Teaching Neuro-Ophthalmology in the Asia-Pacific Region and China: A Personal Perspective

Over the last 30 years, I have been involved in a number of projects helping to educate and train local ophthalmologists in many parts of Asia and the Pacific Islands, which lack adequate training and service in neuro-ophthalmology. In this article, I offer an overview of a number of different teaching initiatives and offer practical suggestions to anyone who might wish to become involved.

Worldwide Neuro-Ophthalmology Section Editor: Kathleen B. Digre, MD Teaching Neuro-Ophthalmology in the Asia-Pacific Region and China: A Personal Perspective Abstract: Over the last 30 years, I have been involved in a number of projects helping to educate and train local ophthalmologists in many parts of Asia and the Pacific Islands, which lack adequate training and service in neuroophthalmology. In this article, I offer an overview of a number of different teaching initiatives and offer practical suggestions to anyone who might wish to become involved. T here are many excellent neuro-ophthalmic centers in Asia such as those in Singapore, Hong Kong, and various cities in Korea and China. However, many parts of Asia and the Pacific Islands lack adequate training and patient care in neuro-ophthalmology. Over the last 30 years, I have been involved in a number of projects directed at helping to educate and train local ophthalmologists (Table 1). In this article, I would like to share my experiences and offer suggestions to anyone who might also be interested in becoming involved. Neuro-Ophthalmological Service and Training In most Southeast Asian developing countries, doctors are employed to work 5-6 days per week in the public hospitals and are not well paid. They are required to retire from public work when aged 60 years and so most augment their income by holding additional private clinics after hours. In some countries, it is very expensive to become a specialist, and this may have an impact on the subsequent ability to do "pro bono" work. Public outpatient care is usually free to the patients although they do have to pay for all investigations, medications, and, if surgery is needed, for all consumables (unless they are charity cases). This means that the "barrage" of neuro-ophthalmologic tests, which might be ordered in developed countries is not appropriate. The emphasis must be on clinical skills with minimal use of ancillary testing. The quality of ophthalmic services in these countries is hampered by a shortage of ophthalmologists, a huge backlog of eye pathology, and a lack of subspecialty training. In addition, there often is little interreferral of difficult cases to those more experienced, meaning that patients may not be able to access appropriate specialist care. "Learning by rote" is still a common educational method used by many medical faculties in Asia. The Oslerian Crompton: J Neuro-Ophthalmol 2015; 35: e31-e35 sequence of history, examination, provisional diagnosis, focused investigation, final diagnosis, and then treatment plan is not always practiced. Instead, what frequently happens is a brief history followed by a cursory examination (not necessarily of both eyes) and then neuroimaging. Fundus examination at the slitlamp and/or using the indirect or direct ophthalmoscope is not routine. The usual reason given for the cursory nature of the examination is "huge patient numbers, hence limited time available per patient." Local Neuro-Ophthalmic Problems Road trauma from motorbikes is the commonest cause of optic neuropathy and double vision because, in part, wearing of protective helmets is not enforced. Many other optic neuropathies are due to infections or toxic causes. Multiple sclerosis is very rare, as is giant cell arteritis. Thyroid eye disease is common, as are intracranial tumors. Unfortunately, the changing lifestyle and adoption of a more Western diet are generating an increased incidence of diabetes, hypertension, atherosclerosis, and obesity. Cigarette smoking is endemic. In the 1980s and 1990s, I took part in a number of 3week visits to provide ophthalmic service and teaching in Melanesia and Micronesia. The Pacific Islands have very small populations scattered on multiple small islands, which can only support general doctors and/or nurse practitioners. It is the bigger nations such as Fiji, the Solomon Islands, and Vanuatu that can support full-time ophthalmologists. Hence, my visits to the small islands involved teaching in general eye surgery with only a small amount of neuro-ophthalmology. Because of local budgetary constraints, rationing