What happens during a neuro-ophthalmic consultation ?
A neuro-ophthalmologic consultation is one of the most comprehensive examinations you will experience. You will be asked to give an account of your current problem and relate your entire medical history, including previous hospitalizations, operations, medical problems in your family members, and medication allergies. You will then have a complete eye examination. This may include testing of your peripheral vision by using a visual field machine and studying the layers of your retina and optic nerve by using an optical coherence tomography (OCT). The neuro-ophthalmologist will review your records and MRI or CT scans , if applicable. Finally, the neuro-ophthalmolgist will discuss the diagnosis (or possible diagnoses), the need for any additional testing and possible treatment.

What should I do before coming to the clinic and what should I bring with me?
To benefit to the maximum from your visit, you need to bring with you all CT or MRI scans you performed before, all your relevant medical reports and letters, and a complete list of your medications including the name and dosage. Please be aware that the doctor will most probably dilate your pupils by applying special drops so it is wise to have someone with you who can drive you home after the visit and if coming during the day bring with you dark sunglasses to wear it after the visit.

My doctor thinks I have optic neuritis, what does that mean?
Optic neuritis is inflammation of the optic nerve and is a common cause of painful loss of vision in young patients. You probably have experienced pain in your eyes and partial or complete loss of vision. Optic neuritis occurs due to “overactive” immune system. The immune system is very important in fighting diseases and bacteria but occasionally can become overactive for unknown reason and attack the body tissues itself, in this case the optic nerve.

What is going to happen to my vision and I am going blind?
In the vast majority of patients, your vision will improve over 4-6 weeks. It may not improve to normal, but it is likely that there will be a substantial improvement whether or not you are treated. However, treatment with intravenous steroids followed by oral steroid pills will likely speed you recovery.

I was diagnosed to have optic neuritis; does that mean that I have multiple sclerosis (MS)?
Optic neuritis can sometimes be the first sign of MS. The doctor would have probably ordered an MRI scan of the brain for you. If this shows areas of inflammation, then this means that you have a higher risk to develop MS in the future. Your doctor may suggest consultation with a neurologist to discuss treatments that might reduce the risk of recurrent disease. Even a normal scan does not guarantee that episodes may not recur over years. Whether or not this turns out to be MS in the future, the prognosis in terms of visual recovery is still good for this particular episode.

Can I cure or prevent MS?
Studies have shown that the use of high dose intravenous steroids in patients at high risk (those with abnormal MRI scan that shows inflammation the central nervous system ) may delay the onset of MS. Recent data suggests that some of the newer medications may also decrease the chance of having another neurologic event. Thus, it is important to recognize those patients at higher risk to start earlier treatment by studying the MRI scan. There is no treatment that will absolutely prevent the development of multiple sclerosis.

My doctor told me that I have NAION, what does that mean?
NAION is a condition that causes sudden loss of vision most commonly in patients over 50 year of age but occasionally younger patients. It is caused by interruption of the blood supply of the optic nerve. Most patient complain of painless, partial loss of vision (dim or dark area above or below when they look straight).  NAION is common in patients who have diabetes, hypertension and high blood cholesterol.

Is there are a treatment for NAION?
Unfortunately at the present time there is no effective treatment for NAION. What you could do however is to make sure that your diabetes, hypertension and cholesterol level are well controlled, if applicable. In addition, you need to make sure that your blood pressure is not over corrected and that there are no big drops in your blood pressure. If you are taking your blood pressure pills at night it is advisable to take them in the morning to avoid drops in blood pressure at night, which can cause reduced blood supply to the optic nerve

What will happen to my vision?
If your central vision is affected, there is a good chance that it will improve within few weeks to months. In about 40 % of patients, vision tends to stay the same. In a minority of patients vision can continue to worsen in the first few weeks then stabilizes.

Will I become blind in the other eye later?
Taking one aspirin daily, treatment of your diabetes, blood cholesterol and blood pressure can reduce the chance of having the other eye affected.

