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Show LETTERS TO THE EDITOR FIG. 1. Trial frame with a spirit level mounted on the transverse bar. 75 with its transverse bar parallel to the superior orbital rims, the spirit level also helped to ensure that the head was straight. Spirit levels vary in sensitivity. We found that very sensitive spirit levels were of little use and that the air bubble should move horizontally by not more than 5 mm per degree of tilt. Yellowtinted liquid allows better visualization of the bubble than an uncolored liquid, especially in dim light. Such spirit levels are cheap and readily available. Avinoam B. Safran, M. D. Andre Mermoud, M. D. Neuro- ophthalmology Unit, Department of Ophthalmology, Geneva University Hospital, CH- 1204 Geneva, Switzerland REFERENCES 1. Halmagyi GM, Gresty MA, Gibson WPR. Ocular tilt reaction with peripheral vestibular lesion. Ann Neurol 1979; 6: 80- 3. 2. Brandt T, Dietrich M. Pathological eye- head coordination in roll: tonic ocular tilt reaction in mesencephalic and medullary lesions. Brain 1987; 110: 649-- 66. 3. Halmagyi GM, Curthoys IS, Dai MJ. Diagnosis of unilateral otolith hypofunction. In: Arenberg IK, Smith DB, eds. DIagnostic neurotology. Neurologic Clinics, vol 8. Philadelphia: WB Saunders, 1990: 313-- 29. The Neuro- ophthalmologist's Bag To the Editor: On many occasions the neuro- ophthalmic examination has to be done at the patient's bedside. Over the years we have assembled a collection of instruments necessary for performing a complete bedside neuro- ophthalrnic examination. We would like to share the contents of our neuro- ophthalmologist's " bag" with you ( Fig. 1, p. 76). The utility of a Rosenbaum vision card, multiple pin hole card, and occluder are well known. We always carry a + 2.50 diopter lens because patients' reading glasses are often not available. The lens has also proved useful for the patient with a third nerve palsy, which causes paralysis of accommodation. Naturally, the lens should be kept in a protective envelope. An ophthalmoscope is mandatory; we use a pocket spectacle pouch to protect it inside the bag. A Finhoff transilluminator has multiple uses and is quickly exchanged with the ophthalmoscope head on the battery handle. It provides a focused beam of light, the intensity of which is varied with the rheostat of the battery, to check pupillary function and to perform the swinging flashlight test. The transilluminator and the red/ green goggles are useful in performing a quick diplopia test. The transilluminator in combination with a + 20 diopter aspheric lens enables us to perform prompt monocular indirect ophthalmoscopy ( 1), and to examine the anterior segment. We also use it to examine old photographs, such as a driver's license, for ptosis or anisocoria. Tropicamide 1%, and phenylephrine 2.5% are needed to dilate the pupils. In addition, we carry bottles of pilocarpine 0.125%, cocaine 10%, and hydroxymethylamphetarnine 1%, for diagnosing Adie's and Horner's pupils. Our pharmacy requires that we carry an index card listing the person on whom the cocaine is used, including the number of drops. We also tape an index card J Clin Neuro- ophthalmol, Vol. 11, No. 1, 1991 76 LETTERS TO THE EDITOR FIG. 1. above the patient's bed to indicate that the pupils were pharmacologically altered. This simple note might spare some house officer a great deal of worry and some unfortunate intensive care or neurologic patient an unnecessary stat head computed tomography ( CT) scan. An unsharpened pencil serves as a tool to test for the " arrow" sign in evaluating vertical diplopia. In this test the pencil is held horizontally with the patient's eyes in primary position, and the patient is asked if the two images are parallel or not. The patient is then tested in right and left gaze. A skew deviation would produce parallel images in all three positions of gaze, whereas a trochlear palsy would produce converging images with the intersecting ends ipsilateral to the affected side. A package of eye patches are useful for occluding one eye during visual acuity or confrontation visual field testing at the bedside. Diplopic patients will be very gratefUl if you give them a few patches for occluding one eye to eliminate their diplopia. Alternatively, " transparent" adhesive tape applied to one spectacle lens will occlude the eye with a better cosmetic result. The tape is also used to lift a ptotic eyelid or to close the lid in a Bell's palsy. A small piece of red cloth and white targets mounted on the pencil's eraser, are used for accurate confrontation visual field testing. Sterile cotton- tipped applicators are a must for testing the corneal reflex and facial sensation. A transparent "'> 1 ; s best for measuring ptosis and levator func-tion. A small pupil gauge can often be found on the Rosenbaum card, but we prefer the Iowa pupil gauge ( 2) because it provides half- millimeter divisions. Because the examination of a patient with visual loss is incomplete without testing color vision, we carry Ishihara pseudoisochromatic plates or American Optical HRR plates. A stethoscope is needed to auscultate the orbits and carotid arteries in patients with suspected arteriovenous fistula or symptoms of cerebrovascular ischemia. Items which we take only on special missions include the exophthalmometer, the ophthalmodynamometer, the Schiotz's tonometer with proparacaine drops, and the camera. The camera is handy, especially during off hours when a professional ophthalmic photographer is unavailable. We also take it on radiology rounds to take shots of CT or magnetic resonance imaging scans directly off the view- box. To photograph a patient we mount the flash off to the side on an extension bracket to avoid annoying reflections. To obtain magnification without the expense or bulk of a macro- zoom lens we carry + 1x, + 2x, and + 4x lenses which mount like a lens filter over the standard 50 millimeter lens and can be used in any combination. For testing optokinetic nystagmus we use a cloth strip with small animals on it which can be purchased at a sewing supply shop- otherwise the OKN drum would occupy our entire bag. A hatchet reflex hammer costs about $ 1.50 and is LETTERS TO THE EDITOR 77 useful to spare your knuckles in testing muscle stretch reflexes, e. g., to support your diagnosis of an Adie's syndrome. A small bottle of oil of wintergreen, cologne, or coffee grounds is used to test for anosmia. A $ 20 bill is useful for catching the attention of a patient with functional visual loss, and to buy an early morning cup of coffee at the cafeteria. Finally, these days we must carry a small card listing the International Classification of Diseases ( 3) codes to common neuro- ophthalmic diagnoses, because if we do not enter the appropriate code on the consultation form, then medical records and the chart will come back to haunt us. Despite all these articles, your neuro- ophthalmic bag will not weigh heavily on your shoulder, especially if you use a bag made from rip- stop nylon. We suggest each person use this list not as an absolute, but as a guide for his/ her own tool kit. Ev-ery person will settle on their own combination of tools and tricks, and we would be interested in hearing about other neuro- ophthalmologist's ideas for additions or deletions to " the bag." Benjamin Hartmann, M. D. David K. Hirsh, M. D. Neuro- Ophthalmology Service Department of Ophthalmology Henry Ford Hospital Detroit, Michigan REFERENCES 1. Hartmann B. Bedside monocular indirect ophthalmoscopy. J Clin Neuro- ophthalmol ( letter to the editor), in press. 2. Hansen Ophthalmic Development Laboratory, Iowa City, Iowa. Courtesy of Dr. Stanley Thompson. 3. Commission on professional and hospital activities: The international classification of diseases, 9th revision, clinical modification. Ann Arbor, Michigan: Edwards Brothers, Inc., 1980. 1Clin Neuro- ophthalmol, Vol. 11, No. 1, 1991 |