of the health dollar was directed at providing benefit to large numbers rather than helping a small number of unfortunate individuals. For example, 1 patient going blind due to a large pituitary tumor and another with antral carcinoma presenting as a lacrimal sac mass were not sent overseas for appropriate treatment because it was considered that the money required was more appropriately spent on malarial control. Table 2 gives reasons why pathology is often so advanced. Sight for All Most developing countries in Asia have good ophthalmology training programs, which focus on producing general ophthalmologists adept at cataract surgery and managing e31 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Worldwide Neuro-Ophthalmology TABLE 1. Pacific and Asian countries where I have taught Location South Pacific Solomon Islands Vanuatu Tuvalu Kiribati Fiji Southeast Asia Thailand Myanmar Vietnam Lao Indonesia Sri Lanka China Number of Visits 2 2 2 5 5 2 3 4 1 10 1 5 common ocular diseases. Few countries have training programs directed at ophthalmic subspecialties. In addition, there is limited opportunity for continuing consultant education. To help address these needs, the South Australian-based, non-government organization, Sight for All (SFA) has developed collaborative relationships (involving signed memoranda of understanding) with Health Ministries in a number of countries in Southeast Asia, including Bangladesh, Bhutan, Kampuchea, Lao, Myanmar, Nepal, Sri Lanka, and Vietnam. One subspecialty identified as being in particular need for development in those countries is neuro-ophthalmology. After a preliminary lecture tour in 2005, SFA was invited to run a neuro-ophthalmology course in Yangon, the former capital of Myanmar (formerly Burma), at the Yangon Eye Hospital. In 2011, Dr Justin O'Day (Melbourne) and I ran this 3-day course, along with a local ophthalmologist, Dr Than Htun Aung, who had recently completed a 1-year fellowship pediatric ophthalmology and adult neuro-ophthalmology in Adelaide. The first day of the course comprised case presentations and concluded with an examination to assess the attendees' fund of knowledge. Two days of intensive lectures followed, covering the major aspects of both afferent and TABLE 2. Factors contributing to advanced pathology Patients often have a "fatalistic" approach to ill health Patients may visit a "natural healer," herbalist, etc. before seeking "Western" medical care There is a widespread lack of knowledge of benefits of medical care and what is possible Patients are often unable to afford the bus fare to nearest clinic Family members may be unable to take time off work to escort the patient to the clinic Medical insurance is uncommon and tends to apply only to the wealthier members of the communities e32 FIG. 1. Teaching courses funded by Sight for all. A. Examination administered by Dr Aung in Myanmar. B. Dr Lueck lectures in Vietnam. C Completion of course in Vietnam. efferent neuro-ophthalmology. At the end of the course, the identical examination was repeated to demonstrate to the students how much they had learned (Fig. 1A). In 2012, a similar course was held at the Vietnam National Institute of Ophthalmology (VNIO) in Hanoi. On this occasion, Dr Christian Lueck (Canberra) assisted Dr O'Day and me (Fig. 1B). Various lessons learned from the previous year were incorporated into this course, including lengthening to 4 days to accommodate the time needed for immediate sequential translation of the lectures into Vietnamese and to allow more training in neuro-ophthalmic examination and in neuroimaging (Fig. 1C). The syllabus is shown in Table 3. Crompton: J Neuro-Ophthalmol 2015; 35: e31-e35 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Worldwide Neuro-Ophthalmology TABLE 3. Syllabus of SFA course in Hanoi, 2012 Day 1 (Mostly afferent) 2 (Mostly efferent) Topic Duration, hr Introduction to neuroophthalmology Clinical neuro-ophthalmological examination technique Optic disc anomalies Optic neuropathies Phakomatoses Interpreting visual fields Chiasmal disorders Higher order visual disturbances/hallucinations Abnormal pupils 1 Ptosis Diplopia-causes Diplopia-management Emergency motility disorders Myasthenia & thyroid eye disease Transient visual loss 1 1 1¼ ¾ 1 ¾ 1 1 ½ ½ ½ ¾ 1 1 In 2013, the same 3 lecturers repeated the course in Vientiane, the capital of Lao It transpired that the level of previous knowledge and training was not as high as in Vietnam so the focus of the lectures had to be somewhat altered. Some educational niceties learned from these courses are provided in Table 4. Over the