Neuro-ophthalmology

The rotations through the Neuro-ophthalmology service at UPMC Eye Center provide residents with the opportunity to learn by providing care to a diverse patient population with a broad range of neuro-ophthalmologic problems

Types of conditions seen and treated include:

optic neuropathy / optic neuritis
intracranial tumors
cranial neuropathies
nystagmus
pupillary abnormalities
evaluation of visual loss / visual field defects
neuro-ophthalmic manifestations of systemic conditions such as
- multiple sclerosis
- mysasthenia gravis
- cancer
- diabetes
- thyroid eye disease
- autoimmune disorders

Adult Neuro-Ophthalmology service is located on the 6th floor Eye and Ear Institute, UPMC Eye Center in Oakland. Dr Shazly is a Mercy Eye Center.
Pediatric Neuro-Ophthalmology is located at Childrens Hopital of Pittsburgh. Dr Ellen Mitchell and Dr Priti Patel.

For Medical Students and Neurology Residents:

Welcome to Neuro-Ophthalmology. We have you scheduled to start your Adult Neuro-Ophthalmology rotation soon with Dr. Gabrielle Bonhomme, Dr. Kocasarac, Dr. Park, Dr. Shazly, and Dr. Zaydan on the Adult Neuro-Ophthalmology service.
You may follow the senior Ophthalmology resident or fellow during the first few days on rotation, but we would like you to begin seeing patients on your own.
Patient notes are currently completed in Epic Care. You are expected to document history, exam, and A/P, or scribe for attending.
Please let us know if you would like to learn to use the slit lamp, lenses, or indirect, but you should become comfortable and adept with your handheld ophthalmoscope.
Examine as many patients as possible, particularly after pupil dilation.
Please feel free to perform focused Neurologic examination on all patients.
Please feel free to contact us with any questions. We look forward to your time with us at the Eye Center, and hope you find your time with us enlightening and beneficial to your medical education

Essential Reading and References for All Trainees

The 5-year risk of MS after optic neuritis: experience of the optic neuritis treatment trial Neurology. 2001;57(12 Suppl 5):S36-45.
Optic nerve decompression surgery for nonarteritic anterior ischemic optic neuropathy (NAION) is not effective and may be harmful. The Ischemic Optic Neuropathy Decompression Trial Research Group." JAMA. 1995;273(8):625-32
Multiple Sclerosis Risk after Optic Neuritis: Final Optic Neuritis Treatment Trial Follow-Up. Arch Neurology. 2008 Jun; 65(6): 727–732.doi: 10.1001/archneur.65.6.727. Beck RW, Trobe JD, Moke PS, et al.
Effect of acetazolamide on visual function in patients with idiopathic intracranial hypertension and mild visual loss: the idiopathic intracranial hypertension treatment trial NORDIC Idiopathic Intracranial Hypertension Study Group Writing Committee, Wall M, McDermott MP, Kieburtz KD, Corbett JJ, Feldon SE, Friedman DI, Katz DM, Keltner JL, Schron EB, Kupersmith MJ.. JAMA. 2014 Apr 23-30;311(16):1641-51. PMID: 24756514
The Idiopathic Intracranial Hypertension Treatment Trial. Clinical Profile at Baseline. JAMA Neurology. 2014 Jun; 71(6): 693–701. doi: 10.1001/jamaneurol.2014.133. Michael Wall, MD, Mark J. Kupersmith, MD, Karl D. Kieburtz, MD, MPH, James J. Corbett, MD, Steven E. Feldon, MD, Deborah I. Friedman, MD, MPH, David M. Katz, MD, John L. Keltner, MD, Eleanor B. Schron, PhD, and Michael P. McDermott, PhD, for the NORDIC Idiopathic Intracranial Hypertension Study Group.
Occult giant cell arteritis: ocular manifestations. Am J Ophthalmology 1998 Apr;125(4):521-6. doi: 10.1016/s0002-9394(99)80193-7. S S Hayreh 1, P A Podhajsky, B Zimmerman
Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children. Neurology 2013;81:1159–1165. Friedman DI, Liu GT, Digre KB. Abstract/FREE Full TextGoogle Scholar
MOG-IgG in NMO and related disorders: a multicenter study of 50 patients. Part 4: Afferent visual system damage after optic neuritis in MOG-IgG-seropositive versus AQP4-IgG-seropositive patients. Journal Neuroinflammation. 2016 Nov 1;13(1):282. doi: 10.1186/s12974-016-0720-6. Florence Pache 1 2, Hanna Zimmermann 1 2, Janine Mikolajczak 1, Sophie Schumacher 1, Anna Lacheta 1, Frederike C Oertel 1, Judith Bellmann-Strobl 1 3, Sven Jarius 4, Brigitte Wildemann 4, Markus Reindl 5, Amy Waldman 6, Kerstin Soelberg 7 8, Nasrin Asgari 7 8, Marius Ringelstein 9, Orhan Aktas 9, Nikolai Gross 10, Mathias Buttmann 11, Thomas Ach 12, Klemens Ruprecht 2, Friedemann Paul 1 2 3, Alexander U Brandt 13, in cooperation with the Neuromyelitis Optica Study Group (NEMOS)

