 The real purpose of this is just to kind of acquaint you folks with those of you that are new to us, with the Pediatric Ophthalmology Service, primary care owns hospital, and that because if you've been on call, it's easier if you have an idea of what's going on. Unfortunately, your senior or senior residents, those who've been on our service in particular, know where everything is and how things work and can help you through things and I would use them as a resource. In terms of our Pediatric Ophthalmology Service, the Pediatric Ophthalmology Service and Division of the Department of Ophthalmology Moran Eye Center is located at Primary Children's Hospital. Our administrative offices are on the 5th floor, where everybody else is already here, but our clinic is on the 4th floor of primary, just when you go over the bridge right side and if you need to get in there to do something with a patient, if you don't have badge access, which you should have to be able to get into the Children's Hospital, be able to consult, your badge should access our clinic if it doesn't. Talk to security if they tell you no. Come by clinic and we'll work it out because if you need to get in there to drag a patient in there, to get an indirect, do whatever, take lid and speculum sets from our clinic. Resident room, keep them in your badge. In terms of our locations, we do have satellite clinics that you need to be aware of. We do right now one at Riverton, which is with a Primary Children's Hospital outpatient clinic, outpatient surgery setup. It's not a hospital, it's an outpatient clinic, and Farmington, similarly we have, that's a university, not an inter-mount facility, Farmington is a facility north. The people primarily involved, Dr. Dries, Dr. Jardine, Go, so we have those clinic staff most days that may be of use to you when you're trying to arrange follow-up for some patient that you've seen as an inpatient here or through the ER, and it turns out they live 100 yards from the Farmington clinic instead of making them go to Riverton to see someone, it may be wise to have them seen at Farmington. Those things, though, can usually be worked out the next morning by our staff if you pass a message along, just help them find the closest place to be seen for follow-up, and you are not responsible under any circumstance to run to Farmington to see patients. Just be aware, I mean, like after hours or something, patients come here to see you. Occasionally, residents have gone down that slippery slope where somebody's wanted to go to St. Mark's or IMC or Jordan Valley Hospital, realize that I don't think our malpractice coverage covers you if you do that, you're not responsible for it. Many of the hospitals in the area, if you haven't caught on to it already, choose to provide a lot of their, in fact, ophthalmology coverage by sending patients to us. Even if they have an ophthalmology call schedule, they call that ophthalmologist, they say, I'm busy, does the patient have insurance? And they say no, and they say fine, send the patient to the university. And does that happen? Yes, it does, unfortunately. You know, the way I look at that is that we generate interesting patients, surgical cases, and various other things by patients that people send to us. And the hope is they send patients to us that do help pay for us all to be here. And we take care of the rest of them because taking care of people is what we do. Now, as far as our service coverage, there are, at the moment, five pediatric ophthalmologists. You may or may not have worked or encountered all of us. Myself, Dave Dries, and then Mariel Young, Leah Owen. Dr. Owen has protected research time. So if you're trying to get a hold of her, they say she's in the lab. She is our first kind of half-time PhD, basic science research person of pediatric ophthalmology. Julie Harmon is our orthoptist, super duper technician with extra schooling, training, and expertise in dealing with ocular motility issues. She is somebody you should latch onto securely when you are on our service or you have a chance to come to clinic, primarily because that is where you will gain a lot of your knowledge about assessing ocular motility and about stroke business. That's what she does. She's a wonderful teacher. She's enthusiastic, and it should work well. You know, to do that when you're on the service, part of what you're doing is, good morning, to spend time with Julie and to see patients with her. Now, retinopathy prematurity exams, you will, by the time you leave here at the end of your residency, have and try to assess an infant for retinopathy prematurity. Will you acquire the expertise to be able to go in and say definitively, the patient is still in zone two, they're in zone three? Gee, this is, you know, aggressive post-year RLP. Probably not for most of you. But my goal, I want you to be able to safely examine infants in the NICU. I want you to know about RLP. If you go do comprehensive ophthalmology out in Vernal, and we send a patient back to your area and ask you to see them in follow-up, I want you to know how to safely take a look at them and do that. You will, when you're on our service, every single week have the opportunity to go with one of us on rounds in the NICU to see babies. Happens every week, every week of the year. And you will get called when you're on call, asking questions about, gee, baby so-and-so had this or that, you know, type RLP. Can they go to the OR and have their own procedure? Or we want to put them on Sudenifil for their heart failure. Is that okay with their RLP? Please do not take it upon yourself to make that decision. Those decisions carry with it potential for everlasting blindness. And some of the largest lawsuits in ophthalmology today are related to retinopathy prematurity, mainly looking at the life expectancy, change in productivity, cost for care of a blind infant. Those are big decisions, and those, from my perspective, always get deferred to faculty. So your job with that is to make sure we get the message and we give them an answer and please do that, and it's perfectly okay to call me. My phone numbers are on this thing, and this is in the list of lectures, this document, and we'll update it with Elaine. But if there's a question, if my cell phone rings and I answer it, you've got me, and I carry it with me most of the time, and it's always okay to call. We also have the luxury now of having photos taken on RLP rounds, and we take photos on every baby, and we make every effort when you're on the service to review those photos together. Photos are used now mainly for documentation here and also yesterday. I saw a couple of babies in primary that I wanted to get Dr. Hartnett's thoughts on, kids that she had treated, and she and Nico