Neuro-ophthalmology as a career.

This essay was written to discuss the reasoning behind the personal decisions made by 2 current neuro-ophthalmology fellows to pursue neuro-ophthalmology as a career. It is meant to enlighten the reader about what role neuro-ophthalmologists play in clinical practice, what makes neuro-ophthalmology unique to all other sub-specialties, and how this contributes to making neuro-ophthalmology not only one of the most medically interesting, yet rewarding sub-specialties in ophthalmology.

The path to becoming a competent practicing physician is an arduous and long journey. As a resident nears the completion of their formal residency training, the decision to pursue further sub-specialty training in a fellowship can be difficult. Selecting to pursue an ophthalmic sub-specialty fellowship allows for a unique opportunity to solidify, refine, and build upon the knowledge you have worked so hard to accumulate through years of undergraduate and graduate medical training. Additionally, this is, a chance to set yourself apart from others and guide you along the path to the expert you wish to become.

If you are interested in neuro-ophthalmology, or are simply not sure, then this monograph may help you to decide. Although we recognize that neurologists might also choose neuro-ophthalmology as a career, this particular piece is written from the perspective of two current ophthalmology based neuro-ophthalmology fellows (AS, NA) and we hope that it is helpful to the ophthalmology reader to explain our passion and personal and professional reasons for pursuing this sub-specialty.

Ophthalmology is about saving vision, but neuro-ophthalmology is sometimes also about saving lives. Isn’t that why we all went into medicine in the first place? There is no other sub-specialty of ophthalmology that relies as heavily on the ophthalmologist's skill in and use of general medicine. There are many blinding and life-threatening diseases that can present to the neuro-ophthalmologist's office (i.e. giant cell arteritis, carotid artery dissection, sarcoidosis, intracranial aneurysm, or stroke). You are now the physician responsible for the very important first diagnosis, and then life or vision-saving treatment. At the end of the day, this reward makes all of the training and long nights worth every minute and reminds you why you became a physician in the first place. As neuro-ophthalmologists, we always like to encourage our comprehensive ophthalmology colleagues to be a “doctor first, an ophthalmologist second (and perhaps a cataract surgeon, third”)

You get to be the “unsung hero”. The neuro-ophthalmologist is often the sub-specialty that others turn to when the etiology of visual decline is in question. They are often uniquely suited to provide a global and comprehensive perspective to any complex medical, neurologic, ophthalmologic, or neurosurgical case. A neuro-ophthalmology patient has often already seen 2, if not 3 or more other specialists by the time they arrive at our door. The other referring providers can include optometrists, ophthalmologists, retina specialists, neurologists, neurosurgeons or even psychiatrists, just to name a few of our very common consulting doctors. Neuro-ophthalmology training prepares you better to handle such complexity, armed with an expanded fund of knowledge that has taught you to think outside of the “eye,” at the whole body, for the cause of visual decline. What makes the neuro-ophthalmologist unique is not just the fund of knowledge, but the global holistic viewpoint of the integration and interaction of complex and systemic disorders on visual function. The same systematic neuro-ophthalmic approach is taken with every patient including a careful and thorough history, a review of all prior records, a thorough and complete ocular examination, a review of any ophthalmic or neuro-imaging, and ordering of any new imaging or laboratory tests that may be necessary. A systematic approach to the differential based on disease mechanism, patient demographics, and typical versus atypical presentations helps prevent misdiagnosis and catches unusual disease presentations. We like neuro-ophthalmology because it is a sub-specialty which teaches not just what to think, but more importantly, how to think, and is, therefore, one of the most important and valuable rotations for young comprehensive ophthalmologists in training. Often, we are the “court of last resort” for patients with difficult and challenging cases. We, being the final arbitrator (especially when we find the answer), enjoy being detectives in these unsolved medical mysteries. We particularly enjoy the sense of satisfaction, medical accomplishment, and difference we can make in patient's lives when we are able to discover a diagnosis that has remained elusive for sometimes many years

Challenging case mix and variety. For many ophthalmologists, cataract, refractive error, diabetic retinopathy, glaucoma, and age-related macular degeneration will be the bulk of their clinical practice. In contrast, the neuro-ophthalmologist is asked to search for subtle or even misdiagnosed ocular or systemic pathology as the cause of vision loss or visual dysfunction. Atypical disease presentations are almost commonplace in the neuro-ophthalmologist's practice, allowing for an enormous variety and complexity of disease processes. There is no “routine day” for us in neuro-ophthalmology clinic as there is always an interesting patient to learn from, a case to present at grand rounds, or even to write up in a journal. Any day can hold a combination of corneal, retinal, optic nerve, rheumatologic, neurologic, infectious, or neurosurgical variety! This not only keeps us all on our toes, but helps motivate a productive and exciting work environment that is stimulating yet satisfying. We learn something new every day about advances in other fields like medicine, surgery, radiology, neurology, or neurosurgery. We enjoy being comprehensive ophthalmology's connection to our colleagues in the medical world and interacting on a daily basis with consultants in multiple disciplines.

These ideas and observations have been our collective experience, and we are both very grateful to have chosen this path and to have been given the opportunity to study neuro-ophthalmology. We believe that neuro-ophthalmology is truly a hidden gem in ophthalmology and is one of the most rewarding sub-specialties in the field of ophthalmology. Although often misunderstood and thought to be intimidating to many ophthalmologists, we believe that any comprehensive ophthalmology resident graduates with a desire to learn something new; a commitment to being a physician first; and interest in interacting with multiple disciplines in medicine. These qualities lead neuro-ophthalmology to be a personal and professionally rewarding career.

The most commonly cited myths cited by ophthalmology residents for not choosing neuro-ophthalmology as a career are “too little surgery,” “too difficult subject matter”, and “too few jobs.” Choosing neuro-ophthalmology as a career does not necessarily mean abandoning the operating room forever. Many practicing neuro-ophthalmologists, in fact, combine medical neuro-ophthalmology with surgical practice in strabismus (e.g., ocular motor cranial neuropathies), glaucoma, or oculoplastics and orbit. The complementary nature of neuro-ophthalmology with these particular surgical subspecialties also creates a specialist with a unique perspective for an academic setting. Although the material is sometimes intimidating to the ophthalmologist, it is a matter of exposure and not difficulty or complexity. We believe that a single year of neuro-ophthalmology fellowship is sufficient to allow the graduating fellow to master the neuroanatomic pathways of the visual system and the major neurologic, systemic, and neurosurgical disorders affecting vision. The gap in knowledge about neuro-ophthalmology in neurology and neurosurgery makes it imperative that a trained neuro-ophthalmologist is available to assist in the care of these patients. Finally, there is typically more demand than supply for the neuro-ophthalmologist, and whole parts of the globe have few or no neuro-ophthalmologists. A trained neuro-ophthalmologist reaching out to these underserved areas will have no problem finding patients.

In summary, we encourage the young eye resident to consider pursuing further study in neuro-ophthalmology. We can certainly attest to the fact that it will bring rewards far greater than you could imagine.