Cover -- Half-title -- Title -- Copyright -- Contents -- Foreword -- Preface -- Acknowledgements -- 1 When ocular disease is mistaken for neurologic disease -- Double images -- What important piece of historical information is still missing in this case? -- What maneuver might be helpful for confirming our suspicion that this patient's double vision is ocular in nature? -- Diagnosis: Monocular diplopia due to cataract -- Headache and bilateral disc edema -- What test was done and what was the diagnosis? -- Diagnosis: Malignant hypertension -- Chronic optic neuropathy -- Having excluded compressive, inflammatory and infiltrative causes of optic neuropathy, what othermechanisms would you consider? How would you proceed? -- Diagnosis: Glaucomatous optic neuropathy -- Painful mydriasis -- What clues suggest an alternative diagnosis? -- Diagnosis: Acute angle closure glaucoma -- Invisible retinal disease -- Twinkling scotoma -- What aspect of this patient's positive visual phenomenon is highly atypical for migraine? -- Diagnosis: Acute idiopathic blindspot enlargement -- Sudden monocular visual loss with normal fundus -- What othermechanism of visual loss would you consider? Are there any historical features that are helpful here? -- Whymight a retinal stroke not have been apparent on examination? -- Hazy night vision -- What specific aspect of this patient's history suggests the correct localization of his visual problem? -- Diagnosis: Hypovitaminosis A -- Swirling vision -- Diagnosis: Cancer-associated retinopathy -- Episodic monocular blur -- This patient's work-up addressed the possibility of retinal vascular disease as the cause of his transientmonocular visual loss (TMVL). Is there something about his history, however, to suggest a different mechanism for his episodes? -- Diagnosis: Transientmonocular visual loss due to corneal decompensation.

FURTHER READING -- Monocular diplopia -- Hypertensive retinopathy -- Twinkling scotoma -- Central retinal artery occlusion -- Hypovitaminosis A -- Cancer-associated retinopathy -- Corneal decompensation -- Glaucoma -- 2 When orbital disease is mistaken for neurologic disease -- Incidental elevation deficit -- What othermechanism could account for this patient's abnormal ocularmotility besides a third nerve palsy? -- Diagnosis: Orbital floor fracture with muscle entrapment -- Painless vertical diplopia -- What clinical features help to localize the source of this patient's ocularmotility disorder? -- Diagnosis: Euthyroid Graves' disease -- Fatigable ptosis -- How is lid fatigability objectively demonstrated? -- What other forms of ptosismight share a similar history of worsening with sustained use? -- Diagnosis: Levator dehiscence -- Painful ptosis and diplopia -- What is the anatomic significance of a superior division palsy? -- The investigation thus far has revealed no intracranial pathology. How would you proceed? -- Diagnosis: Idiopathic orbitalmyositis -- Painful optic neuropathy -- Is this patient's clinical course consistent with a diagnosis of optic neuritis? -- What specific feature of her clinical course raises the possibility of orbital disease? -- Diagnosis: Idiopathic optic perineuritis -- FURTHER READING -- Orbital examination and restrictive orbitopathy -- Levator dehiscence -- Painful ptosis and diplopia -- Optic perineuritis -- 3 Mistaking congenital anomalies for acquired disease -- Headaches and elevated discs -- Inferior altitudinal visual field defects -- Are there clues to the correct diagnosis in this case? -- Diagnosis: Superior segmental hypoplasia -- Incidental abduction deficit -- What feature identifies this woman's abduction deficit as a congenital, rather than acquired, sixth nerve palsy?.

Diagnosis: Type I Duane's syndrome -- Intermittent vertical diplopia -- What other causes of fourth nerve palsy should be considered? -- How would you pursue a diagnosis of congenital fourth nerve palsy in this patient? -- Diagnosis: Congenital fourth nerve palsy -- FURTHER READING -- Pseudopapilledema -- Superior segmental hypoplasia -- Duane's syndrome -- Congenital superior oblique palsy -- 4 Radiographic errors -- Ordering the wrong scan -- Progressive optic neuropathy -- Is there a problem with the diagnosis of "chronic optic neuritis"? -- What clinical features in this case suggest the likely mechanism of her chronic optic neuropathy? -- What additional radiographic evaluation should be obtained? -- Diagnosis: Optic nerve sheathmeningioma -- Headache and papilledema -- Diagnosis: Cerebral venous sinus thrombosis -- Idiopathic ptosis and miosis -- Why is the current study incomplete? -- Diagnosis: Postganglionic Horner syndrome -- Subtle radiographic findings -- "Boxer" ptosis -- The above clinical findings are characteristic of a postganglionic Horner syndrome. Howmight this be related to her preceding trauma? -- Diagnosis: Internal carotid artery dissection -- Headache and bilateral third nerve palsy -- What is the diagnosis? What confirmative study would you order? -- Diagnosis: Pituitary apoplexy -- Progressive sixth nerve palsy -- What aspect of this patient's presentation provides the most compelling diagnostic clue? -- Diagnosis: Petrous ridge meningioma -- Midline and bilateral abnormalities -- Bilateral idiopathic sixth nerve palsy -- Is a diagnosis of vasculopathic sixth nerve palsy still tenable here? -- What are the most common causes of bilateral sixth nerve palsy and what mechanism ismost likely in this case? -- Diagnosis: Clivus tumor -- Atypical pseudotumor cerebri syndrome.

