April 21, 2025 • 47 mins
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.
Dr. Gunturu also serves as Section Editor for the NOVEL NANOS Illustrated Curriculum, and they’ve been working hard to build a virtual education library!
The annual NANOS (North American Neuro-Ophthalmology Society) conference is another fantastic opportunity for students and residents to get more involved in the field of neuro-ophthalmology.
- Check out our website at www.theneurotransmitters.com to sign up for emails, classes, and quizzes!
- Would you like to be a guest or suggest a topic? Email us at contact@theneurotransmitters.com
- Follow our podcast channel on 𝕏 @neuro_podcast for future news!
- Find me on 𝕏 @DrKentris
The views expressed do not necessarily represent those of any associated organizations. The information in this podcast is for educational and informational purposes only and does not represent specific medical/health advice. Please consult with an appropriate health care professional for any medical/health advice.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Michael Kentris (00:02):
Hello and welcome to the Neurotransmitters
, your source for everythingabout clinical neurology.
I'm your host, Dr MichaelKentris, and today we are
talking aboutneuro-ophthalmology.
To help us out with thissubject, we have Dr Manasa
Gunturu, an associate professorin neurology and
neuro-ophthalmology from theUniversity of Mississippi
Medical Center, where she isalso the director of the Adult
(00:24):
Neurology Residency Program.
Thank you so much for joiningus today.
Dr. Manasa Gunturu (00:29):
Thank you, dr Kentris.
Hi everyone, I'm Manasa Gunturuand I'm a neurology-trained
neuro-ophthalmologist.
I work in the University ofMississippi Medical Center.
This is my first time to bedoing a podcast with the
Neurotransmitters team.
I'm so excited.
I feel very honored andthrilled for this opportunity
(00:51):
and I appreciate having me hereand talk more about
neuro-ophthalmology.
Dr. Michael Kentris (00:56):
And we are so glad to have you on.
Neuro-ophthalmology is not asubject we have delved into in
particular depth, so can we juststart out with kind of a broad
strokes definition of what wouldwe consider neuro-ophthalmology
?
Dr. Manasa Gunturu (01:09):
Sure, yeah, I mean neuro-ophthalmologists
treat patients with complexneurological conditions that
affect the visual system.
So we see many patients withactually acute disease that may
be vision threatening or couldbe life threatening too.
So it is, I would say, a verycognitively challenged field but
(01:33):
it's very rewarding, mainlybecause, I would say, many of
the times we come to a diagnosiswith very deep history taking
and very extensive examinationskills.
I keep talking to my patients alot and you know they say, oh,
(01:54):
no one has asked me thisquestion before.
So that comes out many of thetimes during the encounter.
So it definitely feels veryrewarding to take care of the
patients.
Dr. Michael Kentris (02:05):
Excellent.
So, as you mentioned, you saidyou're a neurology-trained
neuro-ophthalmologist.
So, first of all, what drew youin out of the many
subspecialties that areavailable to neurologists?
What brought you intoneuro-ophthalmology specifically
?
Dr. Manasa Gunturu (02:22):
So for me, I would say, the main reason
which dragged me intoneuro-ophthalmology specifically
.
So for me I would say the mainreason which dragged me into
neuro-ophthalmology is becauseof my mentor, who is Dr Corbett.
He retired in my second year oftraining in neurology residency
and he used to supervise mycontinuity clinics.
(02:44):
So every week on fridayafternoon I used to go to the
clinic and any patient I seeeven if they come with epilepsy
or, you know, stroke he used toshow me some neuro-optomic
findings in them.
That was like so exciting so Iused to wait to go to that
clinic and so I'm one of thefive residents who actually
(03:08):
decided in second year itselfwhat fellowship I want to take.
So that has helped me a lotbecause I had a lot of planning
ahead of time.
I knew what I wanted and hementored me along with Dr Parker
, who is anotherneuro-ophthalmologist at the VA.
They have been the people whoguided me all through and made
(03:31):
me decide what I wanted to be.
Dr. Michael Kentris (03:33):
And I know you mentioned that
neuro-ophthalmology deals a lotwith visual issues what kind of
patient population are youseeing most often?
Dr. Manasa Gunturu (03:44):
What kind of patient population are you
seeing most often?
So I see many different kindsof patients, mainly like they
might have a vision issue, whichpeople you know it's more like
a subjective vision loss orcould be double vision or could
be more of a visual fieldeffects or could be more of a
(04:07):
visual field effects, and manyof the times it's more that when
they come to yourophthalmologist they probably
have seen optometrists,ophthalmologists, and they
probably have seen neurologists.
So there is a lot of recordreviewing we have to do because
we obviously don't want torepeat the same kind of workup
which was done before.
So we go through a bunch ofrecords and review what all has
been done in the past.
(04:28):
So they could have beendiagnosed having an optic nerve
problem and they try to seek thehelp of their ophthalmologist
to figure out what is the causeof that optic nerve problem.
Or it could be more that theydon't find anything else but the
(04:49):
patient complains thatsomething is wrong.
So that's I would say half ofthe patients I see will be more
like we don't know what's goingon, but the patient is not happy
.
So sometimes it could be veryvague that they have pretty bad
headaches and that could also bea neuro-ophthalmic issue.
(05:11):
So it's a wide variety ofpatients which come, and also
droopy eyelids is another thingwhich comes to
neuro-ophthalmology.
Many of the times they mighthave had surgeries before for
the droopy eyelid, but later on,of course, on examination we
(05:31):
also evaluate if it was acranial nerve problem or is this
a local muzzle issue.
Dr. Michael Kentris (05:36):
Gotcha.
So one of the complaints you'rementioning like kind of the
non-specific, like blurredvision or visual impairment,
would this kind of fall intolike the family of like
functional neurologic disorders?
Dr. Manasa Gunturu (05:51):
So, yeah, functional neurologic disorders
is definitely an interesting oneOnce we evaluate and usually it
will take probably another oneor two visits before we consider
functional vision loss as theetiology.
First, of course, our goal isto make sure that there is no
clear-cut reason that could betreatable as the initial cause
(06:16):
of the issue and functionalvision loss is.
It could be more of amalingering or it could be more
that you know, it could be anexpression of the stress they're
going through.
So that is another, probablyanother one hour or two hour
session talking about functionalvision loss, but yeah, mainly
(06:40):
if it's related to astress-related cause.
But I think our goal is tofirst ensure that it is not a
treatable reason.
Dr. Michael Kentris (06:51):
Gotcha.
So let's say someone's beenreferred to you.
They've been having some sortof let's just say diminished
visual acuity for X number ofmonths.
They've had an eye exam from anophthalmologist, They've had
MRIs of their brains and orbits,and now they're showing up in
your office and what kind ofquestions are you asking them
(07:15):
beyond kind of the standardthings?
What kind of investigation goesinto these patients?
Dr. Manasa Gunturu (07:21):
Sure, yeah.
So in the history itself, ofcourse we always go through the
timeline and also see aboutprogression and is it an acute,
you know, sudden onset or it'smore of a progressive kind of
issue?
And what other associatedfeatures are there?
Is someone having headaches oris someone having more of an
(07:45):
infection which was a prodromebefore the symptoms started?
Double vision, and we alwaystry to focus on the neurological
symptoms as well, so any focalweakness in the arms and legs.
So I think if they have seenophthalmologists, the
neuro-ophthalmic examinationwill also include the
(08:08):
ophthalmology part but also theneurological part.
So we do a completeneurological exam as well and we
do tests like visual acuity,color vision and checking the
intraocular pressure.
And also deep testing involvesvisual fields, humphrey visual
fields and OCTs, the opticalcoherence testing.
(08:30):
So the OCTs, we do it off theoptic nerve and also the macula,
so some of them we might haveto go further getting the
autofluorescence or alsofluorescein angiograms.
And in the past, like during mytraining, we had the testing of
(08:50):
ERG and also VEP, visual evokedpotentials and
electrorechnograms.
So I did my training at BascomPalmer and we had a whole
department with theelectrodiagnostic testing as
well.
So it was really good that youknow, once we start the testing
(09:10):
we first go to the first year ofone's examination and then the
first year kind of testing withthe OCTs.
So if we need to go furtherthen we go to the next levels.
So our goal definitely is tofirst find out if there is
anything concerning going on andonce we see that then we go
further to come to a diagnosisand the MRI is done in different
(09:33):
places.
But I think always I like tosee my own MRIs, so once I don't
rely on the report.
So that's another thing which Icommonly see.
Dr. Michael Kentris (09:47):
I'm guilty of the same.
Dr. Manasa Gunturu (09:50):
So that is another thing which we really
want the patients to get the MRIso that we can look through,
and also we have a team ofneuroradiologists.
So that's the other good partwith neuro-ophthalmology is like
it's more a collaboration ofyou partnering with different
teams.
So you partner withneurosurgeons, you talk to them,
(10:11):
you partner withophthalmologists,
rheumatologists,neuroradiologists, and if there
is anything emergency, obviouslyyou talk to the ER team and let
them know what's going on andthe patient goes to the hospital
and gets further work done.
I talk with internists and ENTspecialists.
So that's the good part ofneuro-ophthalmology that if you
(10:34):
have to practice neurology as awhole and you don't want to
focus on a single disease, Iwould say neuro-ophthalmology is
the go-to thing.
Dr. Michael Kentris (10:44):
No, that's a good point.
It sounds like definitely a lotof diagnostic testing goes into
some of these more esotericdiseases, and so during a
neuro-ophthalmology fellowship,you are getting all these
training in, like theseneurophysiologic as well as
different imaging modalities aswell.
Dr. Manasa Gunturu (11:05):
Yeah.