reviewed the photos by mid-afternoon, and were able to get back to me, so within 24 hours that had all been accomplished without them having to go to the bedside and see the babies. So the photos are pretty cool. Melissa Chandler, one of our photographers, is now our photographer of choice in the NICU. If you have a chance to tag along with her, you can look as she's taking the photos to see what we're seeing in the back of these kids' eyes. As far as consults go, we have things, as you're aware, divided now with this first-year consult service. Marshall's currently the center of that universe, and we've made an effort to do some recent changes that Sophia Fang, our finishing fellow, came up with to try to make certain that consults are getting to the consult resident, but other questions that are best directed to the resident on the paid service get to them. I need feedback from you all on going over the next month or two as to how that is working. So far my sense of talking to the people to whom that's been disseminated, that would mainly be the NICU, PACU, PACU is oblivious, they're always oblivious, they don't know, and they just call somebody, somebody answers, and they'll probably continue to do that. The folks in the NICU were grateful, and they've already found it useful, using Brad to get messages to me about things real time, and hopefully what we're trying to avoid is having one of you called when you're not in the OR with us while we're still sitting in the OR about clarifying orders on a patient we just operated on that you know nothing about, nobody's checked the patient out to you. That's a total waste of your time, total waste of effort, and that was the major focus of this, similar to a trip I made down to the ER, oh now it was probably just six or seven years ago, I'm looking at their call, their schedule of ophthalmologists that they sent patients to for follow-up from the ER, it was back from in the days when every general ophthalmologist in town was on the staff, they all provided coverage, it turned out when I looked at that list there were at least six or seven ophthalmologists on that list who were dead that they were sending patients to, some of them had died 15 or 20 years ago, and so I had to kind of sit down with the director of the ER, my buddy Jeff Shunk, and say Jeff if you guys would stop referring patients to dead ophthalmologists it would probably be a good thing for patient care, sometimes looking at things critically is helpful. Now as far as consults go, when you have consults please, if there is any question about what's going on with the patient, run it by the resident on our service, they've had a bit more experience with this, their thinking, living, and breathing pediatric ophthalmology at the moment, they can look, they may provide an extra set of eyes, if we have a fellow and we don't this year, the fellow is you know often the faculty supervising consults, but whoever is in clinic here at primary is also your asset, stop by clinic, grab me, grab whoever's there in between patients, we'll talk about it, if you think a kid needs to be sedated please think about who else might want to be there, if there's some really important question they're trying to answer and you've never seen it before, you may want to have if you're on call you're getting the consult, the senior resident or one of the faculty involved so that everybody that needs to see the kid can get a look, the other thing to think about is does the patient really need to be sedated, could the more senior resident, could the faculty get a look without sedation at all, and it may be worth a conversation with the more senior resident if you're the consult person trying to sort that out, I mentioned the outside clinics at forest vacations and meetings, I mean you do what you need to do on our service, you know, send those things and med hub things have changed from the old sheets that we used to sign, but basically somebody works me, I go on med hub, if I can access it on a good day I can most of the time and sign off on it for you, you know, just think about what you're missing, you know, as you go, but vacations are important, meetings are important and I think if you get a chance to go present something on meeting that's a wonderful opportunity, you should do it. What about this American Fort Training School clinic, has anybody here, Mike you've been there, anybody else been there, it is basically a residential center for unplaceable developmentally impaired adults, when I came here to the department I was misled purposefully by our chairman and Alan Crandall who used the word school liberally thinking that somehow children were involved to get me to go out there and take responsibility for providing eye care there and you know, yes pediatric ophthalmology does have, we have special skills in examining kids that don't want to be examined and trying to examine patients without being bit hit or slipping in a puddle of urine, those are useful skills to apply as a resident to acquire and there actually are interesting patients who need care, there is a lot of either self-abusive trauma, trauma things related to diseases that these folks have that result in cataracts, retinal detachment, squalcoma and significant refractive error, the staff there will help sedate patients for you and get a look and from my perspective, if you get a patient who needs you know a surgical procedure, if it's something you're capable of doing, you find an appropriate faculty member you get it taken care of and you do it, you know from my involvement in this is just from years ago, I was content to being the faculty member responsible for it, I can't even in all honesty tell you where the training school is other than it's an American fork because it's been at least 25 years since I've gone through the front door of the place, if you're having problems out there let me know and if you're not getting the pass through reimbursement that goes through Elaine and allows you to get things at the bookstore, let me know, that was worked out, I worked that out when the university basically wanted to put that in the bank and have you do the work for free, when GME found out that I was just passing the money out of the residence, I got some trouble for that so we can't continue that but the other should work and if you know usually the residents go when you're on our service, so you find a day when you're not in clinic, not in the OR and try to arrange it that way so you're not missing something else but if it isn't working out again I need to know, so again things are commonly borrowed from our clinic include if you don't have it with you tonneau pens, lids speculums, drops, you know if you don't know where those things are