Curriculum

Residents can expect an environment of supervised learning in which the resident plays an essential support role in providing sub-specialty care to patients.

A strong emphasis is placed on teaching and residents can expect to teach and be taught by all members of the service including themselves, their peers, faculty, staff, medical students and patients.

While working on the neuro-ophthalmology service the resident will have the opportunity to develop and refine neuro-ophthalmic specific skills including:

taking a thorough and focused neuro-ophthalmic history
performing a complete new patient neuro-ophthalmic exam including but not limited to:
- lid position and function
- exophthalmometry
- ocular motility
- cranial nerve examination
- contrast sensitivity testing
- neutral density afferent testing
forming and narrowing a differential diagnosis
creating and implementing a plan for further diagnosis and treatment
ordering and interpreting ophthalmic diagnostic studies including:
- visual field testing
- ocular coherence tomography
- CT and MRI imaging of the orbit and brain
communicating with and counseling patients
corresponding with patients’ families and other health care providers
presenting patients in a thorough and focused manner
performing a temporal artery biopsy

Schedule

The Neuro-Ophthalmology clinic starts at 7:30 - 8 am on the 6th floor of the Eye and Ear. However, most patients require testing and are ready to be seen at 8:15 am.
Didactic Lecture Series lecture every morning at 7 am in the 9th floor conference room of the EEI in Oakland—The schedule is found on www.ophed.net.
There are several conferences each week, including our Grand Rounds, that you may find educational. Please ask the ophthalmology resident on rotation about how to participate on Zoom or Microsoft Teams:

Minimally invasive skull base Neurosurgery Tumor Board NeuroRadiology conference. Tuesday 5 pm, neurosurgery conf.
Pituitary Conference with Neurosurgery and NeuroEndocrinology. Thursdays 4 or 5 pm. Neurosurgery conf room
Neuroimmunology Neuroradiology Conference. Alternating Fridays, 8 am.

Guerilla Eye Service(GES). free eye exams to those without insurance. The schedule is on www.ophed.net Speak to one of the Ophthalmology senior residents about how to participate.
NeuroRadiology MRI review with Dr Branstetter. Reading room located in EEI 3rd floor (ENT main).

