A Great Conversation With Neil Miller

Kathleen Digre (KD): We are absolutely thrilled today to be speaking with Dr. Neil Miller, who's a professor of ophthalmology, neurology, and neurosurgery at the Johns Hopkins University in Baltimore, Maryland. Neil, thank you so much for being with us today.

Great Conversations Section Editors: Meagan D. Seay, DO Rachel Calix, MD A Great Conversation With Neil Miller Meagan D. Seay, DO, Rachel A. Calix, MD, Kathleen B. Digre, MD K athleen Digre (KD): We are absolutely thrilled today to be speaking with Dr. Neil Miller, who’s a professor of ophthalmology, neurology, and neurosurgery at the Johns Hopkins University in Baltimore, Maryland. Neil, thank you so much for being with us today. Could you tell us a little bit about yourself prior to medical school? Neil Miller (NM): It’s a pleasure to speak with you today. My father was a physician, and I was born in Texas, but he moved to do his training, so I grew up in Omaha, Nebraska. I was there for grade school through high school. KD: Was it because of your father that you considered medical school? NM: Like a lot of children who are children of physicians, I wanted to find something different from what my father was doing, but the more I looked elsewhere, the more I came back to medicine. The key, though, was that one day when I was, I think, a junior in high school, he had a journal and it mentioned a biochemistry course at a school called the Loomis School in Windsor, Connecticut. It was a summer course in biochemistry and he said, “You know, you might enjoy doing some of this stuff.” And I did that. I spent the summer at the Loomis School, where I made a number of connections, including a young man named Hayden Brain, who was a first-year college student at Harvard and he convinced me that I should really go there. KD: To Harvard undergraduate? NM: Yes. NM: Well, first of all, one of my first courses at Harvard was a biology course in which they talked about the fact that certain salamanders can regrow their limbs. They regenerate all the aspects of the limbs, and I was absolutely fascinated by it. There was a guy named Marcus Singer at that time at Case Western Reserve in Cleveland, and he had done a lot of work on this, so I wrote him. Now, I’m just a first-year college student; I knew nothing, but I wrote him and I said, “Gee, your stuff is really interesting. I’d like to learn more.” And the next thing I knew, I got a large box with a 1,000 reprints of his work and other people’s work. I became fascinated by that. So, when I got to Hopkins, I sought Departments of Ophthalmology and Neurology (MDS, KBD), Moran Eye Center, University of Utah, Salt Lake City, Utah; and Departments of Ophthalmology and Neurology (RAC), Ochsner Medical Center, New Orleans, Louisiana The authors report no conflicts of interest. Address correspondence to Meagan D. Seay, DO, Departments of Ophthalmology and Neurology, 65 Mario Capecchi Dr., Salt Lake City, UT, 84132; E-mail: [e-mail] Seay et al: J Neuro-Ophthalmol 2023; 43: 141-147 out some people who were doing some work, and we did regeneration. The salamander also can regenerate its lens from the dorsal iris. So, if you pop out the lens of a salamander, it will, within 30 or 40 days, regenerate a lens. And in doing that, I became more and more interested in ophthalmology. KD: Wow, that’s quite a story. How cool that you got a big box like that, right? Not everybody gets something like that in the mail. NM: Well, I think it was a good example of how someone who is doing work, whether it’s clinical or bench research, can answer somebody and make a change in that person’s life, whether it’s professional or personal or both. KD: Great. Rachel Calix (RC): How old were you at that time and what was the process between undergraduate and medical school for you? NM: I was around 17 or so. The other thing I should mention is that, at that time, the Chairman of the Department of Ophthalmology, Ed Maumenee, had a very specific philosophy about people going into ophthalmology. He really didn’t care whether general medical students went in. He liked to handpick people. In those days, of course, this was before the match. What he would do would be to identify students who were coming to Hopkins, and he would meet with us and say, “Listen, ophthalmology is a great specialty. Why don’t you consider it? By the way, we have money for summer research.” So, this was the way a number of us got into ophthalmology, including my roommate from college, Harry Quigley, one of the world’s experts in glaucoma. Harry and I were roommates in college and then went to Hopkins together as well. Harry had done work with George Wald at Harvard, and we came to Hopkins at the same time, and both of us got interested in ophthalmology. KD: What was your major at Harvard? NM: Biochemistry. KD: Then after Harvard, there’s a story about how you got to Hopkins. Was that for medical school? NM: Yes. One of my good friends was at Hopkins, in medical school, and he convinced both Harry and me to apply. In addition, again, my father was a physician, we’re from the Midwest. And in the Midwest, the