find the resident on our service when they're in clinic and they can show you where everything is and you're welcome to come see patients there, if you see patients there please put covers back on, excuse me, tidy things up and be aware that there are things out front, you know like at our front desk that we don't want families and patients rummaging through necessarily while they're waiting for somebody to be seen so you know do your best with that. Now a couple of specific you know things related to consults, if there's a post-op patient with a problem, whichever one of us did the surgery would love to hear about it, if there's an issue, we may be able to save you a lot of looking, talking and doing, just talking over the phone for five minutes because we may have talked to the patient half an hour ago or the parent, we may know what's going on, we already have concerns, we may want to see the patient, I think that's something that it's always okay to call any of us you know if we operated on the patient recently and there's some sort of trouble regarding political issues, there are some service overlap areas where there's a little bit of competition for patients at time that would include patients with orbital facial fractures, facial injuries and the question is whether plastic surgery, craniofacial surgery, ocular plastics, neurosurgery is going to fix things and for a lot of those things any of those folks could fix a lot of the stuff and so there isn't anything you know if ENT calls us they're going to be taking a patient to the OR to fix fractures and do something and they want us to look at the eyes, we need to look at the eyes, it's the best thing for the patient and so I think that it is not the case that we want to go in and say well this has to be fixed by our ocular plastics folks, it's always okay to offer them say would you like this to have ocular plastics involved and then if there is some issue that you know sounds like somebody's unhappy or grumpy about something that's occurred with that call me, I need to know about it, I need to try to smooth it over, being able to see a lot of these patients involves you know providing consistent good service and good communication so that everybody knows what's going on, that's particularly the case with some of the services where we have folks with larger egos that would include mainly plastic surgery and clainiofacial where people tend to get their knickers in a twist and get all wound up about things and I don't want them yelling at you, I don't care if they yell at me, what about abusive head trauma, we're going to talk about that a little bit if we have time, non-extinal trauma you know if you aren't aware those of you're starting there are things that we see in kids who have been abused particularly shaken that can be very suggestive helpful in a courtroom, help sort things out and you will be asked on a very regular basis at primary to see kids with you know the question is is this child abuse basically and you're looking for retinal hemorrhages and it turns out that although when I first started doing this we thought that every kid with retinal hemorrhages had been shaken that isn't the case you know there are certain patterns of those things that we're going to look at in a bit that are suggestive of that so that what I would do you know with this is first of all get good information do the best exam that you can record what you see and if you think that there I mean if there are retinal hemorrhages every single one of those kids needs to be examined at some point by a faculty member whether that be fellow one of the peds division members retina fellow retina attending and basically the way we want to use that chain of command and what I worked at to keep the retina fellows involved in this is that we go for the peds fellow if there is one peds attendings first they exhaust the peds attendings then after that you call the retina fellow I mean if all of us are out of town at the same meeting that's when the retina fellow gets called and lastly the retina attending and there is pretty good evidence that those kids need to be seen by somebody who's had a lot of experience with this and can make a somewhat authoritative assessment of things within 24 hours so that that is something that will involve somebody seeing them over the weekend now at the same time we take pictures of all of these kids with the reticam if you haven't used the reticam don't let this at bedside be your first attempt to turn it on and do something with it get someone who has used it it is very expensive each of those little lenses that go out there if they slip drop or not correctly attached to the camera are at least $10,000 a piece and I have had residents in the past drop them they don't do well after their drop they don't bounce well there's a book in the library on abuse of had trauma it was edited by Lori Frazier Rob Parrish two colleagues of mine I took all the pictures and wrote everything that has do the eyes in that book and it's there there's also a copy on my bookshelf upstairs which are welcome to go sit in my office and look at things and there's a copy in our clinic primary in addition to the photos we get OCT if there are findings of these circumvacular folds or retinoschesis in the posterior pole to document the anatomy and one of the questions might be why do we document this why is it such a big issue what turns out that we could call to go to court regularly on these things I could not count the number of times I've been in court testifying in these things and it really helps to have good information and the last thing you want to do when you're off doing fellowship somewhere or you're starting to practice is to get subpoenaed and have to come back here and testify and have some defense attorney looking at you saying well doctor at the time you did this how many of these had you seen tell me all about all your expertise in this area they're going to make you look like an absolute fool and not that you don't know 10 times or more about it than they do they're still going to do that that's their job and you want to drop that on one of us not on yourself because if I've seen the patient they're going to call me to go to court not cheap realize that the attendings and what they call safe and healthy families those are the child of you specials pediatricians and primary all have access to access our image system so that once those photos are in there and mal or plan or daniel uploads them they can look at them themselves my phone numbers are under that pager doesn't exist anymore that needs to be deleted I turned it in but I think calls that go to that number still just go to my cell phone that home phone number also doesn't exist the cell