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The Neurotransmitters: Clinical Neurology Education
Neuro-Ophthalmology with Dr. Manasa Gunturu
In this episode, we are joined by Dr. Manasa Gunturu, a neurology-trained neuro-ophthalmologist and associate professor at the University of Mississippi Medical Center.
We discuss the art of detailed history-taking and specialized examination skills, the evaluation of patients with subjective vision loss, double vision, visual field defects, and droopy eyelids – often after they've already seen multiple specialists without answers. We also explore the educational pathways to becoming a neuro-ophthalmologist and the surprising disparity between ophthalmology and neurology training requirements.
With only about 600 practicing neuro-ophthalmologists in the United States and some states having just a single specialist, Dr. Gunturu makes a compelling case for why more neurologists should consider this rewarding subspecialty and shares resources for trainees looking to improve their neuro-ophthalmology skills.
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Hello and welcome to the Neurotransmitters, your source for everything about clinical neurology. I'm your host, Dr Michael Kentris, and today we are talking about neuro-ophthalmology. To help us out with this subject, we have Dr Manasa Gunturu, an associate professor in neurology and neuro-ophthalmology from the University of Mississippi Medical Center, where she is also the director of the Adult Neurology Residency Program. Thank you so much for joining us today.
Dr. Manasa Gunturu:Thank you, dr Kentris. Hi everyone, I'm Manasa Gunturu and I'm a neurology-trained neuro-ophthalmologist. I work in the University of Mississippi Medical Center. This is my first time to be doing a podcast with the Neurotransmitters team. I'm so excited. I feel very honored and thrilled for this opportunity and I appreciate having me here and talk more about neuro-ophthalmology.
Dr. Michael Kentris :And we are so glad to have you on. Neuro-ophthalmology is not a subject we have delved into in particular depth, so can we just start out with kind of a broad strokes definition of what would we consider neuro-ophthalmology?
Dr. Manasa Gunturu:Sure, yeah, I mean neuro-ophthalmologists treat patients with complex neurological conditions that affect the visual system. So we see many patients with actually acute disease that may be vision threatening or could be life threatening too. So it is, I would say, a very cognitively challenged field but it's very rewarding, mainly because, I would say, many of the times we come to a diagnosis with very deep history taking and very extensive examination skills. I keep talking to my patients a lot and you know they say, oh, no one has asked me this question before. So that comes out many of the times during the encounter. So it definitely feels very rewarding to take care of the patients.
Dr. Michael Kentris :Excellent. So, as you mentioned, you said you're a neurology-trained neuro-ophthalmologist. So, first of all, what drew you in out of the many subspecialties that are available to neurologists? What brought you into neuro-ophthalmology specifically?
Dr. Manasa Gunturu:So for me, I would say, the main reason which dragged me into neuro-ophthalmology specifically. So for me I would say the main reason which dragged me into neuro-ophthalmology is because of my mentor, who is Dr Corbett. He retired in my second year of training in neurology residency and he used to supervise my continuity clinics. So every week on friday afternoon I used to go to the clinic and any patient I see even if they come with epilepsy or, you know, stroke he used to show me some neuro-optomic findings in them. That was like so exciting so I used to wait to go to that clinic and so I'm one of the five residents who actually decided in second year itself what fellowship I want to take. So that has helped me a lot because I had a lot of planning ahead of time. I knew what I wanted and he mentored me along with Dr Parker, who is another neuro-ophthalmologist at the VA. They have been the people who guided me all through and made me decide what I wanted to be.
Dr. Michael Kentris :And I know you mentioned that neuro-ophthalmology deals a lot with visual issues what kind of patient population are you seeing most often?
Dr. Manasa Gunturu:What kind of patient population are you seeing most often? So I see many different kinds of patients, mainly like they might have a vision issue, which people you know it's more like a subjective vision loss or could be double vision or could be more of a visual field effects or could be more of a visual field effects, and many of the times it's more that when they come to your ophthalmologist they probably have seen optometrists, ophthalmologists, and they probably have seen neurologists. So there is a lot of record reviewing we have to do because we obviously don't want to repeat the same kind of workup which was done before. So we go through a bunch of records and review what all has been done in the past. So they could have been diagnosed having an optic nerve problem and they try to seek the help of their ophthalmologist to figure out what is the cause of that optic nerve problem.
