Neuro-Ophthalmology in India

Worldwide Neuro-Ophthalmology Section Editor: Kathleen B. Digre, MD Neuro-Ophthalmology in India A lmost all neuro-ophthalmologists in India come from an ophthalmology background, after completing 8–9 years in the medical field, which includes five and a half years of Bachelor of Medicine and Bachelor of Surgery (MBBS) and 3 years of postgraduation in ophthalmology. A significant number of neuro-ophthalmologists combine this training with pediatric ophthalmology. Neuroophthalmology services are usually concentrated in larger ophthalmology departments based in major cities. The story of neuro-ophthalmology in India mirrors the growth of the major eye institutes in the country. India became an independent country in 1947. A growing interest arose in the field of neuro-ophthalmology in the mid-1950s. A neuro-ophthalmology unit was established at the Government Ophthalmic Hospital (Regional Institute of Ophthalmology), Chennai, in 1954, which functioned in conjunction with the Department of Neurosurgery at Madras Medical College. The first neuroophthalmic clinic in India was started at Madurai Medical College in 1965. It was initially led by Dr. G. Venkataswamy, followed by Dr. Krishnamoorthy and then by Dr. G. Natchiar (Fig. 1). In 1967, Dr. L.P. Agarwal founded the RP Center, All India Institute of Medical Sciences (AIIMS), Delhi, and Dr. D.K. Gehlot was the pioneering faculty who provided neuro-ophthalmology services. Residents had a 3-month posting in neurology and neurosurgery to understand the neurological aspects of the specialty. Dr. Gehlot was frequently quoted, “Ophthalmology may be sight saving but neuro-ophthalmology is lifesaving.” Every year approximately 8–10 senior residents are trained in the subspecialty, often combined with expertise in strabismus surgery. The neuro-ophthalmology unit at Aravind Eye Hospital, Madurai, was established in 1977, and it was headed by Dr. G. Natchiar for the next 30 years. Neuro-ophthalmic courses and workshops were conducted periodically from the year 1980. The department at Madurai is currently headed by Dr. Mahesh Kumar, who trained with Dr. Natchiar. Aravind Eye Hospital conducts regular short-term observerships (3 months) in neuro-ophthalmology, and approximately 15 students have completed the course. In 1978, Dr. Vimla Menon (Fig. 2) took over as head of the Department of Neuro-Ophthalmology and Strabismus at RP Center, Delhi. It has grown to 5 faculty, including Dr. Pradeep Sharma and Dr. Rohit Saxena. Dr. Menon was Karna: J Neuro-Ophthalmol 2021; 41: e397-e400 FIG. 1. Dr. G. Natchiar. one of the earliest neuro-ophthalmologists of the country, with a particular interest in optic neuritis and has several research publications on the topic. In 2019–2020, 3,367 new patients and 3,542 return patients were seen at RP Center. The credit for starting neuro-ophthalmology at Sankara Nethralaya, Chennai, South India, goes to Dr. B. Sridhar Rao, a glaucoma specialist, in the year 1981. Dr. Lingam Gopal, an outstanding vitreoretinal surgeon, also developed interest in neuro-ophthalmology. He was mostly selftrained but had observerships with Drs. Lawton Smith and Joel Glaser in Miami, Florida, in 1987. In 1992, Dr. Navin Jayakumar became the first full-time neuroophthalmologist at Sankara Nethralaya (SN) having trained with Drs. Neil Miller, Steven Seldon, Alfredo Sadun, Barrett Katz, Joel Glaser, and Lawton Smith. Dr. Jayakumar established valuable relationships with Drs. G. Arjundas and B. Ramamurthy, renowned in neurology and neurosurgery, respectively. e397 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Worldwide Neuro-Ophthalmology FIG. 2. Dr. Vimla Menon. In the northern part of the country, a neuroophthalmology unit at Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, was started in the Department of Neurosurgery in 1988. It was the vision of late Dr. D.K. Chabbra. Dr. Kumudini Sharma joined the unit from its inception. She completed a neuroophthalmology fellowship at the Texas Tech Health Sciences Center at Lubbock, USA, in 1990. In 2013, an ophthalmology department was formed and neuroophthalmology was shifted under this department. Since 2014, SGPGI has a 1-year postdoctoral certificate course in neuro-ophthalmology, which includes rotations in neurology, neurosurgery, and neuroradiology. In 1997, L V Prasad Eye Institute (LVPEI), Hyderabad, established a dedicated pediatric ophthalmology, strabismus, and neuro-ophthalmology unit. Dr. B. Venkateshwara Rao headed the unit for a decade. Teams led by Dr. Subhash Kaul, Head, Neurology Department, NIMS Hospital; Dr. Manas Panigrahi, Neurosurgeon, NIMS Hospital; and