last 10 years, with the assistance of SFA, a number of Southeast Asian ophthalmologists have visited Australia as fellows. However, it is very expensive to send an ophthalmologist from an Asian country to live and train in Australia for a year, and, in addition, the country of origin loses the services of that doctor. To make matters more difficult, young ophthalmologists from many countries have experienced difficulty in passing the international English examination (IELTS), which is required to work in Australia. For these reasons, SFA adopted a different strategy, which involves training 3 fellows in neuro-ophthalmology in their own country (Vietnam) after a model that has proved successful in pediatric ophthalmology, cornea/anterior segment, and TABLE 5. Monthly topics for SFA course in Hanoi, 2014 Congenital and acquired optic neuropathies Congenital and acquired swollen discs Abnormal pupils Abnormal eye movements Diplopia and its management Ocular myopathies, thyroid eye disease, and myasthenia Chiasmal disorders Retrochiasmal and higher visual function disorders Acquired and functional visual loss Orbital disease, ptosis, and blepharospasm Trauma and revision oculoplastics. The 3 fellows were selected by the VNIO and, in 2014, I had 11 neuro-ophthalmologists from Australia and New Zealand, each spent a week at the VNIO and taught various aspects of neuro-ophthalmology (Table 5). The visiting doctors gave lectures and tutorials, and also taught while attending general clinics. Between visits, the 3 fellows had 3 weeks in which to study a given topic before an examination on that topic was administered at the beginning of the next month by the new instructor. In early 2015, I ran a review course culminating in a final examination, which included a formal case presentation and discussion. The 3 successful fellows were then given a certificate of completion. The aim of this course was to allow the fellows to set up neuroophthalmology clinics and, in due course, to train their own fellows. SFA is now looking at developing similar neuroophthalmic courses in other countries in Southeast Asia, possibly Myanmar in 2017. Other Non-Government Organizations The John Fawcett Foundation is an Indonesian, Bali-based, non-government organization (NGO), which has an agreement with the Balinese Eye Society (Perdami) to provide ongoing professional development by visiting consultant ophthalmologists (Fig. 2). For many years, it has provided free small-incision cataract and lens implant surgery to TABLE 4. Specific details of educational course The PowerPoint lecture presentations were emailed in advance to allow for translation and preparation of a syllabus book An impromptu examination was administered at the beginning of the course, and all identified answer papers were collected without being marked The same examination was repeated at the end of the course, and individuals marked both their "before" and "after" versions for comparison A feedback questionnaire was issued Attendees were awarded a Certificate of Participation Crompton: J Neuro-Ophthalmol 2015; 35: e31-e35 FIG. 2. Teaching in Bali, Indonesia with John Fawcett Foundation. e33 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Worldwide Neuro-Ophthalmology FIG. 3. Lifeline Express railway carriage with external view (A), clinical testing area (B), and teaching room (C). impoverished people by teaching young, local ophthalmologists; while at the same time, paying them to do the surgery. Lifeline Express is a Hong Kong-based NGO, which is committed to providing ongoing continuing professional development courses to 51 different provincial eye centers e34 in China. They have previously set up and trained local ophthalmologists in cataract surgery using 4 different sets of 4 train railway carriages that are shunted around China for this purpose (Fig. 3). Every year, each center selects an ophthalmic subspecialty, and the visiting faculty is then Crompton: J Neuro-Ophthalmol 2015; 35: e31-e35 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Worldwide Neuro-Ophthalmology TABLE 6. Teaching tips Local Services and Equipment Avoid eponymous terms for example, use "oculosympathetic palsy" rather than "Horner syndrome" Avoid abbreviations, for example, "R," "OD," "that is," etc. and also avoid Latin and Greek words wherever possible When lecturing, make sure the spoken words match those on the slides to simplify translation and avoid confusion Do not cause "loss of face" by risking embarrassment, for example, by asking seniors questions in front of their trainees or by trying to extract answers from