Dr. Manasa Gunturu:Or it could be more that they don't find anything else but the patient complains that something is wrong. So that's I would say half of the patients I see will be more like we don't know what's going on, but the patient is not happy. So sometimes it could be very vague that they have pretty bad headaches and that could also be a neuro-ophthalmic issue. So it's a wide variety of patients which come, and also droopy eyelids is another thing which comes to neuro-ophthalmology. Many of the times they might have had surgeries before for the droopy eyelid, but later on, of course, on examination we also evaluate if it was a cranial nerve problem or is this a local muzzle issue.
Dr. Michael Kentris :Gotcha. So one of the complaints you're mentioning like kind of the non-specific, like blurred vision or visual impairment, would this kind of fall into like the family of like functional neurologic disorders?
Dr. Manasa Gunturu:So, yeah, functional neurologic disorders is definitely an interesting one Once we evaluate and usually it will take probably another one or two visits before we consider functional vision loss as the etiology. First, of course, our goal is to make sure that there is no clear-cut reason that could be treatable as the initial cause of the issue and functional vision loss is. It could be more of a malingering or it could be more that you know, it could be an expression of the stress they're going through. So that is another, probably another one hour or two hour session talking about functional vision loss, but yeah, mainly if it's related to a stress-related cause. But I think our goal is to first ensure that it is not a treatable reason.
Dr. Michael Kentris :Gotcha. So let's say someone's been referred to you. They've been having some sort of let's just say diminished visual acuity for X number of months. They've had an eye exam from an ophthalmologist, They've had MRIs of their brains and orbits, and now they're showing up in your office and what kind of questions are you asking them beyond kind of the standard things? What kind of investigation goes into these patients?
Dr. Manasa Gunturu:Sure, yeah. So in the history itself, of course we always go through the timeline and also see about progression and is it an acute, you know, sudden onset or it's more of a progressive kind of issue? And what other associated features are there? Is someone having headaches or is someone having more of an infection which was a prodrome before the symptoms started? Double vision, and we always try to focus on the neurological symptoms as well, so any focal weakness in the arms and legs.
Dr. Manasa Gunturu:So I think if they have seen ophthalmologists, the neuro-ophthalmic examination will also include the ophthalmology part but also the neurological part. So we do a complete neurological exam as well and we do tests like visual acuity, color vision and checking the intraocular pressure. And also deep testing involves visual fields, humphrey visual fields and OCTs, the optical coherence testing. So the OCTs, we do it off the optic nerve and also the macula, so some of them we might have to go further getting the autofluorescence or also fluorescein angiograms. And in the past, like during my training, we had the testing of ERG and also VEP, visual evoked potentials and electrorechnograms. So I did my training at Bascom Palmer and we had a whole department with the electrodiagnostic testing as well.
Dr. Manasa Gunturu:So it was really good that you know, once we start the testing we first go to the first year of one's examination and then the first year kind of testing with the OCTs. So if we need to go further then we go to the next levels. So our goal definitely is to first find out if there is anything concerning going on and once we see that then we go further to come to a diagnosis and the MRI is done in different places. But I think always I like to see my own MRIs, so once I don't rely on the report. So that's another thing which I commonly see.
Dr. Michael Kentris :I'm guilty of the same.
Dr. Manasa Gunturu:So that is another thing which we really want the patients to get the MRI so that we can look through, and also we have a team of neuroradiologists. So that's the other good part with neuro-ophthalmology is like it's more a collaboration of you partnering with different teams. So you partner with neurosurgeons, you talk to them, you partner with ophthalmologists, rheumatologists, neuroradiologists, and if there is anything emergency, obviously you talk to the ER team and let them know what's going on and the patient goes to the hospital and gets further work done. I talk with internists and ENT specialists. So that's the good part of neuro-ophthalmology that if you have to practice neurology as a whole and you don't want to focus on a single disease, I would say neuro-ophthalmology is the go-to thing.
Dr. Michael Kentris :No, that's a good point. It sounds like definitely a lot of diagnostic testing goes into some of these more esoteric diseases, and so during a neuro-ophthalmology fellowship, you are getting all these training in, like these neurophysiologic as well as different imaging modalities as well.
Dr. Manasa Gunturu:Yeah. So neuro-ophthalmology fellowship, I would say it's a different field, based on how much training you get during your residency. So as a neurologist you don't use a slit lamp, right? So when you go into neuro-ophthalmology fellowship, of course they expect you to use the slit lamp and they expect you to do refractions.
