Is neuro-ophthalmology a subspecialty worth considering?

[deleted1081396]

M4 here, just submitted my residency app for neuro. I don't know much about neuro-ophthalmology and info on it seems relatively sparse compared to other neuro subspecialties... Is it a subspecialty worth considering today? What exactly do they do day to day? What does the field's future look like? Do they do any kinds of surgeries or procedures? According to its Wiki page, neuro-ophthalmologists "may be trained to perform eye muscle surgery to treat adult strabismus, optic nerve fenestration for idiopathic intracranial hypertension, and botulinum injections for blepharospasm or hemifacial spasm." I am curious how accurate and common this actually is and if so, what other kinds of procedures they can be trained to do. Thank you.

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[Telamir]

Depends if you go to it from ophthalmology or from neurology.

An ophthalmologist who does neuro ophthalmology would be able to do these procedures/better trained for them as they would have the surgical training from ophthalmology.

A neurologist who does neuroophthalmology tends to focus more on diagnostics and medical management. They are typically in more academic centers than out in private practice although there are a few. It's a small specialty and pretty niche. Very small community of neuro ophthalmologists. You won't get much exposure to it unless you go to an academic center that has it. You'll typically see demyelinating disorders, cranial palsies, optic neuritis, etc.

 

[mrbreakfast]

It's primarily a diagnostic specialty. Eye pathology is relatively esoteric even by neurology standards and the neurology-trained neuro-ophthamologist answers questions like "why can't this patient see" or "why is this patient's eyes moving weirdly." Among the neuro-ophthamologists I've talked to, they primarily see optic neuritis-related things, IIH, help surgeons with localization of cranial nerve palsies, or see functional vision loss.

If you're truly interested in it, look into academic programs that even have neurology-trained neuro-ophthamologists, let alone a fellowship.

 

[Thama]

I know a couple of neurology-trained neuroophthalmologists and they do not do any procedures. I actually get referrals from them for BTX injections for bleph and hemifacial spasm. It's a small subspecialty, but can be very interesting. They get a lot of referrals from ophthalmologists for the weird stuff the eye dentists can't figure out.

 

[Spinothalamic]

Check out this YouTube channel by Dr Lee, chair at Houston Methodist and past president of NANOS, the neuro-op society. It’s a great resource for all neurology residents for short videos teaching important concepts!

I like neuro-op because it’s outpatient and has a very objective, extremely nuanced examination. The proportion of interesting cases (ie zebras) is higher than other subspecialties and there is so much variability in clinic. That being said, you see disorders from basically every subspecialty within neurology even though it’s subspecialized, which I think is cool. You really get to expand your knowledge base in many respects as opposed to some subspecialties where you perhaps really narrow your focus. OCT provides a quick, non-invasive objective test of optic nerve health (similar to EMG in terms of objectivity in some regards) which is really invaluable—as you will learn in neurology any objective measures are helpful for following patients!

It is primarily in academics but there are private practice set ups in decent metro areas. Neurosurgeons both really like having a neuro-op that they trust and it’s a big deal to have access to one. Referrals otherwise come primarily from optometry, ophthalmology, and neurology, with less from PM&R, NSG, endocrine, rheumatology, various other specialties.

I like that most patients have often seen a couple different physicians for the chief complaint and you sometimes get to help the patient out by ending the diagnostic odyssey and finding out what is going on (sometimes really obscure pathology that was missed, sometimes something obvious that makes you lose confidence in healthcare, or sometimes migraine variant or functional).

Coming from neurology it is not procedure heavy—really just Botox for blepharospasm, hemifacial spasm, or chronic migraine in addition are added procedures but as mentioned some don’t do these. OCT, find us photos, and visual fields are billable procedures but are only interpretative. Some neuro-ophthalmologists combine their specialty with headache or MS or general neuro, but the demand is high enough (about 1 for 2.7mil population) that many just do straight neuro-op.

