Neuro-ophthalmology

Neuro-ophthalmology is the subspecialty of both neurology and ophthalmology concerning visual problems that are related to the nervous system [1].

A neuro-ophthalmologist is a physician (neurologist or ophthalmologist) specializing in diseases affecting vision that originate from the nervous system.

Some commonly seen diseases that a neuro-ophthalmologist may see include optic neuritis, optic neuropathy, optic disc edema, ocular myasthenia gravis, brain tumors or stroke affecting vision, idiopathic intracranial hypertension or pseudotumor cerebri, unexplained visual loss, headaches and double vision. Neuro-ophthalmologists are medical doctors who initially specialize in either neurology or ophthalmology, then do subspecialty training, through fellowships, in the complementary field. They are usually full-time faculty at large university-based medical centers, where they also do research and teach. Dr. Neil R. Miller at the Wilmer Eye Institute at Johns Hopkins is often considered one of the top experts in the field. Their referrals may come from neurologists, ophthalmologists, endocrinologists, neurosurgeons and cardiologists. Neuro-ophthalmologists typically attend to diseases of the afferent visual system (most often involving the optic nerve), the efferent visual system (that controls eye movements), or the pupillary reflexes.

The largest international society of neuro-ophthalmologists is the North American Neuro-Ophthalmological Society (NANOS), which organizes an annual meeting and publish the specialized Journal of Neuro-Ophthalmology.It is estimated that the United States requires at least ten to fourteen new neuro-ophthalmology graduates a year. However, approximately five ophthalmology residents enter the field of neuro-ophthalmology per year. This has been attributed to decreased compensation in neuro-ophthalmology as an ophthalmic subspecialty. Only the most complex and difficult cases get referred to neuro-ophthalmology. Hence, a neuro-ophthalmic visit requires an intensive work-up and time commitment which is not recognized in the current climate of medical reimbursements. Other suggested reasons for a decline in neuro-ophthalmology sub-specialists include the difficulty of the specialty, time involved in practicing, and the perception that jobs in the field are lacking. [1] Combining subspecialty fellowship training programs such that highly procedural fields are combined with more cerebral specialties such as occuloplastics with neuro-ophthalmology or uveitis with retina, have been proposed as solutions to this disparity. However, this may limit mastery in one discipline. It is important that residency training programs emphasize “endangered” fields such as neuro-ophthalmology, uveitis and pediatrics with early exposure, and commit to training residents with an interest in these fields. [2]

Online Resources

The Neuro-Ophthalmology Virtual Education Library (NOVEL)

References

1. Frohman, L.P. Ophthalmology 2005;112(5):741-743

2. Doran, M. EyeNet 2009; 13(9):49-53