My doctor told me that I have papilledema (swelling of the optic nerve) because of raised head pressure; do I have a tumor inside my head?
When you have swelling of the optic nerves without tumor seen by CT or MRI scans, which your doctor must have ordered for your already, this is called Idiopathic Intracranial Hypertension (IIH) or pseudotumor cerebri. This is a condition that occurs mostly in young women who are overweight. The high pressure inside the head is not the same as your eye pressure or blood pressure. The high pressure inside your head is thought to be caused by high production or limited absorption of the water that circulates inside the brain (cerebrospinal fluid). You may have headaches and problems with your vision such blurring of the vision when you stand up or sit down and double vision. You also may have gained weight over the last few months before you problem has started. In addition to a CT or MRI of the head, your doctor should have ordered a spinal tap (needle inserted in the lower back to withdraw a sample of the fluid circulating in your brain and spine). This is very important to measure the pressure inside the head and to analyze the sample to make sure that there is no infection or inflammation.

What possibly can result of the high pressure inside my head?
Although you may have headaches, the only permanent damage that can be caused by this condition is to your vision. With time if the pressure inside the head remains high and the optic nerves remain swollen, permanent damage to the optic nerve and to your vision may result. The headaches themselves although can be severe, have no permanent sequelae.

I am too scared to do a spinal tap (needle inserted in the lower back), can I skip this test and start treatment?
Unfortunately without this test, your doctor cannot be sure what is your problem, and therefore would not be able to treat you properly. A spinal tap is almost always a very safe procedure and is needed to be done only once to confirm the diagnosis of idiopathic intracranial hypertesnion (IIH).

How do you treat IIH?
The decision to treat you depends on how much symptoms do you have (headaches) and how much is the disease affecting your vision. The doctor needs to do visual field tests to monitor your vision and look inside your eyes to see  if there is significant swelling in your optic nerves. Treatment is initially with diamox tablets at a dosage determined by your doctor. In some cases, treatment with diamox is not effective and surgery may be needed. Weight reduction is also a good idea since as much as 10% weight loss can improve your condition.

A doctor has recommended that I get in the hospital to have a spinal tap (needle inserted in the back) every now and then to relieve the pressure in the head?
This is generally not effective. You need to have a spinal tap only once initially to make the diagnosis. The fluid that circulates inside the brain even if withdrawn completely can be reformed within hours. Therefore, repeated spinal taps are not recommended except probably in pregnant women who cannot use diamox.

My doctor diagnosed me with ischemic cranial neuropathy. What does that mean?
Ischemic cranial neuropathy is the most common cause of acute double vision in the older population. This can occur in patients with diabetes, hypertension, and hyperlipedemia. The eye is moved by six extra-ocular muscles and these are supplied by nerves that arise from the brain stem. (3rd, 4th, and 6th cranial nerves). What happens in ischemic cranial neuropathy is that the tiny blood supply to these cranial nerve get interrupted, which results in a small “stroke” to the nerve and consequently double vision.  This often resolve over 2-6 months without leaving any residual double vision.
If you experience sudden onset of pain and double vision, you need to see your doctor to make sure that this is truly an isolated ischemic cranial neuropathy and nothing else more serious. Your doctor may need to order brain scan (CT ,MRI, or an angiogram) to exclude other more serious conditions. You may be also asked to see your family doctor to make sure that you do not have diabetes ,hypertension or hyperlipedemia, and if you have these conditions already to make sure that they are adequately controlled.

What is the treatment of ischemic cranial neuropathy?
There are no vitamins, drugs or eye exercises that you can do to speed the recovery from ischemic cranial neuropathy. If you are experiencing pain, you may use an analgesic or a non-steroidal anti-inflammatory (NSAID) like ibuprofen. If you are very bothered by the double vision, you may cover (patch) one eye until your condition improves and you start seeing more clearly.  In rare instances, Botox injections can be given to straighten the eyes but their effect can be unpredictable.

I have had double vision for over 6 months and it will not go away ?
This would be very unusual for ischemic cranial neuropathy and it is highly recommended that you see your doctor, who may order additional diagnostic tests.

I have been diagnosed with ocular myasthenia gravis. What does that mean ?
Ocular myasthenia gravis condition in which there is a blockage of the nerve impulse transmission between the nerve and muscle. The result is that the muscle does not contract; if it affects the eyelids muscles the result is droopy eyelid (ptosis) and if it affects the extra-ocular muscles, the result is double vision (diplopia). The disease is caused by auto-immune damage to the chemical receptors on the muscles, which are necessary to generate muscle contraction.