leading neuroradiologists in Hyderabad provided additional comprehensive patient care. Currently, all 4 tertiary eye care centers of LVPEI, Hyderabad, Visakhapatnam, Bhubaneshwar, and Vijayawada, have dedicated pediatric ophthalmology, strabismus, and neuro-ophthalmology units. Dr. Ramesh Kekunnaya heads the unit at Hyderabad. Dr. Virender Sachdeva e398 (LVPEI, Visakhapatnam) did 1-year clinical research fellowship with Drs. Nancy Newman and Valerie Biousse. Dr. Pratik Chougule (LVPEI) did a research fellowship with Dr. Dan Milea. In 1998, Dr. J.L. Goyal started a neuro-ophthalmology clinic at Guru Nanak Eye Center, Delhi, which has trained a large number of postgraduates. Dr. Satya Karna joined the Department of NeuroOphthalmology at SN, Chennai, in 1999, followed by Dr. S. Ambika, who is the current head of the department. She did her neuro-ophthalmology training with Drs. Andrew Lee, James Goodwin, Avertano Noronha, Joel Glaser, and Bryon Lam. Dr. Rashmin Gandhi joined the department in 2008. The subsequent growth of the department has been meteoric with as many as 6 consultants now practicing full-time neuro-ophthalmology. Since 2008, 8 ophthalmologists have undergone an 18-month neuro-ophthalmology fellowship at SN. The Department of Neuro-Ophthalmology in Narayana Nethralaya (NN), Bangalore, was established by Dr. Rohit Shetty, in 2007. He did an observership in neuroophthalmology at UC Irvine, USA, and leads the team of experienced and dedicated neuro-ophthalmologists. Dr. Abdul Rawoof works with visiting neurologist Dr. Sujith Kumar at Narayana Nethralaya 1,, and Dr. Jyoti Matalia, a neuro-ophthalmologist at NN2, works in collaboration with the neurology and neurosurgery department of the Mazumdar Shaw multispecialty hospital. She is known for her expertise in performing optic nerve sheath fenestration. Dr. Amod Gupta, an astute retina specialist, provided neuro-ophthalmology services during his tenure at Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, during his long tenure. A dedicated neuro-ophthalmology clinic was run from 2011 to 2014 by Dr. Swati Phuljhele Aalok (currently faculty at Rajendra Prasad [RP] Center, AIIMS). A dedicated neuroophthalmology clinic was restarted in January 2019 by Dr. Jaspreet Sukhija, after training with Dr. Gordon Plant in the United Kingdom. Dr. Vivek Lal, a neurologist at the institute, has been a keen contributor to the specialty and also an active participant in the joint conferences. Conferences and Meetings In India, the annual conferences of the neurology and ophthalmology societies include instruction courses, symposia, free papers, and posters in neuro-ophthalmology. Sankara Nethralaya, Chennai, organized the First International Update in Neuro-Ophthalmology in India in 2002 with speakers who included Drs. Andrew Lee, Avertano Noronha, Sharon Tow, Robert Daroff, and Barry Cullen. In 2009, the Second International Update in NeuroOphthalmology was graced by the presence of Drs. Neil Miller, Andrew Lee, Peter Savino, and Prem Subramanian. Karna: J Neuro-Ophthalmol 2021; 41: e397-e400 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Worldwide Neuro-Ophthalmology In 2016, the LVPEI organized Impulse, a focused meeting on pediatric neuro-ophthalmology, at LVPEI, Hyderabad. Since 2018, LVPEI organizes a common pediatric neuro-ophthalmology session for its faculty and fellows, which is also attended by neuroradiology faculty from Citi Neuro Center, Hyderabad, and pediatric neurology team at Rainbow Hospital. In 2017, SN organized Synapse (Symposium in NeuroOphthalmology: Afferents and Efferents)—with Drs. Andrew Lee, Prem Subramanian, Dan Milea, and Clement Tan. National speakers included Dr. Vivek Lal, Head of Neurology at PGIMER, Chandigarh, who has a special interest in neuro-ophthalmology. Synapse-2 was held in 2019 with Drs. Satoshi Kashi, Nancy Newman, Valerie Biousse, Carmen Chan, Dan Milea, and Richard Kho. The Indian Neuro-Ophthalmology Society (INOS) was established in 2018, with the diligent efforts of Dr. Vimla Menon and Dr. Rohit Saxena, who currently serve as president and secretary of the society, respectively. INOS has 130 registered members from all over the country (https://www.inosindia.com). It has conducted 2 annual conferences at New Delhi in 2018 and 2019 and 3 international webinars in 2020. In 2019, Looking Beyond the Eye, an annual meeting of eye and systemic diseases at LVPEI, Visakhapatnam, focused on the theme of “Neuroimaging in common neuro-ophthalmological conditions.” The meeting brought together neuro-ophthalmologists, neurologists, neurosurgeons, and neuroradiologists under one roof and was very well appreciated by