Neuro-Ophthalmology

Supervisors

  • Dr. Edward Margolin, Fellowship Director
  • Dr. Megumi Iizuka

Contact Information

Dr. Edward Margolin
Email: EMargolin@mtsinai.on.ca

Location

  • Mount Sinai Hospital
  • St. Joseph's Hospital
  • St. Michael's Hospital
  • UHN - Toronto Western Hospital


Introduction
Neuro-ophthalmology is the subspecialty or ophthalmology and neurology that studies and treats the disorders of the eye, orbit and the nervous system. Neuro-ophthalmologists evaluate and manage patients with the complex and severe disorders involving any part of the visual pathways in both children and adults.  The scope of the clinical practice of neuro-ophthalmology varies as it blends the skills of two disciplines: neurology and ophthalmology.  The purpose of the fellowship training in neuro-ophthalmology and this fellowship, in particular, is to train a fellow about the pathophysiology and management of a wide spectrum of neuro-ophthalmic disorders through intense and focused training with the preceptors with backgrounds in adult and pediatric ophthalmology and neurology. 

At the end of the fellowship, the fellow will also be able to manage complex surgical strabismus cases in patients with neuro-ophthalmic disorders.  The fellow will also be proficient in evaluating neuro-imaging (CT, MRI and angiography) of the head and neck as it relates to the diagnosis and management of neuro-ophthalmic disorders. 

 

Fellowship Objective
The main objective of this unique fellowship is to train an academic neuro-ophthalmologist who will become a leader in the field, comfortable in managing a wide variety of ambulatory and in-patient adult as well as pediatric neuro-ophthalmic conditions and in managing surgical strabismus cases arising from the practice of neuro-ophthalmology.  They will achieve this through the continuous learning from their mentors whose clinical practices cover all aspects of adult and pediatric neuro-ophthalmology and whose backgrounds are in ophthalmology and in neurology.
 

Admission Requirements
Only individuals who have completed a residency training approved by the AGCME in ophthalmology or neurology in the US of Canada will be considered for the fellowship. International applicants will be considered on an individual basis and their residency training would have to be deemed equivalent to that of the US and Canadian applicants.

 

Duration and Scope of Fellowship
The fellowship will consist of a minimum of twelve months of clinical training including two weeks of vacation.

 

Weekly Schedule
While somewhat flexible, on a weekly basis a fellow will be expected to attend the following clinic/operating rooms. All clinics start at 8 am and finish at 5-6 pm unless otherwise specified.  The fellow will be carrying a pager at all times and will be encouraged to interact with the residents on call in all of the academic hospitals in the University of Toronto system to discuss emergency cases and to see them in clinic if necessary.

Monday:  Clinics with Dr. Margolin or OR with Dr Iizuka
Tuesdays: Clinic with Dr. Margolin
Wednesdays: Clinic with Dr. Iizuka
Thursday: Clinic with Dr. Margolin
Fridays: alternating operating room with Dr. Iizuka + neuro-radiology conference in the afternoon or clinics at Toronto Western Hospital or Mount Sinai Hospital with Dr. Margolin in am and neuro-radiology conference in the afternoon.
 

Other requirements to be completed by the end of the fellowship
The fellow will be required to complete at least one prospective research project by the end of the fellowship and present the findings at the annual Department of Ophthalmology and Vision Science Research Day. The results of the project have to be published.

The fellow will be strongly encouraged to publish case reports and develop educational projects throughout the fellowship and would be expected to have at least three publications in press (in addition to their prospective study) at the end of the fellowship.

The fellow will also be strongly encouraged to compile a collection of cases by the end of the fellowship in PowerPoint format covering a wide variety of neuro-ophthalmic disorders that they have encountered throughout their training with representative clinical history, diagnostic and imaging studies, and the results of the investigations. This collection will serve as the foundation for their teaching dossier upon commencing of their own practice.

 

Evaluation of Fellow’s Progress
Formal evaluation of the fellow’s progress throughout the fellowship will occur quarterly with the mid-year evaluation submitted to the Faculty of Medicine Postgraduate Medical Education Office. Regular information evaluations will occur throughout the fellowship with the intention of guiding the fellow to achieve the stated objectives of the fellowship.
 

