Neuro-ophthalmology in the United Kingdom has a rich and longstanding history with a long list of luminaries that include John Hughlings Jackson (1835–1911), Douglas Argyll Robertson (1837–1909), Harry Moss Traquair (1875–1954), Sir Gordon Morgan Holmes (1876–1965), and William John Adie (1886–1935), to name but a few. These historical figures set the foundation for modern neuro-ophthalmology with their seminal work on fundamental concepts ranging from the topographical organization of the visual cortex to the physiological basis of the pupillary light reflex and to the island of vision. More recent notable figures include William Ian McDonald (1933–2006) for his pioneering work on optic neuritis and multiple sclerosis and Anita Harding (1952–1995) who in a short, but stellar, academic career published some of the defining articles on Leber hereditary optic neuropathy and the inherited neuromuscular diseases. The development of neuro-ophthalmology as a distinct subspecialty in the United Kingdom owes a large part to Michael Sanders who spent his fellowship year with William Hot at University of California, San Francisco, CA in 1967 before returning to practice at Queen Square in London (Fig. 1). This important transatlantic link has since flourished with a significant proportion of the current crop of British neuro-ophthalmologists having trained directly under Sanders' wings.
The majority of neuro-ophthalmologists in the United Kingdom are Fellows of the Royal College of Ophthalmologists (FRCOphth), having initially trained as general ophthalmologists before gaining additional subspecialty experience in neuro-ophthalmology. The minimum period of ophthalmology training is 7 years and, after being awarded a Certificate of Completion of Training, a trainee is eligible to apply for an attending position (known as a Consultant in the United Kingdom). However, an increasing number of neuro-ophthalmologists also come from a neurology background, which further adds to the diversity of skills and expertise. There are a number of well-regarded neuro-ophthalmology fellowships, for example, in Birmingham and in London, which attract both local and overseas trainees. Prospective candidates should keep an eye on the careers section of the British Medical Journal where openings are regularly advertised (http://careers.bmj.com/).
The National Health Service (NHS) in the United Kingdom is a publicly funded system of care that was founded in 1948 at the end of the Second World War. It is the world's largest healthcare system and despite mounting economic pressures, the NHS remains free at the point of use for UK residents. Although neuro-ophthalmology services are usually concentrated in larger ophthalmology departments based in major cities, many neuro-ophthalmologists will also provide outreach clinics, especially in parts of the country with catchment populations spread over large geographical areas. Patients are referred by a number of sources, but the majority of those are from primary care physicians, casualty departments, and secondary referrals from ophthalmology, and other hospital specialties. Most neuro-ophthalmologists who come from an ophthalmology background will also provide a surgical service, for example, cataract and strabismus surgery, depending on their fellowship training and personal interests. Botulinum toxin injections also are frequently provided by neuro-ophthalmologists for the treatment of a wide range of neurological disorders, in particular facial dystonias, and in the management of more complex strabismus cases.
Clinical and Research Meetings
Neuro-ophthalmology is a relatively small subspecialty, but our members are heavily involved in the training of junior trainees at both local and national levels. Through the Royal College of Ophthalmologists, a number of dedicated neuro-ophthalmology teaching days are organized each year, which are always oversubscribed and highly valued by the attendees (http://www.rcophth.ac.uk/). As a result of popular demand, neuro-ophthalmology sessions have also become a permanent fixture of the main ophthalmology meetings in the United Kingdom such as the Annual RCOphth Congress, the Oxford Ophthalmological Congress (http://www.oxford-ophthalmological-congress.org.uk/), and the Annual Meeting of the Association of British Neurologists (ABN; http://www.theabn.org/). Gordon Plant laid the foundation for a Special Interest Group allied to both the ABN and to the Royal College of Ophthalmologists in 2006. This effort culminated in the creation of the United Kingdom Neuro-Ophthalmology Special Interest Group (UKNOSIG), and the sixth annual meeting took place on March 12, 2014 (Governors' Hall, St Thomas' Hospital, London, United Kingdom) with Andrew Lee (Houston, TX) as the keynote speaker (http://www.uknosig.com/). Another important date in the calendar is the annual gathering of the British Isles Neuro-ophthalmology Club (BINOC), which brings together a focused group of consultants with a subspecialty interest in neuro-ophthalmology. The BINOC meeting takes place over 2 days, and it provides the ideal forum for colleagues to discuss complex and unusual cases with a neuroradiologist in attendance.
The close personal links between neuro-ophthalmologists in the United Kingdom and the comprehensive clinical network provided by the NHS are valuable assets that have contributed to both the breadth and depth of neuro-ophthalmology research in this country. Our members are heavily involved at the cutting edge of both basic and translational research with active collaborations across several specialties (Table 1). The UK neuro-ophthalmology community has also been well represented within major international organizations over the years, such the North-American Neuro-Ophthalmology Society and the European Neuro-Ophthalmology Society (EUNOS). Christopher Kennard is the current President of EUNOS and the 11th EUNOS meeting (April 10–13, 2013) that took place in the beautiful and historic setting of Oxford was a great success. The future of neuro-ophthalmology is certainly very bright in the United Kingdom, but as a group, we are not resting on our laurels. A central element of our mission statement is the need to foster the next generation of neuro-ophthalmologists, not only to deliver a first class clinical service, but also to lead the way as the teachers, researchers, and leaders of tomorrow.
I am grateful to Simon Hickman (Sheffield) for his very useful comments on the historical development of neuro-ophthalmology in the United Kingdom.