I enjoy eye movements and nystagmus and realized that in residency even some of the best attendings were mystified by the neuro-op exam which led to some curiosity. This ultimately led to spending time with a neurology-trained doc and the rest is history!

obviously I have a biased point of view haha but it’s always worth checking out, just like every subspecialty of neurology! Edit—I’m a fellow, forgot to say that

 

[sharkbaitwhohaha]

Check out this YouTube channel by Dr Lee, chair at Houston Methodist and past president of NANOS, the neuro-op society. It’s a great resource for all neurology residents for short videos teaching important concepts!

I like neuro-op because it’s outpatient and has a very objective, extremely nuanced examination. The proportion of interesting cases (ie zebras) is higher than other subspecialties and there is so much variability in clinic. That being said, you see disorders from basically every subspecialty within neurology even though it’s subspecialized, which I think is cool. You really get to expand your knowledge base in many respects as opposed to some subspecialties where you perhaps really narrow your focus. OCT provides a quick, non-invasive objective test of optic nerve health (similar to EMG in terms of objectivity in some regards) which is really invaluable—as you will learn in neurology any objective measures are helpful for following patients!

It is primarily in academics but there are private practice set ups in decent metro areas. Neurosurgeons both really like having a neuro-op that they trust and it’s a big deal to have access to one. Referrals otherwise come primarily from optometry, ophthalmology, and neurology, with less from PM&R, NSG, endocrine, rheumatology, various other specialties.

I like that most patients have often seen a couple different physicians for the chief complaint and you sometimes get to help the patient out by ending the diagnostic odyssey and finding out what is going on (sometimes really obscure pathology that was missed, sometimes something obvious that makes you lose confidence in healthcare, or sometimes migraine variant or functional).

Coming from neurology it is not procedure heavy—really just Botox for blepharospasm, hemifacial spasm, or chronic migraine in addition are added procedures but as mentioned some don’t do these. OCT, find us photos, and visual fields are billable procedures but are only interpretative. Some neuro-ophthalmologists combine their specialty with headache or MS or general neuro, but the demand is high enough (about 1 for 2.7mil population) that many just do straight neuro-op.

I enjoy eye movements and nystagmus and realized that in residency even some of the best attendings were mystified by the neuro-op exam which led to some curiosity. This ultimately led to spending time with a neurology-trained doc and the rest is history!

obviously I have a biased point of view haha but it’s always worth checking out, just like every subspecialty of neurology! Edit—I’m a fellow, forgot to say that

I'm in neuromuscular. Highly appreciate the interest in a detailed neurological examination.
I'm curious about some of the zebras you see?

Can you present a cool cases to me? (...yes, i'm the attending and youre the med student)

 

[xenotype]

Check out this YouTube channel by Dr Lee, chair at Houston Methodist and past president of NANOS, the neuro-op society. It’s a great resource for all neurology residents for short videos teaching important concepts!

I like neuro-op because it’s outpatient and has a very objective, extremely nuanced examination. The proportion of interesting cases (ie zebras) is higher than other subspecialties and there is so much variability in clinic. That being said, you see disorders from basically every subspecialty within neurology even though it’s subspecialized, which I think is cool. You really get to expand your knowledge base in many respects as opposed to some subspecialties where you perhaps really narrow your focus. OCT provides a quick, non-invasive objective test of optic nerve health (similar to EMG in terms of objectivity in some regards) which is really invaluable—as you will learn in neurology any objective measures are helpful for following patients!

It is primarily in academics but there are private practice set ups in decent metro areas. Neurosurgeons both really like having a neuro-op that they trust and it’s a big deal to have access to one. Referrals otherwise come primarily from optometry, ophthalmology, and neurology, with less from PM&R, NSG, endocrine, rheumatology, various other specialties.

I like that most patients have often seen a couple different physicians for the chief complaint and you sometimes get to help the patient out by ending the diagnostic odyssey and finding out what is going on (sometimes really obscure pathology that was missed, sometimes something obvious that makes you lose confidence in healthcare, or sometimes migraine variant or functional).

Coming from neurology it is not procedure heavy—really just Botox for blepharospasm, hemifacial spasm, or chronic migraine in addition are added procedures but as mentioned some don’t do these. OCT, find us photos, and visual fields are billable procedures but are only interpretative. Some neuro-ophthalmologists combine their specialty with headache or MS or general neuro, but the demand is high enough (about 1 for 2.7mil population) that many just do straight neuro-op.

