With a territory the size of a continent, divided into 26 states and 1 federal district, and with a population of more than 200 million, Brazil currently is the seventh largest economy in the world. It has a large medical community covering most areas of medicine, including all subspecialties of ophthalmology and neurology, particularly in the more developed states located in the southeast and southern regions of the country. Interest in neuro-ophthalmology (NO) has existed in Brazil for more than 50 years, although the subspecialty was until recently practiced by a very small number of physicians. Over the past 15 years, this has changed, with neuro-ophthalmologists practicing in at least half of the states in the country.
The Foundation of Neuro-Ophthalmology in Brazil
Specific interest in NO began in the states of Minas Gerais, Rio de Janeiro, and São Paulo. Professor Henderson C. de Almeida was the first to train in NO when, in the early 1960s, after studying strabismus with Arthur Jampolsky in San Francisco, he underwent a year of training with Frank B. Walsh in Baltimore. On his return to Brazil in 1965, he was given charge of both the strabismus clinic and the NO clinic of the Federal University of Minas Gerais (UFMG), in the city of Belo Horizonte. After a decade, he decided to focus exclusively on strabismus. He was succeeded at the university by Dr Luiz Roberto M. Oliveira who had completed a fellowship in NO with Neil Miller and strabismus with Stewart Wolf. Dr Oliveira was followed by Dr Marco Aurélio Lana Peixoto, a neurologist with residency training in Birmingham, AL, and Saint Louis, MO. Since the late 1980s, Dr Lana Peixoto has primarily focused on NO and is currently in charge of the clinic at UFMG.
Another pioneer of NO in Brazil, Professor Adalmir M. Dantas from Rio de Janeiro, began practicing NO in the early 1970s and taught at the Fluminense Federal University (Niteroi, Rio de Janeiro) as the head of the Department of Ophthalmology and at the Federal University of Rio de Janeiro (UFRJ) where he attained the position of head professor. In 1979, Professor Dantas was commissioned by the Brazilian Council of Ophthalmology to deliver a series of keynote lectures on “Propedeutics in Neuro-Ophthalmology” for the Brazilian Congress of Ophthalmology in São Paulo (Fig. 1). These lectures encouraged many to consider the field of NO including myself during my last year of medical school.
In the state of São Paulo, interest in NO began at the University of São Paulo Medical School (FMUSP) and Escola Paulista de Medicina (now Federal University of São Paulo, UNIFESP). At FMUSP, the NO clinic began in the 1960s. Initially, patients were seen by professors with interests in other areas of ophthalmology. In 1981, it was transformed into a specialized service under the leadership of Prof. Carlos A. Rodrigues-Alves. After my graduation and residency at FMUSP, I completed an NO fellowship with William Hoyt (San Francisco), and on returning in 1984, developed a busy NO clinic at Hospital das Clinicas (FMUSP), Brazil's largest university hospital. Since the retirement of Dr Rodrigues-Alves, I have led the NO service, with the invaluable assistance of Dr Maria Kiyoko Oyamada. Over the years, the clinic has played a major role in residency and fellowship training and continuing medical education in NO in Brazil. At UNIFESP, NO was pioneered by Dr Paulo M. Imamura since 1975 after completing his ophthalmology training in São Paulo and the University of Tokyo, Japan. Dr Imamura trained many residents and NO fellows, including Dr Luciana da Cruz Noia who is currently in charge of the service. Dr Carlos F. Chicani, who did fellowship training with Neil Miller, is another member of the UNIFESP NO service.
