Editorial

Questions Answered Answers Questioned

Can a patient have migraine without a headache? I have certainly seen cases such as those described by O'Connor and Tredici and have called them migraine. Schatz, in his discussion of the lead article, points out that you must rule out recurrent microembolic phenomena and structural brain abnormalities before classifying a patient as acephalic migraine. The ques­tion is how much of a work-up is appropriate?

If you do not have a CT scan available to you, what is the most important noninvasive test and the most important invasive test if you suspect a patient of having a meningioma? According to Anderson and Khalil, the brain scan and cerebral angiogram will pro­vide the answer in approximately 90% of all cases. The real question is, will you suspect a meningioma in the first place? I have been "burned" in several instances. In one case the patient was sueing his employer for head trauma with resultant "acute" loss of vision in one eye. Skull x-rays were negative. I attributed his contralateral blurred vision to psychological problems. Craniotomy eventually revealed a large frontal menin­gioma. In another instance, the patient's sole com­plaint was difficulty with her reading glasses. I changed these periodically, with some patient satis­faction. Gross field testing at a follow-up examination revealed profound bilateral field loss; a large menin­gioma was removed and the reading vision improved without need for a new prescription. How often should visual fields be tested in your routine patients?

Atropine or cyclopentolate for cycloplegic refrac­tion in esotropic children? Rosenbaum and colleagues warn you about the child who flashes + 2.00 D or more with cyclopentolate. Such children are liable to have significantly more hyperopia. What do you use in your practice to refract esotropic children?

Do you know what the BrOckner test is? It's a useful objective test for determining small angle deviations in young uncooperative children. Can you figure out why

the fixing eye has a darker fundus reflex than the de­viated eye?

Visual acuity is easy to measure and easy to quanti­tate, or is it? What is the effect of contrast on acuity and how is your patient affected? Read Mainster et al for some of the problems and some of the answers. I'm sure many clinicians have noted that their patients readily see a line or two better when the lights are very dim in the room where acuity testing is taking place compared to a moderately well-illuminated room. What then is the acuity that should be recorded?

Can a computer analyze visual fields in a meaningful way? Johnson and Kelter point out that there is a di­rection, but it's presently a little like the "Yellow Brick Road." It is not to difficult to conceive of a situ­ation where automated, computerized visual field de­vices will be set up in optical shops, and for a price, presumably moderate, a patient will test his own field. An abnormal response or answer will send him scur­rying to his eye doctor who will then have to ask the right question(s).

Tso asked wha-t is the pathogenesis of optic nerve­head drusen? He comes up with an answer "drusen are definitely related to axonal degeneration of · the optic nervehead." If glaucoma is also a disease that damages or alters axoplasmic flow and leads to pri­mary axonal degeneration as some theorize, why don't we sometimes see drusen in eyes with glaucomatous optic disc damage? How about in chronic atrophic papilledema?

Do you think a patient could be unfortunate enough to have retinoblastoma in one eye and persistent hyperplastic primary vitreous (PHPV) in the other eye? The odds must be formidable, but there's a case to be made by Morgan and McLean.

Read the Viewpoint for there you will find yourself.

PAUL HENKIND, MD, PHD

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