number is now my only a phone line and it is the same now what are we going to do when you guys get to clinic and in clinic basically you're going to learn how to examine kids take a history and the pertinent things in addition to just examining kids of all ages is to learn how to do a competent motility exam plan surgery to learn how to do surgery as far as muscle surgery you're also going to gain some expertise in how to do an anterior segment exam as needed with appropriate you know equipment how to do a fundus exam as needed with appropriate equipment when it's time to bail and go to the operating I'm doing an exam in our anesthesia it turns out your second year your retina rotation your penis rotation are kind of the key things in terms of this clinical competency committee where we get together and figure out how well you're all doing and so I'm you know kind of your representative for that to go to bat for you to make sure the things are being evaluated well if they're concerns with any of that I'm happy to talk to you about it the other thing I want you to do when you're on the services to gain a firm understanding about how we relate to pediatric services the folks who provide vision support services those are really kind of important contacts and interactions all of you when you start second year on our service and we provide headlights and take advantage of every opportunity you have to do practice surgery with a senior resident or faculty member and we'll try to arrange those I've had Dr. Jardine doing most of that recently as far as doing scleral passes he's kind of combined that with residents and with the medical students that we're looking at taking as residents at Moran we do adult eye muscle surgery that's what goes on there mainly we have most days one or more people operating at primary so there's a lot of surgery that goes on you'll have an opportunity to participate in all of that right now we're not doing any eye muscle surgery at the VA all those VA patients come to see us here now and so they're being done at Moran which is probably a better use of your time so you're seeing those second year third year found that most of the residents or the VA are focusing on doing anterior segment surgery and many were not particularly interested in doing a lot of eye muscle surgery if that changes for some reason we can always send somebody back to the VA but we're not at the moment as far as what to read you know I'll tell you guys this you know when people come on the service to talk about it from my perspective every single day every day of the week that includes weekends holidays and whatever you should be reading an hour a day not phomology an hour a day and whatever subspecialty you're doing and probably and read about interesting patients and so you need to find and carve time in your schedule to set time aside to read and if you're not doing that you're behind you're not doing justice to your education which is recent you're here you know we don't need you as a workforce we're here to train you in ophthalmology so that if you're you know when we look at like preparing for OCAPS no amount of looking through the home study course two weeks before the test is going to make up for what you didn't read during the year so keep in mind you know why you're here and what you're doing and if things aren't working and you're not getting a chance to to read you need to talk to somebody about it please i'm happy to talk to you about it because we need to try to you know make time you're here to learn and it's our job to make sure that that happens as far as journals that may have to do just with teens that you may not may or may not be aware of the journal of apos is kind of the primary pediatric ophthalmology journal binocular vision quarterly is a journal that looks at heavy-duty motility things it's edited by a guy named paul romano who was a pediatric ophthalmologist who became an editor publisher um is worth looking at but i wouldn't look at it regularly the apos journal is certainly look worth looking through you know the contents and the abstracts and the american orthoptic journal julie's society's journal is excellent wordy you're not going to get through the whole thing i think it's useful to use as a resource and there are books on my bookshelf books in clinic and in the library that you can use as a resource but the main thing you should strive to do and probably go through first year and then reviewing your own services go through that whole pediatric ophthalmology basic science book that should be your primary resource i hate absolutely hate trying to tailor what we're doing to get people to do well on tests but to some extent we are doing that i'd much prefer that we just tailor it to what we think you need to know turns out that those two things are probably very closely related and the reality is that you do have to do well on those tests that's how you're going to pass your boards and be able to practice ophthalmology so we have to look at that as a reality as well and uh if you do feel a need to take something from my bookshelf please let my secretary know uh days are long past when i can keep track of who's taken what and i've had many very expensive books disappear over the years some of them have been read in people's bathtubs and come back looking much thicker because they've been under water try to avoid that if you can um you all are everybody up to date and up to speed on icentra it's part of orientation did they do anything with icentra this year was there any kind of introduction to it not for the for the beginning residents but the interns okay pgy twos have already had it right yeah if you've had it once that's what you're going to get but i want to make sure if somebody you're aware of one of your colleagues who hasn't gotten in at all it's going to be a real shock because it is the worst electronic medical record system on the planet um uh you know they you know intermont basically took a system that the university threw out company was going to go into bankruptcy and they decided to make a deal with them to try to build an emr and they basically got what they paid for and if you don't have access to primary let me know or computer access because it's it's really really important let's get rid of this thing and let's see if i can i guess i have to make this smaller to clarify one thing you said early on when we see a call pediatric patients with orbit fractures yeah um i think you said they could follow up with beads or oculoplastics right well no i think i think that i'd send them first to two if it's something that you think urgently needs surgery is definitely going to need surgery they should follow up with plastics otherwise they should follow