It's a white-knuckle situation for sure. A patient presents with what appears to be a swollen optic disc and complaints of nausea. Or maybe it’s a case of double vision that doesn’t fit the mold for strabismus. Perhaps, instead, an OCT scan suggests you have optic neuritis on your hands. 

In any of these—and a dozen more—the pressure’s on. 

So, it’s no surprise that neuro-ophthalmic diagnoses by generalists often don’t go well. As reported in this month’s news section, a prospective study of 496 patients sent to neuro-ophthalmologists found the referral diagnosis was incorrect 49% of the time. Misdiagnosed patients suffered harm in 26% of cases, and unfortunately these adverse effects could have been prevented by earlier referral to neuro-ophthalmology in nearly every case.

Those harms were as serious as it gets, including death due to delay in tumor diagnosis, failure to recognize TIA, progression of permanent vision loss, spontaneous CSF leak, irreversible strabismus and others of equal magnitude.

With all that in the air while a patient’s in your chair, the urge to refer out immediately has to be strong. And, indeed, in many cases that’s exactly what you should do. Not everyone can or should try to be a neuro-ophthalmic specialist—that seems to be underlying message of this study. 

But an equally strong message is that there’s a dearth of those specialists out there. “Improving access to neuro-ophthalmologists has the potential to prevent patient harm, which is made challenging by the current shortage of neuro-ophthalmologists,” the researchers wrote in their paper on the study. “Improving incentives to attract trainees to subspecialize in neuro-ophthalmology will allow expanded access to patients who need care for these complex conditions.”

That’s not your problem—leave it for ophthalmology teaching institutions to sort out. What you can do, though, is hone your skills in triaging these cases to make sure they get a timely and accurate referral. The assessment stage, patient counseling and write-up of referral notes all seem like fertile ground for improvement of clinical and communication skills.

In the above-mentioned study, the most common sources of error involved deficiencies in the physical exam (36%), generation of a complete differential diagnosis (24%), history taking (24%) and use or interpretation of diagnostic testing (13%). That’s all bread-and-butter optometry at this point.

You may have noticed that we’re in the middle of a six-part series on comanagement (see this month’s article about cornea care on page 80). The connective tissue among the whole series is optometric leadership in screening patients and directing the effort. 

As luck would have it, next month’s topic is neuro-ophthalmic care. I encourage you to make time for that one, and even to send us any thoughts on what could help you do a better job in neuro care out there in the trenches. We’ll work it into our coverage for later this year and beyond. Kindly drop me a line at with any anecdotes, frustrations or longstanding problems you experience when conducting neuro workups. As the kids say, my DMs are open.