I enjoy eye movements and nystagmus and realized that in residency even some of the best attendings were mystified by the neuro-op exam which led to some curiosity. This ultimately led to spending time with a neurology-trained doc and the rest is history!

obviously I have a biased point of view haha but it’s always worth checking out, just like every subspecialty of neurology! Edit—I’m a fellow, forgot to say that

Would be very helpful if you would expand on the financial aspects. My general impression was a neuro-based neuro-optho would need to be independently wealthy to survive on the usual productivity but maybe OCT and botox changes this.

 

[Postictal Raiden]

Check out this YouTube channel by Dr Lee, chair at Houston Methodist and past president of NANOS, the neuro-op society. It’s a great resource for all neurology residents for short videos teaching important concepts!

I like neuro-op because it’s outpatient and has a very objective, extremely nuanced examination. The proportion of interesting cases (ie zebras) is higher than other subspecialties and there is so much variability in clinic. That being said, you see disorders from basically every subspecialty within neurology even though it’s subspecialized, which I think is cool. You really get to expand your knowledge base in many respects as opposed to some subspecialties where you perhaps really narrow your focus. OCT provides a quick, non-invasive objective test of optic nerve health (similar to EMG in terms of objectivity in some regards) which is really invaluable—as you will learn in neurology any objective measures are helpful for following patients!

It is primarily in academics but there are private practice set ups in decent metro areas. Neurosurgeons both really like having a neuro-op that they trust and it’s a big deal to have access to one. Referrals otherwise come primarily from optometry, ophthalmology, and neurology, with less from PM&R, NSG, endocrine, rheumatology, various other specialties.

I like that most patients have often seen a couple different physicians for the chief complaint and you sometimes get to help the patient out by ending the diagnostic odyssey and finding out what is going on (sometimes really obscure pathology that was missed, sometimes something obvious that makes you lose confidence in healthcare, or sometimes migraine variant or functional).

Coming from neurology it is not procedure heavy—really just Botox for blepharospasm, hemifacial spasm, or chronic migraine in addition are added procedures but as mentioned some don’t do these. OCT, find us photos, and visual fields are billable procedures but are only interpretative. Some neuro-ophthalmologists combine their specialty with headache or MS or general neuro, but the demand is high enough (about 1 for 2.7mil population) that many just do straight neuro-op.

I enjoy eye movements and nystagmus and realized that in residency even some of the best attendings were mystified by the neuro-op exam which led to some curiosity. This ultimately led to spending time with a neurology-trained doc and the rest is history!

obviously I have a biased point of view haha but it’s always worth checking out, just like every subspecialty of neurology! Edit—I’m a fellow, forgot to say that

Thank you for sharing.

Love his enthusiasm

 

[Thama]

Would be very helpful if you would expand on the financial aspects. My general impression was a neuro-based neuro-optho would need to be independently wealthy to survive on the usual productivity but maybe OCT and botox changes this.

Those I know make a little more money than other academic clinical neurologists. They're often hired by ophtho departments and are valuable to those departments beyond the RVUs generated because they provide a release valve for complex patients that don't just need a quick procedure, thus freeing the other ophthalmologists to pump out the RVUs.

 

[Hank Rearden]

In my experience Neuro-ophth make less than their neurology colleagues, but I don't know any who work for Ophtho departments. Hard to generate RVUs. Most of the neurology-based ones see MS patients and myasthenics as their bread and butter. I rotated with an ophthalmology trained neuro-ophth who spent half his time doing Lasik I think because his neuro-ophth practice generated very little revenue.

 

[Spinothalamic]

Yeah, I’ve heard in academics sometimes the salary is from the ophthalmology department and therefore higher on average than for the neurology department. That being said, I don’t know much about the neurology-trained private practice income. I’ve met a few and they all seemed to do alright but I don’t really have specifics. One of them used 3 techs and basically went room to room seeing a lot of patients. Another was a top earner for his private practice group but this was confounded by interpreting EEG and seeing some general neurology on the side. I’m sure the lucrative potential is much lower compared to other subspecialties, but there are definitely set ups where you can still do well.