Dr. Manasa Gunturu:So the first few months I felt like I was back to medical school again, learning from all my basics. So that was a very interesting experience. So I tagged along with many trainees who were in their first year of training too, but they were the ones who taught me how to even if I identify the picture of the optic nerve is it the right optic nerve or the left optic nerve? So they gave me easy techniques to learn that. So it was not just that I was learning from the neuro-ophthalmologist, I was actually learning from many of my colleagues who were sitting there on the team and I was learning from the neuro-ophthalmologist. I was actually learning from many of my colleagues who were sitting there on the team and I was learning from the technicians how to check the pressure, how to take the visual acuity in the appropriate way, how to do the refractions.
Dr. Manasa Gunturu:So that was a very interesting and humbling experience during fellowship Because many other subspecialties in neurology you know, if it comes to stroke or epilepsy, you've already read EEGs during the training. So it's more, you go to the next step from that. But in your ophthalmology I feel like you start again from your basics and by the end of the year you go deep down into reading OCTs and also VEPs. So it's a very broad training which you get in neuro-ophthalmology.
Dr. Michael Kentris :Yeah, it certainly sounds like it, and that brings me back to something you said at the beginning right? So a neurology-trained neuro-ophthalmologist, implying that there are other paths to becoming a neuro-ophthalmologist as well.
Dr. Manasa Gunturu:Yeah, so ophthalmologists are actually a chunk of the neuro-ophthalmologists who did their training in ophthalmology and they became neuro-ophthalmologists. So there are multiple surveys. If you go and look into the literature which they've done to see what can get more people interested in neuro-ophthalmology. So in those surveys at least two-thirds of them have their background in ophthalmology. So it's only one-third of the neuro-ophthalmologists have training in neurology. So that was a very interesting survey which makes us think what changes can we make in the neurology education to help more neurologists go into this interesting field?
Dr. Michael Kentris :That is a good question. What have the surveys showed us so far?
Dr. Manasa Gunturu:So I think the one which I say in ophthalmology it's a requirement that they have to do neuro-ophthalmology rotation. So at least three months of neuro-ophthalmology is what they focus in the four years of training. But in neurology for us it's not a required rotation. So if you have a neuro-ophthalmologist, that's awesome, that's well and good, so you go and probably do a few days or weeks of training in the clinic rotation or something, but it's not a required rotation for neurology residents. I would say that is one big thing which people probably will make them more interested into neuro-ophthalmology if that could be included into the neurology residency training.
Dr. Michael Kentris :No, that's a good point. I know when I was a resident we had a physician on staff who was a neuro-ophthalmologist, but probably still that was only like a third of his practice. He was still doing general ophthalmology. So I would go on rotation for a few weeks and unfortunately you know from my experience we would see, like you know, your idiopathic intracranial hypertension and things like that, but not a lot of the more unusual or more challenging cases that probably come to a pure neuro-ophthalmologist I would imagine.
Dr. Manasa Gunturu:Yeah, I think that's. The thing is like. You don't see these complex neuro-ophthalmic cases on a daily basis. Don't see these complex neuro-ophthalmic cases on a daily basis, so you would probably see them once in every few days or maybe in a week's time. You will see a few cases, but those are very important ones which probably a neurologist alone by themselves or an ophthalmologist alone by themselves will not be able to solve that situation. So I think getting that exposure is the most important part. As you said, diagnosing papilledema or with IIH is probably more the bread and butter cases for neuro-ophthalmology, but the more need of neuro-ophthalmologists come in in the clinical decision-making. Who are the ones which you just treat with medication? Who are the ones which you decide they have to go for surgery for it? In the same way, who are the ones who you decide, oh, this person needs a scan right away? So that clinical decision-making is probably the best thing for neuro-ophthalmology.
Dr. Michael Kentris :No, that's very helpful, because it does start to get a little no pun intended a little fuzzy when someone's starting to lose the vision. It's like how fast do we need to act on this? Do we have a little bit of leeway in terms of medication management or weight loss, as whatever the cause may be? So yeah, it does. I know in my practice. I had a case not too long ago where I was, you know, in close touch with the ophthalmologist who was seeing this patient who had, thankfully, asymptomatic but papilledema, and we ended up finding out she was taking like 300% of the daily recommended vitamin A and a multivitamin.
