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Teaching and Practicing Neuro-Ophthalmology in Low-Resource Countries

Katz, Bradley J. MD, PhD; Farris, Bradley K. MD; Golnik, Karl C. MD, MEd; Lawlor, Mitchell MD, PhD; Postels, Douglas G. MD, MS

Section Editor(s): Digre, Kathleen B. MD

doi: 10.1097/WNO.0000000000000420
WorldWide Neuro-Opthalmology

Department of Ophthalmology and Visual Sciences and Department of Neurology, John A. Moran Eye Center, University of Utah, Salt Lake City, Utah

Department of Ophthalmology, Dean McGee Eye Institute, University of Oklahoma, Oklahoma City, Oklahoma

Department of Ophthalmology, University of Cincinnati and the Cincinnati Eye Institute, Cincinnati, Ohio

Save Sight Institute, University of Sydney, Sydney, Australia

International Neurologic and Psychiatric Epidemiology Program; Department of Pediatric Neurology, Michigan State University, East Lansing, Michigan

At the 2016 annual meeting of the North American Neuro-Ophthalmology Society (NANOS) in Tucson, Arizona, 4 clinicians discussed their experiences teaching neuro-ophthalmology in low-resource countries. Do these countries even have a need for neuro-ophthalmology? Many of these countries are so overwhelmed with cataract, glaucoma, corneal infections, and eye injuries one might consider neuro-ophthalmology a luxury. Geoff Tabin, MD, Professor of Ophthalmology at the Moran Eye Center in Salt Lake City has spent most of his career trying to improve the delivery of ophthalmic care in low-resource countries. He believes that all ophthalmologists need at least a basic knowledge of this subspecialty. “If a family brings their loved one to an eye doctor with a neuro-ophthalmic problem and that doctor is unable to diagnose or treat the condition, then that family may lose faith in the doctor. When another family member has a condition that the doctor may be able to treat, such as a cataract, the family may not take their family member to that doctor because they could not help them the last time. Over time, the community may lose faith in the doctor. For this reason, every ophthalmologist needs a comprehensive education that includes neuro-ophthalmology.” Many neuro-ophthalmologists may be willing and able to teach in these countries, but may be unprepared for the task. These countries have different diseases, different infrastructure, and varying availability of resources. It was for this reason that the symposium was organized: to allow neuro-ophthalmologists who may be interested in sharing their expertise in low-resource countries to benefit from the experiences of others who are already working there.

Karl Golnik, MD, Professor and Chair of Ophthalmology at the University of Cincinnati and the Cincinnati Eye Institute, highlighted some of the numerous Internet-based resources available for teaching neuro-ophthalmology. These resources include curricula for residents and fellows, training guidelines, and e-learning resources.

Huge variability exists in neuro-ophthalmology education and access to patient care around the world. Many countries have no neuro-ophthalmologists, in part, because of lack of access to training. Fortunately, several groups have created internationally applicable training material. NANOS published a curriculum meant for both neuro-ophthalmology fellowship and resident training. Its core curriculum defines the minimum standards for the clinical neuro-ophthalmologist (1). The Neuro-Ophthalmology Virtual Education Library (NOVEL) has taken this curriculum, and work has begun on the Complete Illustrated Curriculum that will link teaching material to each curricular component. This resource is currently available to NANOS members only and will ultimately be an educational resource available internationally. The International Council of Ophthalmology (ICO) has developed resident and fellowship neuro-ophthalmology curricula. An international panel of neuro-ophthalmologists expressly charged with creating internationally applicable standards created both curricula. The ICO residency curriculum is stratified and contains a “must know” list of topics (2). The ICO fellowship curriculum contains suggested criteria for required components of a neuro-ophthalmology fellowship training program. The Association of University Professors in Ophthalmology, through their Fellowship Compliance Committee, has also created a list of required training program components that must be met to be in “compliance” (3).

Neuro-ophthalmic e-learning resources are widely available for free and all cannot be listed here. NOVEL contains images, videos, lectures, articles, and animations covering all aspects of neuro-ophthalmology (4). The American Academy of Ophthalmology has a series of lectures titled Neuro 101 and several neuro-ophthalmology courses that provide resident and comprehensive ophthalmologist level education (5). Orbis' website Cybersight contains narrated neuro-ophthalmology lectures covering broad neuro-ophthalmic topics (6). The ICO has its “Webinar Project” designed to catalog, record, and facilitate webinar production. The intent is to provide a free platform to encourage sharing of information internationally (2). The Moran Eye Center at the University of Utah has also established an open-source ophthalmology education site for students, residents, fellows, health care workers, and all clinicians involved in vision care (7). Hopefully, these curricula and online resources will help to train the next generation of neuro-ophthalmologists around the world.

Bradley K. Farris, MD, Professor of Ophthalmology at the Dean McGee Eye Institute and the University of Oklahoma, presented his experience in Sichuan, China and Swaziland, Africa. Not only do the physicians and patients in these underserved areas benefit from these partnerships with the Dean McGee Eye Institute but the residents and fellows of the Eye Institute also benefit from the opportunity to practice and teach in China and Africa.