At the end of the day, I got enough information that made me confident that I could do alright even outside of academics and followed my interest.

 

[Spinothalamic]

I'm in neuromuscular. Highly appreciate the interest in a detailed neurological examination.
I'm curious about some of the zebras you see?

Can you present a cool cases to me? (...yes, i'm the attending and youre the med student)

these “Walsh cases” are so fun to watch—mystery cases presented at NANOS each year with difficult/rare/surprising diagnoses. I would start at the 2020 meeting and go back (2021 was virtual and just wasn’t the same). I recall first learning about CAPS (cryoporin-associated periodic syndrome) and CANOMAD as a PGY3 by watching some of these and thinking it was so cool that there were all these disorders that I still hadn’t heard of! I guess that’s medicine though.

NANOS Annual Meeting Collection – NOVEL

novel.utah.edu

But those are the really rare disorders obviously. Otherwise I most enjoy the work-up for diplopia and multiple cranial neuropathies (I’ve seen GPA, sarcoid, IgG4, lymphoma, various cavernous sinus malignancies, checkpoint-associated MG/myositis, etc) and optic neuropathies/perineuritis (AQP4,
GCA, sarcoid, MOG, LHON, DOA, syphilis, GFAP, toxo, etc) probably the most.

I enjoy getting to weigh in on cases of cortical vision loss where things like CJD and PML can be sneaky and require high index of suspicion early on. Another big interest is autoimmune/paraneoplastic encephalitis/rhomboenceohalitis which may come for diplopia. These are all things you may see in general neurology and will diagnose if you take the time and recognize the pattern but for whatever reason can make their way to neuro-op without a diagnosis or treatment regimen.

Then there is a lot of bread and butter like OMG and IIH even though there are still atypical cases of spinal cord malignancies, dAVF, or medication-induced that are interesting and need to be caught during the work-up.

There are frustrating things like NAION or functional vision loss or homonymous hemianopia. I’m not saying there aren’t downsides to the specialty.

But it’s pretty legit😁

 

[deleted1081396]

It doesn't really sound like a field I'd mesh well with. The resources all made it sound like they do more procedures. I'm not interested in research and my goal is to get as far away from academia as possible, as fast as possible. The lifestyle sounds cush but the salary doesn't.

 

[Telamir]

lol

 

[xenotype]

Yeah, I’ve heard in academics sometimes the salary is from the ophthalmology department and therefore higher on average than for the neurology department. That being said, I don’t know much about the neurology-trained private practice income. I’ve met a few and they all seemed to do alright but I don’t really have specifics. One of them used 3 techs and basically went room to room seeing a lot of patients. Another was a top earner for his private practice group but this was confounded by interpreting EEG and seeing some general neurology on the side. I’m sure the lucrative potential is much lower compared to other subspecialties, but there are definitely set ups where you can still do well.

At the end of the day, I got enough information that made me confident that I could do alright even outside of academics and followed my interest.

Neurology PP income will always beat academics with a stick. It is no joke 25-100% higher, and the 'busy' echelon of neurology PP is absolutely 300-400k+. The guy cranking out EEGs and the guy with 3 EMG techs are both probably >400k. They probably don't have a great lifestyle and are workaholics.

It doesn't really sound like a field I'd mesh well with. The resources all made it sound like they do more procedures. I'm not interested in research and my goal is to get as far away from academia as possible, as fast as possible. The lifestyle sounds cush but the salary doesn't.

Yeah that was my impression of neuro-optho. Reliant on optho procedures for billing, or subsidies for academics. If you want to be cranking through patients in private practice not a good route to go from either optho or neuro background. Still might be a great niche for those cut out for it that want a relaxing job- a lot of clinical neurology is not relaxing at all.

 

[Thama]

It doesn't really sound like a field I'd mesh well with. The resources all made it sound like they do more procedures. I'm not interested in research and my goal is to get as far away from academia as possible, as fast as possible. The lifestyle sounds cush but the salary doesn't.

Regular ophtho, not neuro-ophtho, is what fits this description. Just set the LASIK machine to autopilot and put a bag under the cash dispenser.

Then go take a nap and forget this silly idea of going to medical school.