So neuro-ophthalmologyfellowship, I would say it's a
different field, based on howmuch training you get during
your residency.
So as a neurologist you don'tuse a slit lamp, right?
So when you go intoneuro-ophthalmology fellowship,
of course they expect you to usethe slit lamp and they expect
(11:25):
you to do refractions.
So the first few months I feltlike I was back to medical
school again, learning from allmy basics.
So that was a very interestingexperience.
So I tagged along with manytrainees who were in their first
(11:45):
year of training too, but theywere the ones who taught me how
to even if I identify thepicture of the optic nerve is it
the right optic nerve or theleft optic nerve?
So they gave me easy techniquesto learn that.
So it was not just that I waslearning from the
neuro-ophthalmologist, I wasactually learning from many of
my colleagues who were sittingthere on the team and I was
learning from theneuro-ophthalmologist.
(12:06):
I was actually learning frommany of my colleagues who were
sitting there on the team and Iwas learning from the
technicians how to check thepressure, how to take the visual
acuity in the appropriate way,how to do the refractions.
So that was a very interestingand humbling experience during
fellowship Because many othersubspecialties in neurology you
know, if it comes to stroke orepilepsy, you've already read
(12:27):
EEGs during the training.
So it's more, you go to thenext step from that.
But in your ophthalmology Ifeel like you start again from
your basics and by the end ofthe year you go deep down into
reading OCTs and also VEPs.
So it's a very broad trainingwhich you get in
(12:49):
neuro-ophthalmology.
Dr. Michael Kentris (12:50):
Yeah, it certainly sounds like it, and
that brings me back to somethingyou said at the beginning right
?
So a neurology-trainedneuro-ophthalmologist, implying
that there are other paths tobecoming a neuro-ophthalmologist
as well.
Dr. Manasa Gunturu (13:03):
Yeah, so ophthalmologists are actually a
chunk of theneuro-ophthalmologists who did
their training in ophthalmologyand they became
neuro-ophthalmologists.
So there are multiple surveys.
If you go and look into theliterature which they've done to
see what can get more peopleinterested in
(13:24):
neuro-ophthalmology.
So in those surveys at leasttwo-thirds of them have their
background in ophthalmology.
So it's only one-third of theneuro-ophthalmologists have
training in neurology.
So that was a very interestingsurvey which makes us think what
changes can we make in theneurology education to help more
(13:46):
neurologists go into thisinteresting field?
Dr. Michael Kentris (13:49):
That is a good question.
What have the surveys showed usso far?
Dr. Manasa Gunturu (13:55):
So I think the one which I say in
ophthalmology it's a requirementthat they have to do
neuro-ophthalmology rotation.
So at least three months ofneuro-ophthalmology is what they
focus in the four years oftraining.
But in neurology for us it'snot a required rotation.
(14:16):
So if you have aneuro-ophthalmologist, that's
awesome, that's well and good,so you go and probably do a few
days or weeks of training in theclinic rotation or something,
but it's not a required rotationfor neurology residents.
I would say that is one bigthing which people probably will
(14:37):
make them more interested intoneuro-ophthalmology if that
could be included into theneurology residency training.
Dr. Michael Kentris (14:44):
No, that's a good point.
I know when I was a resident wehad a physician on staff who
was a neuro-ophthalmologist, butprobably still that was only
like a third of his practice.
He was still doing generalophthalmology.
So I would go on rotation for afew weeks and unfortunately you
know from my experience wewould see, like you know, your
(15:05):
idiopathic intracranialhypertension and things like
that, but not a lot of the moreunusual or more challenging
cases that probably come to apure neuro-ophthalmologist I
would imagine.
Dr. Manasa Gunturu (15:17):
Yeah, I think that's.
The thing is like.
You don't see these complexneuro-ophthalmic cases on a
daily basis.
Don't see these complexneuro-ophthalmic cases on a
daily basis, so you wouldprobably see them once in every
few days or maybe in a week'stime.
You will see a few cases, butthose are very important ones
which probably a neurologistalone by themselves or an
(15:38):
ophthalmologist alone bythemselves will not be able to
solve that situation.
So I think getting thatexposure is the most important
part.
As you said, diagnosingpapilledema or with IIH is
probably more the bread andbutter cases for
neuro-ophthalmology, but themore need of
neuro-ophthalmologists come inin the clinical decision-making.
(16:00):
Who are the ones which you justtreat with medication?
Who are the ones which youdecide they have to go for
surgery for it?
In the same way, who are theones who you decide, oh, this
person needs a scan right away?
So that clinicaldecision-making is probably the
best thing forneuro-ophthalmology.
Dr. Michael Kentris (16:19):
No, that's very helpful, because it does
start to get a little no punintended a little fuzzy when
someone's starting to lose thevision.
It's like how fast do we needto act on this?
Do we have a little bit ofleeway in terms of medication
management or weight loss, aswhatever the cause may be?
So yeah, it does.
(16:40):
I know in my practice.
I had a case not too long agowhere I was, you know, in close
touch with the ophthalmologistwho was seeing this patient who
had, thankfully, asymptomaticbut papilledema, and we ended up
finding out she was taking like300% of the daily recommended
vitamin A and a multivitamin.
(17:01):
So it's sometimes, yeah, you canget away with avoiding anything
too severe, but sometimes thevision starts going pretty
quickly.
Dr. Manasa Gunturu (17:08):
Exactly.
I think those are the pointswhich we cover very deeply in
the history taking.
So I don't want to say you knowthat many people miss it, but I
think it's just some of them.
Might you know the question?
The way it's asked alsoprobably makes a difference.
If you just ask a multivitamin,maybe not everyone, the patient
(17:30):
might not realize what we areasking.
So I think going more deeply orasking in a way that they
understand, or giving morereasoning behind the question,
probably helps them to get theanswer out.
Dr. Michael Kentris (17:45):
Mm.
Hmm, yeah, you're absolutelycorrect.
I think I had to ask aboutthree times before I got the
answer that, oh yes, I do takelike a vitamin or a supplement
or something like that, and soit really does.
The wording does matter.
I'm starting to move into mymid-career phase so I have more
(18:30):
gray in my beard, but we don'tsee as much emphasis necessarily
on mastering the fundoscopicexam anymore and I work mostly
with non-neurology residentsthese days and I would say
outside of neurology it's evenmore exacerbated.
So I know you've done some workon this field, but what are
your thoughts about the currentstate of education and skill in
use of doing the directfundoscopic exam and what can we
do to help improve that?
Dr. Manasa Gunturu (18:48):
I know.
So that's another thing youknow when I'm on service.
All my residents know thatthat's definitely a question
which I'll ask If a patient hascome with a headache, my next
question will be did you do thepanoptic exam or a fundoscopic
exam?
And you know it depends on whattheir background training is.
(19:09):
So if it's an ophthalmologyresident I'm working with, so my
set of questionnaire is totallydifferent to them because they
are have a very good skill setof evaluating the optic nerve
and differentiating.
Is this a drizzle or is thisreal papilledema?
Is this real papilledema?
But if it's a trainee with adifferent background either
(19:33):
neurology, neurosurgery or ER soour goal is to help them out of
how to identify the optic nerveexamination.
So I definitely go through indetail all to my trainees in
(19:54):
neurology and also in themedical school education as well
.
So we have a lot of medicalstudents who come and work with
us in neurology andophthalmology so I make it a
point that we go through how todo the fundoscopic exam.
So I don't know about thedirection down the lane because
now we have a lot more uhexamination tools which we did
(20:15):
not have during our training.
So we used to rely only onpanoptics or the direct
ophthalmoscopes, but now thereare many non-mydriatic devices
where the patients don't need tobe dilated but you get a good
picture of the optic nerve.
So from that standpoint butdefinitely the direct
(20:36):
ophthalmoscopic exam withoutdilating the patient is a skill
which I always tell them.
It's probably very similar todoing a lumbar puncture.
So when we do a lumbar puncturewe spend a lot of time about
positioning, but once the needlegoes in it's very easy.
The fluid comes out.
But we have to spend a good bitof time of positioning the
(20:59):
patient for the fundoscopic examBecause once you're at the
right position, seeing the opticnerve is very easy.
So that's the other thing whichwe go through during the
training and recently I did asim session for 48 ER residents,
so all the residents from firstyear to third year.
(21:20):
We did a session and by the endof 15 minutes each one of them
was able to see the optic nerve.
So I think understanding thetechnique is the most important
thing in that and, of course,once you see the optic nerve,
also identifying the pathologyof what the problem is or is it
a normal looking optic nerve.
So the more we keep seeing, themore we do the exam on
(21:44):
different people.
That is when we'll understandthat.
So I think practice isdefinitely the key for doing
this optic exam and also, Iwould say, holding the panoptic
and not missing them duringrounds is the other important
thing.
I've done it myself, where Ikeep holding the case of the
(22:07):
panoptic and, you know, in onepatient's room I forget it and I
don't take it to the next, andthen we come back and pick it up
, but because it's a big deviceso we have to remember to take
it and carry it over.
Dr. Michael Kentris (22:21):
Absolutely .
I know when I was a resident Ifound some of my most useful
rotations were my childneurology rotations when I was
starting out, because all thosekids just had such big pupils
that you couldn't miss.
So it definitely helped buildconfidence and the positioning
(22:41):
part kind of like some of thosekids riding a bucking bronco but
I think it helped raise myskills up a little bit.
So I strongly advocate formaking the best of your child
neurology rotations as well.
That's true.
Dr. Manasa Gunturu (22:58):
So the best way I would say to strengthen
the neuro-ophthalmology skillsduring residency or medical
school training is toincorporate the detailed exam of
those cranial nerves like two,three, four and six into the
neurological exam, right?