What features of this case are atypical for a diagnosis of IIH? What alternative diagnosis should be considered? -- Diagnosis: Superior sagittal sinus thrombosis -- Vertical diplopia -- Diagnosis: Symmetric Graves' disease -- FURTHER READING -- Neuro-imaging -- Canalicular meningioma -- Cerebral venous thrombosis -- Horner syndrome and carotid dissection -- Chronic sixth nerve palsy -- 5 Incidental findings (seeing but not believing) -- Empty sella -- Low cerebellar tonsils -- Sphenoid sinus mucocele -- Dolichoectatic basilar artery -- FURTHER READING -- Pseudotumor cerebri syndrome -- Chiari malformation -- Sphenoid sinus mucocele -- Dolichoectatic basilar artery -- 6 Failure of pattern recognition -- Painful ophthalmoplegia -- Where is this patient's lesion? -- Diagnosis: Tolosa Hunt syndrome -- Painful ophthalmoplegia and visual loss -- Based on the clinical findings, where is the lesion? -- Diagnosis: Orbital apex syndrome -- Painless diplopia -- What is thismotility pattern, and what does it tell you about the mechanism of the patient's diplopia? -- Diagnosis: Oculomotor nerve palsy with aberrant regeneration -- Right-sided visual field loss -- What is the significance of this visual field pattern? Does it help to illuminate the findings on her MRI? -- Diagnosis: Lateral geniculate body stroke -- FURTHER READING -- Painful ophthalmoplegia -- Orbital apex syndrome -- Third nerve misdirection -- Lateral geniculate body -- 7 Clinical findings that are subtle -- Painless central gray spot in a teenager -- What is the most likely cause of this patient's neuroretinitis, and how would you test for it? -- Diagnosis: Neuroretinitis due to cat scratch disease -- Chronic "pink eye".

This patient had an additional non-ocular symptom which she did not volunteer because she didn't think it was relevant to her eye problem, yet this symptom was an important clue to the correct diagnosis. What question should be asked? -- Diagnosis: Dural-cavernous fistula -- Bouncing vision -- What is her symptom of "bouncing vision" called and what physical finding would you look for on examination? -- This patient's eye examination, however, was normal, specifically nystagmus was not observed. Why not? -- What examination techniques can help in the detection of nystagmus when the oscillatory amplitude is particularly small? -- Diagnosis: Downbeat nystagmus due to Chiari I malformation -- Farmer with an adduction deficit -- Diagnosis: Myasthenic pseudo-INO -- FURTHER READING -- Neuroretinitis -- Dural-cavernous fistula -- Downbeat nystagmus -- 8 Misinterpretation of visual fields -- Abnormal field and night blindness -- How would you describe this patient's visual field defect? What diagnoses should be considered? -- Diagnosis: Retinitis pigmentosa -- Constricted fields after herniation -- What bedside test can help distinguish non-organic field loss from true constriction of the visual field? -- Diagnosis: Bilateral occipital stroke with macular sparing -- Sudden difficulty reading the paper -- What simple "bedside" test could be performed to further investigate this patient's symptom? -- Diagnosis: Small homonymous scotoma due to occipital stroke -- Post-cardiac bypass visual loss -- Is there another possible explanation for this patient's visual loss, and how would you investigate this alternative mechanism? -- Diagnosis: Bilateral homonymous hemianopic scotomas secondary to bilateral occipital tip strokes -- Pseudo-bitemporal defects -- Incidental field defect -- What is the next step in this patient's evaluation?.

Based on the new interpretation of this patient's visual field defect, what feature of the examination should be reconsidered?.