Leonard A Levin and Anthony C Arnold

Thieme Medical Publishers, Inc., 2005 ISBN 3131383119

When a few minutes on Google can produce a comprehensive review of any diagnostic label, there is a premium to be gained for arriving at the correct diagnosis methodically, safely, and inexpensively. Ask for the opinion of an experienced neuro-ophthalmologist or reach for The Practical Guide?

This book is aimed at ophthalmologists, optometrists, internists, nurse practitioners, neurologists, neurosurgeons, specialists in emergency or in family medicine. The aim is to guide these practitioners in the initial evaluation of neuro-ophthalmic patients. The editors have assembled 54 colleagues in neuro-ophthalmic practice ranging from well-known authors of standard texts to single-handed practitioners. The book is divided into sections on Examination, Signs and Symptoms, Diagnoses, and Procedures.

The first four chapters review the essential techniques of neuro-ophthalmic examination. Methods and interpretation of findings are well illustrated so that the target audience should be able to elicit the clinical signs. Proper emphasis is placed on the relationship between patient and observer. For example, Michael Wall cogently summarizes the inherent limitations of perimetry in his chapter on Choice and Interpretation of Visual Field Testing.

The quick reference guide on the back of the front cover implies that patients may be evaluated first on the basis of symptoms and signs and then the appropriate chapter consulted. But neuro-ophthalmologists would not agree with the inference that only patients with symptoms but no signs should be referred to them.

True, some problems lend themselves to this approach.

So, for example, a practitioner faced with a patient with intermittently different sized pupils could quickly turn to Aki Kawasaki's chapter 15. If anisocoria is transient, the diagnoses of acute glaucoma, ophthalmoplegic migraine, cluster headache, tadpole-shaped pupil and benign episodic mydriasis are considered. Each entity is briefly described. The presentation and appropriate investigation is well illustrated. Cautions or ‘Red flags’ are listed.

Or, a practitioner meeting a patient with an optic nerve tumour could turn to Neil Miller's beautifully illustrated and succinct chapter 27.

More problematic is a topic such as Ocular and Orbital Pain with or without abnormal signs (chapter 13). This chapter reads like a review of the whole subject of neuro-ophthalmology and headache. A generalist who engages with this subject might well soon regret their initial enthusiasm and reach for the telephone. But I found the succinct summaries of pain syndromes with a normal examination very useful. It was fascinating to learn that ipsilateral facial pain may be a presenting sign of non-metastatic lung cancer, it is suggested because the vagus nerve is locally invaded.

It is difficult to maintain a consistent approach in a multiauthor compendium. Some authors have adopted a general approach well suited to a beginner in the specialty; others have provided long lists of multiple causes, giving undue emphasis to rarities. The use of references is not standardized either. For example, the chapter on Diplopia and Polyopia lists 102 papers, whereas the chapter on Nystagmus makes do with four.

There is certainly plenty to interest all ophthalmologists here, but the author's laudable aim to encourage generalists to engage in rarefied neuro-ophthalmic diagnosis is somewhat too ambitious and unrealistic. The neuro-ophthalmologist will still be referred patients, and not just those with symptoms and no signs. Nevertheless, this book will prove a handy reference for experts faced with a perplexing case as well.