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Ocular Differential Diagnosis

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    Ocular Differential Diagnosis. 6th ed. By Frederick Hampton Roy. Pp 753, £60. London: Waverly Europe Ltd, 1997. ISBN 0 683 074156.

    It is testimony to this text’s popularity that this is its 6th edition and that it is written in six languages. Having read it for the first time I remain a little puzzled that it is indeed so popular. Having said this, it is not a book one reads as it is primarily a reference text offering over 700 pages of detailed differential diagnosis of ocular symptoms and signs (not diseases).

    It is classified anatomically to a particular region of the eye (for example, orbit, extraocular muscles, cornea, conjunctiva, etc) and the reader then seeks a particular symptom or sign. The causes are then listed alphabetically thus offering fairly quick reference. The result is lengthy lists of associations and in this respect is useful in identifying rare associations and would be a useful addition to a departmental reference library. It is particularly exhaustive in relation to drug induced toxicity. It includes “diagnostic decision tables” at the end of some of the differential diagnosis lists. These list features of the history, physical signs, and laboratory tests that differentiate each of the more clinically relevant possible diagnoses and are quite helpful although of limited value in everyday practice.

    Despite its exhaustive nature my fairly brief survey of this book in looking up a few examples identified a number of fairly obvious omissions or debatable inclusions. For example, in the differential diagnosis of lid tumours chalazion is not mentioned. In the investigation of orbital disease and cortical blindness no mention is made of magnetic resonance imaging as a useful investigation! In lacrimal disease it is recommended that the investigation of sarcoidosis includes a Kveim test but omits to mention the relevance of a chest x ray.

    Because the listing of causes is alphabetical the reader may gain a false impression of commonality—for example, top of the list of causes of exophthalmos is listed “drug causes”. The most important clinical associations are highlighted but more could be done to indicate relative frequency. There are useful tables indicating association of diseases with age.

    One main concern with such a text is the lack of references. Key references are given but many of the associations listed may be questionable or possibly based on isolated case reports and the reader has no means of assessing this. For example, under causes of excess tears central serous retinopathy is listed (but oddly this condition is not listed as a cause of induced hyperopia). Under psychic causes of excess tears herpes simplex keratitis is listed!

    In conclusion this book offers quick reference for those interested in rare associations. It is of no value to the postgraduate student studying for professional examinations and in many respects could be misleading, giving false impressions of the frequency of certain disease entities. It is of little value in looking up syndromes and may best find a place on the shelves of the ophthalmic equivalent of train spotters.

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