Schedule for all Residents

Attending		Monday	Tuesday	Wednesday	Thursday	Friday
Bonhomme	am		EEI	EEI	EEI	EEI
Bonhomme	pm
Shazly	am	Mercy
Mitchell/Patil	am	CHP
Mitchell/Patil	pm	CHP

Expectations

All residents on the service are expected to

read and become familiar with the Educational Goals and Objectives for the rotation
arrive on time for clinical experiences.
provide courteous care to patients.
take thorough histories and perform complete examinations
complete timely, thorough and accurate documentation using the electronic health record
complete preliminary interpretations for all imaging studies performed on the service
review neuroradiology scans with UPMC neuroradiology team as scheduled during Monday and Friday reading times.
work as part of the neuro-ophthalmology service sharing work with each other and the technical staff as needed
work closely with medical students and other trainees rotating with the service
when necessary complete correspondence with patients’ other health care team
when necessary complete medical disability forms with pertinent exam findings as per medical records, then submit to attending for review and signature
treat the technical and administrative staff with courtesy and respect
when necessary, provide post encounter care for the patient by checking labs, filling out forms and corresponding with patients
read on a daily basis while on the service concentrating on topics brought to the forefront during clinical experiences

Clinic Logistics

ALWAYS record patient phone conversations or radiology reviews in EpiCare for documentation
All NEW NEURO patients
- Please review and edit the tech's chief complaint and histories, which autocomplete from intake exam in the Neuro Hybrid letter for new patients.Review techs’ medical, family, social history
- TECH: Autorefraction vision and pinhole if less than 20/20
- TECH Color vision & contrast sensitivity with Ishihara
- TECH Near vision, best corrected, if complaining of any blurring before drops
- Check pupils but DO NOT DILATE until asked by attending
- Help keep track of patients at testing
- Nerve and macula 5 line raster OCT, Stereo disk photos
- PLEASE INTERPRET in ENTER/EDIT results EPICARE
- Measure alignment if diplopic with Maddox if able, Cover testing, or Krimsky, if unable
RETURN NEURO patient
Copy previous HPI and Progress note in EpiCare, then make appropriate changes in visual acuity box (NEURO OPHTH GENERAL SHORT), exam and plan
Neuroradiology Rounds - we regularly review studies from outside imaging centers with Dr Branstetter, Dr Rothfus, Dr Tsday. It is helpful to email Dr Branstetter in advance to schedule 10-15 minutes to review 2-3 studies at his leisure.
Please notify Melissa Wyse and Attending of any post-call or time off from clinic
Dr. Bonhomme is in clinic Tuesdays, Wednesdays, Thursdays and most Fridays
Dr. Mitchell is in clinic 2 Fridays each month (check Epic) (first priority for residents)
Radiology Review Friday after clinic, or as able
Temporal Artery biopsies, laser procedures, & op cases as able

Neuro-ophthalmology Educational Goals and Objectives

PGY-1 and PGY-2 Goals & Objectives

Medical Knowledge

To describe the neuro-anatomy of the visual pathways.
To describe the neuro-anatomy of the cranial nerves.
To describe the pupillary and accommodative neuro-anatomy.
To describe ocular motility and related neuronal pathways.
To describe the typical features, evaluation, and management of the most common optic neuropathies (e.g., demyelinating optic neuritis, ischemic optic neuropathy [arteritic and nonarteritic], toxic or nutritional optic neuropathy, Leber’s hereditary optic neuropathy, ethambutol toxicity, neuroretinitis, and compressive, inflammatory, infiltrative, and traumatic optic neuropathies).
To describe the typical features, evaluation, and management of the most common ocular motor neuropathies (e.g., third, fourth, sixth nerve palsy).
To describe the typical features of cavernous sinus and superior orbital fissure syndromes (e.g., infectious, vascular, neoplastic, inflammatory etiologies).
To describe the typical features, evaluation, and management of the most common causes of nystagmus (e.g., congenital motor and sensory, downbeat, upbeat, gaze-evoked, drug-induced).
To describe the typical features, evaluation, and management of the most common pupillary abnormalities (e.g., relative afferent pupillary defect, anisocoria, Horner syndrome, third nerve palsy, Adie’s tonic pupil).
To describe the typical features, evaluation, and management of the most common visual field defects (e.g., optic nerve, optic chiasm, optic radiation, occipital cortex).
To describe the epidemiology, clinical features, evaluation, and management of ocular myasthenia gravis.
To describe the epidemiology, clinical features, evaluation, and management of carotid-cavernous fistula.
To describe the epidemiology, differential diagnosis, evaluation and management of congenital optic nerve abnormalities (e.g., optic pit, disc coloboma, papillo-renal syndrome, morning glory syndrome, tilted disc, optic nerve hypoplasia, myelinated nerve fiber layer, melanocytoma, disc drusen, Bergmeister’s papilla).

