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Liu, Volpe, and Galetta’s Neuro-Ophthalmology: Diagnosis and Management
Liu, Volpe, and Galetta’s NeuroOphthalmology
Diagnosis and Management
Grant T. Liu, MD
Professor of Neurology and Ophthalmology and Raymond G. Perelman Endowed Chair in Pediatric Neuro-Ophthalmology; Division of Neuro-Ophthalmology; Departments of Neurology and Ophthalmology; Hospital of the University of Pennsylvania and the Children’s Hospital of Philadelphia; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
Nicholas J. Volpe, MD
George and Edwina Tarry Professor of Ophthalmology; Chairman, Department of Ophthalmology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
Steven L. Galetta, MD
Philip Moskowitz Professor and Chairman, Department of Neurology, NYU Langone Medical Center, NYU School of Medicine, New York, NY; and Professor Emeritus, Perelman School of Medicine, Philadelphia, PA, USA THIRD
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Notices
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
ISBN: 978-0-323-34044-1
Content Strategist: Russell Gabbedy
Content Development Specialist: Trinity Hutton
Project Manager: Julie Taylor
Design: Christian Bilbow
Illustration Manager: Nichole Beard
Marketing Manager: Melissa Fogarty
Video Contents, vi
Dedication, ix
Foreword, x
Preface, xi
Acknowledgments, xii
List of Contributors, xiii
PART ONE HISTORY AND EXAMINATION
1 The Neuro-Ophthalmic History, 3
GRANT T. LIU, NICHOLAS J. VOLPE, and STEVEN L. GALETTA
2 The Neuro-Ophthalmic Examination, 7
GRANT T. LIU, NICHOLAS J. VOLPE, and STEVEN L. GALETTA
PART TWO VISUAL LOSS AND OTHER DISORDERS OF THE AFFERENT VISUAL PATHWAY
3 Visual Loss: Overview, Visual Field Testing, and Topical Diagnosis, 39
GRANT T. LIU, NICHOLAS J. VOLPE, and STEVEN L. GALETTA
4 Visual Loss: Retinal Disorders of Neuro-Ophthalmic Interest, 53
MADHURA A. TAMHANKAR
5 Visual Loss: Optic Neuropathies, 101
STACY L. PINELES and LAURA J. BALCER
6 Optic Disc Swelling: Papilledema and Other Causes, 197
MELISSA W. KO
7 Visual Loss: Disorders of the Chiasm, 237
ROBERT A. AVERY
8 Retrochiasmal Disorders, 293
SASHANK PRASAD
9
Disorders of Higher Cortical Visual Function, 341
VICTORIA S. PELAK
10 Transient Visual Loss or Blurring, 365
MADHURA A. TAMHANKAR
11 Functional (Nonorganic) Visual Loss, 379
GRANT T. LIU, NICHOLAS J. VOLPE, and STEVEN L. GALETTA
12 Visual Hallucinations and Illusions, 395
GRANT T. LIU, NICHOLAS J. VOLPE, and STEVEN L. GALETTA
PART THREE EFFERENT NEUROOPHTHALMIC DISORDERS
13 Pupillary Disorders, 417
LAURA J. BALCER
14
Eyelid and Facial Nerve Disorders, 449
HEATHER E. MOSS
15 Eye Movement Disorders: Third, Fourth, and Sixth Nerve Palsies and Other Causes of Diplopia and Ocular Misalignment, 489
MADHURA A. TAMHANKAR
16
17
Eye Movement Disorders: Conjugate Gaze Abnormalities, 549
DANIEL R. GOLD
Eye Movement Disorders: Nystagmus and Nystagmoid Eye Movements, 585
DANIEL R. GOLD
18 Orbital Disease in Neuro-Ophthalmology, 611
KENNETH S. SHINDLER
PART FOUR OTHER TOPICS
19 Headache, Facial Pain, and Disorders of Facial Sensation, 661
MELISSA W. KO and SASHANK PRASAD Index, 685
Video Contents
PART ONE: HISTORY AND EXAMINATION
Chapter 2 The Neuro-Ophthalmic Examination
Video 2.1 Examination. Afferent System. Confrontation Visual Fields – Nicholas J. Volpe, Stacy L. Pineles, and Heather E. Moss
Video 2.2 Examination. Efferent System. Swinging Flashlight Test to Compare Pupillary Reactivity – Nicholas J. Volpe, Stacy L. Pineles, and Heather E. Moss
Video 2.3 Afferent Pupillary Defect, Right Eye – Grant T. Liu
Video 2.4 Examination. Efferent System. Eye Movements and Assessment of Ocular Alignment – Nicholas J. Volpe, Stacy L. Pineles, and Heather E. Moss
Video 2.5 Convergence – Daniel R. Gold
Video 2.6 Smooth Pursuit and Suppression of the VestibuloOcular Reflex (VOR) – Daniel R. Gold
Video 2.7 Saccades – Daniel R. Gold
Video 2.8 Vestibulo-Ocular Reflex (VOR) and Head Impulse Test (HIT) – Daniel R. Gold
Video 2.9 Optokinetic Nystagmus (OKN) Testing With a Flag –Daniel R. Gold
Video 2.10 Esotropia Demonstrated by Alternate Cover Technique – Grant T. Liu