up with pediatric ophthalmology because we're going to get a hold of the oculoplastics folks if they need surgery and and we're also going to be the ones who make sure that they are seeing that their alignment's good and all of those things so if there's any question have a follow up with us on the other hand if you you know you've got a patient who's every time they try to look up their heart rate goes through the floor and they got what looks like muscle hanging down their maxillary sinus that's the patient who needs uh uh to see the oculoplastics folks now and now let me see here what we've got and this should all right now all right so let's go through this and this let's see this is work yeah it does how about that so the connection between vitreous hemorrhage and intracranial bleeding not directly related to child abuse was described first by turson if you'll read when you read about hemorrhage is turson syndrome where usually you've got subarachnoid hemorrhage uh you know the kind that's associated with the worst headache of your life and vitreous hemorrhage and that was described in 1900 as a pediatrician named kathy who in 19 mid 1940s made the connection between subdural hematomas long bone fractures metaphyseal fractures and child abuse and in 74 the term shaken baby syndrome was coined and they're an estimated 2 million kids that get abused in one way shape or form in the U.S. each year a small percentage of those the presenting findings are ocular kids are very very rare that we see in clinic that come in where we look we say gosh I think this kid's been shaken where we usually meet these kids they're in the PICU and often in the PICU after the neurosurgeons have been draining a subdural or doing something else to save their lives so that of all abused kids somewhere up to 60 percent have some sort of ocular findings usually those are kids again that are shaken um and retinal hemorrhages they're as far as specifically about a quarter of the kids in some studies have retinal hemorrhages as far as kids that are shaken somewhere between 50 and 80 percent so there are kids where we've had documented somebody admitted they're shaken where they don't have retinal hemorrhages that can be for a variety of reasons often realize retinal hemorrhages go away and they can change fairly quickly so they may well have been shaken but when you look at that child two or three months down the road which maybe where some of those reports come from you're not going to see any hemorrhages they've gone away not that the retina hasn't been damaged or visual pathways in the brain haven't been damaged but the hemorrhages have gone away now when you're called to see these kids you know basically you know it says a NET rule out you want to get an idea of what's gone on what the story is that they've been told what the circumstance is um you know a sort of quintessential it happens again and again is that the baby was in the care of the mom's boyfriend and she came home and found the child unresponsive and not breathing or if the person who did it has any sort of sense around them and they're not all messed up on some sort of substance that they've been interacting with they have some sense of guilt when they realize that the kids doing bad things and they call 911 and get help but that kind of scenario is very very common the other one that is very common is the well the baby just rolled off the couch onto a very carpeted floor and we wound up with a combination of skull fractures intercranial bleeding and retinal hemorrhages and a child who showed up in the hospital you know having respiratory difficulties and seizing and you know when things don't fit I mean that is sort of a red flag when you see these kids please get that history and I would I think in my own thinking I want to know about what the intracranial injuries are what's been done about them what they've seen on imaging tests don't forget to ask about their past ocular history you know there are things like I had bad retinopathy prematurity I was born very prematurely that make retinal blood vessels more fragile that may make kids have bleeding that isn't because they're abused we need to identify those things there are other you know systemic disorders um uh glutaric acid area type 2 osteogenesis imperfective things where where retinal hemorrhages have been reported kids who are anticoagulated because they've got some cardiovascular issue those kids are more prone to retinal hemorrhages with fairly minimal trauma so you know part of our job is to do the best for the patient and have an open mind about what we're looking at realize you are when you see that kid becoming part of a multi-disciplinary team that includes the child abuse specials pediatricians caretakers in the NICU neurosurgery a whole bunch of folks including their primary care doc you'll probably be asked questions by law enforcement they may want to know what you found please defer any definitive interpretations of things to one of the peds or retinotendings so that you know if we're giving information out we're giving information out consistently that they can depend on realize we are even though the policemen at times seem kind of grumpy and demanding we are part of the same team we work together um and um i want to continue to look at and the family's part of the program as well i try to avoid extensive uh conversations with aunt sue uncle harry and grandma and grandpa i usually excuse everybody but mom and dad when i look at the kids because i don't see it as my role to have an extended conversation with the family if i can avoid it um and then follow up care when we're seeing these kids one of the things we want to do realize they've had this big insult in their lives hemorrhage is by and large going to clear you may be left with retinal damage but the biggest determinant cause of long-term visual issues are the brain related issues in the visual system central vision loss damage division pathways in the brain damaged occipital cortex those things can really limit things down the road so it becomes our job after the fact when the dust settles neurosurgical injuries have been taken care of to sort out how well they're seeing and what we can do to make their lives better have they acquired various eye problems that need attention do they need vision support services things of that sort and so ongoing i usually try to see kids about six weeks or so after um you know they're discharged from the hospital uh now typical features retinal hemorrhages multiple layers uh if you've got multiple layers involved meaning superficial deep through the retina even sub-retinal hemorrhages and you've got hemorrhages that extend from optic nerve all the way out to the periphery that is a