The Strengthening of Neuro-Ophthalmology as a Subspecialty in Brazil and South America
The development of NO in Brazil and other countries in South America owes much to Dr Hoyt, not only because he personally instructed many fellows but also from his continual support and attendance of important educational events, which significantly fostered interest in the subspecialty. Dr Hoyt lectured at the University of São Paulo in 1990, after which he was a guest of honor at an important meeting in Buenos Aires of the Latin American Club of Neuro-ophthalmology (CLAN) organized in 1988. CLAN is composed of a group of Latin American ophthalmologists and neurologists with special interest in NO and initially led by Cristian Luco (Chile) and Lidia Lopez (Argentina). The 1990 meeting in Buenos Aires, organized by Dr Roberto Ebner and his colleagues, was a landmark in the development of NO in that area of the world. Attendees included A. Dantas, P. Imamura, and myself (Brazil), Ernesto Rios-Montenegro (Peru), Rafael Muci-Mendoza (Venezuela), and many physicians from Argentina and Chile (Figs. 2, 3). Dr Hoyt further strengthened the group by participating in another CLAN meeting in Santiago, Chile, in 1996, organized by Cristian Luco, attended by 2 American CLAN supporters, Rosa Tang and Thomas Hedges III. In 1999, an NO meeting in Belo Horizonte, Minas Gerais, was organized by Dr Lana-Peixoto and attended by approximately 400 Brazilian physicians and CLAN members. American participants included Jack Selhorst, William T. Shults, and Sohan S. Hayreh. The development of NO in Brazil also owes much to other North Americans including Joel Glaser, Norman Schatz, Neil Miller, Alfredo Sadun, Anthony Arnold, Robert Sergott, and Peter Savino who either participated in national or Pan-American meetings that occurred in Brazil or accepted Brazilian physicians as visitors or fellows in their departments.
Neuro-Ophthalmology in Brazil: Training, Clinical Practice, and Challenges
Since the 1970s, a rotation in NO has been part of the ophthalmology residency programs at UFMG, UFRJ, FMUSP, and UNIFESP. Hundreds of ophthalmologists, and some neurology residents, have been exposed to the subspecialty. Over time, NO residency training has been instituted in a great many Brazilian university hospitals and fellowship/postdoctoral training programs. The subspecialty is currently represented in 13 states, and more physicians (almost all ophthalmology-trained) are specializing in NO (Table 1).
While this may sound promising, the number of practicing neuro-ophthalmologists in the country is actually very small when compared with the total number of ophthalmologists and neurologists. In part, this may be explained by the economics of the Brazilian healthcare systems. Most Brazilians are covered by the Unified Healthcare System (SUS), which provides basic healthcare services free of charge but does not include many of the more complex procedures unless it is practiced in government-supported teaching hospitals. A small portion of the Brazilian population has additional coverage through private or employment-related health insurance plans. Yet, reimbursement from these plans is inadequate for time-consuming consultations and procedures. Therefore, ophthalmologists are not strongly motivated to practice NO when relying on remuneration only from health insurance plans. A minority of specialists can afford to restrict their practice to NO, and when they do, they usually treat only private patients or accept only premier health insurance plans. In most cases, the practice of NO is combined with either general ophthalmology or subspecialties such as retina, orbit and ophthalmic plastic surgery, strabismus, and electrophysiology.
Despite these challenges, NO has expanded dramatically in Brazil. The subspecialty is a required subject for the accreditation of ophthalmology residency programs by the Brazilian Council of Ophthalmology, and the subject is included in ophthalmology course curricula and in the programs of all major ophthalmology conferences, such as the annual meetings held by the Brazilian Council of Ophthalmology. The large attendance at lectures on NO is evidence of increasing interest in the subject. In addition, some neurology residency programs offer elective rotations in NO.
Research in NO-related topics has also increased in Brazil. Through CAPES (government program for continuing higher education) and CNPq (National Council for Research and Development), the Brazilian government supports postgraduate research cofunded by universities and local S&T agencies. At least 3 such programs (FMUSP, UNIFESP, and UFMG) have NO-related research projects. The main lines of study in these programs center around structural and functional abnormalities of the optic pathways in chiasmal compression, multiple sclerosis, neuromyelitis optica, papilledema from pseudotumor cerebri, dysthyroid optic neuropathy, and Leber hereditary optic neuropathy.
In conclusion, NO in Brazil is coming of age and is today a subspecialty of which its founding fathers can be proud. As our understanding of disease mechanisms improves and new treatment modalities and diagnostic equipment for visual pathway-related conditions become available, the need for programs offering state-of-the-art training in NO and the number of practicing neuro-ophthalmologists in the country will undoubtedly increase.