PART TWO: VISUAL LOSS AND OTHER DISORDERS OF THE AFFERENT VISUAL PATHWAY
Chapter 3 Visual Loss: Overview, Visual Field Testing and Topical Diagnosis
Video 3.1 Laser Pointer Visual Field Testing –Steven L. Galetta and Grant T. Liu
Chapter 6 Optic Disc Swelling: Papilledema and Other Causes
Video 6.1 Optic Nerve Sheath Fenestration –Nicholas J. Volpe
Chapter 7 Visual Loss: Disorders of the Chiasm
Video 7.1 Post-Fixation Blindness – Grant T. Liu
Chapter 8 Retrochiasmal Disorders
Video 8.1 Left Homonymous Hemianopia – Grant T. Liu
Chapter 9 Disorders of Higher Cortical Visual Function
Video 9.1 Right Parietal Syndrome – Grant T. Liu
Video 9.2 Balint Syndrome – Grant T. Liu
Chapter 12 Visual Hallucinations and Illusions
Video 12.1 Palinopsia – Grant T. Liu
PART THREE: EFFERENT NEUROOPHTHALMIC DISORDERS
Chapter 13 Pupillary Disorders
Video 13.1 Pupillary Light-Near Dissociation in Parinaud Syndrome – Grant T. Liu
Video 13.2 Aberrant Regeneration of the Third Nerve – Steven L. Galetta and Grant T. Liu
Video 13.3 Physiologic Anisocoria – Grant T. Liu
Video 13.4 Horner Syndrome, Left Eye – Nicholas J. Volpe
Video 13.5 Paradoxical Pupils – Imran Jivraj and Grant T. Liu
Chapter 14 Eyelid and Facial Nerve Disorders
Video 14.1 Eyelid Signs in Ocular Myasthenia – Grant T. Liu
Video 14.2 Marcus Gunn Jaw Winking Phenomenon – Robert A. Avery and Grant T. Liu
Video 14.3 Marcus Gunn Jaw Winking Phenomenon in an Infant – Grant T. Liu
Video 14.4 Eyelid Opening Apraxia – Grant T. Liu
Video 14.5 Left Facial Palsy (Central) – Grant T. Liu
Video 14.6 Left Facial Palsy (Peripheral) – Sashank Prasad and Grant T. Liu
Video 14.7 Blepharospasm in Meige Syndrome –Grant T. Liu
Video 14.8 Hemifacial Spasm – Grant T. Liu
Video 14.9 Ocular Myasthenia and Positive Edrophonium Test – Joel Glaser and Grant T. Liu
Video 14.10 Myasthenic Ptosis, Left Eye, Rest Test –Grant T. Liu
Video 14.11 Congenital Myasthenic Syndrome – Grant T. Liu
Video 14.12 Chronic Progressive External Ophthalmoplegia –Grant T. Liu
Chapter 15 Eye Movement Disorders: Third, Fourth, and Sixth Nerve Palsies and Other Causes of Diplopia and Ocular Misalignment
Video 15.1 Internuclear Ophthalmoplegia, Right –Grant T. Liu
Video 15.2 Internuclear Ophthalmoplegia (INO) With Intact Convergence – Grant T. Liu
Video 15.3 Bilateral Internuclear Ophthalmoplegia (INO) –Grant T. Liu
Video 15.4 Convergence Spasm – Grant T. Liu
Video 15.5 IIIrd Nerve Palsy, Right Eye – Grant T. Liu
Video 15.6 IIIrd Nerve Palsy, Right Eye – Grant T. Liu
Video 15.7 IIIrd Nerve Palsy With Aberrant Regeneration, Left Eye – Grant T. Liu
Video 15.8 Cyclic Oculomotor Spasms – Grant T. Liu
Video 15.9 IVth Nerve Palsy, Right EyeThree Step Test – Grant T. Liu
Video 15.10 IVth Nerve Palsy, Left Eye – ductions –Grant T. Liu
Video 15.11 VIth Nerve Palsy, Right Eye – Grant T. Liu
Video 15.12 Duane’s Syndrome Type 1, Left Eye –Grant T. Liu
Video 15.13 Duane’s Syndrome Type 2, Right Eye –Grant T. Liu
Video 15.14 Duane’s Syndrome Type 3, Both Eyes –Grant T. Liu
Video 15.15 Brown’s Syndrome, Left Eye – Grant T. Liu
Video 15.16 Pseudo-Bilateral Internuclear Ophthalmoplegia due to Ocular Myasthenia – Grant T. Liu
Video 15.17 Pseudo-One-and-a-Half Syndrome due to Ocular Myasthenia – Grant T. Liu
Video 15.18 Inferior Rectus Myotoxicity After Cataract Surgery and Retrobulbar Anesthesia, Left Eye – Nicholas J. Volpe
Video 15.19 Neuromyotonia – Grant T. Liu
Chapter 16 Eye Movement Disorders: Conjugate Gaze Abnormalities
Video 16.1 Unilateral Horizontal Gaze Palsy From a Right Pontine Infarct – Grant T. Liu
Video 16.2 Bilateral Horizontal Gaze Palsy – Grant T. Liu
Video 16.3 Horizontal One-and-a-Half Syndrome –Steven L. Galetta and Larry Gray
Video 16.4 Ipsilateral Gaze Deviation and Lateropulsion in Wallenberg Syndrome –Grant T. Liu
Video 16.5 Saccadic Dysmetria – Grant T. Liu
Video 16.6 Supranuclear Gaze Palsy and Lid Retraction – Steven L. Galetta and Grant T. Liu
Video 16.7 Saccadic Palsy After a Type A Aortic Dissection Repair – Grant T. Liu
Video 16.8 Congenital Ocular Motor Apraxia –Grant T. Liu
Video 16.9 Slow Saccades in Spinocerebellar Ataxia 3 –Grant T. Liu