different story than a few hemorrhages that are superficial around the optic nerve so just saying they're positive or they're negative isn't as helpful as being good describers of what's going on every patient with increased intracranial pressure at some point often has small superficial hemorrhages around the optic nerve so if the kid's got increased intracranial pressure because their shunt isn't working that isn't a sign of child abuse necessarily that's just part of what's going on whereas when we see you know a child who's got hemorrhages throughout the retina multiple layers and they have these additional findings of circumvacular folds i'll show you pictures unless they've been really horrifically injured in terms of accidental head trauma that's very likely child abuse and so that's when we can make a pretty infatic statement have there been kids with findings just like what we think is abusive head trauma due to accidental injury yes but those kids have fallen off at least two stories out of concrete been an unrestrained missile in a head-on 60 mile an hour car crash or one child who continually gets reported and shows up in court with defense attorneys is the kid who climbed up on the television one of those big TVs in iraq and pulled the whole thing over on his head crushed his head and as part of his autopsy they found changes that look just like what we see so yes if you have horrific head trauma you can have changes that look just like child abuse so it isn't you know a black and white issue you have to interpret it in the face of what we're seeing this issue of perimacular folds and retina schesis come in and current thinking is that there are more firm attachments between vitreous gel and retina over the posterior pole around retinal blood vessels and that when you have acceleration deceleration movements of the head you wind up with tugging on the retina that can cause the retina schesis that can cause the circumvacular fold that we see to develop those are a sign that there have been acceleration deceleration movements and something to think about it turns out that britney coates who is a phd mechanical engineer in the engineering department and is doing some research here at moran is incredibly interested in unraveling the biomechanical processes involved and so she is doing basic research trying to sort this stuff out right here at the university of utah if you meet her talk for she's really cool now this is a patient who has multiple layered hemorrhages this is taken with the ret cam and fovea should be about here optic nerve doesn't look particularly swollen there is some edema in the retina here but this would be highly suggestive and you know of abuse of head trauma the other eye and again this is over the posterior pole in the left eye same patient and realize you know the more superficial flame hemorrhages deeper dot blot hemorrhages you'll see big dark sub retinal hemorrhages they're all useful another patient now this is the circumvacular fold that we're talking about here where there's a ridge nick mamas has good path you know descriptions of this i guess somebody wanted us to know 745 how nice thank you and uh this again you can see to locate yourself here this is the optic nerve fovea should be here so this kind of outlines this posterior pole area addition in the last six eight years with this our oct findings and it turns out that if you do oct you can see in oct images traction on this area bolstering my contention for years that this is due to vitreous where it's more firmly attached and you can see those changes in the vitreous on oct um it's nice when things kind of support what you think rather than tell you that you're full baloney close up view the same kind of thing so after the fact again central and i use the term central not cortical visual impairment because when you use term cortical visual impairment it implies there's something wrong with the occipital cortex where in fact in a lot of these kids it's more in the optic tract optic radiations that we see changes not necessarily an occipital cortex all and certainly it isn't specific for that you can't separate the two based on the clinical examination so i prefer that term that's just me you can call it what you want um optic atrophy again you'll start to see that usually after an optic nerve insult two to three months later and um usually indicates that you've had some sort of increased intracranial pressure or some axonal injury and then the other thing that'll happen is sub retinal neovascular membrane formation i've got a a kid that i met in the pick you at primary probably now close to 30 years ago it was in the old children's hospital and he had wall-to-wall hemorrhages they told me he was going to die he survived and i followed him up until he graduated from high school and one often did a mission for his church and got married and he's a you know hard-working guy now and doing reasonably well in life but he's got best corrected vision of about 2200 because he was left with large sub retinal neovascular membranes that developed long long before we used intravitural injections of VEGF inhibitors and there was really nothing that Mike Teske could do at the time who i lead on to try to do something that wouldn't have destroyed his central vision with a laser so that these things have been stable for years but sub retinal neovascular membranes are a real issue and can cause long-term vision loss in these kids um are they pathodontic again i touched on this before you have to interpret the findings you know but what i do is i word it in a way that says it's most consistent with or highly suggestive of on the other hand we have to be honest with our findings and if i think it could be related to i say that as well because maintaining equipoise in these areas are one things that you know the defense attorneys really harp on and there's one in particular in town here who i've jousted one of the in the courtroom many times who is a physician attorney er doc who thinks he's the world's expert retinal hemorrhages and he sat in the courtroom and basically you know tells the jury that i'm a company stooge that everybody is you know every kid with retinal hemorrhages by just my saying so has you know been abused and that's all i ever say and there you are i mean it's not true it was the case 30 years ago that we thought most infants with retinal hemorrhages without other explanation had probably been abused but we've learned a lot about it in the intervening years and when there's a disparity between the extent of the injuries and the mechanism you know a red flag should go up not differential diagnosis birth associated retinal hemorrhages you never see him after six weeks of age accidental head trauma i