So if we incorporate thisneuro-ophthalmic skills and
education about the pathologies.
(23:19):
So here in the University ofMississippi we include
neuro-ophthalmic emergencies inthe bootcamp sessions.
So we do a month of boot campsession for first year neurology
residents going into secondyear.
So the last month in June.
So that's another place whereit's not just about explaining
(23:41):
the pathologies, we also gothrough how to examine the optic
nerve and also how to examine apatient with double vision, how
to examine the lid when ptosishappens.
And these sessions are not onlyfor neurology, we do it for
ophthalmology residents andrecently we started doing for
the emergency medicine residentstoo.
Dr. Michael Kentris (23:58):
That's excellent.
So we've been focusing a lot onthe vision itself, but let's
talk about double vision alittle bit.
Obviously.
There are many causes.
Let's talk about double visiona little bit Obviously.
There are many causes.
So when you're trying to teacha framework to a resident for
double vision, how do youtypically approach that?
Dr. Manasa Gunturu (24:18):
So for double vision, definitely, I
think the first thing we alwaysinclude is coming again back to
history.
So we spend a good bit of time.
So by the end of the historytaking 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.
(24:42):
There Is the double vision.
Obviously.
First thing we have to establishif it's unilateral or it's a
binocular double vision.
Have to establish if it'sunilateral 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, thenyou'll be like, okay, I think
(25:05):
you have a refractive error oryou have a cataract or something
not neurologic for the doublevision.
And once after that we try tofigure out is it for near, is it
for distance, is there any onespecific gaze?
Does the double vision getworse?
So with that information andalso seeing if they have
associated droopy eyelid or inthe face, if you see any facial
droop, so many of the otherassociated clinical diagnoses
(25:27):
helps us to come to theconclusion.
Other associated clinicaldiagnoses helps us to come to
the conclusion.
So, on examination in the ERexamination for double vision is
a little different when itcomes to the clinic, where we
have much more devices we haveprisms, we have Maddox rods, so
it gets more easier.
And also evaluation ofnystagmus is another thing.
So there is definitely doublevision is something which we can
(25:52):
spend an hour on it as well inthe clinic to evaluate and also
help the patient.
That solving a case of doublevision and also treating the
patient is definitely veryrewarding because the patient
obviously gets extremely happyonce they start seeing single
and also all their symptomsimprove.
Dr. Michael Kentris (26:11):
What's your initial reaction if a
patient comes in?
They have binocular, I shouldsay bilateral, monocular
diplopia.
Dr. Manasa Gunturu (26:23):
What is my initial reaction?
Dr. Michael Kentris (26:29):
I was just going to say.
Unfortunately, I see thatcomplaint a bit often in the
hospital and the workup tends tobe, let's just say,
underwhelming at times.
Dr. Manasa Gunturu (26:40):
Yeah, so if it's bilateral but monocular,
double vision, definitely youknow it won't take one hour to
see the patient.
Dr. Michael Kentris (26:54):
That's a reasonable assessment.
Now, and this is, you know,partially tongue-in-cheek,
partially for my own edification.
Now, I will sometimes getpatients in and they'll have,
they'll say that they're seeinglike triple or quadruple is
there any reasonable way forthat to physiologically occur?
(27:15):
Is that more likely it's goingto be in that kind of more
functional territory?
Dr. Manasa Gunturu (27:21):
you know it probably can, or it probably
again if it's monocular orbinocular is another thing which
we have to assess.
I've seen that multiple timeswith a refractive error or
someone has a corneal disease ormaybe has cataracts, so that
could be another factor whichneeds to be taken into
(27:44):
consideration.
Dr. Michael Kentris (27:45):
Gotcha.
No, that's fair, that's fair.
Sorry, a little tongue-in-cheekon my part, gotcha.
No, that's fair, that's fair.
Sorry, a little tongue-in-cheekon my part.
So in your experience, you'reteaching a broad array of
(28:13):
learners inuity, the eyemovement, coordination, all
these kinds of things.
I know there's a lot, literallya lot of moving parts to the
visual process.
What are the things that youtend to find learners struggle
with the most?
Dr. Manasa Gunturu (28:28):
I think the main thing is it could be more a
simple thing that how tooperate many of the equipment.
Again, it comes with some ofthe neurological associated
(29:01):
symptoms, even like headache.
So it could be more simple likea toothache giving a headache.
So I think that differentiationwe can see.
Or is it neck pain giving theheadache?
So which could be?
We can tease that out byobviously asking more questions
from the history taking.
(29:21):
But when it comes to a neurologytrainee, I spend a lot more
time in identifying what theabnormality of the optic nerve
is, or how to assess the doublevision evaluation, or how to
interpret the visual fieldtesting, how to interpret the
(29:44):
OCT testing, how to do a B-scan.
So there are many differentthings I think each side we can
learn from each other.
So there are many differentthings I think each side we can
learn from each other.
So that's what I was telling.
Like during your fellowshipalso, you learn a lot from your
co-fellow who has a differentbackground training.
Or you can learn a lot fromoptometry residents who are
there or how to make, how to seewhat amount of prism is needed.
(30:11):
So each one has their ownexpertise.
Dr. Michael Kentris (30:14):
That's a great point to emphasize.
Yeah, I know, as a med studentI spent some time on
ophthalmology as well, and Iremember the doctor gave me a
book it was a short book,thankfully, but it was just
called Optics and I ended upreading 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 thiswhole book over the course of a
rotation, and it was.
I mean, I've always been, youknow, kind of interested in
(30:36):
physics, but it is compared to,like neurology training.
If you haven't done that in thepast, it is quite foreign.
Dr. Manasa Gunturu (30:45):
Yeah, definitely.
I mean, optics is like as yousaid it's.
I'm thankful that it's a smallbook, but when I started to
learn how to do refractions, itwas just mind-boggling to me,
like how much time you can spendon this.
Actually, it's almost like theneurology examination you can
(31:06):
spend an hour on it or, if youget good at it, maybe you can
spend just 10 minutes on it andcome to a conclusion.
Dr. Michael Kentris (31:13):
Now, one thing you have been pointing out
.
Right, you know it's the 21stcentury.
Most neurologists aren'tcarrying around drops in their
little black bags anymore, somost of the time we're talking
about although you know, theboard exams still love to ask
those questions, about thoseright, I don't have any cocaine
(31:34):
on me today.
But it does become like theseolder patients in particular,
like someone in their 80s, maybeeven 90s, where they have these
two, three millimeter pupilsthat don't really dilate on
their own, even in a nice darkroom.
Dr. Manasa Gunturu (31:53):
Yeah.
Or maybe they have kind of apartial cataract, and are there
any patients that you just youknow, you can't really see the
optic nerve very well because ofthe anatomy, like, let's say,
we're not in the office, we'resomewhere in the hospital or
probably being neurology trainedneuro-ophthalmologist, I try
(32:19):
not to dilate, mainly because ofyou know, once you dilate,
definitely you want to make sureyou have the expertise to
evaluate the retinal exam andsee different parts of the rest
of the, not just focus on theoptic nerve exam.
But when it comes to thehospital setting, I think I
(32:39):
would still say, as the years goby during training, the first
thing I've learned is to examinewith the indirect
ophthalmoscope without dilation.
Because once you get expertisein doing the undilated exam,
obviously it's very easy whensomebody is dilated to examine
(33:01):
them.
So if it's the other way around, the struggle is much more
harder.
Is how I felt.
So right now I would say most ofthe 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 ifthey were dilated before and the
(33:23):
eye is quiet and there is noconcerns of angle closure,
glaucoma or there is no othercontraindication to dilate them.
If it's a kid and that's why Itell my residents maybe it's
better not to dilate the kids ifthey were not dilated before.
So try to avoid that.
But the rest of them, I think Ialways give them a picture of
(33:45):
the drops which they have toorder.
So everyone has, you know,identified what all drops they
could order on the patientswhich they need to.
Dr. Michael Kentris (33:54):
Excellent.
Now you used a phrase right nowand I like to think that I'm
pretty decent at interpretingour ophthalmology consult notes,
which are written in a veryunique shorthand most of the
time, but when the eye is quiet,what does that mean?
Dr. Manasa Gunturu (34:40):
So the eye is quiet.
Dr. Michael Kentris (34:41):
I think the main thing we try to explain
in that is, there is noconjunctival chemosis or there
is no inflammation in thevitreous, and so the eye is not
pink or red is one thing, andalso there is no inflammation
behind the pupil is probablywhat you want to tell them as
well.
Okay, that makes sense.
Okay, gotcha.
No, that's good, cause I know alot of times my residents will
come to me and they'll be likewe have this ophthalmology note
and you know it's a, it's awhole mix of acronyms and
numbers and things like that,and usually we're able to, you
know, to make our way through it.
(35:01):
It's pretty okay, but I was justwondering if there was anything
.
I mean quite I assume theopposite is, like you know, is
loud or angry.
So so I'm glad to know that Iwas, you know, in the right
territory.
Dr. Manasa Gunturu (35:13):
Yeah, and I, I think, the different kinds of
cases which ophthalmology sees.
Of course they see the worstthings which happen to the eye
as well.
So when it's a neurology or aneuro-ophthalmic case, of course
their focus is more on manyother parts of the eye exam
(35:35):
rather than what they routinelysee, because they don't worry
much about the intraocularpressure because usually that'll
be normal.
They don't worry about thecornea or you know, they don't
think there is something goingon with the vitreous or anything
like that.
So of course the point overthere is directly to focus on
the eye movements or the opticnerve.
So the rest of the thing is.
(35:55):
Quiet is probably a common termwhich they can use.
