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Show ' oumal of Clill/ cal Neuro- ol'hthalmology lOr 1I. 76- 78, 1990 Letters to the Editor Bedside Monocular Indirect Ophthalmoscopy To the Editor: Neuro- ophthalmologists frequently perform fundus examinations at the bedside, Occasionally, I am unable to see fundus details with the direct ophthalmoscope, This is due either to hazy media or to high refractive errors. In these cases I have found it very useful to use a method of monocular indirect ophthalmoscopy, The Welch Allyn Finoff transilluminator with fiberoptic light source provides bright and uniform illumination, I use this light source and a 20- diopter aspheric lens to perform monocular indirect ophthalmoscopy, as follows: Hold the transilluminator with the right hand and shine the light into the pharmacologically dilated pupil, With the left hand, hold the lens ( Fig. 1) about 10- 15 cm from the patient's eye, Then move the lens backward and forward until one can see clear fundus details, I have found this method very helpful, especially in cases with corneal opacity such as a corneal leukoma or due to recently applied ocular ointment, cataracts, or vitreous hemorrhage that FIG. 1. Hold the tranSilluminator Wlm me ngnt nana and shine the light into the pharmacologically dilated pupil. With the left hand, hold the lens about 10- 15 cm from the eye. Move it until clear fundus details are visible 76 © 1990 Raven Press, Ltd., New York would not allow good fundus examination with the direct ophthalmoscope. Naturally this method serves only as a quick check, and if an abnormal finding is seen I would perform conventional binocular indirect ophthalmoscopy. The principle of monocular indirect ophthalmoscopy is well known, and any bright beam could serve as a light source. My experience with this simple method is excellent, and I would like to recommend it to colleagues. Benjamin Hartmann, M. D. Neuro- ophthalmology Service Department of Ophthalmology Henry Ford Hospital Detroit, Michigan Hysterical Bitemporal Hemianopia " Cured" with Contact Lenses To the Editor: Recently, an 18- year- old woman had sudden onset of decreased peripheral vision in both eyes, Her past medical history was unremarkable. The patient had had one previous episode of " tunnel vision" 2 years previously. Complete physical and neurological examination results were normal. Corrected visual acuity was 20/ 20 OU, Refractive error was 00, - 0.50 sphere; OS, - 0,75 + 0.25 x 88, The remainder of the ophthalmologic examination, including pupils, extraocular movements, and funduscopic examination, was normal. Automated perimetry demonstrated a bitemporal hemianopia ( Fig, 1), Goldmann perimetry and tangent screen testing confirmed these findings but showed inconsistencies in the borders of the defects along the vertical meridian ( Fig. 2.) Cranial computed tomography and pattern reversal visual evoked responses were normal. The patient expressed interest in contact lenses and was fitted LETTERS TO THE EDITOR : [ I ! left Right FIG. 1. Automated threshold perimetry of the central 60° demonstrating bitemporal hemianopia. 77 with daily- wear soft lenses. She claimed return of full visual fields " within minutes" of inserting the lenses. Repeat automated perimetry was normal. A variety of visual field defects have been associated with malingering and hysteria ( 1). These commonly include generalized constriction of the visual field with no expansion to increasing test distance (" tunnel vision"), spiraling or crossing of isopters, and monocular temporal hemianopia ( 2). Although hysterical bitemporal hemianopia has been reported ( 3), it is exceedingly uncommon. Automated perimetry documented a bitemporal hemianopia in our patient, yet manual forms of field testing failed to confirm a reproducible defect. Smith and Baker ( 4) have reported that current automated techniques cannot differentiate functional from organic visual loss. Our findings support this contention. This case emphasizes the need to include functional visual disorders in the differential diagnosis of bitemporal field loss. It is also unique LEFT RIGHT FIG. 2. Goldmann perimetry of the same patient demonstrating incomplete bitemporal hemianopia. Note the inconsistencies along the vertical meridian. JClin Neuro- ophthalmol, Vol. 10, No. 1, 1990 78 LETTERS TO THE EDITOR in that field abnormalities resolved with contact lenses. Richard H. Fish, M. D. Lanning B. Kline, M. D. Vijaya K. Hanumanthu, M. D. A. E. Rainess, M. D. Suite 555 1600 7th Avenue South Birmingham, Alabama 35233 REFERENCES 1. Bajandas FJ, Kline LB. NeuTo- ophthalmology review manual, 3rd ed. Thorofare, New Jersey: Slack Inc, 1988: 00-- 00. 2. Keane JR. Hysterical hemianopia. The " missing half' field defect. Arch Ophthalmol 1979; 97: 865- 6. 3. Mills RP, Glaser JS. Hysterical bitemporal hemianopia. Arch Ophthalmol 1981; 99: 2053. 4. Smith TI, Baker RS. Perimetric findings in functional disorders using automated techniques. Ophthalmology 1987; 9: 1562- 6. |
