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Show NANOS NEWS The Neuro- Ophthalmology Curriculum of the North American Neuro- Ophthalmology Society ( NANOS) Some years ago, the North American Neuro- Ophthalmology Society ( NANOS) recognized the need to outline a suggested neuro- ophthalmology curriculum to serve as a basis for accrediting fellowship training programs and as a guide for ophthalmology and neurology residency training programs and medical student education. In 2004, NANOS created the Curriculum Committee ( Table 1), a subcommittee of the Education Committee. Members were chosen because of their previous experience with curricula at different levels ( American Academy of Ophthalmology, American Academy of Neurology, American Neurologic Association, Association of University Professors of Ophthalmology, NANOS Fellowship Task Force, and NANOS Medical Student Task Force). In devising the curriculum, the committee drew on curricula elaborated by national medical associations and other specialties ( 1- 4), as well as the table of contents of textbooks ( 5- 9). Interestingly, very few other specialties have written detailed curricula that are widely accepted and used. There are even fewer publications concerned with how to design medical curricula ( 10- 12). The curriculum designed by The Society for Academic Emergency Medicine ( SAEM) and the Council of Emergency Medicine Residency Directors ( CORD) ( 4) proved to be the most useful model. Like neuro- ophthalmology, emergency room medicine is a multidisciplinary specialty requiring basic knowledge of specific disorders, management problems, and numerous procedures. The neuro- ophthalmology curriculum ( Appendix) is meant as an educational plan rather than as an all- inclusive list. The core curriculum defines the minimum standards for the clinical neuro- ophthalmologist. Its content will evolve as progress is made in our specialty. It should not be limiting, because the use of this curriculum will vary depending on the neuro- ophthalmologist's primary specialty ( neurology or ophthalmology). The goal of the curriculum is to outline what the neuro- ophthalmologist should know. It is meant to be the basis for what is learned in a neuro- ophthalmology fellowship. It should also help to define a basic curriculum for ophthalmology and neurology residencies. Separate learning objectives will need to be denned for fellows, residents, and medical students. Numerous curricular organizations have emphasized the need for " weighting" each part of the curriculum. This weighting is essential to emphasize what is truly relevant for fellows, residents, and continuing medical education program planning. In weighting this curriculum, we have relied on the experience of the Curriculum in Emergency Medicine developed by SAEM, CORD, and the Neuro- Ophthalmo-logy/ Orbit Knowledge Base Panel of the American Academy of Ophthalmology. We have labeled each topic as " most relevant" ( mastery of the topic required), " more relevant" ( proficiency with the topic required), and " relevant" ( familiarity with the topic required). This curriculum has been approved by the NANOS board and is currently available on the NANOS website ( www. nanosweb. org). The main debate triggered by this first version concerns ophthalmology- trained and neurology-trained neuro- ophthalmologists who had obvious difficulties agreeing on the weighting of topics ( glaucoma would be " most relevant" for ophthalmologists, and symptoms of Gerstmann syndrome would be " most relevant" to neurologists). We have encouraged NANOS members to try it out and provide feedback so as to discover if this curriculum is suitable. The Neuro- Ophthalmology Virtual Educational Library ( NOVEL) ( weblink on NANOS website) has already started using this curriculum to help organize its collections of slides and videos. NOVEL immediately pointed out that we had left out the Tensilon test from our initial draft! Annual revisions and the addition of sub-curricula for residents and medical students are planned. TABLE 1. Curriculum Committee of the North American Neuro- Ophthalmology Society ( NANOS) Valerie Biousse, MD ( Chair) Nancy J. Newman, MD ( Vice Chair) Kimberly Peele Cockerham, MD Larry Frohman, MD Bradley J. Katz, MD David Kaufman, DO Andrew Lee, MD Howard D. Pomeranz, MD, PhD Roger E. Turbin, MD Gregory P. Van Stavern, MD Nicholas J. Volpe, MD Floyd A. Warren, MD Valerie Biousse, MD Department of Neuro- Ophthalmology Emory Eye Center Atlanta, Georgia J Neuro- Ophthalmol, Vol. 26, No. 4, 2006 303 J Neuro- Ophthalmol, Vol. 26, No. 4, 2006 NANOSNews REFERENCES 1. American Academy of Ophthalmology. Basic and Clinical Science Course: Neuro- Ophthalmology. Section 5. San Francisco: AAO; 2003. 