Dr. Michael Kentris (36:01):
Which is good.
It's good to know that it'sgood.
So, neuro-ophthalmologists Idon't know the numbers off the
top of my head, I imagine thereisn't a plethora of you all
throughout the country.
Dr. Manasa Gunturu (36:14):
Yeah, so in the survey exactly, I was also
trying to see how many are there, because we meet commonly in
the annual Neuro-OptimologySociety conference, which is
called NANOS, so North AmericanNeuro-Optimology Society.
So from the United States thereare 600 plus
(36:35):
neuro-ophthalmologists Wow.
Hundred plusneuro-ophthalmologists Wow.
So it's still definitely, Iwould say, a good number of
neuro-ophthalmologists.
But I think when you see howmany are practicing and how many
are there per state, I thinkthere are still few states who
don't have aneuro-ophthalmologist at all.
(36:56):
And I'm from a state where wehave only one
neuro-ophthalmologist in theentire state.
Dr. Michael Kentris (37:03):
So Is that you?
I assume yeah.
Dr. Manasa Gunturu (37:08):
So, but where I did my training in Miami
, we had sixneuro-ophthalmologists in our
institute itself and there weremany other
neuro-ophthalmologists in ourinstitute itself and there were
many otherneuro-ophthalmologists in Miami
and in Florida too.
So I think each state hasobviously a different number of
neuro-ophthalmologists, but it'sa very good, close-knit group
(37:31):
of neuro-ophthalmologists whichwe have, and the conferences are
fun and lots of interestingthings to learn and lots of
workshops as well for thetrainees.
Dr. Michael Kentris (37:41):
I know that's a great point for people
who want to beef up their skills.
So there's some good trainingopportunities at the annual
meeting.
Dr. Manasa Gunturu (37:49):
Yeah, and they sponsor, they give.
There is a journal ofneuro-ophthalmology and if
someone, a trainee, isinterested and you want to
nominate them, they actuallysponsor for the journal for the
whole year.
And I have many trainees inophthalmology and neurology here
who present for the posterpresentations or they do
(38:12):
scientific studies in theconferences and we recently went
to Hawaii for the neuro-optomicconference.
Dr. Michael Kentris (38:21):
Oh, that's a.
I mean that's a good place fora conference, right, but it
sounds like so many things inmedical training that a lot of
times the the career pathway isuh, if there is someone in their
training who models it, itseems to be more likely that
you'll get someone to considerit as an option.
Dr. Manasa Gunturu (38:44):
Yes, yes, and I think the main challenge
for trainees to stay in touchwith neuro-ophthalmology is that
you know the sparsity of thenumber of cases which they see
is that you know the sparsity ofthe number of cases which they
see, but every time when youlook at the list of the
inpatient service, you see anoptic neuritis, you see double
vision, so at least there willbe one or two cases every week.
(39:08):
And sometimes, of course, whenI'm on, that's what my trainees
keep saying, that there are somany neuro-ophthalmic cases
which come on but it's notsomething that they can leave
the service, the inpatientservice, saying we have not seen
a neuro-ophthalmology case atall in the month, so you
definitely see multiple casesevery week.
So continuing to include theneuro-ophthalmology skills in
(39:34):
examining the patient andconsistently reading about them
because it's very easy to shyaway from the complex patient by
consulting ophthalmology orneurology teams, but I think the
art of you know the reward orhappiness in solving the case
with deep history taking andextensive neuro-op exam, is
probably the key.
Dr. Michael Kentris (39:55):
Yeah, I think that's very important.
I remember this was a few yearsback now I had had an inpatient
consult for vision loss in oneeye and he'd been transferred to
our hospital because the otherone didn't have neurology
services.
And so I go and see this guyand I'm doing his fundoscopic
(40:17):
exam, I'm like I'm not getting ared reflex in his one eye and
I'm like you need to see anophthalmologist and he ended up
having a retinal detachment.
Dr. Manasa Gunturu (40:27):
Oh, wow.
Dr. Michael Kentris (40:27):
And it's like you know you'd seen an
emergency physician, you haveseen an internist and now you're
seeing me.
It's like if any one of thesepeople had just pulled out a
fundus scope and looked in youreye, you wouldn't have gotten an
ambulance transfer bill and ahospital admission and all this
other stuff.
So I mean, identifying the redreflex is not the most advanced
(40:52):
fundoscopic skill out there.
Dr. Manasa Gunturu (40:55):
Yeah, that's why I think the relative
afferent pupillary defect, likeRAPD, what we talk about that's
another biggest skill.
When you read about it or lookat the video, it appears very
simple.
Why is it so complicated?
But once we start doing it onthe patients, you know I keep
getting that all the time.
I think there is a RAPD, so Ithink there is not.
(41:16):
But our goal is to make surethat the trainees feel confident
in saying that there is not,rather than wondering if it is
there or not.
Dr. Michael Kentris (41:25):
Right.
Dr. Manasa Gunturu (41:26):
So that's another thing which we also
focus because that's a very goodobjective way when we talk
about functional vision losspatients as well, because not
all the times the fundoscopicexam has to be abnormal.
It could be a retro-orbitalprocess, but if they have a
relative afferent pupillarydefect, I think that is a big
key and you don't even need towait for imaging to start
(41:47):
treating those patients.
You can go ahead and treat thembecause you have an objective
finding.
Dr. Michael Kentris (41:52):
Absolutely .
Those are great points.
Any final thoughts or resourcesthat you would direct people
towards if they want to learnmore about neuro-ophthalmology,
or maybe they aren't at aninstitution that has a
neuro-ophthalmologist availableto work with?
Dr. Manasa Gunturu (42:10):
very invested in Novel, which is a
video resource.
So they collect examinationvideos from different
neuro-ophthalmologists and putin that library and that is a
very good resource to keepchecking on any neuro-ophthalmic
(42:33):
skills, learning skills or alsodiplopia examinations or
relative afferent pupillarydefects all the things which
we've talked about.
That's a very good resource, Iwould say, if you don't have a
local neuro-ophthalmologistwhich you go to.
But otherwise there are manydifferent societies, like even
(42:54):
local societies, not thenational one, but there are some
local societies which conductsymposiums and workshops as well
.
And our university, we dolecture series with faculty, but
also we use the flippedclassroom technique for the
residents where they teach eachother and also they prepare a
(43:17):
huge slideshow and PowerPointteaching the other residents as
well.
It may include a lot of boardquestions in it and reading
about these scientific studies,especially from Journal of
Neuro-Optimology and in AmericanAcademy of Neurology, like the
(43:37):
Green Journal also, there aremany research projects based on
neuro-ophthalmology as well init.
So the other thing which we aretrying to incorporate is an
outpatient sim lab session withreal patients.
So neuro-ophthalmology is not afield which they can simulate,
so we are trying to get realpatients who can come to the sim
(44:01):
lab sessions and let ourresidents examine them.
We've created a sim lab sessionfor emergency neurological
situations where we simulate astroke.
We simulate someone activelyseizing being in status.
But this is something which weare trying to incorporate.
And other thing which I alwaysdo for my trainees and medical
(44:23):
students when they come, is Iemail them review articles.
So we just saw yesterday like adownbeat nystagmus.
So when we see downbeatnystagmus, what are the things
which we have to evaluate?
Well, it's not just ordering anMRI, it's also looking for
other things.
Of course, when it's downbeat,we try to localize it to the
posterior fossa pathologies, butthere could be many different
(44:47):
things, as simple as a B12deficiency, which can give it,
or a thymine deficiency, whichcan give as well.
So I think looking for thosereview articles and reading
about what all could be included, what all the etiology is in it
, and learning from each patientdefinitely is something which
you'll never forget.
Dr. Michael Kentris (45:07):
No, I think that's great.
It's very, very old schoolbringing in the people with the
actual pathology who are kindenough to volunteer their time
to teach the next generation ofphysicians.
That's always great to hear.
Dr. Manasa Gunturu (45:21):
Yeah, many of my patients, they love to do
that.
When I give them that ideathey'll be like sure we'll be
happy to come in and they let mytrainees evaluate.
And you know, I think theyprobably know it'll probably
take a good bit of time whenthey come to your ophthalmology
clinic.
So most of them are very goodat letting other because I think
(45:42):
probably they understand theimportance as well when they
come to Neuro-Optimology becausethey've already seen many
different providers and theycome here.
They get an answer.
So probably that's anotherreason they let us help the
trainees with learningNeuro-Optimology as well.
Dr. Michael Kentris (45:57):
Excellent.
If people want to reach out toyou, find your work, where
should they find you online?
Dr. Manasa Gunturu (46:05):
They can find me on Facebook, twitter and
Instagram as well, but on myemail is mgunturu at umcedu, so
that's another way to reach outto me.
Dr. Michael Kentris (46:22):
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 (46:32):
I would say this is the best thing which
I've decided in my life to takeneuro-ophthalmology.
I enjoy it every day.
It's really rewarding.
I would love to see moretrainees look into
neuro-ophthalmology, becausemany times we take neurology
because we love to examine thepatient and we love to think
about the processes andeverything, and
(46:54):
neuro-ophthalmology actually isjust an added part of that.
So you would get more happinessand a rewarding feeling when
you treat neuro-ophthalmicpatients.
Dr. Michael Kentris (47:09):
Awesome.
So, pippu Ray, please do takeneuro-ophthalmology no it's
great to talk with someone sopassionate about their field and
such a good advocate forinstruction in these skills,
even for people who aren't goinginto the field.
Thank you again for coming onand talking with us about
neurophthalmology again today,and I'll make sure to put some
(47:29):
of those resources in the shownotes for today.