Video 16.10 Vertical Gaze Paresis and Convergence Retraction Saccades in Parinaud’s Syndrome –Grant T. Liu
Video 16.11 Vertical Gaze Paresis and Convergence Retraction Saccades in Parinaud’s Syndrome –Grant T. Liu
Video 16.12 Progressive Supranuclear Palsy – Grant T. Liu
Video 16.13 Saccadic Palsy due to Neimann Pick C –Grant T. Liu
Video 16.14 Benign Paroxysmal Tonic Gaze of Infancy –Grant T. Liu
Chapter 17 Eye Movement Disorders: Nystagmus and Nystagmoid Eye Movements
Video 17.1 Inability to Cancel the Vestibulo-Ocular Reflex (VOR) – Grant T. Liu
Video 17.2 Congenital Nystagmus (Early) – Grant T. Liu
Video 17.3 Congenital Nystagmus (Later) – Grant T. Liu
Video 17.4 Latent Nystagmus – Grant T. Liu
Video 17.5 Spasmus Nutans (Benign) – Robert A. Avery and Grant T. Liu
Video 17.6 Spasmus Nutans (Tumor-Related) – Grant T. Liu
Video 17.7 Vertical Oscillations Associated With Monocular Vision Loss – Grant T. Liu
Video 17.8 Benign Paroxysmal Positional Vertigo Involving the Right Posterior Canal – Grant T. Liu
Video 17.9 Right Dix-Hallpike Maneuver – Daniel R. Gold
Video 17.10 Supine Roll Testing to Evaluate for Horizontal (Lateral) Canal BPPV – Daniel R. Gold
Video 17.11 Epley Maneuver to Treat Right Posterior Canal BPPV – Daniel R. Gold
Video 17.12 Semont Maneuver to Treat Right Posterior Canal BPPV – Daniel R. Gold
Video 17.13 BBQ Roll to Treat Right Geotropic Horizontal Canal BPPV – Daniel R. Gold
Video 17.14 Gufoni Maneuver to Treat Right Geotropic Horizontal Canal BPPV – Daniel R. Gold
Video 17.15 Gufoni Maneuver to Treat Left Apogeotropic Horizontal Canal BPPV – Daniel R. Gold
Video 17.16 Deep Head Hanging Maneuver to Treat Right or Left Anterior Canal BPPV – Daniel R. Gold
Video 17.17 Gaze-Evoked Nystagmus – Grant T. Liu
Video 17.18 Brun’s Nystagmus – Grant T. Liu
Video 17.19 Rebound Nystagmus – Grant T. Liu
Video 17.20 Periodic Alternating Nystagmus – Grant T. Liu
Video 17.21 Downbeat Nystagmus due to a Chiari Malformation – Grant T. Liu
Video 17.22 Downbeat Nystagmus – Grant T. Liu
Video 17.23 Downbeat Nystagmus – Grant T. Liu
Video 17.24 Upbeat Nystagmus – Grant T. Liu
Video 17.25 Torsional Nystagmus – Grant T. Liu
Video 17.26 Asymmetric Nystagmus in Multiple Sclerosis –Grant T. Liu
Video 17.27 Oculopalatal Tremor – Grant T. Liu
Video 17.28 Oculopalatal Tremor – Grant T. Liu
Video 17.29 Oculopalatal and Facial Tremor – Grant T. Liu
Video 17.30 Oculomasticatory Myorhythmia –Steven L. Galetta
Video 17.31 Seesaw Nystagmus – Steven L. Galetta
Video 17.32 Seesaw Nystagmus in Joubert Syndrome –Grant T. Liu
Video 17.33 Hemi-Seesaw-Jerk Nystagmus – Grant T. Liu
Video 17.34 Voluntary Nystagmus – Grant T. Liu
Video 17.35 Square Wave Jerks – Grant T. Liu
Video 17.36 Macro-Square Wave Jerks – Grant T. Liu
Video 17.37 Macrosaccadic Oscillations – Grant T. Liu
Video 17.38 Ocular Flutter – Steven L. Galetta and Larry Gray
Video 17.39 Opsoclonus/Myoclonus due to Neuroblastoma –Grant T. Liu
Video 17.40 Post-Infectious Opsoclonus in a Child –Grant T. Liu
Video 17.41 Post-Infectious Opsoclonus in an Adult –Steven L. Galetta and Grant T. Liu
Video 17.42 Opsoclonus due to West Nile Virus Encephalitis –Grant T. Liu
Video 17.43 Superior Oblique Myokymia – Grant T. Liu
Video 17.44 Superior Oblique Myokymia – Grant T. Liu
Video 17.45 Ocular Bobbing – Jamie Adams
Video 17.46 Ocular Dipping – Iga Gray
Chapter 18 Orbital Disease in Neuro-Ophthalmology
Video 18.1 Pulsatile Enophthalmos – Grant T. Liu
Dedicated to our teachers, mentors, and friends who taught us the science and shared with us their art: Joel S. Glaser, Norman J. Schatz, and Lawton J. Smith; and Simmons Lessell and Joseph F. Rizzo III
Foreword
I am deeply honored that the authors asked me to write the foreword to the third edition of Liu, Volpe, and Galetta’s NeuroOphthalmology: Diagnosis and Management. That there is a third edition speaks volumes about the extent to which this book has been welcomed by neurologists, ophthalmologists, neurosurgeons, and others who evaluate and treat patients with neuro-ophthalmic disorders. This magnificent text is a monumental tribute to the Penn Neuro-Ophthalmology service founded by the authors.
