Neuro-Ophthalmology and Medical Ophthalmology A
Dialogue
Dr
Cogan proposes
.
.
.
increasing interest in neuro\x=req-\ ophthalmology over the past few years within the framework of ophthalmology has surprised some of us. There are several reasons why I would not have expected it. It is not a lucrative field and it requires vast expenditures of time that cannot be conscientiously charged to the patient. It has a low order of effective therapy, a fact that can be most discouraging to the pragmatic physician. And it lacks the glamour of surgery. How, then, can we account for the rise in neuro-ophthalmology's popularity? The answer is, of course, that it has an intellectual appeal that together with neurology is almost unmatched in any other discipline of medicine. Where, for instance, can one find, short of cross-word puzzles, such fascination with sorting out symptomatic hints and synthesizing them into diagnostic entities? Or the thrill of relating syndromes to historical perspectives and the ever stimulating possibility of relating them to specific causes? In a period of advanced technology, the brain is emerging as the ultimate biologic computer. The neurophysiologic literature now abounds with terms of feed-back control, pulse gen-
The
erators, and reverberating circuits that
are more
comprehensible
to
gineers than to medical men. fraternity of bioengineers and rophysiologists talk mostly to
en¬
This neu-
each don't un¬
other beause the rest of us derstand them. But they are finding in the visual and ocular motor sys¬ tems the most accessible models for testing the circuitry of the brain. We are fortunate to have them involved in our area of clinical interests even though there are great gulfs in our communication and understanding. To bridge these gulfs is one of our intel¬ lectual challenges. But I would like to suggest that the recent growth of neuro-ophthalmology within the framework of ophthal¬
mology is perhaps deeper than simply the intellectual appeal. From a practi¬ cal point of view, neuro-ophthalmology is medical ophthalmology, and it incorporates diseases of the retina, the choroid, and even the anterior as¬ pects of the eye. It may well be, so it seems to me, that what is called neuro-ophthalmology is the avant garde of a major division of ophthalmology into medical and surgical disciplines, comparable to the division of neu¬ rology and neurosurgery. There has been reluctance to formalize such a division. Many of us recall the storm of protests that arose when Cordes proposed separate board certification some years ago. These protests came
mostly from those who felt threat¬ ened by having their surgical privi¬ leges removed. More important has
been the reluctance on the part of trainees to accept the idea of medical ophthalmology, fearing that they would be placed in a category of sec¬ ond class physicians. But I believe these fears will vanish when medical ophthalmology, after a period of pio¬ neering, becomes accepted as a digni¬ fied and respectable specialty. After all, it was no longer ago than the pe¬ riod following World War II that neu¬ rology itself was questionably viable. Yet neurology has developed into a major and essential division of medi¬ cine attracting some of the out¬ standing scholars in medicine today. I would not be surprised if, in the fu¬ ture, the outstanding scholars of oph¬ thalmology were those who were medical ophthalmologists. Yet I would side with those who fa¬ vor a conservative approach and not force the issue. Let medical ophthal¬ mology develop under the guise of
neuro-ophthalmology. Certainly neu¬ rologic diseases will always constitute a major interest in medical ophthal¬ mology. Let those who find it as fasci¬ nating as we have apprise trainees of its satisfaction, help them, and bol¬
specializing in medical ophthalmology, whether they come into the field by way of ophthal¬ mology, neurology, or medicine. ster their courage in
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 06/01/2015
While the intellectual appeal has been the positive side of neuroophthalmology's growth, there has been an equally effective negative side brought about by specializa¬ tion within surgical ophthalmology. Whether we like it or not, ophthalmic surgery is becoming fragmented into retina, glaucoma, and strabismus subspecialities as a consequence of tech¬ nical and experimental advances. We may bemoan the passing of the allround ophthalmic surgeon as our fore¬ bears did the general surgeon, but if we needed surgery performed on our¬ selves for a retinal detachment, glau¬ coma, or strabismus (or even for cata¬ racts), we would probably choose the surgeon who specialized in the corre¬ sponding field. There conceivably will be in the future, if there is not now, a time when there is insufficient surgi¬ cal material to allow all ophthalmic surgeons to maintain their technical skills. Or, equally likely, the ophthal¬ mologist may reject the idea of spe¬ cializing in a narrow field of surgery. At that time medical ophthalmology may seem an attractive alternative to him, as it has to some of us. I would venture a prediction that with both pull and push influences at work, medical ophthalmology is
evolving through neuro-ophthalmol¬ ogy into a major discipline that ulti¬ mately will command the stature and respect, if not the money, it deserves. David G. Cogan, MD Bethesda, Md
Dr Lessell
The
replies
.