2. American Academy of Ophthalmology. Basic and Clinical Science Course: Orbit, Eyelids, and Lacrimal System. Section 7. San Francisco: AAO; 2003. 3. American Academy of Neurology. Neuro- Fellowship Core Curriculum: Ophthalmology/ N'euro- Otology Saint Paul, MN: AAN; 2005. Available at: http:// www. aan. com/ about/ sections/ fellowship/ nono. pdf. Accessed September 15, 2006. 4. Society for Academic Emergency Medicine ( SAEM) and Council of Emergency Medicine Residency Directors ( CORD). Model Curriculum for Emergency Medicine Residency Training. Lansing, MI: CORD; 2005. Available at: http:// www. cordem. org/ download/ model. doc. Accessed September 15, 2006. 5. Newman NJ, Galetta SL, eds. Neuro- ophthalmology Update. Continuum: Lifelong Learning in Neurology. 2003; 9:( October). 6. Glaser JS. Neuro- Ophthalmology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 1999. 7. Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders. Cephalalgia. 2004; 24: 9- 160. 8. Liu GT, Volpe NJ, Galetta SL. Neuro- Ophthalmology: Diagnosis and Management. Philadelphia: WB Saunders; 2001. 9. Miller NR, Newman NJ, Biousse y et al. Walsh & Hoyt's Clinical Neuro- Ophthalmology. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. 10. Liesegang TJ, Hoskins HD Jr, Albert DM, et al. Ophthalmic education: where have we come from, and where are we going? Am J Ophthalmol. 2003; 136: 114- 21. 11. Spivey BE. A technique to determine curriculum content. J Med Educ. 1971; 46: 269- 74. 12. Society for Academic Emergency Medicine ( SAEM). Lansing, MI: SAEM; 2005. Model curriculum and guidelines for curriculum development for emergency medicine residency training. Available at: http:// www. saem. org/ services/ educ. html. Accessed September 15, 2006. APPENDIX. The NANOS Neuro- Ophthalmology Curriculum. Subject areas are weighted with superscripts. 1- Most relevant, 2- More relevant, 3- Relevant A. ANATOMY AND PHYSIOLOGY FOR THE NEURO- OPHTHALMOLOGIST Goals: 1. Describe anatomical structures relating to the afferent and efferent visual pathways. 2. Describe the surgical anatomy of the eye and orbits. 3. Understand the function of the visual system and its control. APPENDIX. ( Continued) Topics: A. Bony anatomy* 1 md 2) 1. Orbit( 2) 2. Bony communications a. Superior orbital fissure ® b. Optic canal ® c. Inferior orbital fissure ® d. Ethmoidal foramina ® 3. Skull( 2) a. Anterior cranial fossa b. Middle cranial fossa c. Posterior cranial fossa B. Anatomy of the orbit, the eyelids, and the lacrimal pathways ® C. Afferent visual pathways ® 1. Anatomy and physiology of the eye 2. Retina 3. Optic nerve 4. Optic chiasm 5. Optic tract 6. Lateral geniculate 7. Optic radiations 8. Calcarine cortex 9. Association areas D. Efferent visual pathways ® 1. Supranuclear input 2. Cerebellar connections 3. Nuclear centers 4. Ocular motor nerves a. Abducens ( VI) b. Trochlear ( IV) c. Oculomotor ( III) 5. Extraocular muscles 6. Vestibular pathways E. Facial motor anatomy ® F. Sensory anatomy ( trigeminal system) ® G. Autonomic anatomy ® 1. Sympathetic 2. Parasympathetic a. Lacrimal b. Pupil H. Vascular anatomy ® 1. Arterial anatomy a. Internal carotid arteries and their branches b. Circle of Willis ® c. External carotid arteries and their branches d. Vertebrobasilar system e. Aortic arch f Blood supply of the orbit, eye and optic nerve ® 304 © 2006 Lippincott Williams & Wilkins NANOSNews J Neuro- Ophthalmol, Vol. 26, No. 4, 2006 APPENDIX. ( Continued) APPENDIX. ( Continued) 2. Venous anatomy a. Cerebral venous sinuses and deep venous system b. Cortical veins c. Venous drainage in the neck d. Venous drainage of the eyes and orbits I. Cerebrospinal fluid ® 1. Physiology 2. Contents B. OCULAR AND NEUROLOGIC EVALUATION I. Ocular and neurologic examinations Goals: 1. Know how to perform a detailed ocular examination ( adult and child). 2. Be comfortable with most examination techniques used in ophthalmology. 