Patient Care

To perform a basic pupillary examination
- To describe indications for and perform basic pharmacologic pupillary testing for Horner syndrome, pharmacologic dilation, and Adie’s tonic pupil.
- To list the differential diagnosis of anisocoria (e.g., sympathetic or parasympathetic lesion “physiologic”).
- To describe, detect, and quantitate a relative afferent pupillary defect.
- To list the causes for light-near dissociation (e.g., Argyll-Robertson pupils, diabetic neuropathy, tonic pupil).
To perform a basic ocular motility examination
- To assess ocular alignment using simple techniques (e.g.. Hirschberg, Krimsky).
- To describe and perform basic cover/uncover testing for tropia.
- To describe and perform alternate cover testing for phoria.
- To perform simultaneous prism and cover testing.
- To perform measurement of deviations with prisms.
- To describe the indications for and apply Fresnel and grind-in prisms.
- To describe the indications for and to perform forced duction and forced generation testing.
- To perform an assessment of saccade accuracy and pursuit and optokinetic testing.
- To perform a measurement of eyelid function (e.g., levator function, lid position).
To describe the indications for visual field testing and to perform and interpret perimetry studies
- To perform confrontational field testing (static and kinetic, central and peripheral, red and white targets).
- To perform and interpret a tangent screen test.
- To describe the indications for and perform basic Goldmann perimetry, and interpret results.
- To describe the indications for and perform basic automated perimetry, and interpret results.
To perform basic direct, indirect, and magnified ophthalmoscopic examination of the optic disc (e.g., recognize optic disc swelling, optic atrophy, neuroretinitis).
To describe the anatomy and indications for, order appropriately, and interpret basic radiology studies of the brain and orbits, demonstrating the ability to communicate with radiologists in order to maximize both choice of proper diagnostic test and accuracy of interpretation.
To describe the indications for and interpret basic echography of orbits.

Professionalism

To treat patients with respect and compassion at all times
To treat clinical and administrative staff with respect
To treat medical students with respect and strive to create an atmosphere conducive to education
To arrive on-time for clinical experiences
To prepare in advance for surgical experiences
To work to become part of the clinical team
- To work with the faculty, staff, fellow and other residents on the service to determine your responsibilities
- To remain flexible and offer to help out with the responsibilities of others when you can
To remain visible and available to participate in clinical care throughout the clinical session. If you leave the clinical care area make sure that other members of the service know where you are and why
answer your pager within 10 minutes of being paged.

Interpersonal and communication skills

To communicate your name and role on the service to patients and their families.
- "Hello, I'm Dr. Resident, I'm a resident working with Dr. Attending today."
To present patients to the attending in a succinct but complete way
To maintain timely and legible medical records
To talk when you should be talking, listen when you should be listening

Practice-based learning and improvement

To learn to recognize feedback from faculty, fellows, fellow residents, patients and students
To accept that feedback constructively and work to improve based on it
To accept your role as a teacher as well as a learner. Work to educate students, fellow residents, faculty, staff and patients

Systems based practice

To work for the benefit of your patients to communicate with other health care provider
To act as an advocate for your patient within the health care system
To become aware of the costs of diagnostic and therapeutic interventions. Consider these costs as you recommend and prescribe these interventions.