the delegates. COVER (Congress on Optic Nerve Vasculature and Emerging treatment), a Continuing Medical Education on optic nerve, is conducted by NN, Bangalore, every 4 years with national and international faculty in neuroophthalmology and glaucoma giving their best inputs and sharing the latest treatment protocols. Neuro-ophthalmology is included in ophthalmology course curricula and in the programs of all major ophthalmology conferences, such as the annual meetings held by the All India Ophthalmological Society and Delhi Ophthalmological Society. India took the lead by organizing the first ever Global Neuro-Ophthalmology Case Festival webinar on September 26–27, 2020, with Drs. Neil Miller, Gordon Plant, Mark Kupersmith, Valerie Purvin, and Andrew Lee among several eminent neuro-ophthalmologists discussing a variety of interesting and challenging cases. It was attended live by more than 1,000 participants each day. FIG. 3. Textbook of neuro-ophthalmology for postgraduates by Aravind Eye Hospital, Madurai. FIG. 4. The Sankara Nethralaya Atlas of Neuro-Ophthalmology, second edition. Karna: J Neuro-Ophthalmol 2021; 41: e397-e400 Research and Publications India’s scientific contributions to the field of neuroophthalmology include more than 238 articles and 11 textbooks published between 1970 and 2020, most of these in e399 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Worldwide Neuro-Ophthalmology the past 2 decades (see Supplemental Digital Content, Table 1, http://links.lww.com/WNO/A465). A text book of neuro-ophthalmology was written by Dr. Natchiar in 1985 (Fig. 3), which was the first of its kind for postgraduates, and it was widely read throughout the country. Dr. Vimla Menon’s pioneering research includes determining the role of dexamethasone as a replacement for methylprednisolone in treatment of optic neuritis. One of the first research publications in neuro-ophthalmology from the RP Center, New Delhi, was on the role of visual-evoked potentials (VEP) in optic atrophy published in Indian Journal of Ophthalmology in 1982. Since then, the RP Center has contributed 60 publications in various peer-reviewed journals. The RP Center has pioneered research in the field of optic neuritis including description of distinct features of optic neuritis in Indian population, role of VEP, optical coherence tomography (OCT), functional MRI, and microperimetry. Research on the role of dexamethasone as a substitute for methylprednisolone in the management of optic neuritis, the role of steroids in NAION, ethambutol-related toxic optic neuropathy, and profile of LHON has been completed. The RP Center has multiple publications on the profile and management of cranial nerve palsy, particularly various innovations in the management of third nerve palsy. Various studies have been conducted in collaboration with departments of neurology, neuroradiology, and pediatric neurology at AIIMS, Delhi, in fields of optic neuritis, multiple sclerosis, parkinsonism, Alzheimer disease, idiopathic intracranial hypertension (IIH), and neurodevelopmental disorders in children. e400 The neuro-ophthalmology team at SN, Chennai, published the Sankara Nethralaya Atlas of Neuro-Ophthalmology in 2003 and its second edition in 2007 (Fig. 4). In 2015, SN released the Atlas of Neuroimaging in Ophthalmology authored by Drs. Ambika, Veena Noronha, and Padmaja. Some of the faculty at LVPEI are doing research on important conditions including atypical optic neuritis, atypical presentations of IIH, and cerebral venous sinus thrombosis. The Department of Ophthalmology at Guru Nanak Eye Center, Delhi, has conducted many thesis projects, such as electrophysiological changes in glaucoma, central serous retinopathy, diabetic retinopathy, amblyopia, optic neuritis, anterior ischemic optic neuropathy, central retinal vein occlusion, ethambutol toxicity in adults and children, and traumatic optic neuropathy. They also did 4 thesis projects for Master of Chirurgiae (neurosurgery) on visual functions, field changes, OCT changes, and electrophysiological changes before and after surgical removal of anterior visual pathway compressive lesions and lesions of occipital cortex. As the understanding of disease mechanisms continues to improve in this high-technology era and new treatment modalities for neuro-ophthalmic conditions become available, several new fellowship programs will arise and the number of practicing neuro-ophthalmologists in India will undoubtedly increase. Satya Karna, DO, DNB Department of Ophthalmology, Jaypee Hospital, Noida, India Karna: J Neuro-Ophthalmol 2021; 41: e397-e400 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.