Neuro-ophthalmology Educational Goals and Objectives

PGY-1 and PGY-2 Goals & Objectives

Medical Knowledge

To describe the neuro-anatomy of the visual pathways.
To describe the neuro-anatomy of the cranial nerves.
To describe the pupillary and accommodative neuro-anatomy.
To describe ocular motility and related neuronal pathways.
To describe the typical features, evaluation, and management of the most common optic neuropathies (e.g., demyelinating optic neuritis, ischemic optic neuropathy [arteritic and nonarteritic], toxic or nutritional optic neuropathy, Leber’s hereditary optic neuropathy, ethambutol toxicity, neuroretinitis, and compressive, inflammatory, infiltrative, and traumatic optic neuropathies).
To describe the typical features, evaluation, and management of the most common ocular motor neuropathies (e.g., third, fourth, sixth nerve palsy).
To describe the typical features of cavernous sinus and superior orbital fissure syndromes (e.g., infectious, vascular, neoplastic, inflammatory etiologies).
To describe the typical features, evaluation, and management of the most common causes of nystagmus (e.g., congenital motor and sensory, downbeat, upbeat, gaze-evoked, drug-induced).
To describe the typical features, evaluation, and management of the most common pupillary abnormalities (e.g., relative afferent pupillary defect, anisocoria, Horner syndrome, third nerve palsy, Adie’s tonic pupil).
To describe the typical features, evaluation, and management of the most common visual field defects (e.g., optic nerve, optic chiasm, optic radiation, occipital cortex).
To describe the epidemiology, clinical features, evaluation, and management of ocular myasthenia gravis.
To describe the epidemiology, clinical features, evaluation, and management of carotid-cavernous fistula.
To describe the epidemiology, differential diagnosis, evaluation and management of congenital optic nerve abnormalities (e.g., optic pit, disc coloboma, papillo-renal syndrome, morning glory syndrome, tilted disc, optic nerve hypoplasia, myelinated nerve fiber layer, melanocytoma, disc drusen, Bergmeister’s papilla).

Patient Care

To perform a basic pupillary examination
- To describe indications for and perform basic pharmacologic pupillary testing for Horner syndrome, pharmacologic dilation, and Adie’s tonic pupil.
- To list the differential diagnosis of anisocoria (e.g., sympathetic or parasympathetic lesion “physiologic”).
- To describe, detect, and quantitate a relative afferent pupillary defect.
- To list the causes for light-near dissociation (e.g., Argyll-Robertson pupils, diabetic neuropathy, tonic pupil).
To perform a basic ocular motility examination
- To assess ocular alignment using simple techniques (e.g.. Hirschberg, Krimsky).
- To describe and perform basic cover/uncover testing for tropia.
- To describe and perform alternate cover testing for phoria.
- To perform simultaneous prism and cover testing.
- To perform measurement of deviations with prisms.
- To describe the indications for and apply Fresnel and grind-in prisms.
- To describe the indications for and to perform forced duction and forced generation testing.
- To perform an assessment of saccade accuracy and pursuit and optokinetic testing.
- To perform a measurement of eyelid function (e.g., levator function, lid position).
To describe the indications for visual field testing and to perform and interpret perimetry studies
- To perform confrontational field testing (static and kinetic, central and peripheral, red and white targets).
- To perform and interpret a tangent screen test.
- To describe the indications for and perform basic Goldmann perimetry, and interpret results.
- To describe the indications for and perform basic automated perimetry, and interpret results.
To perform basic direct, indirect, and magnified ophthalmoscopic examination of the optic disc (e.g., recognize optic disc swelling, optic atrophy, neuroretinitis).
To describe the anatomy and indications for, order appropriately, and interpret basic radiology studies of the brain and orbits, demonstrating the ability to communicate with radiologists in order to maximize both choice of proper diagnostic test and accuracy of interpretation.
To describe the indications for and interpret basic echography of orbits.