.
.
of information in ophthalmology and the rate at which it is proliferating will certainly prevent future ophthalmologists from developing and maintaining exper¬ tise in more than a few subdivisions of the specialty. Demographic, social, political, and economic factors will also contribute to changes in the forms of ophthalmic practice. The un¬ certainty of these factors makes pre¬ diction perilous, but if I had to predict, I would guess that neuro-ophthalmology will develop into a disci¬ pline separate from both medical and surgical ophthalmology, rather than forming the nucleus of medical oph¬ sheer
mass
thalmology. Neuro-ophthalmology and ophthal¬ mology are strange bed-fellows. Those features that attract
neuro-ophthalmology
are
one to not those
that attract one to ophthalmology. Thus, it would be surprising if phy¬ sicians attracted into ophthalmology but frustrated by the fragmentation of ophthalmic surgery should elect to become neuro-ophthalmologists. Many, if not most of those who now practice neuro-ophthalmology would not be comfortable having responsi¬ bility for certain of the areas of ophthalmology that are "medical." Refraction, external diseases, and even uveitis are frankly ophthalmic in their orientation, whereas neuroophthalmology is oriented systemi-
cally. Finally, specialization
the trend toward subin
ophthalmic
surgery
will have to be paralled in medical ophthalmology. The trends that work against individual competence in, say, both strabismus and retinal detach¬ ment will also prevent an individual from mastering several of the medical disciplines. Already, to my regret, I must acknowledge that in order to remain current and effective in neuroophthalmology, I must eschew reading and learning in most other fields of ophthalmology. The answer, as I see it, is for neuro-ophthalmology to
develop independently as a specialty staffed by full-time, hospital-based, teacher-investigator-consultants. The clinical training would include one or two years of internal
medicine, a year
each of ophthalmology and neurology, and one or two years of neuro-ophthal¬ mology. The number of neuroophthalmologists would depend on the nature of medical practice at the time the discipline becomes independent. It may be hoped that the number and quality of primary care physicians will be such as to permit the number of neuro-ophthalmologists to be small. Under such a system the neuroophthalmologists would be utilized efficiently, and their patient loads would be sufficiently large for the maintenance of expertise and for teaching and research.
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 06/01/2015
Simmons Lessell, MD Boston
Dialogue
Dr
Cogan proposes
.
.
.
increasing interest in neuro\x=req-\ ophthalmology over the past few years within the framework of ophthalmology has surprised some of us. There are several reasons why I would not have expected it. It is not a lucrative field and it requires vast expenditures of time that cannot be conscientiously charged to the patient. It has a low order of effective therapy, a fact that can be most discouraging to the pragmatic physician. And it lacks the glamour of surgery. How, then, can we account for the rise in neuro-ophthalmology's popularity? The answer is, of course, that it has an intellectual appeal that together with neurology is almost unmatched in any other discipline of medicine. Where, for instance, can one find, short of cross-word puzzles, such fascination with sorting out symptomatic hints and synthesizing them into diagnostic entities? Or the thrill of relating syndromes to historical perspectives and the ever stimulating possibility of relating them to specific causes? In a period of advanced technology, the brain is emerging as the ultimate biologic computer. The neurophysiologic literature now abounds with terms of feed-back control, pulse gen-
The
erators, and reverberating circuits that
are more
comprehensible
to
gineers than to medical men. fraternity of bioengineers and rophysiologists talk mostly to
en¬
This neu-
each don't un¬
other beause the rest of us derstand them. But they are finding in the visual and ocular motor sys¬ tems the most accessible models for testing the circuitry of the brain. We are fortunate to have them involved in our area of clinical interests even though there are great gulfs in our communication and understanding. To bridge these gulfs is one of our intel¬ lectual challenges. But I would like to suggest that the recent growth of neuro-ophthalmology within the framework of ophthal¬
mology is perhaps deeper than simply the intellectual appeal. From a practi¬ cal point of view, neuro-ophthalmology is medical ophthalmology, and it incorporates diseases of the retina, the choroid, and even the anterior as¬ pects of the eye. It may well be, so it seems to me, that what is called neuro-ophthalmology is the avant garde of a major division of ophthalmology into medical and surgical disciplines, comparable to the division of neu¬ rology and neurosurgery. There has been reluctance to formalize such a division. Many of us recall the storm of protests that arose when Cordes proposed separate board certification some years ago. These protests came
mostly from those who felt threat¬ ened by having their surgical privi¬ leges removed. More important has