What are the symptoms of ocular myasthenia?
The most common are droopy lid (ptosis) and double vision (diplopia) , which can come and go. These symptoms can get worse toward the end of the day (evening). Remember that myasthenia can affect muscles elsewhere in the body, therefore if you have difficulty of breathing or swallowing, these are serious signs and you need to see your doctor immediately.

How is ocular myasthenia diagnosed?
The diagnosis can be made clinically if the presentation is very typical. However, to strengthen the diagnosis your doctor may order some blood tests and electrodiagnostic tests (tests that determine how good is the conduction between the nerve and the muscle). Your doctor may use simple tests in the clinic such as the ice test, in which your doctor will apply ice packs on the lids for few minutes and frequently this improves the droopy lid or diplopia for a brief period after the test.

How is ocular myasthenia treated ?
Ocular myasthenia is treated by pills that improve the transmission between the nerve and muscle by blocking the breakdown of the neurotransmitter acetylcholine (the substance that travels between the nerve and muscle and ultimately causes muscle contraction).
Occasionally, steroids and immunosuppressive medications may be used in more severe cases. Enlargement of the thymus gland has been associated with ocular myasthenia and surgical removal of the enlarged thymus gland can improve the condition.

I am interested in cosmetic lid surgery (blepharoplasty), what should I expect and how do I know if it’s right for me?
Blepharoplasty, or more commonly known as cosmetic eyelid surgery, is an elective surgical procedure used to remove wrinkles and excess skin and fat of the upper and/or lower eyelids. The procedure is one of the most common cosmetic surgical procedures done worldwide because the eye is often the focus of attention and plays an important role in determining the personal facial features.  Blepharoplasty aims at tightening the loose skin around the eye, which becomes lax with aging , remove puffiness around the eyelids due to excessive fat tissue (fat bags), put the lower eyelids in proper alignment and tightening the tendons of the lower eyelids. As with any cosmetic enhancement surgery, you should first consider your motivations for surgery to be sure that you're choosing surgery for yourself and that you have realistic expectations. The doctor will explain to you what are the pros and cons of the surgery and how much improvement you should expect.

I would like to have a LASIK surgery, how do I know it is suitable for me?
In order to determine if you are fit for LASIK surgery, you need to have a thorough evaluation to determine if LASIK is suitable for you. You need to see the doctor to obtain a thorough medical history and have an ophthalmic examination. In addition, you will need to do other tests to study the map your cornea and the degree of your refractive error. Certain people with diseases that affect the cornea (cone-shaped cornea, severe dry eye, corneal infections) are not good candidates for LASIK

What results can I expect?
It is important that you have realistic expectations. The goal of any refractive surgical procedure is to reduce your dependence on corrective lenses. If you expect better vision without glasses or contacts you will probably be pleased. You may be disappointed if you expect perfect vision without the need of glasses or contacts. In addition, if you are over 40 for example, you will be probably at least need glasses for near reading.

Are there any side effects?
As with any surgical procedure, there are potential risks including: under or over correction, glare, haloes, night vision problems, loss of best vision, and dry eyes.

What is cataract?
The human eye has a natural clear lens , which means it is transparent to allow the light to pass through it and to be focused on the back of the eye (retina). As we grow older, and usually above the age of 60-70 , the lens becomes less transparent and more opaque , which causes the image to be blurred and look “brown”. Diabetes, heredity, eye trauma and certain medications and smoking can accelerate cataract development

Is cataract surgery (phacoemulsification) right for me?
The timing of surgery depends on the degree of cataract and whether the cataract is interfering with the daily functional and social activities of the patient. If the patient with cataract experiences significant disability and interference with his routine daily work and life style, then he is considered a candidate for cataract surgery.

What is phacoemulsification?
Most modern cataract surgery procedures are performed by phacoemulsification, which is a technique that allow the surgeon to break down the cataract using ultrasonic energy and aspire the cataract material by making a very small incision. The surgeon is then inserts an intra-ocular lens in place of the removed cataractous lens. Special tests done before surgery are needed to determine the power of the intra-ocular lens needed for each individual patient.

What are the risks of phacoemulsification ?
According to the American Society of Cataract and Refractive Surgery (ASCRS), 98% of cataract surgeries are considered successful. However, like any surgical procedures there is a small risks of infection, raised eye pressure, and occasionally a second surgical procedure to remove the residual cataract material or to place a special type of intra-ocular lens.