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Return to Eyes are the Windows to the Brain and a Way to Detect Trouble Overview

More on Eyes are the Windows to the Brain and a Way to Detect Trouble

Eyes are the Windows to the Brain and a Way to Detect Trouble

NEW YORK (Feb 1, 2012)

close up of human eye
(photo: National Eye Institute, National
Institutes of Health)

Poets consider the eyes to be the window to the soul, but to neuro-ophthalmologists they are portals to the brain, through which they can detect neurological problems. Since about a third of the brain is devoted to sight and eye movement, many disorders and diseases that affect the brain produce visual symptoms. Neuro-ophthalmologists, doctors with specialized training in both neurology and ophthalmology, work to diagnose and treat visual problems that arise from the nervous system rather than from the eyes themselves.

Not surprisingly these problems are sometimes difficult to diagnose. "Patients may come to us after seeing five or six other doctors," Golnaz Moazami, M.D., a neuro-ophthalmologist at NewYork-Presbyterian/Columbia University Medical Center, said. "We have to review all the tests they have had and do our own leg work as well. Depending on our exam and the patient's story we start to tease out the problem. Sometimes it can be a lot of work."

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The most common symptoms that send patients to a neuro-ophthalmologist are transient or partial loss of vision, visual disturbances, double vision, abnormal eye movements, unequal pupil size, and eyelid abnormalities. The underlying cause for these problems ranges from serious ones like brain tumors to simple things like a medication that's aggravating vision problems. However, they also can include an aneurysm or stroke, multiple sclerosis, tumors on the pituitary gland or other parts of the brain, undiagnosed cancers such as melanoma, lung, breast, and prostate cancer that have spread to the brain or eyes, myasthenia gravis, seizures, hypertension, and thyroid disease.

Golnaz Moazami, M.D.
Golnaz Moazami, M.D.

One of the diagnostic tools these specialists use often is the visual field test, said Marc Dinkin, M.D., a neuro-ophthalmologist at NewYork-Presbyterian/Weill Cornell Medical Center. "A visual field test is a really important part of our exam because the pattern of field loss in both eyes gives us a good sense of where the problem is," he explained. To perform a visual field test the doctor has patients look at a fixed target while lights of varying size and brightness are projected at different spots in the field. When they detect a light, patients press a button. A computer records and maps their responses, showing where in the visual field the eye has normal sensitivity and where it is abnormal. "A classic example of the usefulness of this is a patient who sees nothing to the right in the right eye and nothing to the right in the left eye either. We know that both of this patient's eyes are fine but that there is a problem in the left brain."

Loss of part of the visual field may manifest itself when patients have problems with routine tasks. Many patients come to Dr. Moazami, for example, complaining that they are having trouble reading, she said. "It turns out their vision is 20/20 but that some part of their field of vision is missing because a tumor or stroke is affecting their occipital lobe," the visual processing center of the brain.

Marc J. Dinkin, M.D.
Marc J. Dinkin, M.D.

When visual loss occurs in one eye, the problem is often rooted in the optic nerve, said Dr. Dinkin, and is commonly due to optic neuritis, an inflammation of the nerve. This can develop in young women, some of whom have multiple sclerosis (MS) or who will go on to develop MS, an autoimmune disease that affects the central nervous system, he said.

Neuro-ophthalmologists are also seeing an increasing number of young, overweight women with loss of vision from a condition called pseudotumor cerebri (also called idiopathic intracranial hypertension). "We don't know how excess weight increases pressure in the brain," said Dr. Moazami, "but as a result the optic nerve is compressed, and if it's not treated patients may go blind." Dr. Dinkin is involved in research at Weill Cornell to see if expanding veins in the brain with stents in certain patients can reduce intracranial pressure and treat the condition.

Among older patients neuro-ophthalmologists see a condition called ischemic optic neuropathy, in which a stroke to the optic nerve produces swelling of the nerve and vision loss. This can occur because blood flow to the optic nerve may decrease with age or because of an inflammatory disease called giant cell arteritis.

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Neuro-ophthalmologists see many patients who report having double vision, which typically develops because the eyes are misaligned. This can result from lesions affecting the brain, cranial nerves, and eye muscles and or from strokes, tumors, MS, thyroid disease and many other conditions. The exact pattern of misalignment can help localize the lesion. "In addition to diagnosing the underlying cause of double vision, we can apply prisms to patients' glasses, which bend the light and may lead to resolution of the double vision. Watching the patient smile as their single vision is restored with the prism is a great reward," said Dr. Dinkin.

The problems that bring patients to a neuro-ophthalmologist are often multifaceted, and both Drs. Dinkin and Moazami often collaborate with neurosurgeons, general neurologists, general ophthalmologists, and rheumatologists to provide comprehensive care. "At a large medical center like NYP it's easier treating patients with these conditions," said Dr. Moazami. "I have many colleagues in neurology and neurosurgery who I can work with."

Contributing faculty for this article:

Marc J. Dinkin, M.D., is an Assistant Attending Opthamologist at NewYork-Presbyterian/Weill Cornell Medical Center and an Assistant Professor of Ophthalmology at Weill Cornell Medical College.

Golnaz Moazami, M.D., is an Assistant Attending Opthamologist at NewYork-Presbyterian/Columbia University Medical Center and an Assistant Professor of Ophthalmology at Columbia University College of Physicians and Surgeons.

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