Dr. Michael Kentris :So it's sometimes, yeah, you can get away with avoiding anything too severe, but sometimes the vision starts going pretty quickly.
Dr. Manasa Gunturu:Exactly. I think those are the points which we cover very deeply in the history taking. So I don't want to say you know that many people miss it, but I think it's just some of them. Might you know the question? The way it's asked also probably makes a difference. If you just ask a multivitamin, maybe not everyone, the patient might not realize what we are asking. So I think going more deeply or asking in a way that they understand, or giving more reasoning behind the question, probably helps them to get the answer out.
Dr. Michael Kentris :Mm. Hmm, yeah, you're absolutely correct. I think I had to ask about three times before I got the answer that, oh yes, I do take like a vitamin or a supplement or something like that, and so it really does. The wording does matter. I'm starting to move into my mid-career phase so I have more gray in my beard, but we don't see as much emphasis necessarily on mastering the fundoscopic exam anymore and I work mostly with non-neurology residents these days and I would say outside of neurology it's even more exacerbated. So I know you've done some work on this field, but what are your thoughts about the current state of education and skill in use of doing the direct fundoscopic exam and what can we do to help improve that?
Dr. Manasa Gunturu:I know. So that's another thing you know when I'm on service.
Dr. Manasa Gunturu:All my residents know that that's definitely a question which I'll ask If a patient has come with a headache, my next question will be did you do the panoptic exam or a fundoscopic exam? And you know it depends on what their background training is. So if it's an ophthalmology resident I'm working with, so my set of questionnaire is totally different to them because they are have a very good skill set of evaluating the optic nerve and differentiating. Is this a drizzle or is this real papilledema? Is this real papilledema? But if it's a trainee with a different background either neurology, neurosurgery or ER so our goal is to help them out of how to identify the optic nerve examination. So I definitely go through in detail all to my trainees in neurology and also in the medical school education as well. So we have a lot of medical students who come and work with us in neurology and ophthalmology so I make it a point that we go through how to do the fundoscopic exam. So I don't know about the direction down the lane because now we have a lot more uh examination tools which we did not have during our training. So we used to rely only on panoptics or the direct ophthalmoscopes, but now there are many non-mydriatic devices where the patients don't need to be dilated but you get a good picture of the optic nerve. So from that standpoint but definitely the direct ophthalmoscopic exam without dilating the patient is a skill which I always tell them.
Dr. Manasa Gunturu:It's probably very similar to doing a lumbar puncture. So when we do a lumbar puncture we spend a lot of time about positioning, but once the needle goes in it's very easy. The fluid comes out. But we have to spend a good bit of time of positioning the patient for the fundoscopic exam Because once you're at the right position, seeing the optic nerve is very easy. So that's the other thing which we go through during the training and recently I did a sim session for 48 ER residents, so all the residents from first year to third year. We did a session and by the end of 15 minutes each one of them was able to see the optic nerve.
Dr. Manasa Gunturu:So I think understanding the technique is the most important thing in that and, of course, once you see the optic nerve, also identifying the pathology of what the problem is or is it a normal looking optic nerve. So the more we keep seeing, the more we do the exam on different people. That is when we'll understand that. So I think practice is definitely the key for doing this optic exam and also, I would say, holding the panoptic and not missing them during rounds is the other important thing. I've done it myself, where I keep holding the case of the panoptic and, you know, in one patient's room I forget it and I don't take it to the next, and then we come back and pick it up, but because it's a big device so we have to remember to take it and carry it over.
Dr. Michael Kentris :Absolutely. I know when I was a resident I found some of my most useful rotations were my child neurology rotations when I was starting out, because all those kids just had such big pupils that you couldn't miss. So it definitely helped build confidence and the positioning part kind of like some of those kids riding a bucking bronco but I think it helped raise my skills up a little bit. So I strongly advocate for making the best of your child neurology rotations as well. That's true.
Dr. Manasa Gunturu:So the best way I would say to strengthen the neuro-ophthalmology skills during residency or medical school training is to incorporate the detailed exam of those cranial nerves like two, three, four and six into the neurological exam, right? So if we incorporate this neuro-ophthalmic skills and education about the pathologies. So here in the University of Mississippi we include neuro-ophthalmic emergencies in the bootcamp sessions. So we do a month of boot camp session for first year neurology residents going into second year. So the last month in June. So that's another place where it's not just about explaining the pathologies, we also go through how to examine the optic nerve and also how to examine a patient with double vision, how to examine the lid when ptosis happens. And these sessions are not only for neurology, we do it for ophthalmology residents and recently we started doing for the emergency medicine residents too.