Mayo Clinic and Hopkins were considered the very best. Actually, I wanted to stay at Harvard Med, but I didn’t get in. My father was absolutely delighted that I got into Hopkins Med. He thought that was the best thing in the world, and ultimately, so did I. 141 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations KD: That’s great. So, you went to medical school, handpicked by Ed Maumenee, and then you did your residency at Hopkins, as well? NM: Right. I did both an internship in medicine and my residency at Hopkins. I really loved internal medicine. I knew I didn’t want to practice general medicine, but I really enjoyed it. In fact, I’ve often told people that one of the best years of my life was my internship. It was great; it was hard work, but I knew it was only one year, and I wanted to learn as much medicine as possible. So, I had a wonderful time as an intern in medicine at Hopkins and then went into the ophthalmology residency there. KD: How did you get into neuro-ophthalmology? NM: Well, it’s interesting. As you know, sadly, Dave Knox just passed away, but in those days, anybody who was possibly interested in ophthalmology was given a preceptor, and Dave was mine. I went to Dave and told him I was interested in ophthalmology. Actually, I was interested in ophthalmic pathology. I wanted to go out to work with some people, including Bill Spencer at the University of California San Francisco (UCSF). And Dr. Knox said, “Well, if you’re going to go into ophthalmology, you ought to know some neurology, and one of the best people to teach you that is this guy, Bill Hoyt, and he’s out in California and he’s at the same institute as Bill Spencer. Why don’t you go out and spend a little time with them both.” I didn’t know anything, so I said, “Fine.” He wrote Dr. Hoyt, and Bill wrote back and said, yes, he’d be happy to have me. I walked on the ward the first day and Dr. Hoyt was haranguing one of his Fellows. He said, “Well, did you look this such and such up?” And the fellow unfortunately said, “I didn’t have time.” And Bill looked at him and said, “Did you have time to sleep?” And right then and there, I knew that’s what I wanted to do. [laughter] NM: I have to say, I spent almost no time during the 3 months that I was there, almost no time at all with Dr. Spencer, which was unfortunate, but I was just so enamored with what Bill was doing. In addition, he had 3 wonderful fellows who were very kind to me. One was Joel Glaser, one was Todd Troost, and one was Enrique Piovanetti from Puerto Rico. And they were incredibly kind and helpful to me and taught me things to say that they thought might impress Dr. Hoyt. So, it was a great experience. KD: Did you then do a fellowship after you finished ophthalmology residency? NM: Yes. I came back to UCSF and spent time with Bill, along with Jack Selhorst and Tom Shults. The 3 of us were fellows at the same time (Fig. 1). KD: Wow, what a powerhouse that is! NM: Great fun. RC: It sounds like it was a very straightforward course all the way through, just laser-focused at the time? NM: It really was. I’d say that the only deviation was that in my junior year of medical school, I wasn’t sure if I 142 really wanted to go into ophthalmology because I liked neurosurgery and I liked neurology, and I really couldn’t decide. Then I just said, “No, I’m going to do ophthalmology.” The problem with neurosurgery was that it just took too long to get where you were going, so I decided to move along. KD: Oh, that’s great. RC: I have to say, Dr. Hoyt comes up in so many of these conversations, and I think you had the bravest approach of anyone [chuckle]. NM: Frank Walsh may be the father of American neuroophthalmology, but Bill really took it to the streets, as it were. Most of us are, in some way, either directly or indirectly, related. There was a great presentation that Barrett Katz once gave about the professional heritage of American neuro-ophthalmology going from Bill on one hand and Lawton Smith on the other. KD: It sounds like Bill Hoyt was a huge mentor to you. Did you spend time with Frank Walsh? Obviously, David Knox was a mentor to you. Who do you think were your greatest mentors when you were getting your feet on the ground? NM: Well, certainly Bill was. He was like a second father to me. In fact, after I finished the student rotation with him, I came back and I was telling my father and mother about how wonderful it was, and my father wrote Bill to thank him for all of his support and help. Bill then gave the letter to his father, Werner, and his father wrote to my father saying how proud he was of Bill, and they had a letter conversation over several years. KD: Wow! NM: Bill was the main one. I didn’t know Dr. Walsh until after I spent time with Bill as a medical student. He told me, “When you get back to Baltimore, look up Dr. Walsh.” So, I did, and he became sort of a second mentor to me, and I would discuss things with both of them. The FIG. 1. (Left to right) Jack Selhorst, Neil Miller, and Bill Hoyt. Seay et al: J Neuro-Ophthalmol 2023; 43: 141-147 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations other person