In 1991, when I came to Penn as Professor and Chair of Ophthalmology and Director of the Scheie Eye Institute, I was disappointed that neuro-ophthalmology consults at Scheie were provided by two part-time physicians, each of whom was on site just one afternoon a week. Having worked at Hopkins with Dr. Frank B. Walsh, the founder of neuroophthalmology, and Dr. Neil Miller, his successor as director of neuro-ophthalmology at Hopkins, I knew that an academic department which aspired to national stature needed a firstclass neuro-ophthalmology unit staffed by full-time faculty. The existing situation pleaded for prompt remediation. There was one bright light. I heard about one young faculty member in the Department of Neurology named Steve Galetta who would on occasion see patients in consultation at Scheie. I was told that he was an excellent diagnostician and teacher but that he was overwhelmingly busy as the only neuroophthalmologist at Penn. I met with Steve and his department chair, Dr. Donald Silberberg, and was pleased to learn that they would welcome my recruiting an ophthalmology-trained neuro-ophthalmologist. However, the demands on Steve’s time were such that a second neuro-ophthalmologist had to be recruited as soon as possible. In fact, Don and Steve had already identified a candidate who had completed his neurology residency at Harvard-Longwood and was about to enter a neuro-ophthalmology fellowship at Bascom Palmer. His name was Grant Liu. While I was somewhat disappointed that the next neuro-ophthalmologist would not have been trained as an ophthalmologist, I knew as soon as I met Grant that he would be an excellent addition to the faculty.
Steve and Grant agreed that recruiting an ophthalmologytrained neuro-ophthalmologist would add an important and valuable dimension to Penn Neuro-ophthalmology. Grant volunteered, “I know just the right person; his name is Nicholas Volpe; but you’ll have to wait a year until he completes his chief residency at Mass Eye and Ear.” Cutting to the chase, I called Nick, invited him to Penn, offered him a position, which he accepted, and the rest is history. So Grant Liu and Nick Volpe both joined the faculty in 1993, and thus was the founding of Penn Neuro-Ophthalmology.
Steve, Grant, and Nick were all exceptionally well-educated, and all were excellent clinicians and gifted teachers both in the clinic and in the lecture hall. Importantly, they all got along and supported each other. Within just a few years,
they recruited additional neuro-ophthalmologists with complementary sub-specialty interests and established the largest neuro-ophthalmology service in the country, and one which arguably was second to none. Among the many notable achievements were the establishment of a joint rotation for both neurology and ophthalmology residents, creation of a joint fellowship and a joint medical student elective, and establishment of continuing education courses both at Penn and at the annual meeting of the American Academy of Ophthalmology. Last but surely not least, their collaboration produced a highly respected textbook, Neuro-Ophthalmology: Diagnosis and Management, whose first edition was published in 2000.
In 1972, when Dr. A. Edward Maumenee offered me a position as Assistant Professor of Ophthalmology at Johns Hopkins, he mentioned that his philosophy in recruiting faculty was “to pick good people and then stay out of their way.” When I came to Penn as Chair of Ophthalmology in 1991, I resolved to embrace that philosophy. I’d like to believe that the magnificent and world-renowned Penn neuro-ophthalmology service led by Drs. Galetta, Liu, and Volpe exemplifies the result of following that philosophy.
In the preface, the authors have described how they were able, since publication of the second edition in 2010, to add valuable new information, describe new diagnostic tests, and update references without increasing the size of the volume. I commend them for succeeding in this effort. It is heartwarming that several of their former fellows, now highly respected neuro-ophthalmologists at leading academic institutions, have authored several chapters in this highly readable third edition of what has become a classic text. If you liked the first and second editions, you’ll love the third edition. As the saying goes, “plus ça change, plus c’est la même chose.”
In closing, let me say how proud I am of the academic and professional accomplishments of the three authors and how pleased I am to number them among valued and admired friends. As their mentor, Norm Schatz, wrote in the foreword to the first edition, quoting from the Talmud, “Let the honor of your student be as dear to you as your own.” Steve Galetta, Grant Liu, and Nick Volpe are the best of the best. I wish them continued success in all their professional and academic endeavors and continued happiness and fulfillment in their personal lives.
Stuart L. Fine, MD Clinical Professor of Ophthalmology, University of
Colorado School of Medicine
Emeritus Professor and Chair of Ophthalmology, University of Pennsylvania
Emeritus Director, Scheie Eye Institute, University of Pennsylvania
Preface
The fear that books are going away is over. People are still buying books. Despite the wealth of information available on the internet, both electronic and print books are still popular. A medical textbook with useful guidelines, illustrations, and references carefully organized within a one volume text still seems helpful.
We wrote in the second edition’s preface that our book could not be encyclopedic, but instead we could offer thoughtful approaches to the diagnosis and management of neuroophthalmic disorders. We were glad to see that the book, like the first edition, was well-received and widely used. In our travels we have noticed copies of both editions on bookshelves in clinics and offices throughout the world. Our colleagues continue to tell us that they recommend our book as essential reading for their fellows, residents, and students.
