NANOS Intro

North American Neuro-Ophthalmology Society

Proposed by the Curriculum Committee of the North American Neuro-Ophthalmology Society (NANOS)

Chair:

Valerie Biousse, MD (N and O)*

Co-chair:

Nancy J. Newman, MD (N)

Members:

Kimberly Peele Cockerham, MD (O)

Bradley J. Katz, MD (O)

David Kaufman, DO (N)

Andrew Lee, MD (O)

Howard D. Pomeranz, MD, PhD (O)

Roger E. Turbin, MD (O)

Greg P. Van Stavern, MD (N)

Nick J. Volpe, MD (O)

Floyd A. Warren, MD (O)

*(N: board certified in neurology; O: board certified in ophthalmology)

Neuro-ophthalmologists care for patients with visual problems related to the nervous system. Neuro-ophthalmology requires specialized training and expertise in diseases involving the eye and the brain. It is a subspecialty of both neurology and ophthalmology, and neuro-ophthalmologists are usually board certified in neurology, ophthalmology, or both.

The scope of practice of neuro-ophthalmologists may vary tremendously depending on their background (board certified in neurology or ophthalmology), and whether they perform surgery or not (ophthalmology is a surgical subspeciality, while neurology is not). In addition, a number of ophthalmology-trained neuro-ophthalmologists have additional training in oculoplastics or pediatric ophthalmology, allowing them to perform highly specialized surgical procedures.

Neuro-ophthalmology is still a "young speciality" and its definition varies from a place to another. Indeed, the subject material is extremely broad and the clinical experiences are fragmented and heterogeneous. Only a few fellows are trained in neuro-ophthalmology each year, and their knowledge and experience vary depending on where and with whom they trained. Not all residency programs have a detailed neuro-ophthalmology curriculum and very few medical schools include our speciality in their curriculum. A plan of action is being developed by The North American Neuro-Ophthalmology Society to improve the quality of our training program, have the fellowship accredidated by both the American Academies of Neurology and Ophthalmology, and increase the number of trainees. The first step of such a plan of action is the development of a neuro-ophthalmology curriculum.

It is important to note that "curriculum" is defined as an educational plan rather that an all-inclusive list. The curriculum Committee of the North American Neuro-Ophthalmology Society has developed this core curriculum in neuro-ophthalmology. This curriculum defines the minimum standards for the clinical neuro-ophthalmologist; its content should evolve as progresses are made in our specialty. It should not be limiting as the extent of this curriculum will vary depending on the neuro-ophthalmologist's primary speciality (neurology or ophthalmology).

The goal of this curriculum is to outline "what the neuro-ophthalmologist should know". It is the basis for the curriculum that should be taught in neuro-ophthalmology fellowship and should help define a more basic curriculum for ophthalmology and neurology residencies. Specific learning objectives, outlining parts of this curriculum, need to be defined for fellows, residents, and medical students.

We also have attempted to weigh each part of this curriculum in order to emphasize what is really relevant to our specialty and assist others in creating more focused curriculum such as for fellows, residents or CME programs planning. We have "weighted" each topic as "most relevant", "more relevant", and "relevant", as appropriate, with each topic. Our definition of "most relevant", "more relevant", and "relevant" appear on the next page.

The first part of the curriculum includes a synopsis of anatomy and physiology and examination techniques relevant to neuro-ophthalmology, as well as a number of "neuro-ophthalmic manifestations of" various disorders. Indeed, most diseases have neuro-ophthalmic manifestations. Some are common or particularly important as they may lead to early diagnosis and management of specific disorders. They are emphasized in this outline.

The second part includes a list of what really "belongs to the neuro-ophthalmologist", including disorders of the afferent visual pathways and efferent neuro-ophthalmic structures such as eye movement disorders and pupillary and eyelid abnormalities.

Weighing system proposal:

The curriculum includes a list of topics relevant to our specialty. Each topic is followed by the relevant score indicated in superscript.

We are proposing that topics be prioritized to indicate the depth and breadth of knowledge in the area that is required of a specialist in neuro-ophthalmology. We have used previous experience from the Curriculum in Emergency Medicine developed by the Society for Academic Emergency Medicine (SAEM) and the Council of Emergency Medicine Residency Directors (CORD), and from the Neuro-Ophthalmology/Orbit Knowledge Base Panel from the American Academy of Ophthalmology to develop the following weighting system:

Most relevant (mastery of the topic):

Knowledge or skills that are essential to the independent management of illness and injury in patients with neuro-ophthalmic disorders. This level of knowledge or skill is required to manage clinical problems that a) pose significant risks to patients' health or visual function, b) require prompt diagnosis or management to insure optimal outcome, and c) are typically diagnosed and/or managed by neuro-ophthalmologists (i.e. common diseases seen on a daily basis by neuro-ophthalmologists). Because this knowledge/skill leads to important decisions and interventions, it must be comprehensive in breath and depth, and accessible to the neuro-ophthalmologist without the benefit of consultation.
More relevant (proficiency with the topic):

Knowledge or skills that are used by the neuro-ophthalmologist, but are not essential for the independent and timely diagnosis and/or management of common neuro-ophthalmologic disorders. This level of knowledge or skills may be possessed by the highly trained neuro-ophthalmologist, but lacking in-depth knowledge/skill neuro-ophthalmologist may review reference texts, consult other specialists, or refer to other physicians without posing a risk to patients's health or visual function. Typically, clinical problems requiring this level of knowledge/skill are managed in other settings or by other specialists. The neuro-ophthalmologist may commonly provide initial evaluation of these problems, but generally not definitive management. Rare disorders classically evaluated by neuro-ophthalmologists are also included in this category.
Relevant (familiarity with the topic):

Knowledge pertaining to clinical conditions that are either benign or not directly related to neuro-ophthalmology, and do not pose an imminent threat to patients' health or visual function. Immediate diagnosis and management of these conditions by a neuro-ophthalmologist are beyond the scope of standard practice. This level of knowledge facilitates comprehensive and thorough diagnosis and/or management of complex clinical problems encountered in neuro-ophthalmology, but referral to other specialists is generally required for the diagnosis and/or management of these conditions.

Proposed by the Curriculum of the North American Neuro-Ophthalmology Society (NANOS)