The following are different CanMeds proficiencies that the fellow would have to master throughout the fellowship

MEDICAL EXPERT
Throughout the fellowship the fellow will participate in clinical discussion, rounds and conference in a manner that promotes the spirit of inquiry and scholarship with in depth understanding of basic mechanisms or normal and abnormal states and the application of the most current and evidenced-based knowledge to practice.

Throughout the fellowship, the fellow will continue to develop neuro-ophthalmology examination skills and will regularly perform evaluations, including history and examination of children and adults, which will involve the full ophthalmological and neurological examinations. The fellow will understand the indications and the evaluation of the results of the diagnostic technology in neurology and ophthalmology, including but not limited to:

  • Testing of the visual function (manual perimetry, automated perimetry, contrast sensitivity, color vision, etc).
  • Neuro-imaging (MRI and CT.
  • Ocular electrophysiology (including visual evoked potentials, electroretinography, electro-oculography, and recordings of the ocular movements).
  • Ultrasound—A scan, B scan and duplex Doppler ultrasound as they apply to neuro-ophthalmology.

The fellow will be knowledgeable about the indications and the use and limitations of pharmacological, radiological and surgical therapies that may be used for adult and pediatric patients with neuro-ophthalmic disorders.

The fellow will be exposed to a broad variety of adult and pediatric neuro-ophthalmological disorders with the following minimal number of cases seen within twelve months:

  • Neuro-ophthalmic clinical cases: 500
  • Complete examinations: 250
  • Visual fields: must perform at least one manual and one automated visual field
  • Afferent visual pathway disorders (NA-AION, A-AION, optic neuritis, optic atrophy from any cause, congenital disc anomalies, papilledema, compressive optic neuropathies, idiopathic intracranial hypertension, optic chiasm disorders): 100.
  • Efferent pathway disorders (including disorders of the pupil, lid, ocular motility, nystagmus): 50.
  • Systemic disorders with neuro-ophthalmic manifestations (including multiple sclerosis, chronic progressive external ophthalmoplegia, thyroid orbitopathy, myasthenia gravis, cerebrovascular disorders, headaches): 50.
  • Surgical experience with exposure to adult strabismus surgery and performance at least 40 surgeries on extraocular muscles in patients with neuro-ophthalmic disorders.
  • Achieved competency in performing temporal artery biopsies (at least 20 cases).

 

Didactic teaching
The fellow will be required to participate in clinical conferences, didactic lectures, and journal clubs in neuro-ophthalmology and attend grand rounds in the Department of Ophthalmology.  The fellow will be required to attend and present at least a poster at the annual North American Neuro-Ophthalmological Society Meeting.

 

Teaching
Fellowship will take place in a scholarly environment with the fellow interacting daily with ophthalmology and neurology residents, fellows in other sub-specialties in ophthalmology and neurology, and medical students. Fellows will be required to participate in daily clinical teaching in the clinic with the ophthalmology residents and to present at least two formal didactic lectures to ophthalmology and neurology residents throughout the year. They will also be encouraged to participate in the lectures and group discussions of the Brain and Behavior course in the undergraduate medical curriculum.

 

 

COMMUNICATOR
Fellows will participate on a daily basis in verbal and written communication with patients, many of whom have complex and life threatening illnesses, and will be expected to present the results of their findings, discuss the proposed treatment plan and to be able to effectively answer questions in a competent and effective manner to the patients and their families.

They will encounter and learn how to deal with situations where communication with patients can be difficult and will learn how to communicate their findings to the patients with non-organic visual loss in an effective and non-confrontational manner. They will also communicate effectively with their colleagues (residents, faculty members, medical students) as well with multiple support personnel working in the clinics. They will also project professional and competent attitude in their interactions with the operating room teams.

The fellow will be required to maintain an accurate and complete documentation of every clinical encounter through the use of the electronic medical records and in paper charts where applicable.

They will be strongly encouraged to attend at least one workshop offered by the Faculty of Medicine or Ontario Medical Association on effective communication skills.

