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Internet teleneurology
  1. Parashkev Nachev
  1. Correspondence to Dr Parashkev Nachev, Institute of Neurology, UCL, 33 Queen Square, London WC1N 3BG, UK; p.nachev{at}

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It is often remarked that the digital age has revolutionised our access to information. But, it has also revolutionised the access of information to us. That second revolution is arguably greater, for though we spend a little more time in front of screens today compared with 20 years ago, the screens we faced then, unlike the interactive machines we face now, could not watch us back. Google is the most successful advertising platform not because it reaches so many of us, but because it knows so much about us. To put it neuroanatomically, it is the efferent, not the afferent limb of the circuit that has been the most dramatic change.

Now the behavioural pathology advertisers are concerned with—buying things one does not need—is merely one of a myriad that interests cognitive neurologists and can be explored online in the same way. Koiava et al describe an elegant internet application for detecting and characterising large visual field defects in patients with focal brain injury.1 Though shorter and simpler, the authors' new method shows comparable performance to the well established Humphrey automated perimetry, at 10° and 24° settings. This opens the possibility of detecting and monitoring large visual field defects, remotely, in the patient's own home, and on a scale that no resource-efficient study could possibly match.

One might object that the patients here were evaluated in a controlled setting: additional elements, however, could easily be added to ensure data quality in remote application. For example, a webcam with face recognition—now standard on laptops and tablets—could monitor the patient's head position in relation to the screen, both in eccentricity and depth, and of course the application could be automatically sensitive to the dimensions of the screen. The confounding effects of unmonitored gaze shifts could be countered with salient events at fixation and suitable brevity of the test stimuli. Auditory distractions could be detected with the computer's microphone, another piece of standard kit these days. The richness of efference here can go a long way towards compensating for the loss of direct supervision.

Indeed, since our lives are now so deeply integrated into the internet, such methodology potentially allows one to embed functional testing transparently within the natural stream of interaction. One can imagine an application, operating in the background, that continuously detects differential responsiveness to events in different areas of the screen as the patient goes about his ‘web-life’, producing ecologically accurate measures of functional performance. No conventional perimetry could ever do that, indeed no conventional form of any kind of clinical assessment.

This application is part of a suite with a broader focus on language rehabilitation (, where the advantages of the medium are even more obvious. This is fertile ground, as rich an area for innovation in cognitive neurology as our age has to offer. And as digital technology becomes more intricately enmeshed with our lives, it can only get richer still.


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  • Linked article 302270.R1.

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

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