Abstract
The annual Birmingham neuro-ophthalmology conference is a popular 1-day meeting that attracts a multidiscipline assembly of orthoptists, neurologists, pediatricians and ophthalmologists. There is a changing program that suits all grades and includes many eminent neuro-ophthalmology speakers.
Updates on the efferent pathways
Mike Burdon (Birmingham, UK) started the proceedings with a presentation on examining eye movements. He outlined a stepwise approach to history taking in diplopia. This included checking for monocular diplopia, asking about orientation, variation with eye position, progression and variability. Examination must include noting fixation and alignment, then checking ductions, versions, smooth pursuits, saccades and convergence. Other ophthalmic and neurological signs should also be looked for.
In ‘cases and conundra’, audience participation was skillfully sought by Andrew Jacks (Birmingham, UK). Eye movement video and pictures illustrated over 25 cases, including dramatic footage of Duane’s retraction. Each case had a salient message aimed at recognizing clinical signs and localizing the lesions.
From the basic mechanics of pause cells, burst cells and the neural integrator, Tim Matthews (Birmingham, UK) unzipped the brain stem to demonstrate the topographical supranuclear eye movement control centers and how they relate to one another. Disorders of these eye movements were then illustrated by video, with Tim Matthews and Liz Tomlin (London, UK) critically appraising the examination of eye movements. They both gave advice from the medical and orthoptic points of view regarding how to spot abnormalities. One of the most useful tips was to look at the nose when examining eye movements and nystagmus, as then the observer can get a fuller picture of what is atypical.
Paul Riordan-Eva (King’s College Hospital and the National Hospital for Neurology and Neurosurgery, London, UK) gave a logical talk on nystagmus by breaking down the characteristics of these abnormal eye movements and their etiologies. Describing the waveform (jerk or pendular); the direction and variation with gaze, time, fixation and head position; and the intensity (amplitude and frequency) helps diagnose the cause. An omission, particularly made by juniors during examinations, is not spending long enough watching the movements, as they can miss periodic alternating nystagmus. Questions were aimed at what treatment modalities are available and what doses to use, particularly if a balance disorder is associated with the nystagmus.
Abnormalities with pupils were explored by Fion Bremner (Moorfields Eye Hospital and National Hospital For Neurology and Neurosurgery, London, UK) from parasympathetic and sympathetic lesions to the non-neurogenic causes. Investigations of Horner’s syndrome should be dependent on the context. He emphasized that in any acute Horner’s syndrome case there should be a high index of suspicion of a carotid dissection, even if it presents without pain. He reminded us to test the accommodative pupil reflex with presbyopic correction where appropriate. The audience was particularly interested in the irritative sympathetic lesions, which can lead to ‘springing pupils’ that can dilate for hours, and ‘tadpole pupils’, where the patient can have a funny sensation in their eye and the pupil appears abnormal for a few minutes.
The third Michael Saunders lecture
James Acheson (Moorfields Eye Hospital and National Hospital For Neurology and Neurosurgery, London) explored reasons why some adult patients who should experience diplopia, simply do not, in his lecture ‘The eye on the move – motion detection in strabismus patients’. Retinal image movement is excessive in nystagmus and ophthalmolplegia causing considerable malaise, nausea and dizziness in some patients. The oscillopsia is particularly noticeable when trying to do tasks, such as walking. Therefore, in any acute-onset nerve palsy we occlude the deviated eye, not only to remove the false image but also to eliminate the retinal image movement. Over time, this unpleasant motion appears to settle and some authors have postulated a central adaptive mechanism to achieve this. Acheson presented evidence of increased visual motion thresholds (damping of an appreciation of movement) in both the affected and nonaffected eyes that are independent of etiology. In acquired strabismus, some patients appear to develop this quickly; others do not and, as a consequence, are symptomatic. This is likely to represent a visual–vestibular motion detection adaptive response to abnormal retinal slippage.
With over 125 delegates, the annual Birmingham Neuro-ophthalmology Conference is an established educational meeting. The evolving program and relaxed atmosphere is the secret to its success. For 2009, please contact, Hilary Baggott; Tel.: +44 121 507 6785; [email protected]
Financial & competing interests disclosure
The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.