In order for a third edition to maintain this success, however, the book had to grow. The second edition benefitted from incorporating the colored fundus photos and anatomical drawings within the text and from the addition of supplemental videos. For the third edition, it would have been insufficient merely to update the references. Also, our numerous additional administrative responsibilities have limited our time for academic pursuits, so we needed help. Thus, in an attempt to expand the depth and breadth of the book, we asked some of the former Penn Neuro-Ophthalmology fellows to update (but not rewrite) many of the chapters and add their expertise. These individuals had been our trainees but had gone on to establish themselves as independent leaders and have distinguished themselves in neuro-ophthalmology. These authors are listed in the table of contents and at the beginning of the individual chapters to which they contributed. The three of us are now editors of the book as well as authors, and the book title now has revised with an apostrophe added: “Liu, Volpe, and Galetta’s Neuro-Ophthalmology: Diagnosis and Management.”
The field has expanded rapidly, and we have tried to incorporate all the developing trends including the proliferation of new technologies, such as optical coherence tomography, which have become essential to all our practices. But at the same time we made every effort to preserve the true fundamentals of neuro-ophthalmology: history, examination, differential diagnosis, and management. Therefore, the format
of the book, with four parts and 19 chapters, remains the same as it was in the first and second editions. The figures on the book cover reflect how our diagnosis and management today depends upon our examination, neuroimaging, and new technologies.
Because the book is still designed for nonexperts evaluating neuro-ophthalmology patients, we agreed with our publisher that the size of the third edition should not increase in order to maintain its usefulness, popularity, and cost. Therefore, we set the goal of keeping the word, reference, table, and figure counts relatively similar to second edition’s. This task was difficult for our contributors and us, as we had to eliminate the same number of words and references that we added. On the other hand we were forced to identify and remove outdated text and articles (particularly those published before 2000 unless classic), streamline wordy passages, and replace substandard and previously published figures with more illustrative and original ones. It was also our job as editors having multiple contributors to maintain consistency between the chapters in terms of style, format, and content and to keep redundancy to a minimum.
Because video examples of eye movement and eyelid disorders, pupillary abnormalities, and examination techniques dynamically enhance the text, and having the videos online instead of on a DVD gave us a bit more flexibility, this edition features almost twice the number of videos as the previous one. We also replaced some of the older videos that had poor lighting, movement, or background noise with better quality ones. We are sure the readers will enjoy viewing examples of these common and uncommon neuro-ophthalmic abnormalities.
We remember with great admiration the words of wisdom from our mentors—advice we hear as daily whispers in our ears from Drs. Glaser, Schatz, Smith, Lessell and Rizzo, to whom we dedicate this edition.
Despite our lack of geographic proximity, this book has kept the three of us together. It binds us. This third edition still reflects our views and shared editorial thoughts about the practice of neuro-ophthalmology.
Grant T. Liu, MD
Nicholas J. Volpe, MD
Steven L. Galetta, MD
Acknowledgments
Since the publication of the second edition of this book, Nick and Steve have left the University of Pennsylvania to become department chairmen at other institutions. The three of us had been colleagues at Penn for 17 years, then Steve and I for two more. Therefore, I am so glad that we have this book as an excuse for continued frequent emails, phone conversations, and meetings in person. I am grateful to Nick and Steve for their continued friendship and collaboration. I still learn from them. I was absolutely thrilled to have our former fellows collaborate with us to update the chapters. While we keep in touch with all our former fellows, it was rewarding to have many of them work with us in a collective effort that hopefully will continue for many more editions. I would like to thank them for their hard work and for putting up with our editing and my endless, repetitive demands for endnote perfection.
I also want to thank my chiefs Drs. Frances Jensen, Monte Mills and Joan O’Brien for their unwavering support of my career and the neuro-ophthalmology services at Penn and the Children’s Hospital of Philadelphia.
I appreciate having Elsevier’s Russell Gabbedy, who was with us for the second edition, again lead us during the planning and writing of the third edition. Trinity Hutton, our Content Development Specialist at Elsevier, deserves a medal for tolerating our missed deadlines. I would also like to thank her for working with me to get the brightness and the contrast of the radiology figures exactly the way I wanted. In addition, I would like to recognize Julie Taylor, our Project Manager at Elsevier, for her and her team’s extraordinary attention to detail (ie, catching all our mistakes and inconsistencies) during the typesetting and proof stages.
My wife Geraldine continues to be my greatest supporter, and I can’t thank her enough. My daughter Alex and son Jonathan, featured prominently in the examination figures in Chapter 2 when they were young children, incredibly have now both graduated college. Time flies.
Meanwhile, my golf game is getting worse.
Grant T. Liu, MD
My professional life and the products of my academic endeavours have benefitted from the wisdom, encouragement, mentoring, guidance and friendship of my family, mentors, and colleagues. My parents Nick and Lydia and brothers Russell and Robert initially set the stage for a lifetime of achievement and learning and defined success through hard work and passion. They continue to encourage, comfort and inspire me, and they are always there for me. I am the best person and neuro-ophthalmologist I can be because of Simmons Lessell. I miss him but constantly hear his voice. Joseph Rizzo taught (teaches) me so much, continues the tradition of neuro-ophthalmic excellence and inspires me in all of my academic endeavours. My colleagues at Penn
and now at Northwestern have taught me so much and made the practice of ophthalmology so thrilling. My students, residents and fellows define and teach me, and along with this book are really all that I am most proud of as an academic ophthalmologist. My true and dear friend Stuart Fine, who believed in me and taught me so much, has been a tireless supporter of all of my academic and administrative triumphs, and got me through all of the tribulations. Eric Neilson, my “newest” friend and mentor, continues to support me as Dean and leads Northwestern with the academic missions of education and discovery in the forefront. Thank you all for your constant support and commitment to my success.