You can also find me I'm alsoon Twitter, slash x at Dr
Kentris, and then you can alsofind more of our stuff on the
neurotransmitters website at theneurotransmitterscom.
Dr Gunturo.
Thank you again for your time.
Dr. Manasa Gunturu (47:47):
Thank you.
Thank you, Dr Kentris.
It was really nice being thereand talking about everything
about neuro-ophthalmology.
Dr. Michael Kentris (47:53):
Thank you,
Hello and welcome to the Neurotransmitters
, your source for everythingabout clinical neurology.
I'm your host, Dr MichaelKentris, and today we are
talking aboutneuro-ophthalmology.
To help us out with thissubject, we have Dr Manasa
Gunturu, an associate professorin neurology and
neuro-ophthalmology from theUniversity of Mississippi
Medical Center, where she isalso the director of the Adult
(00:24):
Neurology Residency Program.
Thank you so much for joiningus today.
Dr. Manasa Gunturu (00:29):
Thank you, dr Kentris.
Hi everyone, I'm Manasa Gunturuand I'm a neurology-trained
neuro-ophthalmologist.
I work in the University ofMississippi Medical Center.
This is my first time to bedoing a podcast with the
Neurotransmitters team.
I'm so excited.
I feel very honored andthrilled for this opportunity
(00:51):
and I appreciate having me hereand talk more about
neuro-ophthalmology.
Dr. Michael Kentris (00:56):
And we are so glad to have you on.
Neuro-ophthalmology is not asubject we have delved into in
particular depth, so can we juststart out with kind of a broad
strokes definition of what wouldwe consider neuro-ophthalmology
?
Dr. Manasa Gunturu (01:09):
Sure, yeah, I mean neuro-ophthalmologists
treat patients with complexneurological conditions that
affect the visual system.
So we see many patients withactually acute disease that may
be vision threatening or couldbe life threatening too.
So it is, I would say, a verycognitively challenged field but
(01:33):
it's very rewarding, mainlybecause, I would say, many of
the times we come to a diagnosiswith very deep history taking
and very extensive examinationskills.
I keep talking to my patients alot and you know they say, oh,
(01:54):
no one has asked me thisquestion before.
So that comes out many of thetimes during the encounter.
So it definitely feels veryrewarding to take care of the
patients.
Dr. Michael Kentris (02:05):
Excellent.
So, as you mentioned, you saidyou're a neurology-trained
neuro-ophthalmologist.
So, first of all, what drew youin out of the many
subspecialties that areavailable to neurologists?
What brought you intoneuro-ophthalmology specifically
?
Dr. Manasa Gunturu (02:22):
So for me, I would say, the main reason
which dragged me intoneuro-ophthalmology specifically
.
So for me I would say the mainreason which dragged me into
neuro-ophthalmology is becauseof my mentor, who is Dr Corbett.
He retired in my second year oftraining in neurology residency
and he used to supervise mycontinuity clinics.
(02:44):
So every week on fridayafternoon I used to go to the
clinic and any patient I seeeven if they come with epilepsy
or, you know, stroke he used toshow me some neuro-optomic
findings in them.
That was like so exciting so Iused to wait to go to that
clinic and so I'm one of thefive residents who actually
(03:08):
decided in second year itselfwhat fellowship I want to take.
So that has helped me a lotbecause I had a lot of planning
ahead of time.
I knew what I wanted and hementored me along with Dr Parker
, who is anotherneuro-ophthalmologist at the VA.
They have been the people whoguided me all through and made
(03:31):
me decide what I wanted to be.
Dr. Michael Kentris (03:33):
And I know you mentioned that
neuro-ophthalmology deals a lotwith visual issues what kind of
patient population are youseeing most often?
Dr. Manasa Gunturu (03:44):
What kind of patient population are you
seeing most often?
So I see many different kindsof patients, mainly like they
might have a vision issue, whichpeople you know it's more like
a subjective vision loss orcould be double vision or could
be more of a visual fieldeffects or could be more of a
(04:07):
visual field effects, and manyof the times it's more that when
they come to yourophthalmologist they probably
have seen optometrists,ophthalmologists, and they
probably have seen neurologists.
So there is a lot of recordreviewing we have to do because
we obviously don't want torepeat the same kind of workup
which was done before.
So we go through a bunch ofrecords and review what all has
been done in the past.
(04:28):
So they could have beendiagnosed having an optic nerve
problem and they try to seek thehelp of their ophthalmologist
to figure out what is the causeof that optic nerve problem.
Or it could be more that theydon't find anything else but the
(04:49):
patient complains thatsomething is wrong.
So that's I would say half ofthe patients I see will be more
like we don't know what's goingon, but the patient is not happy
.
So sometimes it could be veryvague that they have pretty bad
headaches and that could also bea neuro-ophthalmic issue.
(05:11):
So it's a wide variety ofpatients which come, and also
droopy eyelids is another thingwhich comes to
neuro-ophthalmology.
Many of the times they mighthave had surgeries before for
the droopy eyelid, but later on,of course, on examination we
(05:31):
also evaluate if it was acranial nerve problem or is this
a local muzzle issue.
Dr. Michael Kentris (05:36):
Gotcha.
So one of the complaints you'rementioning like kind of the
non-specific, like blurredvision or visual impairment,
would this kind of fall intolike the family of like
functional neurologic disorders?
Dr. Manasa Gunturu (05:51):
So, yeah, functional neurologic disorders
is definitely an interesting oneOnce we evaluate and usually it
will take probably another oneor two visits before we consider
functional vision loss as theetiology.
First, of course, our goal isto make sure that there is no
clear-cut reason that could betreatable as the initial cause
(06:16):
of the issue and functionalvision loss is.
It could be more of amalingering or it could be more
that you know, it could be anexpression of the stress they're
going through.
So that is another, probablyanother one hour or two hour
session talking about functionalvision loss, but yeah, mainly
(06:40):
if it's related to astress-related cause.
But I think our goal is tofirst ensure that it is not a
treatable reason.
Dr. Michael Kentris (06:51):
Gotcha.
So let's say someone's beenreferred to you.
They've been having some sortof let's just say diminished
visual acuity for X number ofmonths.
They've had an eye exam from anophthalmologist, They've had
MRIs of their brains and orbits,and now they're showing up in
your office and what kind ofquestions are you asking them
(07:15):
beyond kind of the standardthings?
What kind of investigation goesinto these patients?
Dr. Manasa Gunturu (07:21):
Sure, yeah.
So in the history itself, ofcourse we always go through the
timeline and also see aboutprogression and is it an acute,
you know, sudden onset or it'smore of a progressive kind of
issue?
And what other associatedfeatures are there?
Is someone having headaches oris someone having more of an
(07:45):
infection which was a prodromebefore the symptoms started?
Double vision, and we alwaystry to focus on the neurological
symptoms as well, so any focalweakness in the arms and legs.
So I think if they have seenophthalmologists, the
neuro-ophthalmic examinationwill also include the
(08:08):
ophthalmology part but also theneurological part.
So we do a completeneurological exam as well and we
do tests like visual acuity,color vision and checking the
intraocular pressure.
And also deep testing involvesvisual fields, humphrey visual
fields and OCTs, the opticalcoherence testing.
(08:30):
So the OCTs, we do it off theoptic nerve and also the macula,
so some of them we might haveto go further getting the
autofluorescence or alsofluorescein angiograms.
And in the past, like during mytraining, we had the testing of
(08:50):
ERG and also VEP, visual evokedpotentials and
electrorechnograms.
So I did my training at BascomPalmer and we had a whole
department with theelectrodiagnostic testing as
well.
So it was really good that youknow, once we start the testing
(09:10):
we first go to the first year ofone's examination and then the
first year kind of testing withthe OCTs.
So if we need to go furtherthen we go to the next levels.
So our goal definitely is tofirst find out if there is
anything concerning going on andonce we see that then we go
further to come to a diagnosisand the MRI is done in different
(09:33):
places.
But I think always I like tosee my own MRIs, so once I don't
rely on the report.
So that's another thing which Icommonly see.
Dr. Michael Kentris (09:47):
I'm guilty of the same.
Dr. Manasa Gunturu (09:50):
So that is another thing which we really
want the patients to get the MRIso that we can look through,
and also we have a team ofneuroradiologists.
So that's the other good partwith neuro-ophthalmology is like
it's more a collaboration ofyou partnering with different
teams.
So you partner withneurosurgeons, you talk to them,
(10:11):
you partner withophthalmologists,
rheumatologists,neuroradiologists, and if there
is anything emergency, obviouslyyou talk to the ER team and let
them know what's going on andthe patient goes to the hospital
and gets further work done.
I talk with internists and ENTspecialists.
So that's the good part ofneuro-ophthalmology that if you
(10:34):
have to practice neurology as awhole and you don't want to
focus on a single disease, Iwould say neuro-ophthalmology is
the go-to thing.
Dr. Michael Kentris (10:44):
No, that's a good point.
It sounds like definitely a lotof diagnostic testing goes into
some of these more esotericdiseases, and so during a
neuro-ophthalmology fellowship,you are getting all these
training in, like theseneurophysiologic as well as
different imaging modalities aswell.
Dr. Manasa Gunturu (11:05):
Yeah.
So neuro-ophthalmologyfellowship, I would say it's a
different field, based on howmuch training you get during
your residency.
So as a neurologist you don'tuse a slit lamp, right?
So when you go intoneuro-ophthalmology fellowship,
of course they expect you to usethe slit lamp and they expect
(11:25):
you to do refractions.
So the first few months I feltlike I was back to medical
school again, learning from allmy basics.
So that was a very interestingexperience.