Dr. Michael Kentris :That's excellent. So we've been focusing a lot on the vision itself, but let's talk about double vision a little bit. Obviously. There are many causes. Let's talk about double vision a little bit Obviously. There are many causes. So when you're trying to teach a framework to a resident for double vision, how do you typically approach that?
Dr. Manasa Gunturu:So for double vision, definitely, I think the first thing we always include is coming again back to history. So we spend a good bit of time. So by the end of the history taking itself, I tell the residents we might have to, should have a clue by now, even without examining the patient, where the problem could be. So from the history itself, lots of clues will be. There Is the double vision. Obviously.
Dr. Manasa Gunturu:First thing we have to establish if it's unilateral or it's a binocular double vision. Have to establish if it's unilateral or it's a binocular double vision. So once it's binocular, definitely it's us who have to evaluate. Because if it's not, then you'll be like, okay, I think you have a refractive error or you have a cataract or something not neurologic for the double vision. And once after that we try to figure out is it for near, is it for distance, is there any one specific gaze? Does the double vision get worse?
Dr. Manasa Gunturu:So with that information and also seeing if they have associated droopy eyelid or in the face, if you see any facial droop, so many of the other associated clinical diagnoses helps us to come to the conclusion. Other associated clinical diagnoses helps us to come to the conclusion. So, on examination in the ER examination for double vision is a little different when it comes to the clinic, where we have much more devices we have prisms, we have Maddox rods, so it gets more easier. And also evaluation of nystagmus is another thing. So there is definitely double vision is something which we can spend an hour on it as well in the clinic to evaluate and also help the patient. That solving a case of double vision and also treating the patient is definitely very rewarding because the patient obviously gets extremely happy once they start seeing single and also all their symptoms improve.
Dr. Michael Kentris :What's your initial reaction if a patient comes in? They have binocular, I should say bilateral, monocular diplopia.
Dr. Manasa Gunturu:What is my initial reaction?
Dr. Michael Kentris :I was just going to say. Unfortunately, I see that complaint a bit often in the hospital and the workup tends to be, let's just say, underwhelming at times.
Dr. Manasa Gunturu:Yeah, so if it's bilateral but monocular, double vision, definitely you know it won't take one hour to see the patient.
Dr. Michael Kentris :That's a reasonable assessment. Now, and this is, you know, partially tongue-in-cheek, partially for my own edification. Now, I will sometimes get patients in and they'll have, they'll say that they're seeing like triple or quadruple is there any reasonable way for that to physiologically occur? Is that more likely it's going to be in that kind of more functional territory?
Dr. Manasa Gunturu:you know it probably can, or it probably again if it's monocular or binocular is another thing which we have to assess. I've seen that multiple times with a refractive error or someone has a corneal disease or maybe has cataracts, so that could be another factor which needs to be taken into consideration.
Dr. Michael Kentris :Gotcha. No, that's fair, that's fair. Sorry, a little tongue-in-cheek on my part, gotcha. No, that's fair, that's fair. Sorry, a little tongue-in-cheek on my part. So in your experience, you're teaching a broad array of learners inuity, the eye movement, coordination, all these kinds of things. I know there's a lot, literally a lot of moving parts to the visual process. What are the things that you tend to find learners struggle with the most?
Dr. Manasa Gunturu:I think the main thing is it could be more a simple thing that how to operate many of the equipment. Again, it comes with some of the neurological associated symptoms, even like headache. So it could be more simple like a toothache giving a headache. So I think that differentiation we can see. Or is it neck pain giving the headache? So which could be? We can tease that out by obviously asking more questions from the history taking.
Dr. Manasa Gunturu:But when it comes to a neurology trainee, I spend a lot more time in identifying what the abnormality of the optic nerve is, or how to assess the double vision evaluation, or how to interpret the visual field testing, how to interpret the OCT testing, how to do a B-scan. So there are many different things I think each side we can learn from each other. So there are many different things I think each side we can learn from each other. So that's what I was telling. Like during your fellowship also, you learn a lot from your co-fellow who has a different background training. Or you can learn a lot from optometry residents who are there or how to make, how to see what amount of prism is needed. So each one has their own expertise.