Although we no longer practice and teach together, Grant and Steve will always be the very essence of my academic neuro-ophthalmology career. I would not be where I am without having them (and Mark Moster) as colleagues and friends. I am so pleased that the distance between us is vastly shortened by our efforts around “the book.” Once again, the book would not have happened without Grant, and I am thrilled to include the finest of the next generation of neuroophthalmologists, our fellows, as authors.
Finally, my family, my children Nick, Matt, Lena and Tessa make me so proud, inspire me to achieve, and make my life simply wonderful. My dear wife Francesca literally makes everything I do possible, never wavers in her support and love, and constantly cheers me on. They are what really matters and for what I am most grateful.
Nicholas J. Volpe, MD
I would like to thank those individuals who have had a major impact in my life: My parents Louis and Winifred Galetta for their unending love. My coaches, Brother Pat Pennell, Frank McCartney, James Tuppeny, Irv Mondschein and Bill Wagner for teaching me how to win and lose. My colleagues, Laura Balcer, Robert I. Grossman, Francisco Gonzalez, Stuart Fine, Nancy J. Newman, Valerie Biousse, Janet Rucker, Floyd Warren, Eric Raps and Larry Gray for their brilliance and friendship. My mentors Norman J. Schatz, Joel Glaser and J. Lawton Smith, Donald Silberberg, Donald Gilden and Arthur K. Asbury for teaching me with untiring enthusiasm. To the residents and fellows of Penn and NYU who have taught me more than I have been able to teach them. I want to extend my deepest appreciation to Nick Volpe and Grant Liu who were there from the beginning and who were the greatest teammates that one could have in neuro-ophthalmology. To our patients who we humbly serve in their most challenging moments. Finally, to my family, Genie, Kristin, Michael, and Matthew for their love and support and for making it all worthwhile.
Steven L. Galetta, MD
Robert A. Avery, DO, MSCE
Assistant Professor of Ophthalmology and Neurology
Division of Neuro-Ophthalmology
Departments of Ophthalmology and Neurology
Children’s Hospital of Philadelphia and the Hospital of the University of Pennsylvania
Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA, USA
Laura J. Balcer, MD, MSCE
Professor of Neurology, Population Health and Ophthalmology
Vice Chair, Department of Neurology
NYU Langone Medical Center New York, NY, USA
Daniel R. Gold, DO
Assistant Professor of Neurology, Ophthalmology, Neurosurgery, Otolaryngology - Head & Neck Surgery
Division of Neuro-Visual & Vestibular Disorders
The Johns Hopkins University School of Medicine Baltimore, MD, USA
Melissa W. Ko, MD
Associate Professor of Neurology and Ophthalmology Division of Neuro-Ophthalmology
Departments of Neurology and Ophthalmology
SUNY Upstate Medical University Syracuse, NY, USA
Heather E. Moss, MD, PhD
Assistant Professor of Ophthalmology and Neurology
Division of Neuro-Ophthalmology
Departments of Ophthalmology and Neurology & Neurosciences
Byers Eye Institute at Stanford Stanford School of Medicine
Stanford University Palo Alto, CA, USA
Victoria S. Pelak, MD
Professor of Neurology and Ophthalmology
Divisions of Neuro-Ophthalmology and Behavioral Neurology
Departments of Neurology and Ophthalmology
The Rocky Mountain Lions Eye Institute and The University of Colorado Hospital
The University of Colorado School of Medicine
Aurora, CO, USA
List of Contributors
Stacy L. Pineles, MD, MS
Associate Professor of Ophthalmology
Department of Ophthalmology, Stein Eye Institute
University of California, Los Angeles
David Geffen School of Medicine Los Angeles, CA, USA
Sashank Prasad, MD
Associate Professor of Neurology Chief, Division of Neuro-Ophthalmology
Brigham and Women’s Hospital Harvard Medical School Boston, MA, USA
Kenneth S. Shindler, MD, PhD
Associate Professor of Ophthalmology and Neurology Division of Neuro-Ophthalmology
Departments of Ophthalmology and Neurology
Scheie Eye Institute
F.M. Kirby Center for Molecular Ophthalmology
Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA, USA
Madhura A. Tamhankar, MD
Associate Professor of Ophthalmology and Neurology Division of Neuro-Ophthalmology
Departments of Ophthalmology and Neurology
Scheie Eye Institute
Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA, USA
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Title: Suljettu puutarha Runoja
Author: Aino Kallas
Release date: July 24, 2024 [eBook #74115]
Language: Finnish
Original publication: Helsinki: Otava, 1915
Credits: Tuula Temonen
*** START OF THE PROJECT GUTENBERG EBOOK SULJETTU PUUTARHA ***
SULJETTU PUUTARHA
AINO KALLAS
Helsingissä, Kustannusosakeyhtiö Otava, 1915.
Runoja Kirj.
SISÄLLYS:
I Suljettu puutarha
Kapinoiva Danaidi
Valkea tähti
Chimère
Mykkä
Kotiin
Talttumus
Nuotio
Tähtien laskija
Koidulan hauta-uurnaan
Jasmiini-uni
Finis poëseos
Vainajan virsi
Paimentolaissielu
Ylitse muurin
II
Syrjässä valtateiltä
Suojärvi Liivinmaalla
Viron orjan laulu
Mene tekel
Pimeät joulut
Moriturus
Kuolleen sydän
Kaatuneille
III
Koitto ja Hämärä
Kynestin neiti
IV Tuuli hauta
Mooseksen sauva
Varjossa vuorten
Kevät
Värisevien haapojen alla
SULJETTU PUUTARHA
Oi yrttitarhat, joist'ei päivä tiedä! — Kuin nääntyneenä näivettyvi puu, ei liiku lehvät, ruoho ruskettuu, ei päivän kuultoa yön kukat siedä, ne terän sulkee, tomuun kumartuu.