3. Know how to perform a detailed neurologic examination ( adult and child). Topics: A. Ocular evaluation 1. Evaluation of visual function ( visual acuity, stereopsis, color vision, contrast sensitivity, basics of refraction, confrontation visual fields, Amsler grid, photostress testing/ ' 2. Ocular examination, intraocular pressure, resistance to retropulsion, exophthalmometry^ ' 3. Pupillary examination^ ' 4. Funduscopic examination ® 5. Use of lensometer, phoropter, slit lamp, direct and indirect Ophthalmoscopes, slit lamp biomicroscopy of the fundus ® 6. Ocular motility, use of prisms, cover testing, red glass, maddox rod, forced duction test, sensory testing ® 7. Ocular examination of the young child ® B. Neurologic evaluation 1. Neurologic examination ( adult and child) ® 2. Basic cognitive evaluation ( mini mental status) ® C. Neuro- ophthalmic evaluation of the comatose patient ® D. Examination of children 1. Developmental milestones for children ® 2. Visual maturation of children^ V) II. Ancillary tests obtained in neuro- ophthalmology Goals: 1. Know how to order and how to interpret most ancillary tests obtained in neurology and ophthalmology. 2. Know the contraindications and side- effects of these tests. Topics: A. Visual field testing Automated perimetry ( familiarity with current perimeters and different testing strategies/ ' Goldmann perimetry ( should be able to perform/ ' Tangent screen ( should be able to perform) ® B. Electrophysiology Visual evoked responses ® Electroretinogram ® Multifocal electroretinogram ® Dark adaptation ® Eye movement recordings ® C. Ocular and orbital ultrasound ® D. Retinal fluorescein angiography ® E. Nerve fiber layer analysis Optical coherence tomography ( OCT), HRT, GDX ® F. Imaging Computed tomography ® Magnetic resonance imaging ® Vascular imaging ( ultrasonography, CTA, MRA, CTV, MRV, conventional angiogram) ® Functional neuro- imaging ( MRI, SPECT, PET) ® G. Lumbar puncture with opening pressure ® C. NEURO- OPHTHALMIC SYMPTOMS AND SIGNS Goals: 1. Know how to evaluate and manage symptoms and signs commonly encountered in neuro- ophthalmology. 2. Recognize the most common ocular causes of visual loss that may mimic neuro- ophthalmic diseases. ( continued on next page) J Neuro- Ophthalmol, Vol. 26, No. 4, 2006 NANOS News APPENDIX. ( Continued) The NANOS Neuro- Ophthalmology Curriculum. Subject areas are weighted with superscripts. 1- Most relevant, 2- More relevant, 3- Relevant Topics: A. Visual loss( 1) Transient^ V) Permanent* 1^ Unexplained visual loss( 1) Non organic visual loss( 1) B. Positive visual phenomena*^' C. Visual hallucinations'^ D. Visual field loss( 1) E. Higher cortical dysfunction* 1^ F. Normal and abnormal optic nerve* 1-* Edema ( disc swelling, papilledema) and pseudopapilledema/ anomalous nerves Optic atrophic Optociliary shunt vessels Cupped optic nerve Optic disc anomalies/ pseudopapilledema G. Oscillopsia, nystagmus, ocular oscillations*^ H. Double vision*- 1- 1 I. Abnormal extraocular movements* 1-* J. Ptosis( 1) K. Lid retraction, lagophthalmos, lid lag( 1) L. Proptosis, enophthalmos^ ' M. Pupillary changes, anisocoria( 1) N. Abnormal facial movements^ 1- 1 0. Facial weakness, hemifacial spasm*- 1- 1 P. Ocular pain, facial pain, headaches( 1) D. DISORDERS OF THE AFFERENT AND EFFERENT VISUAL PATHWAYS 1. Diseases of the optic nerve Goal: 1. Diagnose and evaluate patients with optic nerve diseases ( no details are provided in this section as all optic nerve diseases should be known by a neuro- ophthalmologist). Topics: A. Ischemic optic neuropathy* 1^ APPENDIX. ( Continued) Anterior Posterior Diabetic papillopathy B. Inflammation^ ' Non infectious Idiopathic optic neuritis Optic neuritis and multiple sclerosis Other inflammatory optic neuritides Sarcoidosis, orbital inflammation, lupus, etc. Infectious Optic perineuritis Neuroretinitis C. Compression/ infiltration^ ' D. Paraneoplastic*^ E. Traumatic^ V) F. Toxic( 1) G. Nutritional( 1) H. Metabolic( 1) I. Hereditary^ ' I Congenital( 1) K. Glaucoma( 2) Classification of glaucoma Evaluation and basic management of glaucoma L. Raised intracranial pressure ( papilledema)< 1) M. Decreased intraocular pressure ( hypotony)( 2) II. Orbital pathology causing neuro- ophthalmic manifestations Goal: 1. Diagnose and evaluate patients with orbital diseases. Topics: A. Trauma( 2) B. Mass lesions*- 2-' Neoplasms C. Inflammation/ infection^ ' Orbital inflammation Thyroid orbitopathy Orbital cellulitis Abscess 306 © 2006 Lippincott Williams & Wilkins NANOSNews J Neuro- Ophthalmol, Vol. 26, No. 4, 2006 APPENDIX. ( Continued) APPENDIX. ( Continued) D. Orbital manifestations of dural fistulas^' III. Diseases of the chiasm Goal: 1. Diagnose and evaluate patients with chiasmal disorders. Topics: A. Chiasmal visual field defects ® B. Compression/ infiltration*^ ' C. Inflammation^ ' D. Trauma ® E. Ischemia/ hemorrhage^ ' IV Diseases of the retrochiasmal visual pathways Goal: 1. Diagnose and evaluate patients with lesions of the retrochiasmal visual pathways. Topics: A. Optic tract( 1) B. Lateral geniculate ® C. Radiations( 1) D. Calcarine cortex' ( i) E. Association areas'( 2) F. Specialized syndromes ® Anton's syndrome ( cerebral blindness) Riddoch's phenomena: Statico- kinetic dissociation Balint syndrome Gerstmann syndrome Cerebral achromatopsia Alexia without agraphia Acalculia Agraphia ( with associated alexia) Agnosias Visual neglect L- R confusion Akinetopsia Concept of " Blindsight" V Pupillary pathology Goal: 1. Diagnose and evaluate patients with abnormal pupillary reactions. Topics: A. Normal pupillary responses ® B. Effects of drugs on the pupils ® C. Congenital pupillary abnormalities ® D. Pupillary changes secondary to ocular diseases ® Traumatic, foreign body Inflammation Neovascularisation Ocular surgery, laser E. Traumatic pupillary changes ® F. Evaluation and management of anisocoria ® G. Evaluation and management of a large or a small pupil ® H. Evaluation and management of specific pupillary disorders ® Adie's tonic pupil Tadpole pupil ® Argyll- Robertson pupil Correctopia ® Physiologic anisocoria Horner's syndrome Third nerve palsy Afferent pupillary defect Light near dissociation VI. Eye movement systems pathology Goal: 1. Diagnose and evaluate patients with abnormal eye movements. Topics: A. Vestibular ocular system ® B. Optokinetic nystagmus*^ ' C. Saccades ® D. Pursuit ® E. Convergence ® F. Divergence ® G. Specific ocular motor syndromes ® Cranial nerve palsies Third, fourth and sixth ( continued on next page) 307 J Neuro- Ophthalmol, Vol. 26, No. 4, 2006 NANOS News APPENDIX. ( Continued) The NANOS Neuro- Ophthalmology Curriculum. Subject areas are weighted with superscripts. 1- Most relevant, 2- More relevant, 3- Relevant Supranuclear palsies Internuclear ophthalmoplegia One and half syndrome Horizontal gaze palsy Monocular elevation deficit Vertical gaze palsy Skew deviation Ocular tilt reaction Ocular motor apraxia Spasm of the near triad Convergence insufficiency Divergence insufficiency Decompensation of phorias Restriction syndromes Ocular neuromyotonia Cyclic oculomotor paresis ® H. Classical brain stem syndromes ® Foville Millard- Gubler Duane's syndrome Mobius syndrome Locked In syndrome Nothnagel Benedickt Weber Claude syndrome Wallenberg syndrome Syndrome of the anterior inferior cerebellar artery I. Ocular motility disturbance by location^' Medulla Pons Mesencephalon Dorsal midbrain syndrome Cerebellar pathology VII. Nystagmus and disorders of ocular stability Goals: 1. Diagnose and evaluate patients with ocular oscillations. 2. Recognize the localizing nystagmus. APPENDIX. ( Continued) Topics: A. Jerk nystagmus ® B. Pendular nystagmus ® C. Congenital vs acquired nystagmus ® D. Central vs peripheral nystagmus ® E. Specific types of nystagmus and their localizing i ( 1 if common and 2 if rare) Down beat nystagmus ® Upbeat nystagmus ® Rebound nystagmus ® Brim's nystagmus ® Periodic alternating^ ' Convergence retraction nystagmus ® See saw nystagmus ® Divergence nystagmus ® Sensory nystagmus ® Congenital motor nystagmus ® Spasmus nutans/ dissociated nystagmus/ monocular nystagmus ® Latent nystagmus ® F. Induced nystagmus ® Valsalva Sounds ( Tullio's phenomena) Calorics: hot or cold water in ear( 1) G. Ocular oscillations( 1) Superior oblique myokymia Square wave jerks Opsoclonus Flutter Ocular bobbing Oculopalatal myoclonus Oculomasticatory myorhythmia ® VIII. Eyelid position abnormalities Goal: 1. Diagnose and manage patients with eyelid position abnormalities. Topics: A. Eyelid retraction ® B. Ptosis ® Pseudoptosis ® 308 © 2006 Lippincott Williams & Wilkins NANOSNews J Neuro- Ophthalmol, Vol. 26, No. 4, 2006 APPENDIX. ( Continued) APPENDIX. ( Continued) Congenital*^ With elevator palsy( 2) Marcus Gunn Jaw Wink( 2) Blepharophimo sis'- 3 -* Levator dehiscence ® Myopathic( 1) Neuro- muscular transmission* ® Neuropathic ® Apraxia of eyelid opening Third nerve dysfunction Aberrant regeneration of third nerve Horner's syndrome Blepharospasm ® C. Eyelid nystagmus ® D. Eyelid twitch( 1) IX. Facial nerve dysfunction Goals: 1. Diagnose and evaluate patients with facial nerve dysfunction. 2. Treat patients with blepharospasm and hemifacial spasm. Topics: A. Central and peripheral facial palsy ® B. Blepharospasm ® C. Hemifacial spasm ® D. Facial dystonia ® E. Facial myokymia ® F. Oculomasticatory myorhythmia ( Whipple's/ G. Facial tics( 3) H. Facial myotonia*^ ' E. SYSTEMIC, NEUROLOGIC, AND OPHTHALMIC DISORDERS COMMONLY ASSOCIATED WITH NEURO- OPHTHALMIC MANIFESTATIONS I. Developmental and congenital anomalies with neuro- ophthalmologic consequences Goals: 1. Know how to recognize and evaluate congenital neuro- ophthalmologic syndromes. 