So I tagged along with manytrainees who were in their first
(11:45):
year of training too, but theywere the ones who taught me how
to even if I identify thepicture of the optic nerve is it
the right optic nerve or theleft optic nerve?
So they gave me easy techniquesto learn that.
So it was not just that I waslearning from the
neuro-ophthalmologist, I wasactually learning from many of
my colleagues who were sittingthere on the team and I was
learning from theneuro-ophthalmologist.
(12:06):
I was actually learning frommany of my colleagues who were
sitting there on the team and Iwas learning from the
technicians how to check thepressure, how to take the visual
acuity in the appropriate way,how to do the refractions.
So that was a very interestingand humbling experience during
fellowship Because many othersubspecialties in neurology you
know, if it comes to stroke orepilepsy, you've already read
(12:27):
EEGs during the training.
So it's more, you go to thenext step from that.
But in your ophthalmology Ifeel like you start again from
your basics and by the end ofthe year you go deep down into
reading OCTs and also VEPs.
So it's a very broad trainingwhich you get in
(12:49):
neuro-ophthalmology.
Dr. Michael Kentris (12:50):
Yeah, it certainly sounds like it, and
that brings me back to somethingyou said at the beginning right
?
So a neurology-trainedneuro-ophthalmologist, implying
that there are other paths tobecoming a neuro-ophthalmologist
as well.
Dr. Manasa Gunturu (13:03):
Yeah, so ophthalmologists are actually a
chunk of theneuro-ophthalmologists who did
their training in ophthalmologyand they became
neuro-ophthalmologists.
So there are multiple surveys.
If you go and look into theliterature which they've done to
see what can get more peopleinterested in
(13:24):
neuro-ophthalmology.
So in those surveys at leasttwo-thirds of them have their
background in ophthalmology.
So it's only one-third of theneuro-ophthalmologists have
training in neurology.
So that was a very interestingsurvey which makes us think what
changes can we make in theneurology education to help more
(13:46):
neurologists go into thisinteresting field?
Dr. Michael Kentris (13:49):
That is a good question.
What have the surveys showed usso far?
Dr. Manasa Gunturu (13:55):
So I think the one which I say in
ophthalmology it's a requirementthat they have to do
neuro-ophthalmology rotation.
So at least three months ofneuro-ophthalmology is what they
focus in the four years oftraining.
But in neurology for us it'snot a required rotation.
(14:16):
So if you have aneuro-ophthalmologist, that's
awesome, that's well and good,so you go and probably do a few
days or weeks of training in theclinic rotation or something,
but it's not a required rotationfor neurology residents.
I would say that is one bigthing which people probably will
(14:37):
make them more interested intoneuro-ophthalmology if that
could be included into theneurology residency training.
Dr. Michael Kentris (14:44):
No, that's a good point.
I know when I was a resident wehad a physician on staff who
was a neuro-ophthalmologist, butprobably still that was only
like a third of his practice.
He was still doing generalophthalmology.
So I would go on rotation for afew weeks and unfortunately you
know from my experience wewould see, like you know, your
(15:05):
idiopathic intracranialhypertension and things like
that, but not a lot of the moreunusual or more challenging
cases that probably come to apure neuro-ophthalmologist I
would imagine.
Dr. Manasa Gunturu (15:17):
Yeah, I think that's.
The thing is like.
You don't see these complexneuro-ophthalmic cases on a
daily basis.
Don't see these complexneuro-ophthalmic cases on a
daily basis, so you wouldprobably see them once in every
few days or maybe in a week'stime.
You will see a few cases, butthose are very important ones
which probably a neurologistalone by themselves or an
(15:38):
ophthalmologist alone bythemselves will not be able to
solve that situation.
So I think getting thatexposure is the most important
part.
As you said, diagnosingpapilledema or with IIH is
probably more the bread andbutter cases for
neuro-ophthalmology, but themore need of
neuro-ophthalmologists come inin the clinical decision-making.
(16:00):
Who are the ones which you justtreat with medication?
Who are the ones which youdecide they have to go for
surgery for it?
In the same way, who are theones who you decide, oh, this
person needs a scan right away?
So that clinicaldecision-making is probably the
best thing forneuro-ophthalmology.
Dr. Michael Kentris (16:19):
No, that's very helpful, because it does
start to get a little no punintended a little fuzzy when
someone's starting to lose thevision.
It's like how fast do we needto act on this?
Do we have a little bit ofleeway in terms of medication
management or weight loss, aswhatever the cause may be?
So yeah, it does.
(16:40):
I know in my practice.
I had a case not too long agowhere I was, you know, in close
touch with the ophthalmologistwho was seeing this patient who
had, thankfully, asymptomaticbut papilledema, and we ended up
finding out she was taking like300% of the daily recommended
vitamin A and a multivitamin.
(17:01):
So it's sometimes, yeah, you canget away with avoiding anything
too severe, but sometimes thevision starts going pretty
quickly.
Dr. Manasa Gunturu (17:08):
Exactly.
I think those are the pointswhich we cover very deeply in
the history taking.
So I don't want to say you knowthat many people miss it, but I
think it's just some of them.
Might you know the question?
The way it's asked alsoprobably makes a difference.
If you just ask a multivitamin,maybe not everyone, the patient
(17:30):
might not realize what we areasking.
So I think going more deeply orasking in a way that they
understand, or giving morereasoning behind the question,
probably helps them to get theanswer out.
Dr. Michael Kentris (17:45):
Mm.
Hmm, yeah, you're absolutelycorrect.
I think I had to ask aboutthree times before I got the
answer that, oh yes, I do takelike a vitamin or a supplement
or something like that, and soit really does.
The wording does matter.
I'm starting to move into mymid-career phase so I have more
(18:30):
gray in my beard, but we don'tsee as much emphasis necessarily
on mastering the fundoscopicexam anymore and I work mostly
with non-neurology residentsthese days and I would say
outside of neurology it's evenmore exacerbated.
So I know you've done some workon this field, but what are
your thoughts about the currentstate of education and skill in
use of doing the directfundoscopic exam and what can we
do to help improve that?
Dr. Manasa Gunturu (18:48):
I know.
So that's another thing youknow when I'm on service.
All my residents know thatthat's definitely a question
which I'll ask If a patient hascome with a headache, my next
question will be did you do thepanoptic exam or a fundoscopic
exam?
And you know it depends on whattheir background training is.
(19:09):
So if it's an ophthalmologyresident I'm working with, so my
set of questionnaire is totallydifferent to them because they
are have a very good skill setof evaluating the optic nerve
and differentiating.
Is this a drizzle or is thisreal papilledema?
Is this real papilledema?
But if it's a trainee with adifferent background either
(19:33):
neurology, neurosurgery or ER soour goal is to help them out of
how to identify the optic nerveexamination.
So I definitely go through indetail all to my trainees in
(19:54):
neurology and also in themedical school education as well
.
So we have a lot of medicalstudents who come and work with
us in neurology andophthalmology so I make it a
point that we go through how todo the fundoscopic exam.
So I don't know about thedirection down the lane because
now we have a lot more uhexamination tools which we did
(20:15):
not have during our training.
So we used to rely only onpanoptics or the direct
ophthalmoscopes, but now thereare many non-mydriatic devices
where the patients don't need tobe dilated but you get a good
picture of the optic nerve.
So from that standpoint butdefinitely the direct
(20:36):
ophthalmoscopic exam withoutdilating the patient is a skill
which I always tell them.
It's probably very similar todoing a lumbar puncture.
So when we do a lumbar puncturewe spend a lot of time about
positioning, but once the needlegoes in it's very easy.
The fluid comes out.
But we have to spend a good bitof time of positioning the
(20:59):
patient for the fundoscopic examBecause once you're at the
right position, seeing the opticnerve is very easy.
So that's the other thing whichwe go through during the
training and recently I did asim session for 48 ER residents,
so all the residents from firstyear to third year.
(21:20):
We did a session and by the endof 15 minutes each one of them
was able to see the optic nerve.
So I think understanding thetechnique is the most important
thing in that and, of course,once you see the optic nerve,
also identifying the pathologyof what the problem is or is it
a normal looking optic nerve.
So the more we keep seeing, themore we do the exam on
(21:44):
different people.
That is when we'll understandthat.
So I think practice isdefinitely the key for doing
this optic exam and also, Iwould say, holding the panoptic
and not missing them duringrounds is the other important
thing.
I've done it myself, where Ikeep holding the case of the
(22:07):
panoptic and, you know, in onepatient's room I forget it and I
don't take it to the next, andthen we come back and pick it up
, but because it's a big deviceso we have to remember to take
it and carry it over.
Dr. Michael Kentris (22:21):
Absolutely .
I know when I was a resident Ifound some of my most useful
rotations were my childneurology rotations when I was
starting out, because all thosekids just had such big pupils
that you couldn't miss.
So it definitely helped buildconfidence and the positioning
(22:41):
part kind of like some of thosekids riding a bucking bronco but
I think it helped raise myskills up a little bit.
So I strongly advocate formaking the best of your child
neurology rotations as well.
That's true.
Dr. Manasa Gunturu (22:58):
So the best way I would say to strengthen
the neuro-ophthalmology skillsduring residency or medical
school training is toincorporate the detailed exam of
those cranial nerves like two,three, four and six into the
neurological exam, right?
So if we incorporate thisneuro-ophthalmic skills and
education about the pathologies.
(23:19):
So here in the University ofMississippi we include
neuro-ophthalmic emergencies inthe bootcamp sessions.
So we do a month of boot campsession for first year neurology
residents going into secondyear.
So the last month in June.