 

 

COLLABORATOR
Throughout the fellowship, the fellow will be required to complete at least one longitudinal research project. In the course of this project, they will be encouraged to collaborate with colleagues from other clinical disciplines (particularly colleagues from the Department of Medical Imaging) and the colleagues who are conducting basic science research.

Throughout the fellowship, while treating a wide variety of neuro-ophthalmic conditions fellows will be required to collaborate with the healthcare team members from other disciplines (internal medicine, oncology, radiology, laboratory medicine, physical medicine and rehabilitation, nursing, physiotherapy, occupational therapy, speech therapy, etc.). Team approach to the management of patients and the importance of an integrative and holistic approach will be emphasized throughout the training. Periodic evaluations will be conducted with the fellow throughout the training to discuss their effectiveness as a collaborator.

Fellows will also effectively work with other health professionals to prevent, negotiate, and resolve inter-professional conflicts.


MANAGER
The fellow will be exposed to the management aspects of tertiary neuro-ophthalmic practice and will be familiar with the working flow of the practice and the roles and responsibilities of multiple employees within the practice (administrative and technical staff).

The fellow will be required to direct the workflow of the technicians on a daily basis and learn how to effectively manage human resources issues while being exposed to several different practice models throughout the fellowship. They will be prepared to manage their own practice upon the completion of the fellowship.

The fellow will also recognize the importance of appropriate health care resource utilization and learn how to balance the effectiveness with optimal patient care and will apply evidence and management processes for cost-appropriate resource utilization.

 

 

HEALTH ADVOCATE
Principles of ethical and humane treatment of patients in accordance with the Code of Ethics of the American Academy of Ophthalmology and the American Academy of Neurology will be emphasized throughout the training period.

The fellow will advocate on behalf of their patients by presenting their clinical findings to the colleagues from a variety of disciplines (particularly to radiologists) to ensure timely and effective access to diagnostic and treatment modalities.

The fellow will be expected to learn the principle of healthy nutrition and modification of cardiovascular risk factors and educate the patients on a daily basis about the importance of their own involvement in health and well-being.

The fellow will understand the inter-cultural differences of the patients they see and will attempt to use these differences to improve health care outcomes in each individual case.

 

SCHOLAR
The fellow will be required to complete at least one longitudinal research project by the end of the fellowship and present the results of their project at the annual Department of Ophthalmology Research Day. They are expected to publish the results of their project

The fellow will be required to present at least one poster at the annual North American Neuro-Ophthalmological Society meeting.

The fellows will be required to participate in the didactic teaching of ophthalmology and neurology residents and present at least two formal lectures throughout the fellowship.

They will participate in the daily clinical teaching of ophthalmology and neurology residents and medical students.

The fellow will be strongly encouraged to complete a short course on statistics and biomedical research offered by the Faculty of Medicine at the University of Toronto.

The fellow will be required to research the literature as it applies to unusual and difficult cases encountered in the clinics and to present their findings to the faculty and residents.

The fellow will be required to acquire a collection of clinical teaching cases that they have encountered throughout the fellowship on different aspects on neuro-ophthalmology (including clinical presentation, results of various diagnostic and imaging studies and clinical outcomes). This collection should be created in PowerPoint format and presented to the all fellowship preceptors at the presentation during the last month of the fellowship. Fellows will be encouraged to collaborate with the residents in acquiring their collection as well as with their colleagues at the Department of Medical Imaging.

 

PROFESSIONAL
The fellow, through observation of the faculty mentors throughout the duration of the fellowship, will demonstrate a commitment to the patients and their profession and society at large through strict adherence to ethical standards and moral code. They will attempt to participate in the process of self-regulation through the review of the policies of the College of Physicians and Surgeons of Ontario. They will also learn through observing their mentors the importance of their commitment to their own health and sustainable practice.

 

OUR PAST FELLOWS:

Dr. Jasmin Gopwani--neuro-ophthalmologist at West Indies University School of Medicine

Dr. Kinda Najem--neuro-ophthalmologist at the University de Montreal

Dr. Cindy Lam--neuro-ophthalmologist at the University of Toronto, Dept. Ophthalmology