mentioned that's rare and then all of these things have been looked at in this lataric acid area is a biggie and every defense attorney who deals with these cases knows about this stuff and has this stuff and they've read all the stuff i've written about it and they bring the book to the darn courtroom and show me pictures from it and i've signed a couple of them it's kind of cool but you know it's because what they're doing is they're trying to schmooze you to sway your testimony you know they're doing their i've come to terms with the idea that they're just doing their job their job is to get the best result they can for their client not necessarily to see that justice is served and that's a huge difference and it took me a long time to catch on to that now the other thing that i want you to be aware of is there are these perioptic nursing hemorrhages that are only seen at autopsy when they call us you get a call from somebody in the pick you and they say well someone just passed away this kid was suspected of abusive head trauma what do we need to do well one of the things we want to suggest is a yeah they need to go to the medical examiner's office but please have them put a note on there that we want the eyes sent to nick mamalice's lab nick when worked sees these eyes for the me's office and does his own kind of eye autopsy and is able to see retinal hemorrhages folds and some other changes that aren't seen clinically that are difficult to find with ultrasound or other imaging modalities and that would include these interscleral hemorrhages optic nerve sheath hemorrhages that dr harry i've not been able to get him to be able to see them with his ultrasound about half of the patients you see you're going to have findings in just one eye and we don't know exactly why that is but it doesn't make it an exclusion or anything where you say well just one eye is involved it can't be shaking and is cpr the cause no no studies support that and blood trauma usually you've got other findings of blood trauma you've got various bruises lacerations things of that sort i have seen one patient where a parent took a child took their thumbs and held out of the kid's head and shook everything else and this kid had an autopsy ruptures of the lens capsule in both eyes and breaks deep in the corny decimase layer so trying to sort that out we couldn't figure out what had happened until somebody fessed up and it was their thumbs on this kid's eyes when they were holding the kid still that were the the bad this is that how many of you seen kids now get abusive head trauma and what have you seen and then i've seen ones that like we're just negative like the whole entire exam and post your poll like just no hemorrhage whatsoever everything looks fine you say and so you report that and that's you know the both of those things are darn useful things you know from the standpoint of the child abuse you know our child abuse pediatrics colleagues have a really tough practice life i mean they see all these sexually abused kids and not just you know shaking baby syndrome and they they deal with all of these and they deal with the families you know they try to get the family sorted out and get people in the right direction get them counseling get them jail if that's what they need but you know they're they're they're very open-minded maintain a lot of equal poise in terms of certain things out i have a lot of respect for me to a great job um what do you see marshal um i saw one where it's pretty unilateral where one eye was like the fused renal hemorrhages and all the quads the other one had like one upright by the disc that's all one where the the radiologist described like the fresher like there's a skull freshers like the worst you'd seen and came in the baby was um already a completely unresponsive like pupils were like fixed and inside was um like on one side there's a clear dm folds or um macular folds um or circum-macular folds with um renal hemorrhages and vitreous hemorrhages everywhere like scaring the optic disc on the other side there's a big renal detachment with vitreous hemorrhage and then where dr tree's thought looked like just a squirrel tunnel where the optic nerve should have been so it's like really bad yeah that's that's that's awful you know and and that you know you can think you might do some of these stories i mean it really gets your attention you know but you i still remember the very first kid i ever saw this as a resident it was it was awful you know and the kid was seen just prior to being a multiple organ donor it was bad i mean it would have been easier i think if my son hadn't been the same age that was hard i remember one of your mentors lia owen the very first you know child was a victim of abusive head trauma that she saw it was hard so you know if you're having troubles with any of these you should see him it's okay to talk about that you know and if you by any means if you find you're not getting somebody to see a kid you can't find somebody to see him and me call me because my cell phone if it's with me it's on and you know if i'm in a position to respond that i'm in the u.s i'm happy to come see the kid with you um you know i'm not i don't take call anymore it happens when you get old they let you not take call it's a good thing not taking call that is i don't know about getting old it's better than the older and but i think that you know in terms of these kids it is okay to call and i am around and i'm happy to see him with you um you know to staff those things because you need to be a good advocate for that patient make sure somebody sees questions about stuff we've talked about some of the residents have mentioned this but if we get called to see a patient um who's in the or either for an a and t or a neuro surgery procedure and that service wants us to do a retinal exam right do we need to do that with an attending you have to do it with an attending you cannot go into the or accept in an overt emergency so you know where there would be an exception and where i would go to bat for you you'll occasionally get a call from the or saying drop whatever you're doing come to or one at primary right now i mean usually those are directed at faculty and it's always been the same circumstance you have an ent surgeon who has been irrigating a sinus and suddenly the eye is out to hear you look in the back of the eye there's no retinal perfusion what's that lateral conditonomy and yeah upper and lower cruise catholicis if you do not know how to do that you grab somebody more senior they'll show you how to do it the idea is that when you have acute accumulation of either blood irrigating fluid air in the orbit it can cause the interorbital pressure to be greater than the systolic blood