Neuro-Ophthalmology at Penn
by Michele Szkolnicki
This article appeared in the May 2001 issue of "The Scheie Looking Glass."

More than fifty years ago, the late Dr. Frank Walsh of Johns Hopkins decided to limit his ophthalmic practice to patients with neurologic conditions that affected vision or eye movements. That decision effectively created the subspecialty of neuro-ophthalmology. When Dr. Walsh shared his decision with one of his mentors, he was greeted with the comment, "You'll starve!" Despite that admonition, Dr. Walsh proceeded with his plan and the rest, as they say, is history.

Fast-forward 65 years: The Neuro-ophthalmology Service at Scheie Eye Institute/University of Pennsylvania, the largest in the country, consists of four full time faculty representing the disciplines of Ophthalmology and Neurology. These doctors collaborate in patient care, educational activities, and clinical research. Although each has his or her own clinical practice, they confer frequently regarding the evaluation and management of patients with difficult problems. They also share responsibility for post-graduate training, educating residents in the departments of Neurology and Ophthalmology, teaching medical students, and conducting continuing medical education courses. In the area of clinical research, each has his or her own area of interest although they actively support each other's projects.

The Beginning

The neuro-ophthalmology service at Scheie/Penn began its meteoric growth in 1992 when then Neurology Chair, Don Silberberg and recently arrived Ophthalmology Chair, Stuart Fine determined to develop a joint service staffed with both neurologists and ophthalmologists. At that time, Dr. Steven Galetta was the only full time faculty member practicing neuro-ophthalmology. Drs. Nicholas Volpe and Grant Liu, who met in Boston while performing their residencies at Harvard-affiliated hospitals, were recruited to the program. Dr. Liu was trained as a neurologist and completed his neuro-ophthalmology fellowship at Bascom Palmer Eye Institute in Miami. Dr. Volpe was trained as an ophthalmologist at the Massachusetts Eye and Ear Infirmary where he also completed his neuro-ophthalmology fellowship. When this new group established a fellowship in neuro-ophthalmology, Dr. Laura Balcer came from her Neurology residency at PENN to become the program's first fellow. At the completion of her fellowship, she joined the group. The result was a neuro-ophthalmology service staffed by doctors who trained in separate disciplines and at separate institutions; thereby adding considerable breadth in clinical expertise and in clinical research. In short, the whole became greater than the sum of the parts.

The Research

Dr. Steven Galetta
's interest in optic neuritis in patients with multiple sclerosis (MS) began in his residency at a time when there was no effective treatment for MS. He participated in several important clinical trials for optic neuritis in MS including the highly touted CHAMPS program. CHAMPS (Controlled High Risk Subjects Avonex Multiple Sclerosis Prevention Study) found that patients at high risk for MS following a single "demyelinating event", such as abrupt vision loss or double vision, might have their risk for subsequent events decreased by the administration of Avonex (interferon b1a). Dr. Galetta has participated in numerous clinical trials and has witnessed FDA approval of 4 separate medications for the treatment of MS.

Dr. Nicholas Volpe, surgeon in the group, and has a surgical practice devoted to the correction of ocular misalignment, often the cause of double vision. In addition to his practice and surgical schedule, he conducts clinical research in ischemic optic neuropathy and other optic nerve disorders. Of particular interest is his research on the portable pupilometer, a device to measure pupillary light reflex (the pupil's response to light). This measurement can be critical in the detection of serious forms of vision loss in their early stages. Dr. Volpe hopes that his work will result in the implementation of the pupillometer as standard practice for eye health screening.

Dr. Grant Liu uses "Functional MRI" to discover how the brain processes visual information. One study uses this evaluation method to study vision processing in people with amblyopia, commonly termed "lazy eye". The abnormalities in the brains of animals with amblyopia are well known, but the abnormalities in humans with this condition have been demonstrated only rarely. Dr. Liu wants to discover the brain's contribution to lazy eye. His use of "Functional MRI" for this purpose, supported by foundations such as the Lions Club, Fight for Sight, and Knights Templar, has never been done before.

Dr. Laura Balcer's clinical research focus is at the heart of what makes clinical research so valuable. She studies and compares the measurement tools themselves to assure that data are reliable. A grant from the MS society is allowing her to identify which visual function tests work best in identifying vision problems in patients with MS. Persons with MS often see 20/20 by routine measurements but report that their vision is "somehow different". Preliminary studies have indicated that visual problems in MS may be detected better by using low contrast charts (use gray or faded lettering rather than black and white). Dr. Balcer's research is the first time that vision testing modalities for people with MS have been compared and evaluated.

The Book

Five years in the making, the recently published text book of neuro-ophthalmology is the ultimate testament of their collaboration, cooperation, and mutual respect.

The concept was to create a one volume text that would serve as a reference for students and primary care providers. The resulting publication, Neuro-Ophthalmology: Diagnosis and Management has been praised as a valuable tool at the resident and professor levels. It was written entirely by Drs. Liu, Volpe and Galetta; there are no guest authors and no names on individual chapters. The result is a publication with an evenness in style not seen typically in multi-authored texts. (And it's doing well on the "market". With an initial printing of 4000, it sold 1600 copies in the first 4 months.)

But the book was much more than an academic pursuit. Dr Galetta explains it as "evidence of the determination of our unique group. One can only imagine the commitment required to complete such an enterprise in addition to clinical practice, research, education, and of course, spending time with our families."

The Future

With over 30 years of clinical practice experience among them and an average age of only 38, there is seemingly little that this group cannot accomplish. All hope to continue to make considerable contributions to the field of neuro-ophthalmology by easing the burden of MS, understanding better how the brain functions and processes light, developing medical and surgical modalities to treat visual disturbances, and being able to measure treatment outcomes reliably. These breakthroughs will require continued commitment, grant funding, and enlightened philanthropy to support clinical research. However, one crucial factor to success is already present: these investigators' unfailing support of eachother.