Dr. Michael Kentris :That's a great point to emphasize. Yeah, I know, as a med student I spent some time on ophthalmology as well, and I remember the doctor gave me a book it was a short book, thankfully, but it was just called Optics and I ended up reading this whole book over the course of a book. It was a short book, thankfully, but it was just called Optics, and I ended up reading this whole book over the course of a rotation, and it was. I mean, I've always been, you know, kind of interested in physics, but it is compared to, like neurology training. If you haven't done that in the past, it is quite foreign.
Dr. Manasa Gunturu:Yeah, definitely. I mean, optics is like as you said it's. I'm thankful that it's a small book, but when I started to learn how to do refractions, it was just mind-boggling to me, like how much time you can spend on this. Actually, it's almost like the neurology examination you can spend an hour on it or, if you get good at it, maybe you can spend just 10 minutes on it and come to a conclusion.
Dr. Michael Kentris :Now, one thing you have been pointing out. Right, you know it's the 21st century. Most neurologists aren't carrying around drops in their little black bags anymore, so most of the time we're talking about although you know, the board exams still love to ask those questions, about those right, I don't have any cocaine on me today. But it does become like these older patients in particular, like someone in their 80s, maybe even 90s, where they have these two, three millimeter pupils that don't really dilate on their own, even in a nice dark room.
Dr. Manasa Gunturu:Yeah.
Dr. Manasa Gunturu:Or maybe they have kind of a partial cataract, and are there any patients that you just you know, you can't really see the optic nerve very well because of the anatomy, like, let's say, we're not in the office, we're somewhere in the hospital or probably being neurology trained neuro-ophthalmologist, I try not to dilate, mainly because of you know, once you dilate, definitely you want to make sure you have the expertise to evaluate the retinal exam and see different parts of the rest of the, not just focus on the optic nerve exam. But when it comes to the hospital setting, I think I would still say, as the years go by during training, the first thing I've learned is to examine with the indirect ophthalmoscope without dilation. Because once you get expertise in doing the undilated exam, obviously it's very easy when somebody is dilated to examine them. So if it's the other way around, the struggle is much more harder. Is how I felt.
Dr. Manasa Gunturu:So right now I would say most of the patients probably I'll be able to examine without dilation. But if I really need to dilate, of course I don't shy away from dilating them, especially if they were dilated before and the eye is quiet and there is no concerns of angle closure, glaucoma or there is no other contraindication to dilate them. If it's a kid and that's why I tell my residents maybe it's better not to dilate the kids if they were not dilated before. So try to avoid that. But the rest of them, I think I always give them a picture of the drops which they have to order. So everyone has, you know, identified what all drops they could order on the patients which they need to.
Dr. Michael Kentris :Excellent. Now you used a phrase right now and I like to think that I'm pretty decent at interpreting our ophthalmology consult notes, which are written in a very unique shorthand most of the time, but when the eye is quiet, what does that mean?
Dr. Manasa Gunturu:So the eye is quiet.
Dr. Michael Kentris :I think the main thing we try to explain in that is, there is no conjunctival chemosis or there is no inflammation in the vitreous, and so the eye is not pink or red is one thing, and also there is no inflammation behind the pupil is probably what you want to tell them as well. Okay, that makes sense. Okay, gotcha. No, that's good, cause I know a lot of times my residents will come to me and they'll be like we have this ophthalmology note and you know it's a, it's a whole mix of acronyms and numbers and things like that, and usually we're able to, you know, to make our way through it.
Dr. Michael Kentris :It's pretty okay, but I was just wondering if there was anything. I mean quite I assume the opposite is, like you know, is loud or angry. So so I'm glad to know that I was, you know, in the right territory.
Dr. Manasa Gunturu:Yeah, and I, I think, the different kinds of cases which ophthalmology sees. Of course they see the worst things which happen to the eye as well. So when it's a neurology or a neuro-ophthalmic case, of course their focus is more on many other parts of the eye exam rather than what they routinely see, because they don't worry much about the intraocular pressure because usually that'll be normal. They don't worry about the cornea or you know, they don't think there is something going on with the vitreous or anything like that. So of course the point over there is directly to focus on the eye movements or the optic nerve. So the rest of the thing is. Quiet is probably a common term which they can use.
Dr. Michael Kentris :Which is good. It's good to know that it's good. So, neuro-ophthalmologists I don't know the numbers off the top of my head, I imagine there isn't a plethora of you all throughout the country.