2. Recognize and manage neuro- ophthalmic complications of in- utero or birth injuries. 3. Recognize neuro- ophthalmic complications of child abuse. Topics: A. Visual maturation ® B. Complications of prematurity^ ' C. Cerebral palsy ® D. Complications of birth injuries ® E. Congenital hydrocephalus ® F. Cranial dysostoses ( craniosynostosis) ® G. Amblyopia( 2) H. Congenital optic nerve anomalies ® Bergmeister papilla Optic nerve dysplasia and aplasia/ hypoplasia Septo- optic dysplasia Optic nerve coloboma Optic nerve pit Morning glory syndrome Optic nerve drusen Tilted disc Myelinated nerve fibers Staphyloma I. Common malformations of the eye and orbit ® J. Skull base malformations. Chiari malformation* 1^ K. Fibrous dysplasia ® L. Ocular manifestations of child abuse( 2) II. Systemic disorders commonly associated with neuro- ophthalmologic manifestations Goals: 1. Know how to recognize and diagnose various systemic disorders commonly associated with neuro- ophthalmic symptoms and signs. 2. Recognize the neuro- ophthalmic complications of systemic disorders. Topics: A. Specific hereditary ocular and neurologic diseases with neuro- ophthalmic presentation*^ ' ( continued on next page) 309 J Neuro- Ophthalmol, Vol. 26, No. 4, 2006 NANOS News APPENDIX. ( Continued) The NANOS Neuro- Ophthalmology Curriculum. Subject areas are weighted with superscripts. 1- Most relevant, 2- More relevant, 3- Relevant B. Neurocutaneous syndromes ® 1. Neurofibromatosis NF- 1 NF- 2 2. Tuberous sclerosis 3. von Hippel- Lindau 4. Sturge- Weber 5. Ataxia telangiectasia 6. Wyburn- Mason C. Vascular disease Vascular risk factors ® Prevention of vascular disease ® Neuro- ophthalmic manifestations of vascular diseases ® Hypercoagulable states ® D. Systemic hypertension ® E. Metabolic diseases including diabetes mellitus ® F. Autoimmune diseases, classification of vasculitides ® Specific vasculitides with ocular and neurologic manifestations Giant cell arteritis^' Sarcoidosis ® Lupus ® Wegener granulomatosis ® G. Complications of cancers, paraneoplastic syndromes; principles of treatmenr ' Neuro- ophthalmic complications of chemotherapy, and radiation therapies ® H. Complications of infections ® Specific infections with common neuro- ophthalmic complications ( AIDS or syphilis for example) III. Neurologic disorders commonly associated with neuro- ophthalmologic manifestations Goals: 1. Recognize and evaluate neuro- ophthalmologic complications of head injury ( acute and chronic). 2. Know the neuro- ophthalmic complications of raised intracranial pressure. 3. Diagnose and manage increased intracranial pressure. 4. Understand the pathophysiology and management of acute and chronic intracranial hypertension. APPENDIX. ( Continued) 5. Recognize and evaluate neuro- ophthalmo logic complications of cerebrovascular disease. 6. Know the classification of stroke and the basics of the vascular evaluation. 7. Know the general principles of stroke management. 8. Know how to recognize and manage ocular vascular diseases. 9. Recognize and evaluate neuro- ophthalmologic manifestations and complications of seizures. 10. Diagnose and evaluate patients with headache and facial pain. 11. Know the basis of management of primary benign headaches and facial pain such as migraine, cluster headache and trigeminal neuralgia. 12. Recognize and diagnose various neurologic disorders commonly associated with neuro- ophthalmic symptoms and signs. 13. Recognize the neuro- ophthalmic complications of neurologic disorders. Topics: A. Head and ocular injury 1. Recognize and evaluate neurological complications of head injury ® 2. Neuro- ophthalmic complications of brain injury ( acute and late)( 1) 3. Traumatic optic neuropathies ( direct and indirect) ® 4. Traumatic cranial nerve palsies ( III, IV, and Vlth) ® 5. Diagnose and evaluate orbital and facial fractures ® 6. Recognized the complications of ocular trauma ® 7. Evaluate post- traumatic visual loss ® 8. Diagnosis of post- concussion syndrome ® B. Increased intracranial pressure 1. Differential diagnosis and management of intracranial hypertension ® Intracranial mass, infection or bleed Meningitis Subarachnoid hemorrhage Hydrocephalus Cerebral venous thrombosis Idiopathic intracranial hypertension. 