Int J Ophthalmol Clin Res ISSN: 2378-346X

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International Journal of Ophthalmology and Clinical Research

Professor at Ciencias Medicas of Minas Gerais (FELUMA), Belo Horizonte, Brazil

Neuro-ophthalmology is a subspecialty of Ophthalmology representing an intersection of two Medical areas: neurology and ophthalmology. In fact, a neuro-ophthalmic disorder may be related to any area of internal Medicine.

Unfortunately, neuro-ophthalmology is facing a human resource crisis, even in the USA. Annually, few residents and fellows of ophthalmology are entering this subspeciality [1,2]. In Brazil we have been able to identify at least three major causes for this situation: poor financial compensation in comparison to other subspecialties, few teaching centers of neuro-ophthalmology in the country; and lack of resources from the Brazilian public health system for the subspecialty's needs.

Doctors specializing in ophthalmology often choose surgical subspecialties as cornea, cataract, glaucoma, retina, and others that provide more financial rewards than basic non-procedural clinical areas such as neuro-ophthalmology. Furthermore, most ophthalmic teaching centers in Brazil have a good amount of high technology equipment destined to the surgical areas, and less attention is given to neuro-ophthalmic services. High technology procedures also allure doctors who are just entering Medicine and deviates their attention to the area of intervention instead of the less glamorous but high-demand area of clinical ophthalmic practice.

Unfortunately there is no official data, from the ninety-five ophthalmic teaching centers accredited by the Brazilian Council of Ophthalmology, of how many offer neuro-ophthalmic services. It is believed they represent less than half of them, and even fewer are indeed training neuro-ophthalmologists. Actually, there are some states in Brazil that have neither a training center nor neuro-ophthalmologist practitioners. This situation is even likely to get worse since less teaching centers in neuro-ophthalmology will be made available if few doctors are being trained in the subspecialty. This is not a unique problem to Brazil; Chile, for example, has only four neuro-ophthalmic teaching centers, and some other countries have no neuro-ophthalmologists whatsoever [3,4].

In Brazil, almost all ophthalmic teaching centers are supported by the Brazilian public health system. In this system the government provides health care to low-income patients, and medical residents and fellows have the opportunity to receive specialized medical education. Doctors usually follow a residency program supervised by a senior specialist. In the ophthalmic centers that offer neuro-ophthalmology assistance, the subspecialty is a mandatory part of the residency training program. However, in order to be considered a neuro-ophthalmology practitioner, a resident must complete at least a 6-month fellowship in neuro-ophthalmology after finishing the residency.

Adding to the problems of this subspecialty in Brazil, neuro-ophthalmology patients need much more than regular appointments. They usually require laboratory services including genetic tests, muscle biopsies, magnetic resonance imaging, temporal artery biopsies, spinal taps, hospitalization, etc.; most teaching centers in Brazil, however, do not offer these services promptly, if at all. Access to the public health system may take months or even years, and blindness, for instance, may install much faster than the time required to get an appointment. Concomitantly, residents do not have the opportunity to establish a final diagnosis of the clinical cases because of the delay in getting exams done, which, in turn, causes great frustration and even less interest in the subspecialty.

Lack of interest in neuro-ophthalmic training goes beyond the major concerns already noted. Neuro-ophthalmology is a subspeciality considered as one of the most difficult to study as it is believed to deal with rare diseases which are still considered untreatable or of limited recovery. In fact, this is not completely true. There are some neuro-ophthalmic disorders, as myasthenia gravis, pseudo tumor cerebri, and other optic and motor neuropathies that are quite common and respond well to treatment if diagnosis is established early in the course of the disease.

Neuro-ophthalmology requires the knowledge of other clinical areas of Medicine, time consuming appointments, and skilled interpretation of ancillary tests to achieve a final diagnosis. Most doctors prefer to diagnose "unhidden" and curable diseases, such as cataract, that may take a few minutes to solve the patient's visual complaint using high technology surgery.

Although some doctors remain skeptical, it may happen what Geoff Tabin, MD, professor of Ophthalmology at the Moran Eye Center in Salt Lake City said at the 2016 annual meeting of the North American Neuro-Ophthalmology Society in Tucson [4]. "If a family brings their loved one to an eye doctor with a neuro-ophthalmic problem and that doctor is unable to diagnose or treat the condition, then that family may lose faith in the doctor. When another family member has a condition that the doctor may be able to treat, such as a cataract, the family may not take their family member to that doctor because they could not help them the last time. Over time, the community may lose faith in the doctor. For this reason, every ophthalmologist needs comprehensive education that includes neuro-ophthalmology". The intention here is not to demand that every eye doctor must know everything in Ophthalmology, but eye doctors should have awareness that the patient's visual complaint may be related to a neuro-ophthalmic concern and therefore should promptly refer them to a neuro-ophthalmic center or neuro-ophthalmologist.

Finally, public health measures are urgently needed to stimulate ophthalmic teaching centers to provide high standard training in all subspecialties, including neuro-ophthalmology. The government should also effectively support neuro-ophthalmic needs.

If more high standard neuro-ophthalmic centers are available, more neuro-ophthalmologists will be well trained to fill the gap in this subspecialty, and, consequently, more patients will be helped. By increasing the number of doctors in this area, more sight and life threatening diseases could be diagnosed, and thousands of eyes and lives could be spared not only in Brazil but in the whole world.

References

1. Frohman LP (2008) The human resource crisis in neuro-ophthalmology. J Neuroophthalmol 28: 231-234.
   


2. Frohman LP (2005) How can we assure that neuro-ophthalmology will survive? Ophthalmology 112: 741-743.
   


3. Salgado CM (2016) The History of Neuro-Ophthalmology in Chile. J Neuroophthalmol 36: e13-e15.
   


4. Katz BJ, Farris BK, Golnik KC, Lawlor M, Postels DG (2016) Teaching and Practicing Neuro-Ophthalmology in Low-Resource Countries. J Neuroophthalmol 36: e16-e18.