been the reluctance on the part of trainees to accept the idea of medical ophthalmology, fearing that they would be placed in a category of sec¬ ond class physicians. But I believe these fears will vanish when medical ophthalmology, after a period of pio¬ neering, becomes accepted as a digni¬ fied and respectable specialty. After all, it was no longer ago than the pe¬ riod following World War II that neu¬ rology itself was questionably viable. Yet neurology has developed into a major and essential division of medi¬ cine attracting some of the out¬ standing scholars in medicine today. I would not be surprised if, in the fu¬ ture, the outstanding scholars of oph¬ thalmology were those who were medical ophthalmologists. Yet I would side with those who fa¬ vor a conservative approach and not force the issue. Let medical ophthal¬ mology develop under the guise of
neuro-ophthalmology. Certainly neu¬ rologic diseases will always constitute a major interest in medical ophthal¬ mology. Let those who find it as fasci¬ nating as we have apprise trainees of its satisfaction, help them, and bol¬
specializing in medical ophthalmology, whether they come into the field by way of ophthal¬ mology, neurology, or medicine. ster their courage in
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 06/01/2015
While the intellectual appeal has been the positive side of neuroophthalmology's growth, there has been an equally effective negative side brought about by specializa¬ tion within surgical ophthalmology. Whether we like it or not, ophthalmic surgery is becoming fragmented into retina, glaucoma, and strabismus subspecialities as a consequence of tech¬ nical and experimental advances. We may bemoan the passing of the allround ophthalmic surgeon as our fore¬ bears did the general surgeon, but if we needed surgery performed on our¬ selves for a retinal detachment, glau¬ coma, or strabismus (or even for cata¬ racts), we would probably choose the surgeon who specialized in the corre¬ sponding field. There conceivably will be in the future, if there is not now, a time when there is insufficient surgi¬ cal material to allow all ophthalmic surgeons to maintain their technical skills. Or, equally likely, the ophthal¬ mologist may reject the idea of spe¬ cializing in a narrow field of surgery. At that time medical ophthalmology may seem an attractive alternative to him, as it has to some of us. I would venture a prediction that with both pull and push influences at work, medical ophthalmology is
evolving through neuro-ophthalmol¬ ogy into a major discipline that ulti¬ mately will command the stature and respect, if not the money, it deserves. David G. Cogan, MD Bethesda, Md
Dr Lessell
The
replies
.
.
.
of information in ophthalmology and the rate at which it is proliferating will certainly prevent future ophthalmologists from developing and maintaining exper¬ tise in more than a few subdivisions of the specialty. Demographic, social, political, and economic factors will also contribute to changes in the forms of ophthalmic practice. The un¬ certainty of these factors makes pre¬ diction perilous, but if I had to predict, I would guess that neuro-ophthalmology will develop into a disci¬ pline separate from both medical and surgical ophthalmology, rather than forming the nucleus of medical oph¬ sheer
mass
thalmology. Neuro-ophthalmology and ophthal¬ mology are strange bed-fellows. Those features that attract
neuro-ophthalmology
are
one to not those
that attract one to ophthalmology. Thus, it would be surprising if phy¬ sicians attracted into ophthalmology but frustrated by the fragmentation of ophthalmic surgery should elect to become neuro-ophthalmologists. Many, if not most of those who now practice neuro-ophthalmology would not be comfortable having responsi¬ bility for certain of the areas of ophthalmology that are "medical." Refraction, external diseases, and even uveitis are frankly ophthalmic in their orientation, whereas neuroophthalmology is oriented systemi-
cally. Finally, specialization
the trend toward subin
ophthalmic
surgery
will have to be paralled in medical ophthalmology. The trends that work against individual competence in, say, both strabismus and retinal detach¬ ment will also prevent an individual from mastering several of the medical disciplines. Already, to my regret, I must acknowledge that in order to remain current and effective in neuroophthalmology, I must eschew reading and learning in most other fields of ophthalmology. The answer, as I see it, is for neuro-ophthalmology to
develop independently as a specialty staffed by full-time, hospital-based, teacher-investigator-consultants. The clinical training would include one or two years of internal
medicine, a year
each of ophthalmology and neurology, and one or two years of neuro-ophthal¬ mology. The number of neuroophthalmologists would depend on the nature of medical practice at the time the discipline becomes independent. It may be hoped that the number and quality of primary care physicians will be such as to permit the number of neuro-ophthalmologists to be small. Under such a system the neuroophthalmologists would be utilized efficiently, and their patient loads would be sufficiently large for the maintenance of expertise and for teaching and research.
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 06/01/2015
Simmons Lessell, MD Boston
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