2. Neuro- ophthalmic manifestations and complications ® C. Vascular disease of the brain and the eye 1. Classification of stroke ® 310 © 2006 Lippincott Williams & Wilkins NANOSNews J Neuro- Ophthalmol, Vol. 26, No. 4, 2006 APPENDIX. ( Continued) APPENDIX. ( Continued) 2. Mechanisms ® Vein vs artery Hemorrhage vs ischemia Embolism vs thrombosis vs hemodynamic Large artery vs small artery 3. Diagnosis and evaluation of stroke ® Vascular evaluation Cardiac evaluation Hypercoagulable states 4. Basics of acute treatment and secondary prevention of stroke*- 2'' 5. Neuro- ophthalmologic manifestations of stroke ® 6. Ocular ischemia ® Transient visual loss Central and branch retinal artery occlusions Ocular ischemic syndrome Central and branch vein occlusions 7. Venous sinus thrombosis^ ' 8. Subarachnoid hemorrhage, neuro- ophthalmic manifestations^ ' 9. Intracranial vascular malformations, diagnosis and neuro- ophthalmologic manifestations^ ' Aneurysms Arteriovenous malformations Dural fistulas Carotid cavernous fistulas ( direct, indirect) Cavernous hemangiomas D. Seizures with neuro- ophthalmologic manifestations 1. Occipital seizures ® 2. Pupillary changes, ocular movement changes during seizures ® E. Neuro- ophthalmic manifestations of neoplasms 1. Intracranial tumors^ ' 2. Skull base tumors ® 3. Orbital rumors^' 4. Optic nerve rumors^ ' 5. Benign vs malignant neoplasrrr ' 6. Primary vs secondary ® 7. Pediatric vs adult tumors ® F. Demyelinating disease 1. Multiple sclerosis^ ' Relationships between optic neuritis and multiple sclerosis'-' Treatment strategies ® Vision assessment in multiple sclerosis ® 2. Devic's disease ® 3. Acute disseminated encephalomyelitis ® G. Infections ( neuro- ophthalmic manifestations of localized and systemic infections) 1. Intracranial infections^ ' Abscess Cerebritis Empyema Meningitis Meningo- encephalitis 2. Whipple's disease ® 3. Orbital infections ( cellulitis) ® 4. Optic nerve infection ( infectious optic neuritis and neuroretinitis) ® 5. Creutzfeld- Jacob disease ® H. Metabolic diseases ® 1. Wilson's disease 2. Vitamin deficiencies ( vitamin A, Bl, B12, ...) 3. Metabolic storage diseases 4. Amyloidosis I. Neuro- degenerative diseases ® 1. Parkinson syndromes Parkinson's disease Progressive supranuclear palsy 2. Alzheimer, frontotemporal dementia 3. Vascular dementias ® 4. Amyotrophic lateral sclerosis ® 5. Hereditary ataxias ® K. Polyradiculopathies 1. Guillain- Barre ® 2. Miller Fisher varianr ' L. Neuro- muscular transmission deficits' 1. Physiology of the neuromuscular ( i) transmission*^ ' 2. Myasthenia gravis ® 3. Lambert- Eaton myasthenic syndrome^ ' 4. Toxic neuromuscular transmission defect ( Botulism, medications) ® ( continued on next page) J Neuro- Ophthalmol, Vol. 26, No. 4, 2006 NANOSNews APPENDIX. ( Continued) The NANOS Neuro- Ophthalmology Curriculum. Subject areas are weighted with superscripts. 1- Most relevant, 2- More relevant, 3- Relevant M. Myopathies ( involving the extraocular muscles) 1. Congenital myopathies/ oculopharyngeal muscular dystrophy dystrophies/ Ion Channel Disorders ( Myotonia) ® 2. Mitochondrial diseases ® Chronic progressive external ophthalmoplegia ( CPEO) 3. Ischemic ® Giant cell arteritis Orbital ischemic syndrome 4. Metabolic - Toxic ® Drug induced, toxic 5. Inflammatory^ ' Thyroid orbitopathy Orbital inflammatory disease 6. Neoplasm/ infiltration ® 7. Congenital syndromes involving the extraocular muscles Anomalous muscle insertions^ ' Brown's syndrome^ ' Congenital fibrosis of the extraocular muscles ( CFEOM) ® Duane's syndrome ® High myopia ® N. Headache and facial pain 1. Classification of headaches and facial pain proposed by the International Headache Society ( IHS) ® 2. Migraine ® Migraine without aura ® Migraine with visual aura ® 3. Tension headaches ® Episodic Chronic 4. Cluster headache ® 5. Headache associated with increased intracranial pressure ® 6. Headache and facial pain of vascular origin ® 7. Ocular pain related to ocular of optic nerve disease ® 8. Trigeminal neuralg ia ® 9. Herpes zoster ( zoster ophthalmicus) *•' 10. Referred ocular pain ® Vascular ( i. e. dissection) APPENDIX. ( Continued) Ocular ischemic syndrome Cavernous sinus syndrome IV Ocular diseases commonly associated with- or mimicking neuro- ophthalmologic disorders Goals: 1. Know how to recognize and diagnose various ocular disorders commonly associated with neuro- ophthalmic symptoms and signs. 2. Recognize the neuro- ophthalmic complications of ocular disorders. 