who was really, really significant to me was Ron Smith, who was my chief resident as a first-year resident in ophthalmology and subsequently was chair at the USC, Doheny. When Ron was chief resident, his philosophy was to actively support the specific interests of the residents. By that time, I was interested in neuroophthalmology having spent the months with Dr. Hoyt, and Ron said, “I’m going to make you the resident neuro-ophthalmologist, and you can give us talks in rounds, and things like that.” He did that with all of the residents, and it made all the difference in the world. KD: Well, that’s pretty cool. An interesting way to get residents into a subspecialty, huh? NM: Yeah. KD: Maybe we should adopt that for neuroophthalmology, just deputize certain residents, and say, “Well, you’re the neuro-ophthalmology resident.” NM: Yeah. It really was very supportive of those of us who had some sort of interest in things. It’s interesting, when I’m on the committee for our residency selection, one of the questions we always ask the applicants is, “What makes a good leader?” I do think that this aspect of supporting the interests of the residents is a really important part of their training. KD: Yes, exactly. I know Bill Hoyt would take a fellow only if they had a job to go back to. So, were you already planning to go back to Hopkins? NM: I didn’t know for sure. I knew I was planning to go into academics. I knew Dr. Maumenee wanted me to return to Hopkins on the staff, but I had other options as well, including Bascom Palmer, and even UCSF was a potential. But I really liked what there was at Hopkins. When I went back during the fellowship, I had written to Don Long, who was the chair of neurosurgery, and Guy McKhann, who was chair of neurology, and I told them that I was thinking of coming back, if they were willing to give me a faculty position in their respective departments. I said, “You don’t have to pay me, but I’d like a faculty position in neurology and neurosurgery so that I feel closer to the residents, fellows, and faculty.” Both were really encouraging in terms of, “Whatever you want. We’re happy to have you come back” (Figs. 2, 3). KD: So that’s how you decided to head back to Baltimore, and you’ve been there ever since, right? NM: Yes, indeed [chuckle]. NM: I’ve tried to leave, but it’s a very, very special place. I think one of the best examples is that if you fly into Baltimore, and you get into a taxi, and you say, “I need to go to the Wilmer Eye Institute,” they know exactly where to take you. The types of patients we see, both acute and chronic, tertiary and local, it’s just an amazing experience. RC: Is there anything that really tempted you away from your path, or made you second guess, because it sounds like you had this plan for yourself and it worked out. But did anything ever try to tempt you away? Seay et al: J Neuro-Ophthalmol 2023; 43: 141-147 NM: No. I was really so fortunate. One of the other things is that I really wanted to do some type of surgery. I had mentioned my father was a physician. He was, actually, a general surgeon, and one of the best surgeons I’ve ever seen, very, very gentle with tissue. So, I wanted to do some surgery. Dr. Walsh thought I should do strabismus surgery, FIG. 2. Ron Burde and Neil Miller. FIG. 3. A gathering of previous fellows at NANOS. (Left to right) George Sanborn, Andrew Lee, Pamela Blake, Maryam Aroichane, Eric Eggenberger, Wayne Cornblath, and Neil Miller. 143 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations but I really wasn’t that interested in little people whose eyes turn out or in. But I was interested in the paralytic aspects of it, and I was interested in orbital disease because when you operate on the orbit, it’s real surgery instead of that little picky stuff. I used to say that it’s not real surgery if there is not blood [laughter]. So, it was a really unique situation, a unique opportunity for me because there was no one full-time in oculoplastics or orbital surgery at Hopkins. We had a wonderful orbital surgeon, Charlie Iliff, who at that time was on the editorial board of the Archives of Ophthalmology and was a wonderful, wonderful guy. I had the opportunity to train with him. I also went out to Moorfields for a couple of weeks to train with one of the experts there. So, I had this wonderful opportunity to come in and be the primary neuro-ophthalmologist. NM: We mentioned Dave Knox. Dave split his time between neuro-ophthalmology and uveitis, and there was plenty for a neuro-ophthalmologist to do. Dave, in his usual manner, was wonderful in terms of accepting me and saying whatever he could do to help, he would be happy to do. For a short time, we shared a secretary. Eventually, I was able to do clinical neuro-ophthalmology, but I was also able to do orbital surgery, thyroid eye disease, decompressions, and removal of tumors, and I got to work with the neurosurgeons and ENT. Really, it was a magical time and, actually, has been throughout the years. In fact, one of the sad things was that I would have fellows who would train and see what a wonderful situation I had, and then would go