Dr. Manasa Gunturu:Yeah, so in the survey exactly, I was also trying to see how many are there, because we meet commonly in the annual Neuro-Optimology Society conference, which is called NANOS, so North American Neuro-Optimology Society. So from the United States there are 600 plus neuro-ophthalmologists Wow. Hundred plus neuro-ophthalmologists Wow. So it's still definitely, I would say, a good number of neuro-ophthalmologists. But I think when you see how many are practicing and how many are there per state, I think there are still few states who don't have a neuro-ophthalmologist at all. And I'm from a state where we have only one neuro-ophthalmologist in the entire state.
Dr. Michael Kentris :So Is that you? I assume yeah.
Dr. Manasa Gunturu:So, but where I did my training in Miami, we had six neuro-ophthalmologists in our institute itself and there were many other neuro-ophthalmologists in our institute itself and there were many other neuro-ophthalmologists in Miami and in Florida too. So I think each state has obviously a different number of neuro-ophthalmologists, but it's a very good, close-knit group of neuro-ophthalmologists which we have, and the conferences are fun and lots of interesting things to learn and lots of workshops as well for the trainees.
Dr. Michael Kentris :I know that's a great point for people who want to beef up their skills. So there's some good training opportunities at the annual meeting.
Dr. Manasa Gunturu:Yeah, and they sponsor, they give. There is a journal of neuro-ophthalmology and if someone, a trainee, is interested and you want to nominate them, they actually sponsor for the journal for the whole year. And I have many trainees in ophthalmology and neurology here who present for the poster presentations or they do scientific studies in the conferences and we recently went to Hawaii for the neuro-optomic conference.
Dr. Michael Kentris :Oh, that's a. I mean that's a good place for a conference, right, but it sounds like so many things in medical training that a lot of times the the career pathway is uh, if there is someone in their training who models it, it seems to be more likely that you'll get someone to consider it as an option.
Dr. Manasa Gunturu:Yes, yes, and I think the main challenge for trainees to stay in touch with neuro-ophthalmology is that you know the sparsity of the number of cases which they see is that you know the sparsity of the number of cases which they see, but every time when you look at the list of the inpatient service, you see an optic neuritis, you see double vision, so at least there will be one or two cases every week. And sometimes, of course, when I'm on, that's what my trainees keep saying, that there are so many neuro-ophthalmic cases which come on but it's not something that they can leave the service, the inpatient service, saying we have not seen a neuro-ophthalmology case at all in the month, so you definitely see multiple cases every week. So continuing to include the neuro-ophthalmology skills in examining the patient and consistently reading about them because it's very easy to shy away from the complex patient by consulting ophthalmology or neurology teams, but I think the art of you know the reward or happiness in solving the case with deep history taking and extensive neuro-op exam, is probably the key.
Dr. Michael Kentris :Yeah, I think that's very important. I remember this was a few years back now I had had an inpatient consult for vision loss in one eye and he'd been transferred to our hospital because the other one didn't have neurology services. And so I go and see this guy and I'm doing his fundoscopic exam, I'm like I'm not getting a red reflex in his one eye and I'm like you need to see an ophthalmologist and he ended up having a retinal detachment.
Dr. Manasa Gunturu:Oh, wow.
Dr. Michael Kentris :And it's like you know you'd seen an emergency physician, you have seen an internist and now you're seeing me. It's like if any one of these people had just pulled out a fundus scope and looked in your eye, you wouldn't have gotten an ambulance transfer bill and a hospital admission and all this other stuff. So I mean, identifying the red reflex is not the most advanced fundoscopic skill out there.
Dr. Manasa Gunturu:Yeah, that's why I think the relative afferent pupillary defect, like RAPD, what we talk about that's another biggest skill. When you read about it or look at the video, it appears very simple. Why is it so complicated? But once we start doing it on the patients, you know I keep getting that all the time. I think there is a RAPD, so I think there is not. But our goal is to make sure that the trainees feel confident in saying that there is not, rather than wondering if it is there or not.
Dr. Michael Kentris :Right.
Dr. Manasa Gunturu:So that's another thing which we also focus because that's a very good objective way when we talk about functional vision loss patients as well, because not all the times the fundoscopic exam has to be abnormal. It could be a retro-orbital process, but if they have a relative afferent pupillary defect, I think that is a big key and you don't even need to wait for imaging to start treating those patients. You can go ahead and treat them because you have an objective finding.