reluctant and shy audiences who are used to didactic teaching Allow considerable time for questions and clarification Slitlamps are usually available in each clinic room, but fundus lenses are rare. Indirect ophthalmoscopes are scarce, and it is not uncommon for one to be shared between the clinic, the wards, and the operating theaters. I strongly suggest taking your own fundus lens and ophthalmoscope, as well as prism bars and any other essential equipment. I would strongly suggest that if you are asked to demonstrate a surgical technique, you only use locally available equipment. It is not helpful to demonstrate equipment, that is, neither available nor affordable to the observers. Teaching Issues matched to teach those subjects. The teams meet in Hong Kong or Beijing In either July or October and then disperse to the various centers where they offer 3 intense days of teaching (didactic lectures, case presentations, and demonstration of surgical techniques). The teams then reconvene to debrief before heading home. David Taylor (Emeritus Professor, Institute of Child Health, London) and I have been tasked with recruiting ophthalmologists from the various subspecialties. To date, we have been assisted by ophthalmologists from the UK, USA, Europe, Asia, and Australasia. If anyone is interested in finding out more, please contact me through email ([e-mail]). Lessons I Have Learned Local Facilitator In planning a teaching tour, it is very important to have a local facilitator. He/she can organize the venue, arrange accommodations, local transport, and meals, in addition, to negotiating any necessary bureaucracy required by the local hospital administration and/or Ministry of Health. The facilitator also can arrange for local trainees to present cases. Emailing PowerPoint presentations and handouts through Dropbox (or similar) allows the slides to be translated in advance, which makes everything much easier for both lecturer and audience. We have found that attendees prefer sequential translation (i.e., the lecturer delivers a sentence in English, which is immediately followed by translation into the local language) rather than simultaneous translation through headphones. TABLE 7. Tips on setting up a neuro-ophthalmology service Design the neuro-ophthalmology service with clinics in both general and specialist eye hospitals Hold regular teaching grand rounds Rotate all ophthalmologic trainees through neuroophthalmology Design appropriate referral systems Encourage summary letters sent to referring doctors Create clinical databases Crompton: J Neuro-Ophthalmol 2015; 35: e31-e35 Because of the limited availability of laboratory and imaging studies, emphasis must be on developing clinical skills. In my experience, the doctors in training know a great deal but their knowledge tends to be structured in the form of lists with little cross-correlation between the lists and patients' symptoms and signs. Problem-based learning and medical school training are often somewhat lacking in terms of basic science and pathology. Flexibility in the lecture timetable, the level of teaching, and the speed of delivery is important to meet the needs of the local audience. Because those in attendance gain confidence in the lecturer, it is likely that he/she will receive many requests for opinions on clinical problems from local practices. In addition, there are often many requests for fellowship training positions. Table 6 offers some extra teaching tips and Table 7 some suggestions for setting up a local neuro-ophthalmology service. CONCLUSIONS Neuro-ophthalmology lends itself to itinerant teaching. Such knowledge is eagerly sought after by our Asian colleagues who are extremely considerate and generous hosts. I have found such teaching to be incredibly satisfying and rewarding and very much hope others will as well. John Crompton, FRANZCO Neuro-Ophthalmology Service, Department of Ophthalmology and Visual Science, Royal Adelaide Hospital and University of Adelaide, Adelaide, Australia ACKNOWLEDGMENTS J. Crompton has worked with 4 non-government organizations (NGOs), namely Australian South Pacific Eye Care Teams, Sight For All, Life Line Express, and the John Fawcett Foundation. The first 3 NGOs have funded travel and accommodation, but none has offered honoraria or other personal financial support. This article is based on a lecture delivered at the 41st Annual meeting of the North American Neuro-Ophthalmology Society in San Diego, CA, as part of a symposium on international neuro-ophthalmology on February 23rd, 2015. e35 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.