3. Recognize the ocular diseases mimicking neuro- ophthalmic disorders. Topics: A. Ocular neoplasms ® Benign vs malignant Primary vs secondary Pediatric vs adult neoplasms B. Ocular infections ® External Endophthalmitis Neuroretinitis^ ' C. Ocular inflammation ( uveitis/ ' Classification of uveitis Neuro- ophthalmic disorders associated with uveitis ® Optic neuritis and uveitis ® Meningo- uveitis ® D. Retinal disorders ® Vascular ® Degenerative/ hereditary ® Inflammatory/ infectious^ 3 -* Outer retinopathies/ White dot syndromes ® E. Glaucoma ® F. Ocular causes of acute and chronic visual loss ® V Neuro- ophthalmic manifestations of iatrogenic diseases Goal: 1. Recognize neuro- ophthalmic complications of iatrogenic diseases. Topics: A. Radiation ® B. Chemotherapy ® 312 © 2006 Lippincott Williams & Wilkins NANOSNews J Neuro- Ophthalmol, Vol. 26, No. 4, 2006 APPENDIX. ( Continued) APPENDIX. ( Continued) C. Various drugs with specific neuro- ophthalmologic complications, including Cyclosporine ® FK- 506 ( tacrolismus) ( 1) Amiodarone ® Hydroxychloroquine^ ' Ethambutol( 1) Vasoconstritors^ ' Steroids( 1) Facial and orbital injections ® D. Alcohol Thiamine deficiency^ Y) Wernicke encephalopathy ® E. Neuro- ophthalmic complications of surgical procedures Post operative visual loss ® Epidural anesthesia ® Ocular and orbital surgery ® Neurosurgery ® Endovascular procedures ® VI. Functional disorders Goal: 1. Recognize patients with functional visual complaints. Topics: A. Terminology^ ' Factitious ( Munchausen's) Malingering Conversion reaction Exaggeration Hypochondriasis Somatization disorder B. Clinical presentations ® Visual loss ® Visual field defects ® Spasm of near triad ® Nystagmus ® C. Specific techniques of evaluation ® F. PROCEDURES COMMONLY PERFORMED/ OBTAINED IN NEURO- OPHTHALMOLOGY I. Surgical and endovascular procedures and their complications Goals: 1. Describe the principles of some surgical procedures ( only ophthalmology- trained neuro- ophthalmologists may have practical experiences with these procedures). 2. Understand and recognize the complications of surgical procedures commonly performed by or ordered by neuro - ophthalmologists. Topics: A. Temporal artery biopsy^ ' B. Principles and complications of strabismus surgery ® C. Canthotomy, cantholysis ® D. Approaches for orbital biopsies and orbital tumors ® E. Optic nerve sheath fenestration ® F. Orbital decompression ® G. CSF shunting procedures ® H. Monitoring of intracranial pressure ® I. Pituitary surgery ( transphenoidal adenomectomy) ® J. Interventional neuroradiology techniques ® 1. Cerebral angiography and venography ® 2. Embolization ® 3. Angioplasty ® 4. Stenting ® 5. Intravenous and intra- arterial thrombolysis^ ' II. Botulinum toxin therapy Goals: 1. Know the principles and side- effects of botuninum toxin therapy. 2. Be familiar with the neuro- ophthalmic indications for botulinum toxin therapy. Topics: A. Treatment of blepharospasm, hemifacial spasm, Meige syndrome ® B. Treatment of strabismus ® III. Tensilon test Goal: 1. Know the principles of the pharmacologic testing for myasthenia gravis and side- effects of ephodronium chloride ( Tensilon). ( continued on next page) 313 J Neuro- Ophthalmol, Vol. 26, No. 4, 2006 NANOSNews APPENDIX. ( Continued) The NANOS Neuro- Ophthalmology Curriculum. Subject areas are weighted with superscripts. 1- Most relevant, 2- More relevant, 3- Relevant Topics: A. Diagnostic of myasthenia gravis ® G. PATIENT COUNSELING Goals: 1. Know the legal implications of visual loss. 2. Be able to counsel the visually impaired patient. 3. Be able to perform genetic counseling. Topics: A. Definition of legal blindness ® B. Legal requirements for driving ( visual) in the state in which you practice neuro- ophthalmology ® C. Counseling of the visually impaired patient ® Liaison with rehabilitation services ( neurologic and for the visually impaired) Liaison with a low vision service D. Genetic counseling^ ' Principles of genetics, genetic testing, and genetic counseling E. RESEARCH, ADMINISTRATION, EDUCATIONAL RESOURCES I. Administration Goals: 1. Know the basic principles of leadership and administration. 2. Understand the function of a neuro- ophthalmology department within the institution and its relationship with other departments. 3. Understand the importance of quality improvement and risk management programs. 4. Understand the function of accrediting agencies and their relationship with neuro- ophthalmology. Topics: A. Credentialing, career development, recruitment, budgeting, health care financing, managed care, public relations, personnel management, marketing, hospital administration, practice management, contracts, work schedule( 3) B. JCAHO requirements relating to neuro- ophthalmology ( staffing, equipment and supplies, facilities, quality insurance) ® APPENDIX. ( Continued) II. Research Goals: 1. Understand various types of study design and methodology. 