So that's another place whereit's not just about explaining
(23:41):
the pathologies, we also gothrough how to examine the optic
nerve and also how to examine apatient with double vision, how
to examine the lid when ptosishappens.
And these sessions are not onlyfor neurology, we do it for
ophthalmology residents andrecently we started doing for
the emergency medicine residentstoo.
Dr. Michael Kentris (23:58):
That's excellent.
So we've been focusing a lot onthe vision itself, but let's
talk about double vision alittle bit.
Obviously.
There are many causes.
Let's talk about double visiona little bit Obviously.
There are many causes.
So when you're trying to teacha framework to a resident for
double vision, how do youtypically approach that?
Dr. Manasa Gunturu (24:18):
So for double vision, definitely, I
think the first thing we alwaysinclude is coming again back to
history.
So we spend a good bit of time.
So by the end of the historytaking 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.
(24:42):
There Is the double vision.
Obviously.
First thing we have to establishif it's unilateral or it's a
binocular double vision.
Have to establish if it'sunilateral 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, thenyou'll be like, okay, I think
(25:05):
you have a refractive error oryou have a cataract or something
not neurologic for the doublevision.
And once after that we try tofigure out is it for near, is it
for distance, is there any onespecific gaze?
Does the double vision getworse?
So with that information andalso seeing if they have
associated droopy eyelid or inthe face, if you see any facial
droop, so many of the otherassociated clinical diagnoses
(25:27):
helps us to come to theconclusion.
Other associated clinicaldiagnoses helps us to come to
the conclusion.
So, on examination in the ERexamination for double vision is
a little different when itcomes to the clinic, where we
have much more devices we haveprisms, we have Maddox rods, so
it gets more easier.
And also evaluation ofnystagmus is another thing.
So there is definitely doublevision is something which we can
(25:52):
spend an hour on it as well inthe clinic to evaluate and also
help the patient.
That solving a case of doublevision and also treating the
patient is definitely veryrewarding because the patient
obviously gets extremely happyonce they start seeing single
and also all their symptomsimprove.
Dr. Michael Kentris (26:11):
What's your initial reaction if a
patient comes in?
They have binocular, I shouldsay bilateral, monocular
diplopia.
Dr. Manasa Gunturu (26:23):
What is my initial reaction?
Dr. Michael Kentris (26:29):
I was just going to say.
Unfortunately, I see thatcomplaint a bit often in the
hospital and the workup tends tobe, let's just say,
underwhelming at times.
Dr. Manasa Gunturu (26:40):
Yeah, so if it's bilateral but monocular,
double vision, definitely youknow it won't take one hour to
see the patient.
Dr. Michael Kentris (26:54):
That's a reasonable assessment.
Now, and this is, you know,partially tongue-in-cheek,
partially for my own edification.
Now, I will sometimes getpatients in and they'll have,
they'll say that they're seeinglike triple or quadruple is
there any reasonable way forthat to physiologically occur?
(27:15):
Is that more likely it's goingto be in that kind of more
functional territory?
Dr. Manasa Gunturu (27:21):
you know it probably can, or it probably
again if it's monocular orbinocular is another thing which
we have to assess.
I've seen that multiple timeswith a refractive error or
someone has a corneal disease ormaybe has cataracts, so that
could be another factor whichneeds to be taken into
(27:44):
consideration.
Dr. Michael Kentris (27:45):
Gotcha.
No, that's fair, that's fair.
Sorry, a little tongue-in-cheekon my part, gotcha.
No, that's fair, that's fair.
Sorry, a little tongue-in-cheekon my part.
So in your experience, you'reteaching a broad array of
(28:13):
learners inuity, the eyemovement, coordination, all
these kinds of things.
I know there's a lot, literallya lot of moving parts to the
visual process.
What are the things that youtend to find learners struggle
with the most?
Dr. Manasa Gunturu (28:28):
I think the main thing is it could be more a
simple thing that how tooperate many of the equipment.
Again, it comes with some ofthe neurological associated
(29:01):
symptoms, even like headache.
So it could be more simple likea toothache giving a headache.
So I think that differentiationwe can see.
Or is it neck pain giving theheadache?
So which could be?
We can tease that out byobviously asking more questions
from the history taking.
(29:21):
But when it comes to a neurologytrainee, I spend a lot more
time in identifying what theabnormality of the optic nerve
is, or how to assess the doublevision evaluation, or how to
interpret the visual fieldtesting, how to interpret the
(29:44):
OCT testing, how to do a B-scan.
So there are many differentthings I think each side we can
learn from each other.
So there are many differentthings I think each side we can
learn from each other.
So that's what I was telling.
Like during your fellowshipalso, you learn a lot from your
co-fellow who has a differentbackground training.
Or you can learn a lot fromoptometry residents who are
there or how to make, how to seewhat amount of prism is needed.
(30:11):
So each one has their ownexpertise.
Dr. Michael Kentris (30:14):
That's a great point to emphasize.
Yeah, I know, as a med studentI spent some time on
ophthalmology as well, and Iremember the doctor gave me a
book it was a short book,thankfully, but it was just
called Optics and I ended upreading 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 thiswhole book over the course of a
rotation, and it was.
I mean, I've always been, youknow, kind of interested in
(30:36):
physics, but it is compared to,like neurology training.
If you haven't done that in thepast, it is quite foreign.
Dr. Manasa Gunturu (30:45):
Yeah, definitely.
I mean, optics is like as yousaid it's.
I'm thankful that it's a smallbook, but when I started to
learn how to do refractions, itwas just mind-boggling to me,
like how much time you can spendon this.
Actually, it's almost like theneurology examination you can
(31:06):
spend an hour on it or, if youget good at it, maybe you can
spend just 10 minutes on it andcome to a conclusion.
Dr. Michael Kentris (31:13):
Now, one thing you have been pointing out
.
Right, you know it's the 21stcentury.
Most neurologists aren'tcarrying around drops in their
little black bags anymore, somost of the time we're talking
about although you know, theboard exams still love to ask
those questions, about thoseright, I don't have any cocaine
(31:34):
on me today.
But it does become like theseolder patients in particular,
like someone in their 80s, maybeeven 90s, where they have these
two, three millimeter pupilsthat don't really dilate on
their own, even in a nice darkroom.
Dr. Manasa Gunturu (31:53):
Yeah.
Or maybe they have kind of apartial cataract, and are there
any patients that you just youknow, you can't really see the
optic nerve very well because ofthe anatomy, like, let's say,
we're not in the office, we'resomewhere in the hospital or
probably being neurology trainedneuro-ophthalmologist, I try
(32:19):
not to dilate, mainly because ofyou know, once you dilate,
definitely you want to make sureyou have the expertise to
evaluate the retinal exam andsee different parts of the rest
of the, not just focus on theoptic nerve exam.
But when it comes to thehospital setting, I think I
(32:39):
would still say, as the years goby during training, the first
thing I've learned is to examinewith the indirect
ophthalmoscope without dilation.
Because once you get expertisein doing the undilated exam,
obviously it's very easy whensomebody is dilated to examine
(33:01):
them.
So if it's the other way around, the struggle is much more
harder.
Is how I felt.
So right now I would say most ofthe 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 ifthey were dilated before and the
(33:23):
eye is quiet and there is noconcerns of angle closure,
glaucoma or there is no othercontraindication to dilate them.
If it's a kid and that's why Itell my residents maybe it's
better not to dilate the kids ifthey were not dilated before.
So try to avoid that.
But the rest of them, I think Ialways give them a picture of
(33:45):
the drops which they have toorder.
So everyone has, you know,identified what all drops they
could order on the patientswhich they need to.
Dr. Michael Kentris (33:54):
Excellent.
Now you used a phrase right nowand I like to think that I'm
pretty decent at interpretingour ophthalmology consult notes,
which are written in a veryunique shorthand most of the
time, but when the eye is quiet,what does that mean?
Dr. Manasa Gunturu (34:40):
So the eye is quiet.
Dr. Michael Kentris (34:41):
I think the main thing we try to explain
in that is, there is noconjunctival chemosis or there
is no inflammation in thevitreous, and so the eye is not
pink or red is one thing, andalso there is no inflammation
behind the pupil is probablywhat you want to tell them as
well.
Okay, that makes sense.
Okay, gotcha.
No, that's good, cause I know alot of times my residents will
come to me and they'll be likewe have this ophthalmology note
and you know it's a, it's awhole mix of acronyms and
numbers and things like that,and usually we're able to, you
know, to make our way through it.
(35:01):
It's pretty okay, but I was justwondering if there was anything
.
I mean quite I assume theopposite is, like you know, is
loud or angry.
So so I'm glad to know that Iwas, you know, in the right
territory.
Dr. Manasa Gunturu (35:13):
Yeah, and I, I think, the different kinds of
cases which ophthalmology sees.
Of course they see the worstthings which happen to the eye
as well.
So when it's a neurology or aneuro-ophthalmic case, of course
their focus is more on manyother parts of the eye exam
(35:35):
rather than what they routinelysee, because they don't worry
much about the intraocularpressure because usually that'll
be normal.
They don't worry about thecornea or you know, they don't
think there is something goingon with the vitreous or anything
like that.
So of course the point overthere is directly to focus on
the eye movements or the opticnerve.
So the rest of the thing is.
(35:55):
Quiet is probably a common termwhich they can use.
Dr. Michael Kentris (36:01):
Which is good.
It's good to know that it'sgood.
So, neuro-ophthalmologists Idon't know the numbers off the
top of my head, I imagine thereisn't a plethora of you all
throughout the country.
Dr. Manasa Gunturu (36:14):
Yeah, so in the survey exactly, I was also
trying to see how many are there, because we meet commonly in
the annual Neuro-OptimologySociety conference, which is
called NANOS, so North AmericanNeuro-Optimology Society.
