Neuro-ophthalmology is the subspecialty of both neurology and ophthalmology concerning visual problems that are related to the nervous system.
Some commonly seen diseases that a neuro-ophthalmologist may see include optic neuritis, optic neuropathy, papilledema, ocular myasthenia gravis, brain tumors or stroke affecting vision, idiopathic intracranial hypertension, unexplained visual loss, headaches, diplopia, blepharospasm or hemifacial spasm. Some surgical neuro-ophthalmologist may treat strabismus and perform eye muscle surgeries or optic nerve fenestration surgery for the treatment of idiopathic intracranial hypertension (pseudotumor cerebri). Other neuro-ophthalmologist may treat blephrospam or hemifacial spasm using botulinum toxin injections. Neuro-ophthalmologists are medical doctors who initially specialize in either neurology, ophthalmology, or both, 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 but may be engaged in private practice. 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 publishes the 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. Combining subspecialty fellowship training programs such that highly procedural fields are combined with more cerebral specialties such as oculoplastics 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.