Oi yrttitarhat, joist'ei päivä tiedä!
Vaan hämyn langetessa lumot laukee, käy kuiske kuuma yli kukkien, ja tuoksu tulvii tumma, kuumeinen, kun herää kukat, rakkauteen raukee, puut seisoo punehtuen, väristen. Oi yrttitarhat, jotka yöksi aukee!
KAPINOIVA DANAIDI
Zeus, oi uupuvi orjasi, pois ota polttava vaiva, kauan jo ammensin aaltoja vierivän veen, ehtinyt on aiooneja taas läpi ruukkuni raskaan virrata vuosien vuo, aikojen äärettyys, synkkänä vyöryvä Styx ja Akheron ankea, tumma, autio aamu ja yö, päiväni päättymätön, silmien syylliset veet, maan lapsien lohduton itku, arkien loppumaton, lyijynlaimea vuo! Harteilt' orjasi, oi ota, Zeus, tää taakkani turha, ankeus ainainen, tehtävä täyttymätön, niin kuni lapsille maan, elo suo lyhyt loppuva mulle, täyttää ruukkuni vain, vaipua vierelle sen! Kas, tulivirran vaahtohon, Zeus, nyt ruukkuni kastan, ah, en katsoa sen kuumia kuohuja voi! Hetkesi tullut on, tytär Danaon, talttunut ammoin, liekkejä laineet tuo, hehkua heittää veet! Oi, ota orjuus tää, — tai patsaas korkean paateen, herjaus huulilla, Zeus, ruukkuni pirstaks lyön!
VALKEA TÄHTI
Tänään, valkea tähti, inehmon itkevän löydät, sätehes valkean valossa väriseväisen, lapsen, jonk' usko ja pettymys aina on uusi, huomenna tielläsi tapaat vain kuvan jäisen.
Tänään ihmehet tehdä vois ijäinen valos, juhlien juottaa sielun kuin jalo viini, mutta jos huomenna tuikit, kaikki on turhaa, kuollut on katu, ovet on teljetty kiinni,
Chimère, sun siintoos sielu vaiti vajoo ja uppoo hopeasi hohteeseen, sun valoos aukee, atoomeiksi hajoo, sun kirkkautees katoo kaikkineen. Chimère, sun vuokses vaihdan elon tyynen, sun vuokses kerran vielä kaikki myynen.
Chimère, oi harha outo, olematon, on olos unta utuisinta vaan, ja sentään öitten rauhan, päivän raton, ja riemut hiljaiset ja rikkaat maan, Chimère, sun etees uhriks kaikki kannan, ja laivat poltan, elämäni annan.
Chimère, sa kangastuksin taivaat täytät, ja niinkuin vesikaari vettä juo, sa purppuraista punaa juovan näytät, se virtaa suonissas kuin värivuo. Chimère, ma verettömäks varjoks vaihdun, sun loin, sa elät, itse harhaks haihdun.
MYKKÄ
Ah, ennen ehtikö vaiti-olo, kun puheen oppi tää povi polo? En surmaa säiky, en ijäisyyttä, vain vait'olon äärettyyttä!
Ma vaikenin ajat pitkät ammoin, ma omaa mykkyyttä kaihdin, kammoin, en puhetta oppinut, sanoja saanut, en vaikenemasta laannut.
Vaan mykkänä kuolla jos kohtalo mulla, mun täytyis tuvilta Tuonen tulla ja huutaa huulin, jotk' elo sulki, sanat kauan kaivatut julki.
Maa mykkä, et vaieta enää voisi, sanat saisi hieta, ja somer soisi, mun haudastani kuin sävel heläis, ja mun kuollut sieluni eläis!
KOTIIN
Sinne tahdon, vanhaan valkamaan, missä ruuhta vartoo kirkkoväet, lepät rannan kaartaa, kultaa kukkuu käet, niemen päässä nuottakota laho, riippukoivu, aurinkoinen aho, venhe maassa vanha, unohdettu. Oi te varjot armaat, valkopäiset, on kuin katsantonne kirkastettu viihtyis yhä tyynten vetten yllä, täyttäis tutut taivaat hymyilyllä, luhdat, kummut, lukot hämäräiset, pyhän pihlajaisen pihamaan! Rauhan rannat, teiltä rauhan saan!
TALTTUMUS
Talvinen ehtoo ennättää, putoaa puista hohtava härmä, hangella kuutamo kimmeltää, kirkkain kitehin kukkii jää, lumessa ikkunan särmä.
Kadonneita et kaipaile, tulevista et tuskaa tunne, seuraat sädettä kuutamon, viileä, raukea sielus on, et kysy, miksi, et, kunne?
Viivyn varjona vierelläs, kuutamon kylmässä valossa lymyyn, olen sun sielusi raukeus, olen sen talvinen talttumus, jäisenä kiteenä hymyyn.
NUOTIO
Kas, lapset laitumelle eksyneet, yön tullen risut, oksat kokoon riipii, ja luona loimuavan nuotion tulesta turvaa etsii, yhteen hiipii, — vaan äkkiä niin äänetöntä on, salainen kauhu, outo autius, alussa arka vain kuin aavistus, povessa kunkin kytee, kasvaa salaa, — niin nopeasti nuotiomme palaa, ja tuhka tumma, hehku hiilloksen, ei varjella voi yöltä varjojen! Oi lapset, eksyneet yön selkään, te tilaa tehkää luokse nuotion, mun lailla teidän, ah, niin vilu on, ja yötä pitkää, pimeyttä pelkään!