pressure perfusing the retina so you have at that point a central retinal artery occlusion and you need to acutely decompress the orbit so every ophthalmologist should know how to do this you basically just take a straight hemostat one blade inside one outside the lateral can't just go back to your tips just touch the lateral rim clamp take straight scissors usually blunt tip like steven scissors cut and then you reach inside above and below you feel this thing that feels kind of like a guitar string with the tips of your scissors you put the scissors around it you cut it and that's what that involves what you're doing is you're allowing the lids to move forward to dissipate the force and hopefully fluid will be reabsorbed if it's an ongoing arterial hemorrhage you're kind of toast it's not a good thing and I have seen that but most of the time here you go to the or to do that you wind up with a situation where things dramatically improve there's a paper in ophthalmology from about 1983 was written by myself and one of my fellow residents of michigan john fleishman about doing just that with acute orbital emphysema you know i i saw a patient in the ER university michigan who had dramatic uh i it was a prisoner he was in there because he'd fallen hit his face and he had a floor fracture but he had 2020 vision normal motility and i said fine we just need to see him and follow him he looks great and i'm getting in my car in the parking lot in this surgery resident from the ER starts banging on the side of my car saying you got to come back and see this guy right now something awful just happened well what he did is he vomited and he pushed a whole bunch of air into his orbit and so he went to no light perception from 2015 vision and he had a rock heart orbit and with a shios tenometer his scale reading is zero with a 15 gram weight which is equivalent to about an intraocular pressure of 90 it was huge and so i just kind of looked at him i've been up for hours and hours like two days i think straight so i just said give me a suture removal kit i looked at the guy and said this is going to hurt you more and it's going to hurt me and what cut cut and five minutes later his vision was 2020 you know it's a very gratifying procedure and it's one of those things like you know every general surgeon should know how to get into a chest cross-clamp the aorta you know momentarily or they shouldn't be doing general surgery i think every ophthalmologist should know how to do a lateral canthotomy and upper lower cruciantholysis because you can save vision with that procedure um and so um i didn't make the procedure up we didn't write we just wrote up because people had talked about it you know with hambridge and various things but you know at the time thinking was orbital emphysema was just something to kind of say oh yeah that's air in the orbit so what and uh you know so that was the first time somebody reported you know patients and my buddy john had had a similar patient with air in the orbit and but as far as the or goes the idea the or's responsibility is to to kind of make sure things are going okay let's say you go in and you do something you think you need to do something and something happens you're kind of holding the bag and the or is holding the bag so that's where they hold the line if you need something we'll find somebody and and you know and it may be if you know often you'll find if it's you know daytime hours one of us is there you know i can poke my head in and be the attending the record then you can do whatever you need to do and it's all good and i'm also then there to be you know a backup to look with you if there's an issue but yes unfortunately you do need someone in the or you can go into the MRI scanner and if you've got somebody there who's sedating things and well that brings up one other issue let's say you've sedated kids in the past you've you know spent a lot of time on an ICU rotation or something you're comfortable with that can you just say i want to give this kid you know some propofol and and i'm going to take responsibility for and i'm going to take a look at the eyes and the answer is no categorically absolutely there are specific sedation privileges and uh for the longest time i was the only one of our faculty who had sedation privileges in primary and i gave up because it just wasn't doing it often enough and it's just oh so much more convenient to have somebody who's doing it regularly do it so they're staying on top of things but i mean you need to have pals and you need you just watch a video and answer a bunch of questions but i think if you're going to sedate kids there are people they're telling me it's time to go so um so i think that that and that's a great question that comes up but if you think i mean again call you know i'm in clinic i can run down i can be the stack of record in between patients and help you do things but you actually you need to find a faculty of record it doesn't mean that they need to come and sit there the whole time you know i'll come help you do time out run out the door and let you look at the kid or if there's something you want me to see look at it with you um and we'll get patients taken care of that way if somebody doesn't like something they can blame me and they're not going to try to hang you because one of my roles at primary is to sort of be the source of most blame if things aren't going well because i'm in a better position to grumble back at somebody or you know we also want to make sure we're taking the absolute best care of patients other questions about any of this as far as just the logistics or this abusive head trauma again look at the stuff in the home study course if you have it or no brand pass that information out try to you know get smart about it and be aware of it and um you know it's been one of my interests i mean i think when i was a resident i got interested in post anesthetic retinal hemorrhages and looked at a lot of the military there's a whole bunch of you believe what they used to do to soldiers they still do i guess but they would take these guys in these machines that would simulate massive g forces while they're trying to decide how far they could push people and have them survive you know in airplanes and spacecraft and guess what they accumulated a wealth of data about retinal hemorrhages and g forces so while we can't really take lab animals maybe children never in shape one a little more than the other and see who gets retinal hemorrhages um they certainly have done things like that with soldiers um where you you fling this one forward a little faster harder than the last one and you see what happened to it and yes your tax dollars have paid for that oh so anyway thanks for coming this morning