out and would not be able to find something just as nice. KD: Yeah. It also tells me a little bit about your interest in tumors. When you started, it was just you and David Knox at Wilmer. Is that right? NM: Yes, Frank Walsh had stopped seeing patients. There were some who were referred to him, but when they were referred to him, he usually called and asked me if I would see the patients and then I would consult with him. So, it worked out for several years. KD: That’s great. You were an editor of the Fourth Edition of Walsh & Hoyt, and then all the subsequent editions. Tell us a little bit about how that happened (Fig. 4). NM: Well, the publisher went to Walsh and said, “We’d really like to do another edition of the book.” Frank really felt that he was too old to take it on. It was too much of a challenge. He talked to Bill, and Bill was having none of it. He did not have a really positive experience with the publisher at Williams & Wilkins, and so he said he didn’t want anything to do with it. So, Dr. Walsh asked me if I would be willing to do it, and it was interesting because, at the same time, Dr. Maumenee had asked me if I wanted to take over revising the Duke Elder ophthalmology series. I said, “I’m not that interested in doing general ophthalmology, but I could take on the Walsh & Hoyt and call it that.” I then contacted Bill and asked him if he would be willing to 144 FIG. 4. (Left to right) Neil Miller, Bill Hoyt, Valerie Biousse, Nancy Newman, and John Kerrison holding the sixth edition of Walsh & Hoyt’s Clinical Neuro-Ophthalmology. work with me on it. He said no [chuckle]. And then I asked David Zee if he would help me with the ocular motor stuff, and he said he’d be happy to read some stuff, but he said he was more interested in doing original work than writing about other people’s work. But he, ultimately, was very helpful. Actually, I went out to San Francisco to visit Bill, and we walked through the library, and he said, “You see all those books? Those books were written by people who knew as little about their subject as you do about neuroophthalmology.” So, I thought that was pretty good. KD: Oh, he had a way with words, didn’t he? NM: Oh, he was great. I remember one time, he said that anybody who complimented him on the third edition clearly hadn’t read it carefully [chuckle]. But what he taught me, he said, “If you look at the third edition, there are areas that are really extensive, and then there are topics that are not.” That was the whole idea; if they knew something specific, they would write as much as possible about it. But it was an interesting issue. The most important thing I did was to get the publisher to agree that because it was going to take a long time, each volume would be published separately, so we didn’t have to wait for 10 years, and then have everything out of date. And that worked out well. KD: I remember you had to buy it in series, 5 volumes. NM: Yes. KD: Is that where some of your encyclopedic mind came from in terms of being able to reference things better than anybody? It’s just phenomenal. NM: Well, that was part of it. But every month, I will go through about 60 journals. Now, obviously online, and download, but in the old days, I would xerox articles that I thought were worthwhile. We now have a journal club, for instance, every month, where we talk about a couple of the articles. In fact, when I was a fellow, the joke was that we were all going to get some sort of light-intensity poisoning from the green light of the xerox machine. When we finished Seay et al: J Neuro-Ophthalmol 2023; 43: 141-147 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations our rounds and all, we would go to the library and look up, if you remember, it was Current Contents, I think it was called. KD: Index Medicus. NM: Well, yeah. But you had this little book that you would have. KD: Yeah, the Current Contents . Yes, and then Index Medicus. NM: So we would go and we’d look up everything, and we’d go to the medical libraries and just xerox tons and tons of articles. KD: That’s amazing. Is there any aspect of your career that you would have never guessed you would have ended up doing throughout your life? NM: I don’t know that I ever thought about it. It just sort of naturally came ahead. I think the biggest issue was about 10 or 15 years ago, when I started to consider whether or not I wanted to be a chairman. Because that was the normal thing. At Hopkins, in particular, you rose through the ranks and eventually you became a chair. And that was something Dr. Maumenee and subsequently Arnall Patz and Mort Goldberg and now Peter McDonnell have been very proud of is the number of leaders around the world that have come from Wilmer. But at about the time that I might have considered it, our daughter was young and she didn’t want to move. And, quite frankly, I didn’t want to do all of that administrative work that had changed dramatically for chairs. When Dr. Maumenee was chair, he saw patients 2 days a week, he operated 2 days a week, and 1 day a week was administrative. Now, it’s pretty much the reverse of that —almost no surgery, a boutique