PGY-3 Goals & Objectives

(in addition to PGY-2 level goals listed for the Inpatient Consult Service)

Medical Knowledge

To describe typical and atypical features, evaluation, and management of the most common optic neuropathies (e.g., papilledema, optic neuritis, ischemic, inflammatory, infectious, infiltrative, compressive, and hereditary optic neuropathies).
To describe typical and atypical features, evaluation, and management of the more complex supranuclear and internuclear palsies and less common ocular motor neuropathies (e.g., progressive supranuclear palsy and internuclear ophthalmoplegia).
To describe typical and atypical features, evaluation, and management of the more complex and less common forms of nystagmus (e.g., rebound, convergence, retraction).
To describe typical and atypical features, evaluation, and management of the more complex and less common pupillary abnormalities (e.g., light-near dissociation, pharmacologic miosis).
To describe typical and atypical features, evaluation, and management of the more complex and less common visual field defects (e.g., lateral geniculate, monocular temporal crescent).
To describe more advanced aspects of visual field indications, selection, and interpretation (e.g., artifacts of automated perimetry, testing and thresholding strategies).
To describe neuro-ophthalmic aspects of common systemic diseases (e.g., hypertension, diabetes, thyroid disease, myasthenia gravis, temporal arteritis, systemic infections and inflammation).
To describe neuro-ophthalmologic findings in trauma (e.g., traumatic optic neuropathy, traumatic brain injury).
To describe typical features of inherited neuro-ophthalmologic diseases (e.g., Leber’s hereditary optic neuropathy, autosomal dominant optic atrophy, spinocerebellar degenerations).
To recognize, evaluate, and treat ocular myasthenia gravis.

Patient Care

To describe the indications for and understand how to interpret the results of tests for myasthenia gravis. (e.g. sleep test, ice test, Tensilon test, prostigmine test)
To perform a detailed cranial nerve evaluation (e.g, testing of trigeminal and facial nerve function).
To describe the more advanced interpretation of neuro-radiologic images (e.g., indications and interpretation of orbital tumors, thyroid eye disease, pituitary adenoma, optic nerve glioma, optic nerve sheath meningioma).
To describe the evaluation, management, and specific testing (e.g., stereopsis, mirror test, redgreen testing) of patients with “functional” visual loss (e.g., recognize non-organic spiral or tunnel visual fields).
To describe the indications for, to perform, and to list the complications of temporal artery biopsy.

Professionalism

To treat patients with respect and compassion at all times
To treat clinical and administrative staff with respect
To treat medical students with respect and strive to create an atmosphere conducive to education
To arrive on-time for clinical experiences
To prepare in advance for surgical experiences
To work to become part of the clinical team
- To work with the faculty, staff, fellow and other residents on the service to determine your responsibilities
- To remain flexible and offer to help out with the responsibilities of others when you can
To remain visible and available to participate in clinical care throughout the clinical session. If you leave the clinical care area make sure that other members of the service know where you are and why
answer your pager within 10 minutes of being paged.

Interpersonal and communication skills

To communicate your name and role on the service to patients and their families.
- "Hello, I'm Dr. Resident, I'm a resident working with Dr. Attending today."
To present patients to the attending in a succinct but complete way
To maintain timely and legible medical records
To talk when you should be talking, listen when you should be listening

Practice-based learning and improvement

To learn to recognize feedback from faculty, fellows, fellow residents, patients and students
To accept that feedback constructively and work to improve based on it
To accept your role as a teacher as well as a learner. Work to educate students, fellow residents, faculty, staff and patients

Systems based practice

To work for the benefit of your patients to communicate with other health care provider
To act as an advocate for your patient within the health care system
To become aware of the costs of diagnostic and therapeutic interventions. Consider these costs as you recommend and prescribe these interventions.