In 2000, the Dean McGee Eye Institute (DMEI) initiated academic exchange relationships with the Sichuan Province People's Hospital in Chengdu, China. Since that time, there have been annual visits to the hospital for the purpose of improving resident education, blindness prevention programs in rural areas, overall clinical and surgical care, as well as mutual efforts to establish an International Eye Hospital. In 2010, DMEI initiated a similar effort in Swaziland, Africa. Over the past 6 years, annual visits emphasized improved relationships with the local ophthalmologists, providing subspecialty support as well as working with all 3 local hospitals in Swaziland providing ophthalmic education through lectures, clinical care, and surgical management. A 2-year Global Eye Fellowship program was developed 4 years ago at DMEI to help in this effort. DMEI also has worked with local government and non-government organizations to provide primary ophthalmic care in rural communities, including adult and pediatric vision screening, and providing multiple surgical mini-camps per year to address the overwhelming local cataract blindness burden. These annual efforts in both Sichuan, China, and Swaziland, Africa, have been developed for the purpose of complying with the goals of the World Health Organization's Vision 2020 program, allowing DMEI's senior residents each year to participate in these worthy causes. The goal is to not only provide a visual “life-line” of hope to these areas of great need in the world but also for American residents and faculty to experience the global burden of blindness, as well as the opportunity to serve in areas around the world, both now and in the future.

Mitchell Lawlor, MD, trained in both neuro-ophthalmology and glaucoma, practices at the Sydney Eye Hospital and is a clinical lecturer at the University of Sydney. Dr. Lawlor addressed the difficulties one faces when practicing neuro-ophthalmology in low-resource countries. He emphasized the need to understand the differences in the epidemiology of neuro-ophthalmic diseases in these countries and the need to be sensitive to the resources available to patients and physicians working there.

The epidemiology of optic neuritis changes with geographical location. In low-resource environments, the costs of studies to determine etiology are most commonly borne by the patient. Simple blood tests may cost up to a week's wages, while a brain CT, if available, may cost 1 month's wages. Maximizing the yield from investigations involves knowledge of local disease prevalence and maximizing pre-test probability with a detailed examination. Knowledge of local practice is also imperative: if there is no neurosurgical service, then paying for CT in the context of a bitemporal hemianopia may not be useful for the patient. Teaching in low-resource environments often means not having a definitive diagnosis, but instead treating based on probabilities. This often requires a broad knowledge base: the key to establishing quality health care in low-resource environments is to avoid fragmented “silo”-based responses to individual diseases. Training local staff to have comprehensive skills in assessing the visual system is likely to have the highest yield in ensuring sustainable local capacity development.

Douglas G. Postels, MD, MS, is an Associate Professor of Pediatric Neurology at Michigan State University, but spends the majority of his time in sub-Saharan Africa. Dr. Postels took time out of his busy travel schedule to deliver the final presentation of the symposium, “The Eye–Brain Interface in Cerebral Malaria.” Two-thirds of children diagnosed with cerebral malaria have specific fundus findings that make the ophthalmic examination of these children a rapid means of identifying this devastating complication of this infection. In 2008, Dr. Postels was presented the Visiting Professor Award from the World Federation of Neurology for his work in Malawi.

Cerebral malaria, defined as coma in a patient with Plasmodium parasitemia, is diagnosed in 350,000 people annually, the majority of them African children less than 5 years old (8). The disease carries high rates of mortality, and neurological morbidity is common in those who survive (9,10). Two-thirds of children diagnosed with cerebral malaria have specific retinal changes consisting of macular whitening, hemorrhages, and vessel color changes (11–13). Each of the findings of malarial retinopathy has clear correlations with brain pathology in children dying of their illness (14,15); the eye is commonly thought of as a critical window into the brain in this clinical syndrome. Pathological findings in the brain and neuroradiology studies have shown that increased brain volume is a critical risk factor for death in children with cerebral malaria (16). Several centers in sub-Saharan Africa have combined clinical care and medical research to establish determinants in the pathophysiological pathways between malaria infection and death and disability. Clinical trials targeting these determinants are ongoing. The goal of these trials is to decrease death rates and increase neurological health in children with this devastating neurological condition.

Neuro-ophthalmologists have much to contribute to countries that are just developing vision care services. Although most of us practice in places where we have easy access to high-tech diagnostic equipment, laboratory testing, MRIs, and the latest surgical techniques, it can be highly rewarding to rely on your clinical skills and your trusty ophthalmoscope. If you are planning a trip to teach or practice in a low-resource country, consider contacting one of the authors for advice about your trip and take advantage of the e-learning resources listed by Dr. Golnik. If you would like to work in one of these countries, consider contacting Orbis (17) the Himalayan Cataract Project (18) or one of the authors.

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ADDENDUM

There is some debate about use of the term “developing world.” Hans Rosling and Bill Gates among others have advocated a move away from the term. There is no accepted alternative but “low-income countries,” “low-middle income,” or “low resource” are all thought to be more descriptive rather than the binary option of developing and developed. For this reason, we have adopted the term “low resource” in this report.

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© 2016 by North American Neuro-Ophthalmology Society