visual field would have had to be normal as well in this scenario, Dr. Wilhelm was able to identify the problem. Avoid implying a brain tumor Dr. Wilhelm also described an oversight in communication that can inadvertently lead patients to draw dramatic conclusions. "The classic mistake in young patients is to send them off to a neurologist for 'further examination,' because that will really scare the patients into thinking the worst. Eye doctors need to learn to identify pupillary symp- toms. We should be able to diagnose pupillary irregularities ourselves." In patients with a fixed pupil that does not respond to light, Dr. Wilhelm examines the near response, which may be slower, but intact, preclud- ing a tumor. He uses the slit lamp to observe pupil reactions. He notes whether the pupil is completely immobile or if some segments are mobile and others are immobile, which causes a worm-like contrac- tion. This is typical for a tonic pupil, in general a harmless condition; Tips to overcome oversights in neuro-ophthalmology A temporal visual field defect. The left eye was almost blind due to the large supersellar tumor causing it. Source: Helmut Wilhelm, MD Center for Ophthalmology and Neuro-ophthalmology, Tübingen, Germany, who spoke at a sympo- sium on "Learning from Mistakes" at the 114th Congress of the German Ophthalmological Society in the fall of 2016. He shared some pointers for navigating through these neuro- ophthalmologic gray zones. Perform the flashlight test The most common omission is performing a swinging flashlight test, in which the patient looks straight ahead and the light is shone into one eye at a time, preferably in darkness for best detection. This should be done before mydriatics are applied, which may account for why the test is sometimes left out, Dr. Wilhelm said. Skipping this simple test can lead the clinician to a false conclusion and potentially conceal the actual diagnosis. Dr. Wilhelm described the case of a patient who had seen seven eye doctors because of slowly decreasing visual acui- ty. Although he suffered from the effects of a large cystic tumor that required prompt surgical atten- tion, he had been diagnosed with a number of conditions as the cause of his failing eyesight, including high IOP and was even offered LASIK as a solution. The symptom that gave it away was a relative afferent pupil- lary defect that was identified during the swinging flashlight test. Balance inventive patients with evidence According to Dr. Wilhelm, inventive patients can fool even a practiced clinician into believing there is more going on than there actually is. However, by performing the right examinations and examining the evidence, the doctor should be able to discover the real problem. When logic fails, optic neuritis is a common go-to. In fact, it rep- resents a common diagnostic pitfall in patients with reduced visual acu- ity and a general lack of symptoms. Dr. Wilhelm explained, "Sometimes the doctor just doesn't see any telltale signs, but he has to come up with an explanation for poor vision. On top of it, when patients pretend or want to believe they have symp- toms, it can be hard to see through. If you don't do the right tests, you won't come to the right conclu- sions. As for optic neuritis, you can only diagnose it when you have the matching diagnostic findings." For example, Dr. Wilhelm described a case of a young woman who had acutely reduced vision on one side. After several rounds of treatment Presentation spotlight

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