PGY-4 Goals & Objectives

(in addition to PGY-3 level goals)

Medical Knowledge

To describe typical and atypical features, evaluation, and management of the most advanced and least common optic neuropathies (e.g., chronic or recurrent optic neuritis, and posterior ischemic, autoimmune, toxic/nutritional).
To describe typical and atypical features, evaluation, and management of the most complex and least common ocular motor neuropathies and their mimics (e.g., progressive supranuclear palsy).
To describe typical and atypical features, evaluation, and management of the most complex and least common forms of nystagmus (e.g., surgical treatment options, using the null point in either prism or surgical therapy).
To describe typical and atypical features, evaluation, and management of the most advanced and least common pupillary abnormalities (e.g., pupil findings in coma, transient pupillary phenomenon).
To describe typical and atypical features, evaluation, and management of the most complex and least common visual field defects (e.g., combination or bilateral lesions, cortical visual impairment).
To describe the most advanced aspects of visual field indications, selection, and interpretation (e.g., variability in automated perimetry, application of specific testing and thresholding strategies for different patient populations with different neuro-ophthalmic conditions, different testing abilities (e.g., young or old age, mental status, hand-eye coordination, reaction time).
To describe, evaluate, and treat the neuro-ophthalmic aspects of systemic diseases (e.g., malignant hypertension, diabetic papillopathy, toxicity of systemic medications, pseudotumor cerebri).
To describe, evaluate, and treat the neuro-ophthalmologic manifestations of trauma (e.g., corticosteroid or surgical therapy in traumatic optic neuropathy).
To describe, evaluate, and provide appropriate genetic counseling for neuro-ophthalmologic diseases (e.g., Leber’s hereditary optic neuropathy, chronic progressive external ophthalmoplegia, von Hippel-Lindau syndrome).
To recognize, evaluate, and treat (or refer) more complex forms of nystagmus.
To recognize, evaluate, and treat (or refer) transient monocular or binocular visual loss.

Patient Care

To perform and interpret the results of tests for myasthenia gravis, and to recognize and treat the complications of the procedures.
To perform and interpret the complete cranial nerve evaluation (e.g., testing of trigeminal and facial nerve function) and basic neurologic exam in the context of neuro-ophthalmic localization and disease.
To interpret neuro-radiologic images in neuro-ophthalmology (e.g., interpretation of orbital imaging for orbital pseudotumor and tumors, thyroid eye disease, intracranial imaging modalities and strategies for tumors, aneurysms, infection, inflammation, and ischemia), and to appropriately discuss, in advance of testing, the localizing clinico-radiologic features with the neuroradiologist in order to obtain the best study and intrepretation of the results.
To recognize patients with “functional” visual loss (non-organic visual loss) and provide appropriate counseling and follow-up.

Professionalism

To treat patients with respect and compassion at all times
To treat clinical and administrative staff with respect
To treat medical students with respect and strive to create an atmosphere conducive to education
To arrive on-time for clinical experiences
To prepare in advance for surgical experiences
To work to become part of the clinical team
- To work with the faculty, staff, fellow and other residents on the service to determine your responsibilities
- To remain flexible and offer to help out with the responsibilities of others when you can
To remain visible and available to participate in clinical care throughout the clinical session. If you leave the clinical care area make sure that other members of the service know where you are and why
answer your pager within 10 minutes of being paged.

Interpersonal and communication skills

To communicate your name and role on the service to patients and their families.
- "Hello, I'm Dr. Resident, I'm a resident working with Dr. Attending today."
To present patients to the attending in a succinct but complete way
To maintain timely and legible medical records
To talk when you should be talking, listen when you should be listening

Practice-based learning and improvement

To learn to recognize feedback from faculty, fellows, fellow residents, patients and students
To accept that feedback constructively and work to improve based on it
To accept your role as a teacher as well as a learner. Work to educate students, fellow residents, faculty, staff and patients

Systems based practice

To work for the benefit of your patients to communicate with other health care provider
To act as an advocate for your patient within the health care system
To become aware of the costs of diagnostic and therapeutic interventions. Consider these costs as you recommend and prescribe these interventions.