TÄHTIEN LASKIJA
Laps loppumattoman unelman, miten osuin merelle outoon laivaan? Joku kuiskasi mulle korvahan: sun täytyy laskea tähdet taivaan!
En hyödyks ollut ma ollenkaan, en pahaa tehnyt, en liioin hyvää, kädet ristissä ikäni istuin vaan ja keulassa katselin vettä syvää.
Mun tähdet laskea täytynee, ne vilkkuvat väreessä aallon kalvon, mun huuleni lukuja hymisee, jos nukun, jos silmät suurina valvon.
Satatuhanteen saakka ehdin jo, vaan jäljellä miljoonaa on sata, on auringon takana aurinko, ja laskematta on linnunrata.
KOIDULAN HAUTA-UURNAAN
Oi, uurna usein unhoitettu, jalo, sa malja kaunis elon sammuneen, sun pintaas kristalliseen, kirkkaaseen, vain taittuu hautaholvin harmaa valo.
Sa luotu olit maljaks jumalain ja vapauden pyhää mahlaa varten, nyt täyttää tuhka sun ja tyhjyys vain.
Pikari puhdas elon nektarin, oi malja, muovailema Runotarten, sa täytyit kukkuroilleen kyynelin.
JASMIINI-UNI
Kuolkaamme jasmiinivihmaan varisevaiseen, tukehtuin tuhanten jasmiinikukkain tuoksuun, elkäämme enää tahtoko auvoon maiseen, ei enää mailman kiistävän kilpajuoksuun!
Vaivumme jasmiinihautaan kuin vuoteelle elon, kuin olis alla keväinen, kukkiva keto, unohtain kohtalon vallat ja kuolemanpelon, jasmiinituoksua viimeinen henkemme veto.
Kuolema, kussa on otas ja kalkkisi kussa? ijäiset ilmat jasmiinituoksuksi vaihtuu, jasmiini-unessa uudessa, kirkastetussa, kukkaissieluksi valkeaks sielumme haihtuu.
FINIS POËSEOS
Kuollut on Runo, kuollut on Runo, ma laulan, tyhjä on taivas, autio avaruus, laulu on kuolosta linnun kaarevakaulan, surmasi kauniin untensa kaukaisuus.
Lennä, valkea lintu, vartovi surma, halki hyisten ilmojen havisten, povessa pyörtymys pyhä, hullaannuttava hurma, sydän oudosta onnesta vavisten.
Valkea tuli sulle tuikkien vastaa, majakka maista ylempi, taivainen, ah, mikä sulo siihen sulkansa kastaa, ah, mikä autuus vaipua valoon sen!
vaan kunis laulujen laittoon herkkyvi huulet, sinis mun suokaatte kiittää kuoloa sun!
Laulan rohkean, laulan sankarin surmaa, varrella arkiviikkojen ainaisten, laulan unien unta, pyhän haavehen hurmaa, keskellä mailman jäisen ja järkeisen.
Laulu on kuolosta linnun kaarevakaulan, surmasi kauniin untensa kaukaisuus, kuollut on Runo, kuollut on Runo, ma laulan, tyhjä on taivas, autio avaruus!
VAINAJAN
VIRSI
Ystävä ylhä, kotia kohti mun vietkö? Varjona kanssasi kuljen kukkaista rantaa, mutta et tarvitse kaikkea taakkaani kantaa: että jo kuolin, elkösi koskaan tietkö!
Ei että laulava laulu, mi mieltäsi viihtää, vain on kaikua kaiken katoavaisen, vain on hautaushymniä hurmion maisen, ei voi kiehtoa se, ei vertasi kiihtää.
Ei että huulet, joita sa suutelet illoin, ammoin, ammoin jo ehtivät maatua maaksi, että mun ammoin tuuditti Tuonelan haaksi, maille, joilta ma palaan, mutta, ah, milloin?
PAIMENTOLAISSIELU
Oi, tähdet, teiltäkö sielun sain? te kulkurit kuumat ja vaikenevaiset, te taivaan tanhuan paimentolaiset! Mun sirottui sieluni länteen ja itään, ei pantu levähdyspaikkaa mitään, mutt' tilaa jos mulle ei maan päällä lie, jää kaikkeus aina ja avaruus, yli maallisten maitten käy henkeni tie, jää kodiksi sille korkeus uus, en uurnaa ummehtunutta siedä, mun tuhkani saakoot tuulet viedä, en maast' ole tullut, en maahan palaa, ijät kaiket henkeni harhata halaa! Oi tähdet, teiltäkö sielun sain?
YLITSE MUURIN
Ylitse muurin yössä kukat sataa, hyväily arka ohikulkijalle, ylitse muurin vieraan, ynseän, kuin kädenanto oudon ystävän, tervehdys kesäyölle tuoksuvalle.
Niin vitkaan täällä elo vierii, mataa, etäälle pyrkii, ehtimättä sinne, kuin vuosisadat nukkunut se ois, heräjää hetkeksi, taas nukkuu pois, ikävöi ijät, tietämättä minne.
Ylitse muurin yössä kukat sataa.
SYRJÄSSÄ VALTATEILTÄ
Panen palamaan kynttiläisen, uneksin: valtava valomeri vapauden tuloa tervehtii!
Hiljaa hymisen voitonhymnin, uneksin: rummut, torvenraiku kantaa sen yli kaupungin!