So from the United States thereare 600 plus
(36:35):
neuro-ophthalmologists Wow.
Hundred plusneuro-ophthalmologists Wow.
So it's still definitely, Iwould say, a good number of
neuro-ophthalmologists.
But I think when you see howmany are practicing and how many
are there per state, I thinkthere are still few states who
don't have aneuro-ophthalmologist at all.
(36:56):
And I'm from a state where wehave only one
neuro-ophthalmologist in theentire state.
Dr. Michael Kentris (37:03):
So Is that you?
I assume yeah.
Dr. Manasa Gunturu (37:08):
So, but where I did my training in Miami
, we had sixneuro-ophthalmologists in our
institute itself and there weremany other
neuro-ophthalmologists in ourinstitute itself and there were
many otherneuro-ophthalmologists in Miami
and in Florida too.
So I think each state hasobviously a different number of
neuro-ophthalmologists, but it'sa very good, close-knit group
(37:31):
of neuro-ophthalmologists whichwe have, and the conferences are
fun and lots of interestingthings to learn and lots of
workshops as well for thetrainees.
Dr. Michael Kentris (37:41):
I know that's a great point for people
who want to beef up their skills.
So there's some good trainingopportunities at the annual
meeting.
Dr. Manasa Gunturu (37:49):
Yeah, and they sponsor, they give.
There is a journal ofneuro-ophthalmology and if
someone, a trainee, isinterested and you want to
nominate them, they actuallysponsor for the journal for the
whole year.
And I have many trainees inophthalmology and neurology here
who present for the posterpresentations or they do
(38:12):
scientific studies in theconferences and we recently went
to Hawaii for the neuro-optomicconference.
Dr. Michael Kentris (38:21):
Oh, that's a.
I mean that's a good place fora conference, right, but it
sounds like so many things inmedical training that a lot of
times the the career pathway isuh, if there is someone in their
training who models it, itseems to be more likely that
you'll get someone to considerit as an option.
Dr. Manasa Gunturu (38:44):
Yes, yes, and I think the main challenge
for trainees to stay in touchwith neuro-ophthalmology is that
you know the sparsity of thenumber of cases which they see
is that you know the sparsity ofthe number of cases which they
see, but every time when youlook at the list of the
inpatient service, you see anoptic neuritis, you see double
vision, so at least there willbe one or two cases every week.
(39:08):
And sometimes, of course, whenI'm on, that's what my trainees
keep saying, that there are somany neuro-ophthalmic cases
which come on but it's notsomething that they can leave
the service, the inpatientservice, saying we have not seen
a neuro-ophthalmology case atall in the month, so you
definitely see multiple casesevery week.
So continuing to include theneuro-ophthalmology skills in
(39:34):
examining the patient andconsistently reading about them
because it's very easy to shyaway from the complex patient by
consulting ophthalmology orneurology teams, but I think the
art of you know the reward orhappiness in solving the case
with deep history taking andextensive neuro-op exam, is
probably the key.
Dr. Michael Kentris (39:55):
Yeah, I think that's very important.
I remember this was a few yearsback now I had had an inpatient
consult for vision loss in oneeye and he'd been transferred to
our hospital because the otherone didn't have neurology
services.
And so I go and see this guyand I'm doing his fundoscopic
(40:17):
exam, I'm like I'm not getting ared reflex in his one eye and
I'm like you need to see anophthalmologist and he ended up
having a retinal detachment.
Dr. Manasa Gunturu (40:27):
Oh, wow.
Dr. Michael Kentris (40:27):
And it's like you know you'd seen an
emergency physician, you haveseen an internist and now you're
seeing me.
It's like if any one of thesepeople had just pulled out a
fundus scope and looked in youreye, you wouldn't have gotten an
ambulance transfer bill and ahospital admission and all this
other stuff.
So I mean, identifying the redreflex is not the most advanced
(40:52):
fundoscopic skill out there.
Dr. Manasa Gunturu (40:55):
Yeah, that's why I think the relative
afferent pupillary defect, likeRAPD, what we talk about that's
another biggest skill.
When you read about it or lookat the video, it appears very
simple.
Why is it so complicated?
But once we start doing it onthe patients, you know I keep
getting that all the time.
I think there is a RAPD, so Ithink there is not.
(41:16):
But our goal is to make surethat the trainees feel confident
in saying that there is not,rather than wondering if it is
there or not.
Dr. Michael Kentris (41:25):
Right.
Dr. Manasa Gunturu (41:26):
So that's another thing which we also
focus because that's a very goodobjective way when we talk
about functional vision losspatients as well, because not
all the times the fundoscopicexam has to be abnormal.
It could be a retro-orbitalprocess, but if they have a
relative afferent pupillarydefect, I think that is a big
key and you don't even need towait for imaging to start
(41:47):
treating those patients.
You can go ahead and treat thembecause you have an objective
finding.
Dr. Michael Kentris (41:52):
Absolutely .
Those are great points.
Any final thoughts or resourcesthat you would direct people
towards if they want to learnmore about neuro-ophthalmology,
or maybe they aren't at aninstitution that has a
neuro-ophthalmologist availableto work with?
Dr. Manasa Gunturu (42:10):
very invested in Novel, which is a
video resource.
So they collect examinationvideos from different
neuro-ophthalmologists and putin that library and that is a
very good resource to keepchecking on any neuro-ophthalmic
(42:33):
skills, learning skills or alsodiplopia examinations or
relative afferent pupillarydefects all the things which
we've talked about.
That's a very good resource, Iwould say, if you don't have a
local neuro-ophthalmologistwhich you go to.
But otherwise there are manydifferent societies, like even
(42:54):
local societies, not thenational one, but there are some
local societies which conductsymposiums and workshops as well
.
And our university, we dolecture series with faculty, but
also we use the flippedclassroom technique for the
residents where they teach eachother and also they prepare a
(43:17):
huge slideshow and PowerPointteaching the other residents as
well.
It may include a lot of boardquestions in it and reading
about these scientific studies,especially from Journal of
Neuro-Optimology and in AmericanAcademy of Neurology, like the
(43:37):
Green Journal also, there aremany research projects based on
neuro-ophthalmology as well init.
So the other thing which we aretrying to incorporate is an
outpatient sim lab session withreal patients.
So neuro-ophthalmology is not afield which they can simulate,
so we are trying to get realpatients who can come to the sim
(44:01):
lab sessions and let ourresidents examine them.
We've created a sim lab sessionfor emergency neurological
situations where we simulate astroke.
We simulate someone activelyseizing being in status.
But this is something which weare trying to incorporate.
And other thing which I alwaysdo for my trainees and medical
(44:23):
students when they come, is Iemail them review articles.
So we just saw yesterday like adownbeat nystagmus.
So when we see downbeatnystagmus, what are the things
which we have to evaluate?
Well, it's not just ordering anMRI, it's also looking for
other things.
Of course, when it's downbeat,we try to localize it to the
posterior fossa pathologies, butthere could be many different
(44:47):
things, as simple as a B12deficiency, which can give it,
or a thymine deficiency, whichcan give as well.
So I think looking for thosereview articles and reading
about what all could be included, what all the etiology is in it
, and learning from each patientdefinitely is something which
you'll never forget.
Dr. Michael Kentris (45:07):
No, I think that's great.
It's very, very old schoolbringing in the people with the
actual pathology who are kindenough to volunteer their time
to teach the next generation ofphysicians.
That's always great to hear.
Dr. Manasa Gunturu (45:21):
Yeah, many of my patients, they love to do
that.
When I give them that ideathey'll be like sure we'll be
happy to come in and they let mytrainees evaluate.
And you know, I think theyprobably know it'll probably
take a good bit of time whenthey come to your ophthalmology
clinic.
So most of them are very goodat letting other because I think
(45:42):
probably they understand theimportance as well when they
come to Neuro-Optimology becausethey've already seen many
different providers and theycome here.
They get an answer.
So probably that's anotherreason they let us help the
trainees with learningNeuro-Optimology as well.
Dr. Michael Kentris (45:57):
Excellent.
If people want to reach out toyou, find your work, where
should they find you online?
Dr. Manasa Gunturu (46:05):
They can find me on Facebook, twitter and
Instagram as well, but on myemail is mgunturu at umcedu, so
that's another way to reach outto me.
Dr. Michael Kentris (46:22):
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 (46:32):
I would say this is the best thing which
I've decided in my life to takeneuro-ophthalmology.
I enjoy it every day.
It's really rewarding.
I would love to see moretrainees look into
neuro-ophthalmology, becausemany times we take neurology
because we love to examine thepatient and we love to think
about the processes andeverything, and
(46:54):
neuro-ophthalmology actually isjust an added part of that.
So you would get more happinessand a rewarding feeling when
you treat neuro-ophthalmicpatients.
Dr. Michael Kentris (47:09):
Awesome.
So, pippu Ray, please do takeneuro-ophthalmology no it's
great to talk with someone sopassionate about their field and
such a good advocate forinstruction in these skills,
even for people who aren't goinginto the field.
Thank you again for coming onand talking with us about
neurophthalmology again today,and I'll make sure to put some
(47:29):
of those resources in the shownotes for today.
You can also find me I'm alsoon Twitter, slash x at Dr
Kentris, and then you can alsofind more of our stuff on the
neurotransmitters website at theneurotransmitterscom.
Dr Gunturo.
Thank you again for your time.
Dr. Manasa Gunturu (47:47):
Thank you.
Thank you, Dr Kentris.
It was really nice being thereand talking about everything
about neuro-ophthalmology.
Dr. Michael Kentris (47:53):
Thank you,
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