practice, and a ton of administrative work. So, it turned out that it just wasn’t the thing to do for me. I almost went to UCSF. But things just didn’t work out the way they might have. And I’ve been absolutely delighted to keep doing what I’ve been doing. KD: You’ve been doing a lot more research and lab work now. Had you always been doing lab work and did that salamander idea ever come back to you? NM: It’s interesting. Of course, the newer molecular genetics and proteomics and all have left what we did back in the 60s far behind. But I always enjoyed doing bench research. And you get to a certain point in your career from a clinical standpoint, where you sort of say the learning curve has flattened out. I was fortunate enough to have a fellow who was interested in doing bench research and started the collaboration at the University of Maryland that led to my doing it. I was fortunate enough to get some funding. I’ve been working in that lab for probably 15 years or more. KD: What are you working on? NM: A model of ischemic optic neuropathy, of nonarteritic anterior ischemic optic neuropathy. The head of the lab, Steve Bernstein, developed the first reproducible animal model in a rat. Then, we subsequently went ahead and developed the model in the mouse and also in the nonhuman primate. We’re just about to try working with Seay et al: J Neuro-Ophthalmol 2023; 43: 141-147 an intermediate animal, the ferret. If that doesn’t work, the tree shrew. It’s been very exciting work and we’re limited, of course, for the last couple of years because of the pandemic, but now things are hopefully getting back on track. RC: You’ve had such a wide-reaching career between publishing, leadership, and education. What would you say your biggest successes are? NM: I think I’m most proud of the teaching that I’ve done over the years to residents and fellows. It’s always exciting when a resident will call me and say, “I remembered you told me such and such, and I just saw a patient, and this is what happened.” One particular experience I had was one of our former residents, who was and is a very prominent corneal specialist, saw a patient who was having difficulty with vision, with cornea breakdown. He tested the cranial nerves because he had remembered a lecture I had given and found that there was corneal anesthesia and that led him to do imaging, which showed a tumor in the cavernous sinus. These are the types of things that I think I’m most proud of. It’s nice to be able to help patients one at a time but also to teach people who are going to help patients in large groups. It’s a bit like the loaves and fishes in that sense. RC: Absolutely. Do you feel like your approach to training has a certain style, or did it evolve over time? What did you find was most important in training? NM: I think that the most important thing was to remember that even though you’re hopefully evolving, the people you’re teaching are at the same sort of level year after year. So you have new people coming in, who, if you’re not careful, you teach in a more complicated manner because you’ve taught this stuff so long that you know it, and you’re going to go beyond that. Often you’ll talk about how to assess somebody with visual loss, and you’re talking about doing this study and that study and then you realize they don’t even know what a relative afferent defect is. So, you have to remind yourself to keep it oriented to the level of the people you’re trying to teach. I think that gets harder as you get older. KD: I’d like to ask a little bit about the Walsh meeting and then NANOS meeting and your becoming president of NANOS. Tell us a little bit about your background because you were more on the Walsh team and then you slid over to NANOS. Tell us a little bit about that. NM: Well, as you know, NANOS was born out of the Rocky Mountain Neuro-Ophthalmology Meeting and that meeting initially was for general ophthalmologists and neurologists. It was not a specific neuro-ophthalmology meeting for neuro-ophthalmologists and I wasn’t all that interested in doing that. But the Walsh meeting or what turned out to be, used to be called the NeuroOphthalmology Pathology meeting. It was Ron Burde, I think, who named it the Walsh Society. It was just people getting together once a year for a day and a half during which they shared interesting cases. That was what I 145 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations enjoyed doing, and I didn’t really have anything to do with the Rocky Mountain meeting. NM: Then, Tom Carlow contacted me and said, “We’re changing it. We’re making it more of a neuro-ophthalmic meeting, and it’d be really great if you would attend.” And I said, “Okay, under those circumstances, I think it’s great.” In the early days of NANOS, there was a “we-they” concept. There were the Walshers and the NANOSers. And there was a lot of suspicion, I guess, you could say, in terms of what was really going on. And I credit Steve Feldon when he was president of NANOS with really bringing everybody into the fold, so that we were all one group. It’s been interesting to see what’s happened to the Walsh part