Dr. Michael Kentris :Absolutely. Those are great points. Any final thoughts or resources that you would direct people towards if they want to learn more about neuro-ophthalmology, or maybe they aren't at an institution that has a neuro-ophthalmologist available to work with?
Dr. Manasa Gunturu:very invested in Novel, which is a video resource. So they collect examination videos from different neuro-ophthalmologists and put in that library and that is a very good resource to keep checking on any neuro-ophthalmic skills, learning skills or also diplopia examinations or relative afferent pupillary defects all the things which we've talked about. That's a very good resource, I would say, if you don't have a local neuro-ophthalmologist which you go to. But otherwise there are many different societies, like even local societies, not the national one, but there are some local societies which conduct symposiums and workshops as well. And our university, we do lecture series with faculty, but also we use the flipped classroom technique for the residents where they teach each other and also they prepare a huge slideshow and PowerPoint teaching the other residents as well. It may include a lot of board questions in it and reading about these scientific studies, especially from Journal of Neuro-Optimology and in American Academy of Neurology, like the Green Journal also, there are many research projects based on neuro-ophthalmology as well in it.
Dr. Manasa Gunturu:So the other thing which we are trying to incorporate is an outpatient sim lab session with real patients. So neuro-ophthalmology is not a field which they can simulate, so we are trying to get real patients who can come to the sim lab sessions and let our residents examine them. We've created a sim lab session for emergency neurological situations where we simulate a stroke. We simulate someone actively seizing being in status. But this is something which we are trying to incorporate. And other thing which I always do for my trainees and medical students when they come, is I email them review articles. So we just saw yesterday like a downbeat nystagmus. So when we see downbeat nystagmus, what are the things which we have to evaluate? Well, it's not just ordering an MRI, it's also looking for other things. Of course, when it's downbeat, we try to localize it to the posterior fossa pathologies, but there could be many different things, as simple as a B12 deficiency, which can give it, or a thymine deficiency, which can give as well.
Dr. Manasa Gunturu:So I think looking for those review articles and reading about what all could be included, what all the etiology is in it, and learning from each patient definitely is something which you'll never forget.
Dr. Michael Kentris :No, I think that's great. It's very, very old school bringing in the people with the actual pathology who are kind enough to volunteer their time to teach the next generation of physicians. That's always great to hear.
Dr. Manasa Gunturu:Yeah, many of my patients, they love to do that. When I give them that idea they'll be like sure we'll be happy to come in and they let my trainees evaluate. And you know, I think they probably know it'll probably take a good bit of time when they come to your ophthalmology clinic. So most of them are very good at letting other because I think probably they understand the importance as well when they come to Neuro-Optimology because they've already seen many different providers and they come here. They get an answer. So probably that's another reason they let us help the trainees with learning Neuro-Optimology as well.
Dr. Michael Kentris :Excellent. If people want to reach out to you, find your work, where should they find you online?
Dr. Manasa Gunturu:They can find me on Facebook, twitter and Instagram as well, but on my email is mgunturu at umcedu, so that's another way to reach out to me.
Dr. Michael Kentris :I think, yeah, that'll be perfect if they can email me Any final thoughts, final call-outs for neuro-ophthalmology as a field.
Dr. Manasa Gunturu:I would say this is the best thing which I've decided in my life to take neuro-ophthalmology. I enjoy it every day. It's really rewarding. I would love to see more trainees look into neuro-ophthalmology, because many times we take neurology because we love to examine the patient and we love to think about the processes and everything, and neuro-ophthalmology actually is just an added part of that. So you would get more happiness and a rewarding feeling when you treat neuro-ophthalmic patients.
Dr. Michael Kentris :Awesome.
Dr. Michael Kentris :So, pippu Ray, please do take neuro-ophthalmology no it's great to talk with someone so passionate about their field and such a good advocate for instruction in these skills, even for people who aren't going into the field. Thank you again for coming on and talking with us about neurophthalmology again today, and I'll make sure to put some of those resources in the show notes for today. You can also find me I'm also on Twitter, slash x at Dr Kentris, and then you can also find more of our stuff on the neurotransmitters website at the neurotransmitterscom. Dr Gunturo. Thank you again for your time.
Dr. Manasa Gunturu:Thank you. Thank you, Dr Kentris. It was really nice being there and talking about everything about neuro-ophthalmology.
Dr. Michael Kentris :Thank you,
