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  • Opinion

    Neuro-Ophthalmology’s SOS: Save Our Subspecialty

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    Ruth D. Williams, MD

    By Ruth D. Williams, MD, Chief Medical Editor, EyeNet

    For almost 30 years, I’ve worked in close proximity to Jeffrey Haag, one of our practice’s neuro-ophthalmol­ogists. We frequently share cases and advice, and it’s a collaboration that greatly benefits my patients. I sometimes tell a patient, “I’m the optic nerve doctor if the problem is glaucoma, and Dr. Haag is the optic nerve doctor for every­thing else.” I think of Jeff and our other neuro-ophthalmolo­gists, Tim Kietzman and Evan Price, as the ocular internists, neuro-imaging experts, eye movement gurus, and all-around eye brainiacs. Neuro-ophthalmologists are invaluable, but we don’t have enough of them.

    While a shortage of neuro-ophthalmologists is an old problem, the concern about supply and demand is growing. In a survey of its U.S. members (with a 95% response rate!), the North American Neuro-Ophthalmology Society found that only eight states have enough neuro-ophthalmologists—and that six states don’t have a single one. In an analysis of the findings, the authors state, “At least one-third of respon­dents reported being 25+ years beyond fellowship training, suggesting that access will worsen if a robust training pipeline is not created immediately.”1 This academic year (2020-2021), only 17 of the neuro-ophthalmology fellowship positions were filled, and 13 remain unfilled.

    Concerned about the deficit, Courtney Francis, a neuro-ophthalmologist at the University of Washington, decided to assess the barriers to pursuing a career in neuro-ophthalmol­ogy. She conducted a survey of U.S. PGY-4 ophthalmology residents about their perceptions of neuro-ophthalmology.2 Along with John Chen, a neuro-ophthalmologist at the Mayo Clinic, she discusses three common misconceptions: It’s a nonsurgical subspecialty, it’s poorly compensated, and it’s limited to academia.

    Let’s address these assumptions. First, although some res­idents characterized neuro-ophthalmology as a nonsurgical subspecialty, this is often not true. In fact, some neuro-oph­thalmology fellowships offer extensive surgical training in strabismus surgery, orbital surgery, temporal artery biopsies, Botox injections, and/or cataract surgery. My colleague Jeff Haag was a superb and busy cataract surgeon for many years. Although he recently retired from surgery, he continues his comprehensive appointments, interspersed with neuro ses­sions. Because neuro-ophthalmology encompasses so many diseases, there are diverse options for a surgical practice.

    What of the second perception regarding compensation? In fact, there is a wide range of salaries and compensation packages for neuro-ophthalmologists, and they are often quite competitive. Recognizing that neuro exams can be time-con­suming, some groups will subsidize their subspecialists who generate less revenue because it allows other ophthalmolo­gists to be more efficient. Another option: Some neuro-ophthalmologists have busy surgical practices or general comprehensive sessions, which bolsters their revenue stream.

    Finally, is neuro-ophthalmology limited to academia? No. As I noted, our practice has three busy neuro-ophthalmologists. The opportunities in private practice will increase, espe­cially given the trend toward consolidation into groups who wish to provide care for all ophthalmic subspecialties.

    The best reasons for choosing a career in neuro-ophthalmology come from the neuro-ophthalmol­ogists themselves. As Peter Quiros, a neuro-ophthalmologist at UCLA Stein Eye Institute and Doheny Eye Institute, says, “Neuro-ophthalmology covers all the reasons many of us cite for becom­ing ophthalmologists: We improve vision and quality of life, we diagnose and treat eye and systemic disease, and we perform surgeries that have impact­ful outcomes on patient lives, all while often being the final authority on the patient’s problem.” I hope neuro becomes the new “hot” subspecialty in ophthalmology.


    1 DeBusk AA et al. J Neuroophthalmol. In press.

    2 Solomon AM et al. Factors affecting ophthalmology resident choice to pursue neuro-ophthalmology fellowship training. Accepted by J Neurooph­thalmol.