PGY-3 Goals & Objectives

(in addition to PGY-2 level goals listed for the Inpatient Consult Service)

Medical Knowledge

To describe typical and atypical features, evaluation, and management of the most common optic neuropathies (e.g., papilledema, optic neuritis, ischemic, inflammatory, infectious, infiltrative, compressive, and hereditary optic neuropathies).
To describe typical and atypical features, evaluation, and management of the more complex supranuclear and internuclear palsies and less common ocular motor neuropathies (e.g., progressive supranuclear palsy and internuclear ophthalmoplegia).
To describe typical and atypical features, evaluation, and management of the more complex and less common forms of nystagmus (e.g., rebound, convergence, retraction).
To describe typical and atypical features, evaluation, and management of the more complex and less common pupillary abnormalities (e.g., light-near dissociation, pharmacologic miosis).
To describe typical and atypical features, evaluation, and management of the more complex and less common visual field defects (e.g., lateral geniculate, monocular temporal crescent).
To describe more advanced aspects of visual field indications, selection, and interpretation (e.g., artifacts of automated perimetry, testing and thresholding strategies).
To describe neuro-ophthalmic aspects of common systemic diseases (e.g., hypertension, diabetes, thyroid disease, myasthenia gravis, temporal arteritis, systemic infections and inflammation).
To describe neuro-ophthalmologic findings in trauma (e.g., traumatic optic neuropathy, traumatic brain injury).
To describe typical features of inherited neuro-ophthalmologic diseases (e.g., Leber’s hereditary optic neuropathy, autosomal dominant optic atrophy, spinocerebellar degenerations).
To recognize, evaluate, and treat ocular myasthenia gravis.

Patient Care

To describe the indications for and understand how to interpret the results of tests for myasthenia gravis. (e.g. sleep test, ice test, Tensilon test, prostigmine test)
To perform a detailed cranial nerve evaluation (e.g, testing of trigeminal and facial nerve function).
To describe the more advanced interpretation of neuro-radiologic images (e.g., indications and interpretation of orbital tumors, thyroid eye disease, pituitary adenoma, optic nerve glioma, optic nerve sheath meningioma).
To describe the evaluation, management, and specific testing (e.g., stereopsis, mirror test, redgreen testing) of patients with “functional” visual loss (e.g., recognize non-organic spiral or tunnel visual fields).
To describe the indications for, to perform, and to list the complications of temporal artery biopsy.

PGY-4 Goals & Objectives

(in addition to PGY-3 level goals)

Medical Knowledge

To describe typical and atypical features, evaluation, and management of the most advanced and least common optic neuropathies (e.g., chronic or recurrent optic neuritis, and posterior ischemic, autoimmune, toxic/nutritional).
To describe typical and atypical features, evaluation, and management of the most complex and least common ocular motor neuropathies and their mimics (e.g., progressive supranuclear palsy).
To describe typical and atypical features, evaluation, and management of the most complex and least common forms of nystagmus (e.g., surgical treatment options, using the null point in either prism or surgical therapy).
To describe typical and atypical features, evaluation, and management of the most advanced and least common pupillary abnormalities (e.g., pupil findings in coma, transient pupillary phenomenon).
To describe typical and atypical features, evaluation, and management of the most complex and least common visual field defects (e.g., combination or bilateral lesions, cortical visual impairment).
To describe the most advanced aspects of visual field indications, selection, and interpretation (e.g., variability in automated perimetry, application of specific testing and thresholding strategies for different patient populations with different neuro-ophthalmic conditions, different testing abilities (e.g., young or old age, mental status, hand-eye coordination, reaction time).
To describe, evaluate, and treat the neuro-ophthalmic aspects of systemic diseases (e.g., malignant hypertension, diabetic papillopathy, toxicity of systemic medications, pseudotumor cerebri).
To describe, evaluate, and treat the neuro-ophthalmologic manifestations of trauma (e.g., corticosteroid or surgical therapy in traumatic optic neuropathy).
To describe, evaluate, and provide appropriate genetic counseling for neuro-ophthalmologic diseases (e.g., Leber’s hereditary optic neuropathy, chronic progressive external ophthalmoplegia, von Hippel-Lindau syndrome).
To recognize, evaluate, and treat (or refer) more complex forms of nystagmus.
To recognize, evaluate, and treat (or refer) transient monocular or binocular visual loss.

Patient Care

To perform and interpret the results of tests for myasthenia gravis, and to recognize and treat the complications of the procedures.
To perform and interpret the complete cranial nerve evaluation (e.g., testing of trigeminal and facial nerve function) and basic neurologic exam in the context of neuro-ophthalmic localization and disease.
To interpret neuro-radiologic images in neuro-ophthalmology (e.g., interpretation of orbital imaging for orbital pseudotumor and tumors, thyroid eye disease, intracranial imaging modalities and strategies for tumors, aneurysms, infection, inflammation, and ischemia), and to appropriately discuss, in advance of testing, the localizing clinico-radiologic features with the neuroradiologist in order to obtain the best study and intrepretation of the results.
To recognize patients with “functional” visual loss (non-organic visual loss) and provide appropriate counseling and follow-up.