2. Understand basic statistical methods. 3. Learn techniques of analyzing biomedical research. 4. Know methods of obtaining consent for biomedical research. 5. Understand the ramifications of ethical considerations in research. 6. Understand HIPPAA, Institutional Review Boards, Human Subjects Research Education Programs. 7. Understand grants and funding for research. Topics: A. Read and analyze scientific articles ® B. Research funding ® C. Development of a research project ® D. Ethical issues in research, including consent and researchers' interactions with corporate funding sources ( conflict of interest/ E. Write and publish a manuscript ® III. Large previous and ongoing studies addressing specific neuro- ophthalmic issues Goals: 1. Read scientific publications reporting the results of major studies in the field of neuro- ophthalmology. 2. Understand the clinical applications of these studies in terms of evidence- based medicine. Topics: A. Optic Neuritis Treatment Trial ( ONTT) ® B. Longitudinal Optic Neuritis Study ( LONS) ® C. CHAMPS study ® D. Ischemic Optic Neuropathy Decompression Trial ( IONDT) ® IV Ethics and professionalism Goals: 1. Apply ethical principles to specific patient encounters to assist in decision making. 314 © 2006 Lippincott Williams & Wilkins NANOSNews J Neuro- Ophthalmol, Vol. 26, No. 4, 2006 APPENDIX. ( Continued) 2. Learn basic legal principles relevant to ophthalmology ( surgery) and neurology. Topics: A. Proper documentation in medico- legal proceedings ® B. Knowledge of cost, resource allocation, quality of care, access to care issues ® C. Basic familiarity with medical malpractice^ ' D. Physician- physician relationships^ ' E. Laws relating to drug dispensing, regulation, and abuse ® F. Role of expert witness in medico- legal procedures ® V Neuro- ophthalmologic resources Goals: 1. Know about available educational resources in neuro- ophthalmology 2. Participate in improvement of resources. Topics: A. Organizations ® NANOS( 1) INOS EUNOS AAN ANA AAO ARVO Regional organizations NEI NINDS B. Journals ® C. NOVEL database ® http:// medstat. med. utah. edu/ neuroophth. NOVEL_ updates/ Superscripts refer to the following weighting system: 1) Most relevant ( mastery of the topic required): Knowledge or skills that are essential to the independent management of illness and injury in patients with neuro- ophthalmic disorders. This level of knowledge or skill is required to manage clinical problems that a) pose significant risks to patients' health or visual function, b) require prompt diagnosis or management to insure optimal outcome, and c) are typically diagnosed and/ or managed by neuro- ophthalmologists ( i. e. common diseases seen on a daily basis by neuro- ophthalmologists). Because this knowledge/ skill leads to important decisions and interventions, it must be comprehensive in breath and depth and accessible to the neuro- ophthalmologist without the benefit of consultation. 2) More relevant ( proficiency with the topic required): Knowledge or skills that are used by the neuro- ophthalmologist, but are not essential for the independent and timely diagnosis and/ or management of common neuro- ophthalmologic disorders. This level of knowledge or skills may be possessed by the highly trained neuro- ophthalmologist, but lacking in-depth knowledge/ skill, a neuro- ophthalmologist may review reference texts, consult other specialists, or refer to other physicians without posing a risk to patient's health or visual function. Typically, clinical problems requiring this level of knowledge/ skill are managed in other settings or by other specialists. The neuro- ophthalmologist may commonly provide initial evaluation of these problems but generally not definitive management. Rare disorders classically evaluated by neuro- ophthalmologists are also included in this category. 3) Relevant ( familiarity with the topic required): Knowledge pertaining to clinical conditions that are either benign or not directly related to neuro-ophthalmology and do not pose an imminent threat to patients' health or visual function. Immediate diagnosis and management of these conditions by a neuro- ophthalmologist are beyond the scope of standard practice. This level of knowledge facilitates comprehensive and thorough diagnosis and/ or management of complex clinical problems encountered in neuro- ophthalmology, but referral to other specialists is generally required for the diagnosis and/ or management of these conditions. 315 |