of the meeting with imaging as it is, it’s harder and harder to present things that you can’t figure out on your own. NM: In the past, we never talked to the pathologists or the radiologists, we would just present things. Then, of course, the radiologists would say, “No, you’ve missed the lesion over here!” And even pathology; I can remember several situations in which the pathologist said, “I don’t agree with your interpretation because of this, this, and this.” But it had gotten much more warm and fuzzy over the years so that now the pathologists know what’s going on ahead of time and they communicate with the presenter so that the presenter pretty much knows what he or she is presenting, and that’s appropriate for such a large group. In the original Walsh meetings, there were maybe 20, 30 people at most. KD: Wow. Now, even during a pandemic, we likely have 500 people coming to NANOS and Walsh. It’s pretty amazing. NM: Yeah, it’s fantastic. KD: Any highlights of your NANOS presidency that you’d like to bring up? NM: One thing that I am proud of is that, as you know, there had never been a female president of NANOS, so I told Tom that I would become president only if a female was the next president. We know who that was. It was you! KD: Yeah. NM: So, I was very proud of that. And then from another standpoint, I established the research committee of NANOS, which then morphed into NORDIC and has made some great strides. So, I was pleased with those 2 aspects of the presidency. KD: Yes. It all is iterations as we go along, and now we’ve got this enormous organization with all kinds of things going on. It’s amazing, really amazing. Neil, what do you do in your free time? Do you have free time? NM: I do. I do have it now. As you know, I stopped seeing patients last year, but I still do research. I did make a deal that I would rotate with my colleagues on consults from the residents. About once a month, I get a week of consults from the residents. First of all, they keep me honest because I’ve got to understand what the newer things are. These kids are just so brilliant. It’s just unbelievable. I’m glad I did my residency when I did. I don’t think I’d ever 146 get one now. But it’s great fun to work with them. But when I’m not doing that, I have, for many years, played bass fiddle, but I never had much time to practice. Nowadays, I’ll practice several times a week. The good news about the pandemic is that I’ve had time. The bad news is that I have not been able to get together with people, and I have not convinced people like Dan Milea who we can somehow put our act together over the internet. But I’m still working on him. KD: Oh, that’s good. If you had advice for people who are in their early careers, what advice would you give people? NM: I would say what I was told in my early career, work hard, know your limitations, and ask for help when you need it. KD: That’s pretty good advice for everyone. If you were going to influence someone to go into neuroophthalmology, what would you tell them? NM: Well, I think it’s the most wonderful subspecialty around. It allows you to use your brain. When things work out well, it’s really great for the patients. You can do pretty much anything you want in terms of being a diagnostician or treater. We used to joke that in neuro-ophthalmology, we said, “diagnose and adios.” Now, we don’t have to do that. There are tons of medical and surgical treatments for our neuro-ophthalmic patients. So, I think it’s a great field. FIG. 5. (Left to right) Norman Schatz, Joel Glaser, and Neil Miller. Seay et al: J Neuro-Ophthalmol 2023; 43: 141-147 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Great Conversations FIG. 6. (Left to right) Robert Hepler, David Knox, Bill Hoyt, and Neil Miller. You can specialize in things. Once somebody asked me what specialty I was in, I said, “Neuro-ophthalmology.” And they said, “No, no, no. Within neuro-ophthalmology, do you concentrate on the pupil or on the optic nerve or .” It’s like, “I’m not that specialized” [laughter]. KD: What makes NANOS special to you? NM: It’s the combination of comradery and science. It’s just an amazing meeting. We are one of the few specialties where there is no competition in terms of seeing patients. If a patient wants to go up to New York or Boston or someplace to get a second opinion, or come to me, nobody’s upset about that. We all try to help each other and our patients. It’s a very collegial subspecialty, and NANOS Seay et al: J Neuro-Ophthalmol 2023; 43: 141-147 FIG. 7. (Left to right) David Knox, Neil Miller, Jonathan Horton, Peter McDonnell, and Timothy McCulley. has, particularly in the last maybe 10, 12 years, really fostered that. And the people are really nice (Figs. 5–7). KD: Well, Neil, thank you so much for spending this hour with us and for sharing your life stories. NM: Well, thank you all. ACKNOWLEDGMENTS M. D. Seay and K. B. Digre are supported in part by an unrestricted grant from the Research to Prevent Blindness, New York, NY, to the Department of Ophthalmology & Visual Sciences, University of Utah. 147 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.